Numbness/Weakness

Numbness-Weakness

• DDX:
  • – TIA
    
  • – Stroke
    
  • – Guillain Barre
    
  • – MS
    
  • – DM peripheral
    
  • – Myasthenia Gravis
    
  • – Todds Paralysis
• Physical Exam:
  • – VS: State (or WNL or WNL except…) (no orthostatic changes)
  • – General: Patient is in no acute distress
  • – HEENT: Inspect head, mouth, carotid auscultation and palpation, thyroid exam
    • NC/AT, Conjunctivae normal, PERRLA, (EOMI without nystagmus,) Fundoscopic exam normal, red reflex intact, no papilledema;
  • – Chest Exam: Auscultation
    • Clear breath sounds bilaterally/Clear breath sounds bilaterally
  • – Heart Exam: Auscultation, Palpate pulses
    • RRR, S1, S2 wnl, No murmurs, rubs, or gallops heard, Carotid upstroke NL, no bruit. Radial, Posterior tibial, dorsalis pedis pulse intact 2+ b/l, feet warm
  • – Neuro Exam: Mental Status Exam, Cranial nerves (including fundoscopic exam), Motor exam, DTRs, Gait, sensory exam
    • Alert and Oriented x 3, CN 2-12 intact grossly (except …); Motor: Strength 5/5 in all muscle groups; Sensation: Intact to pinprick and soft touch; DTRs, symmetric 2+ in upper and lower extremities, (-) babinski bilaterally; Gait: Normal
• Work-up:
  • – CBC with diff
    
  • – Electrolytes
    
  • – Glucose
    
  • – ECG
    
  • – CT (CT—head)
    
  • – MRI (MRI—brain)
    
  • – Doppler U/S—Carotids
    
  • – Echo
    
  • – PT/PTT
    
  • – EMG/Nerve Conduction Study
    
  • – Serum B12
    
  • – Tensilon test (MG) – ACH receptor antibodies

Arnold Chiari Malformation

• Def:
  • A type of neural tube defect were there is a development deformity in the hindbrain that results in an asymptomatic or symptomatic type
• Presentation:
  • – paralysis of SCM, bilateral weakness of lateral eye movements, and facial weakness

Diabetic Peripheral Neuropathy

• Presentation:
  • – tingling and numbness in the hands and feet (glove and-stocking distribution)
  • – Hx of diabetes mellitus, hypertension, and alcoholism
  • – decreased soft touch, vibratory, and position sense in the feet
  • –  burning foot paresthesias, that are worse at night and loss of ankle reflexes
  • – Neuropathic disorders associated with diabetes mellitus.
  • – Presumed to be as a result from diabetic microvascular injury involving small blood vessels that supply nerves (vasa nervorum)
  • – Relatively common conditions which may be associated with diabetic neuropathy include third nerve palsy; mononeuropathy; mononeuropathy multiplex; diabetic amyotrophy; a painful polyneuropathy; autonomic neuropathy; and thoracoabdominal neuropathy.
• DDX:
  • – Diabetic Peripheral Neuropathy
  • – Alcoholic Peripheral Neuropathy
  • – Vitamin B12 deficiency
  • – Hypocalcemia
  • – Hyperventilation
  • – Paraproteinemia/Myeloma
• Work-up:
  • – CBC with diff, HbA1c, ESR, Calcium, Serum B12
  • – Urinary Analysis
  • – Serum and urine protein electrophoresis

Guillain-Barre Syndrome (GBS)

• Presentation:
  • – ascending loss of strength in the lower legs over the past two weeks. recent URI.
  • – Acute, autoimmune, polyradiculoneuropathy affecting the peripheral nervous system, usually triggered by an acute infectious process.
  • – Several types of GBS, but unless otherwise stated, GBS refers to the most common form, acute inflammatory demyelinating polyneuropathy (AIDP).
  • – Severe and usually ascending paralysis starting with lower limb (legs) weakness that ascends to upper limbs and face along with complete loss of DTRs.
• DDX:
  • – Guillain-Barré Syndrome (GBS)
  • – Multiple Sclerosis (MS)
  • – Polymyositis
  • – Myasthenia Gravis (MG)
  • – Peripheral Neuropathy
  • – Tumor in the vertebral canal
• Work-up:
  • – CBC with diff, Electrolytes, CPK, Serum B12
  • – LP—CSF analysis
    
  • – MRI— spine
    
  • – EMG/Nerve Conduction Study
    
  • – Tensilon Test
• Treatment:
  • – plasmapheresis followed by immunoglobulins and supportive care
  • (ventilator b/c death may occur if severe pulmonary complications and dysautonomia are present)

Multiple Sclerosis (MS)

• Presentation:
  • – weakness, loss of sensation, and tingling in leg
  • – eye pain, decreased vision, and double vision
  • – feeling “electric shocks” down the spine upon flexing head
  • – Nervous system disease that affects brain and spinal
    cord
    
  • – Damages the myelin sheath, the material that surrounds and protects your nerve cells
    
  • – Damage slows down or blocks messages between your brain and your body, leading to the symptoms of MS
• DDX:
  • – Multiple Sclerosis (MS)
    
  • – Stroke
    
  • – Conversion Disorder
    
  • – Malingering
    
  • – CNS Tumor
    
  • – Neurosyphillis
    
  • – Syringomyelia
    
  • – CNS Vasculitis
• Work-up:
  • – CBC with diff, ESR
    
  • – MRI— brain
    
  • – LP—CSF analysis
    
  • – Retinal evoked potentials

Myasthenia Gravis (MG)

• Presentation:
  • – occasional double vision and droopy eyelids that quikly resolves
  • – Neuromuscular disease leading to fluctuating muscle weakness and fatiguability
  • – Autoimmune disorder → weakness d/t circulating antibodies that block AChR at post-synaptic neuromuscular junction → inhibit ACh NT stim effect
  • – Treated medically with cholinesterase inhibitors or immunosuppressants, and, in selected cases, thymectomy
• DDX:
  • – Myasthenia Sravis (MG)
    
  • – Horner’s Syndrome
    
  • – Multiple Sclerosis (MS)
    
  • – Intracranial Tumor Compressing CN III, IV, or VI
    
  • – Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrig’s Disease
• Work-up:
  • – Tensilon test
    
  • – ACh Receptor Antibodies (in serum)
    
  • – CXR
    
  • – CT—chest
    
  • – MRI—brain
    
  • – EMG

Spinal Muscle Atrophy

• Def:
  • Autosomal recessive disorder where motor neurons with cell bodies in the SC that innervate skeletal muscles degenerate
  • deletion of survival motor neuron gene 1

Stroke

• Presentation:
  • – slurred speech
  • – facial drooping and numbness
  • – hand weakness
  • – Babinski’s sign
  • Hx: hypertension, diabetes mellitus, and heavy smoking
  • Five Warning Signs:
    1. Sudden Severe Headache → no apparent reason
    2. Sudden weakness → Numbness and/or tingling in face, arm, or leg
    3. Sudden dizziness → unsteadiness or sudden falls, especially with any of the other warning signs
    4. Sudden vision trouble → sudden loss of vision (sight), particularly in one eye, or double vision
    5. Sudden Speech trouble → Temporary loss of speech or trouble understanding speech
• DDX:
  • – Stroke
    
  • – Transient Ischemic Attack (TIA)
    
  • – Seizure
    
  • – Intracranial neoplasm
    
  • – Subdural or epidural hematoma
• Work-up:
  • – CBC with diff, Electrolytes, PT/PTT/INR
    
  • – CT—head
    
  • – MRI—brain (preferred)
    
  • – Doppler U/S—Carotids
    
  • – Echocardiography

Tethered Cord 

• Def:
  • Dysfunction in development of NS where the SC gets stuck on the lower vertebrae and gets stretched
• Presentation:
  • – dermatomal and myotomal deficits in lower limbs, pain in saddle region and lower limbs, and bowel/bladder dysfunction

Todds paralysis

• Presentation:
  • – hemiparesis (after a tonic-clonic seizure) that resolves over a few hours
  • – Focal weakness in a part of body after a seizure.
    
  • – Weakness typically affects appendages and is localized to either the left or right side of the body.
    
  • – Usually subsides completely within 48 hours
    
  • – Todd’s paresis may also affect speech, eye position (gaze) or vision.
• DDX:
  • – Todd’s paralysis
    
  • – TIA
    
  • – Stroke
    
  • – Complicated Migraine
    
  • – Malingering
• Work-up:
  • – CBC with diff, Electrolytes
    
  • – EEG
    
  • – MRI—brain
    
  • – Doppler U/S—Carotid

Transient Ischemic Attack (TIA)

• Presentation:
  • – episode of slurred speech (mins)
  • – Facial drooping and numbness
  • – hand weakness
  • – Resolves < 24 hours
  • – Hx: hypertension, diabetes mellitus, and heavy smoking
• DDX:
  • – Transient Ischemic Attack (TIA)
    
  • – Hypoglycemia
    
  • – Seizure
    
  • – Stroke
    
  • – Facial nerve palsy
• Work-up:
  • – CBC with diff, Glucose, Electrolytes
    
  • – ECG
    
  • – CT—head
    
  • – MRI—brain, spine
    
  • – Doppler U/S—Carotids
    
  • – Echocardiography
    
  • – EEG