Approach to a case of motor and sensory disorders
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Transcript of Approach to a case of motor and sensory disorders
![Page 1: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/1.jpg)
APPROACH TO A CASE OF MOTOR AND SENSORY DISORDERS
Introductory Lecture Series
Dept. of Medicine
IV Term
Dr C Khati
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Why Motor and Sensory Disorders together?
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Why Motor and Sensory Disorders together?
Shared routes
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Why Motor and Sensory Disorders together?
Shared routes
Identification by the company kept
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Overall Objective
To identify
1. Where is the lesion?
Neuro-Anatomical Localization
2. What is the lesion?
Pattern Recognition
Etiological Diagnosis
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Complex Brain Processing
CC
HISTORY
EXAMINATION
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How to go further?
• Basic Neuroanatomy
• Basic Pathophysiology
Symptom Based Approach
Pattern Recognition
Etiological List
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How to go further?
• Basic Neuroanatomy
• Basic Pathophysiology
Symptom Based Approach
Pattern Recognition
Etiological List
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How to go further?
• Basic Neuroanatomy
• Basic Pathophysiology
Symptom Based Approach
Pattern Recognition
Etiological List
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Specific Learning Objectives
• Recapitulate Neuro-anatomy
• Recap Neurophysiology
• Clinical Features (Symptom based approach)
• Pattern Recognition (Symptoms and signs)
• Etiological List
• Investigation List
• Take Home Messages
• Videos/ Case studies
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Neuroanatomy
• Motor Pathways
– Pyramidal Tract
– Motor unit
• Sensory Pathways
– Dorsal Columns
– SpinothalamicTract
• Reflex Pathway
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Neuroanatomy
• Motor Pathways
– Pyramidal Tract
– Motor unit
• Sensory Pathways
– Dorsal Columns
– SpinothalamicTract
• Reflex Pathway
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Neuroanatomy
• Motor Pathways
– Pyramidal Tract
– Motor unit
• Sensory Pathways
– Dorsal Columns
– SpinothalamicTract
• Reflex Pathway
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Motor Pathway
• Pyramidal or
Corticospinal tract
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MOTOR PATHWAY
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UMN Lesion
1. Weakness
2. No atrophy (No fasciculation)
3. Increased tone
4. Increased DTR
5. Extensor Plantar (Babinski Positive)
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Motor unit – a motor neuron and all the
muscle fibers it innervates
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• Motor unit – a motor neuron and all the
muscle fibers it innervates
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Motor unitStructural Organization of PNS in
Region of a Spinal Nerve
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LMN Lesion
• All lesions involving a motor unit are LMN
(Lower Motor Neuron) lesions
1. Weakness
2. Atrophy (with fasciculation &/fibrillation)
3. Decreased tone (hypotonia)
4. Decreased DTR (hyporeflexia)
5. Flexor Plantar (Downgoing toes)
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Extra Pyramidal System
(Basal Ganglia)
1. Chorea
2. Athetosis
3. Hemiballismus
Cerebellum
1. Intention tremor
2. Ataxia
3. Nystagmus
4. DTR/tone ipsilaterally
5. Asthenia
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Ascending Pathways
• Dorsal Column/Medial
Lemniscal Pathway:
Touch, vibration, proprioception
• Anterolateral System:
Spinothalamic tract- pain & temp
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At medulla
Dorsal column-Medial Lemniscus Pathway
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Ascending tracts & their crossings
• Dorsal Column: As internal arcuate fibers in
Medulla
• Lateral Spinothalmic tract: Fibers cross at the
same level of segment where they enter the
spinal cord
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Reflexes
• Superficial reflexes:– All sup reflexes lost in pyramidal lesions
– Local reflex lost to a local arc lesion (eg cremasteric
reflex)
• Deep Tendon Reflexes– Exaggerated: Pyramidal lesions
– Absent/Reduced: LMN lesions
– Nerve lesions (e.g.Radial N lesion - triceps jerk C7-8)
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Reflexes
• Superficial reflexes:– All sup reflexes lost in pyramidal lesions
– Local reflex lost to a local arc lesion (eg cremasteric
reflex)
• Deep Tendon Reflexes– Exaggerated: Pyramidal lesions
– Absent/Reduced: LMN lesions
– Nerve lesions (e.g.Radial N lesion - triceps jerk C7-8)
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Reflexes
• Superficial reflexes:– All sup reflexes lost in pyramidal lesions
– Local reflex lost to a local arc lesion (eg cremasteric
reflex)
• Deep Tendon Reflexes– Exaggerated: Pyramidal lesions
– Absent/Reduced: LMN lesions
– Nerve lesions (e.g.Radial N lesion - triceps jerk C7-8)
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STRETCH REFLEX & RECIPROCAL INNERVATION
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Neurophysiology
• Impulse generation
• Impulse conduction
- in axons
- across synapses
• Energy dependant electrochemical gradient
• Neurotransmitters
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Neurophysiology
• Impulse generation
• Impulse conduction
- in axons
- across synapses
• Energy dependant electrochemical gradient
• Neurotransmitters
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Neurophysiology
• Impulse generation
• Impulse conduction
- in axons
- across synapses
• Energy dependant electrochemical gradient
• Neurotransmitters
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Neurophysiology
• Hierarchy of control mechanisms
– Posture and baseline muscle tone
– Superimposed movement
– Coordination for targeted movement
• UMN regulatory control on LMN (inhibitory)-modulates tone and reflex
– Monosynaptic axn- withdrawal response
– Polysynaptic axn- for coordinated action
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Neurophysiology
• Hierarchy of control mechanisms
– Posture and baseline muscle tone
– Superimposed movement
– Coordination for targeted movement
• UMN regulatory control on LMN (inhibitory)-modulates tone and reflex
– Monosynaptic axn- withdrawal response
– Polysynaptic axn- for coordinated action
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Neurophysiology
• Hierarchy of control mechanisms
– Posture and baseline muscle tone
– Superimposed movement
– Coordination for targeted movement
• UMN regulatory control on LMN (inhibitory)-modulates tone and reflex
– Monosynaptic axn- withdrawal response
– Polysynaptic axn- for coordinated action
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Pathophysiology
• Larger fibres
• Smaller fibres
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Pathophysiology
• Neuronal Necrosis (energy failure)
• Apoptosis (programmed death- gradual)
• Axonal Degeneration
• Demyelination
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Pathophysiology
• Neuronal Necrosis (energy failure)
• Apoptosis (programmed death- gradual)
• Axonal Degeneration
• Demyelination
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Symptom Based Approach
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Symptom Based Approach I System Disorder
Sensory (-)Numbness (Hypoaesthesia)(+)Tingling (dysaesthesia)(+)Pain (Neuralgia/ Poorly localised)(+)Hyperpathia &Causalgia (non sensory stim.)
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Symptom Based Approach I System Disorder
Sensory (-)Numbness(+)Tingling (+)Pain(+)Hyperpathia &Causalgia (non sensory stim.)
Motor •Weakness – Proximal vs Distal, Regional•Movement Disorder- Initiation, Coordination, Tremors, spasms/ jerks
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Symptom Based Approach I System Disorder
Sensory (-)Numbness(+)Tingling (+)Pain(+)Hyperpathia &Causalgia (non sensory stim.)
Motor •Weakness – Proximal vs Distal, Regional•Movement Disorder- Initiation, Coordination, Tremors, spasms/ jerks
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Symptom Based Approach I System Disorder
Sensory (-)Numbness(+)Tingling (+)Pain(+)Hyperpathia &Causalgia (non sensory stim.)
Motor •Weakness – Proximal vs Distal, Regional•Movement Disorder- Initiation, Coordination, Tremors, spasms/ jerks
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Symptom Based Approach I System Disorder
Sensory (-)Numbness(+)Tingling (+)Pain(+)Hyperpathia &Causalgia (non sensory stim.)
Motor •Weakness •Movement Disorder
Associations & Accompaniments
•Sphincter (incontinence/ retention)•Cranial Nerves• EPS/ Cerebellum•Autonomic disturbance
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Symptom Based Approach I System Disorder
Sensory (-)Numbness(+)Tingling (+)Pain(+)Hyperpathia &Causalgia (non sensory stim.)
Motor •Weakness •Movement Disorder
Associations & Accompaniments
•Sphincter (incontinence/ retention)•Cranial Nerves• EPS/ Cerebellum•Autonomic disturbance
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Symptom Based Approach I System Disorder
Sensory (-)Numbness(+)Tingling (+)Pain(+)Hyperpathia &Causalgia (non sensory stim.)
Motor •Weakness •Movement Disorder
Associations & Accompaniments
•Sphincter (incontinence/ retention)•Cranial Nerves• EPS/ Cerebellum•Autonomic disturbance
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Symptom Based Approach I System Disorder
Sensory (-)Numbness(+)Tingling (+)Pain(+)Hyperpathia &Causalgia (non sensory stim.)
Motor •Weakness •Movement Disorder
Associations & Accompaniments
•Sphincter (incontinence/ retention)•Cranial Nerves• EPS/ Cerebellum•Autonomic disturbance
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Symptom Based Approach I System Disorder
Sensory (-)Numbness(+)Tingling (+)Pain(+)Hyperpathia &Causalgia (non sensory stim.)
Motor •Weakness •Movement Disorder
Associations & Accompaniments
•Sphincter (incontinence/ retention)•Cranial Nerves• EPS/ Cerebellum•Autonomic disturbance
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Symptomatic Approach II
Temporal Profile Condition
Continuous •Static•Progressive•Improving
VascularInfections and Para-infectious ProcessesDegenerativeDemyelinatingTumorTraumaMetabolicNutritionalDrugs and Toxins
Episodic•Intermittent•Remittent
•Abnormal Movement•Hypo and Hyperkalemia•Porphyria•TIA•Seizure•Demyelination
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Symptomatic Approach II
Temporal Profile Condition
Continuous •Static•Progressive•Improving
VascularInfections and Para-infectious ProcessesDegenerativeDemyelinatingTumorTraumaMetabolicNutritionalDrugs and Toxins
Episodic•Intermittent•Remittent
•Abnormal Movement•Hypo and Hyperkalemia•Porphyria•TIA•Seizure•Demyelination
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Symptomatic Approach II
Temporal Profile Condition
Continuous •Static•Progressive•Improving
VascularInfections and Para-infectious ProcessesDegenerativeDemyelinatingTumorTraumaMetabolicNutritionalDrugs and Toxins
Episodic•Intermittent•Remittent
•Abnormal Movement•Hypo and Hyperkalemia•Porphyria•TIA•Seizure•Demyelination
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Symptomatic Approach II
Temporal Profile Condition
Continuous •Static•Progressive•Improving
VascularInfections and Para-infectious ProcessesDegenerativeDemyelinatingTumorTraumaMetabolicNutritionalDrugs and Toxins
Episodic•Intermittent•Remittent
•Abnormal Movement•Hypo and Hyperkalemia•Porphyria•TIA•Seizure•Demyelination
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Symptomatic Approach II
Temporal Profile Condition
Continuous •Static•Progressive•Improving
VascularInfections and Para-infectious ProcessesDegenerativeDemyelinatingTumorTraumaMetabolicNutritionalDrugs and Toxins
Episodic•Intermittent•Remittent
•Abnormal Movement•Hypo and Hyperkalemia•Porphyria•TIA•Seizure•Demyelination
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Present Illness
• Symptoms
Clarify SymptomsOnset, Duration and Progression
Onset
Some Disability
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Pattern List• Hemiplegia-
• Crossed
• Uncrossed
• Quadriplegia
• Paraplegia
• Plexuspathy
• Radiculopathy (mono/poly)
• Monoplegia
• Muscle groups
• Hemisensory loss
– Complete (Thalamus)
– Harlequinn (Brain Stem)
• Sensory loss below a level
• Brown Sequard (hemi-cord)
• Dissociated/suspended loss
• Radiculopathy (mono/poly)
• Peripheral Neuropathy
• Mononeuropathy
• Mononeuropathy Multiplex
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Pattern List• Hemiplegia-
• Crossed
• Uncrossed
• Quadriplegia
• Paraplegia
• Plexuspathy
• Radiculopathy (mono/poly)
• Monoplegia
• Muscle groups
• Hemisensory loss
– Complete (Thalamus)
– Harlequinn (Brain Stem)
• Sensory loss below a level
• Brown Sequard (hemi-cord)
• Dissociated/suspended loss
• Radiculopathy (mono/poly)
• Peripheral Neuropathy
• Mononeuropathy
• Mononeuropathy Multiplex
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Pattern List• Hemiplegia-
• Crossed
• Uncrossed
• Quadriplegia
• Paraplegia
• Plexuspathy
• Radiculopathy (mono/poly)
• Monoplegia
• Muscle groups
• Hemisensory loss
– Complete (Thalamus)
– Harlequinn (Brain Stem)
• Sensory loss below a level
• Brown Sequard (hemi-cord)
• Dissociated/suspended loss
• Radiculopathy (mono/poly)
• Peripheral Neuropathy
• Mononeuropathy
• Mononeuropathy Multiplex
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Pattern List• Hemiplegia-
• Crossed
• Uncrossed
• Quadriplegia
• Paraplegia
• Plexuspathy
• Radiculopathy (mono/poly)
• Monoplegia
• Muscle groups
• Hemisensory loss
– Complete (Thalamus)
– Harlequinn (Brain Stem)
• Sensory loss below a level
• Brown Sequard (hemi-cord)
• Dissociated/suspended loss
• Radiculopathy (mono/poly)
• Peripheral Neuropathy
• Mononeuropathy
• Mononeuropathy Multiplex
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Pattern List• Hemiplegia-
• Crossed
• Uncrossed
• Quadriplegia
• Paraplegia
• Plexuspathy
• Radiculopathy (mono/poly)
• Monoplegia
• Muscle groups
• Hemisensory loss
– Complete (Thalamus)
– Harlequinn (Brain Stem)
• Sensory loss below a level
• Brown Sequard (hemi-cord)
• Dissociated/suspended loss
• Radiculopathy (mono/poly)
• Peripheral Neuropathy
• Mononeuropathy
• Mononeuropathy Multiplex
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PPeripheral
Neuropathy
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Sensory loss below a level
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COMPLETE CORD TRANSECTION
•Sensory: All sensations
impaired below level oflesion
• Motor: Quadriplegia/
Paraplegia depending onlevel of lesion
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UNILATERAL HEMISECTION OF CORD(Brown Sequard Syndrome)
• Motor: I/L UMN
• Sensory: I/L sensation loss
• Pain: C/L Pain & Temp. Loss
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Sensory loss below a level
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LESIONS AFFECTING SPINAL CORD CENTRALLY
• Seen in Syringomyelia- cavitationcentral grey matter of spinal cord
• Sensory: Spinothalamic are first tobe affected followed by dorsal column
• Motor: Affected last- initially LMNthen UMN type
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LESIONS AFFECTING SPINAL CORD CENTRALLY
• Seen in Syringomyelia- cavitationcentral grey matter of spinal cord
• Sensory: Spinothalamic are first tobe affected followed by dorsal column
• Motor: Affected last- initially LMNthen UMN type
![Page 67: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/67.jpg)
LESIONS AFFECTING SPINAL CORD CENTRALLY
• Seen in Syringomyelia- cavitationcentral grey matter of spinal cord
• Sensory: Spinothalamic are first tobe affected followed by dorsal column
• Motor: Affected last- initially LMNthen UMN type
![Page 68: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/68.jpg)
Sensory -1st Order NeuronSpinothalamic
• Crude Touch
• Pain
• Temperature
• Superficial reflexes (afferent)
Dorsal Column
• Fine Touch
• Pressure
• Stretch
• Position
• Vibration
• 2 point discrimination
• Deep reflexes (afferent)
![Page 69: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/69.jpg)
Thalamic Sensory Features(2ndOrder neuron)
• Deep seated poorly localised pain
• All modalities of sensations
• Always opposite side
![Page 70: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/70.jpg)
Cortical Sensory Features(3rd order Neuron)
• Hemi- neglect
• Hemi –inattention
• Inability to localise touch
• Agraphaesthesia
• Asteriognosis
• 2 Point -Discrimination
![Page 71: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/71.jpg)
Motor Symptoms
• Weakness – Reduction in normal power of one or more muscles
• Proximal Vs Distal
• Groups vs Regions
• Plegia vs Paresis
![Page 72: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/72.jpg)
Motor Symptoms
• Weakness
• Fatiguability- Inability to sustain activity (comparative)
• Twitching in muscles (fasciculation)
• Spasms and Cramps
• Myalgias
• Dyskinesias
• Imbalance/ unsteadiness
• Difficulty in movement
![Page 73: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/73.jpg)
Motor SignsUMN
• Weakness(Pyramidal / regional distribution)
• No Atrophy
• Spasticity (Ridgity in EPS)
• Exaggerated Deep Tendon Jerks (DTJs)
• Extensor Plantar
• Tremors (in EPS and Cerebellar involvement )
• Gait
LMN
• Weakness (Segmental / distal distribution)
• Atrophy
• Flaccidity (Decreased tone)
• Diminished DTJs
• Flexor Plantar
• Fasciculations
• Gait
![Page 74: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/74.jpg)
Motor SignsUMN
• Weakness(Pyramidal / regional distribution)
• No Atrophy
• Spasticity (Ridgity in EPS)
• Exaggerated Deep Tendon Jerks (DTJs)
• Extensor Plantar
• Tremors (in EPS and Cerebellar involvement )
• Gait
LMN
• Weakness (Segmental / distal distribution)
• Atrophy
• Flaccidity (Decreased tone)
• Diminished DTJs
• Flexor Plantar
• Fasciculations
• Gait
![Page 75: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/75.jpg)
Motor SignsUMN
• Weakness(Pyramidal / regional distribution)
• No Atrophy
• Spasticity (Ridgity in EPS)
• Exaggerated Deep Tendon Jerks (DTJs)
• Extensor Plantar
• Tremors (in EPS and Cerebellar involvement )
• Gait
LMN
• Weakness (Segmental / distal distribution)
• Atrophy
• Flaccidity (Decreased tone)
• Diminished DTJs
• Flexor Plantar
• Fasciculations
• Gait
![Page 76: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/76.jpg)
Gait
![Page 77: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/77.jpg)
Etiological List• Vascular
• Infections and Para-infectious Processes
• Degenerative
• Demyelinating
• Vasculitis
• Metabolic
• Nutritional
• Tumor
• Trauma
• Drugs and Toxins
![Page 78: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/78.jpg)
Investigations
• Routine Haematology and Biochemistry
• Imaging and Contrast Studies
• Nerve Conduction Studies
• CSF
• EMG
• Nerve Biopsy
• Muscle Biopsy
• Special Tests- B12 assay, Copper, Neuronal/receptor antibodies, Serology for infections, Hormone assays, Porphobilinogens, Immunological &Tumour Markers, etc
![Page 79: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/79.jpg)
Take Home Messages: Shared routes
MOTOR• Cerebral Cortex• Internal Capsule• Mid Brain (peduncles)• Pons • Medulla• Spinal Cord• Nerve Roots• Plexuses• Peripheral Nerves• Motor end plates
• SENSORY• Cortex• Internal Capsule• Thalamus• Pons• Medulla• Spinal Cord• Roots• Plexuses/Cords• Peripheral nerves• Receptors
![Page 80: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/80.jpg)
Take Home Messages: Shared routes
MOTOR• Cerebral Cortex• Internal Capsule• Mid Brain (peduncles)• Pons • Medulla• Spinal Cord• Nerve Roots• Plexuses• Peripheral Nerves• Motor end plates
• SENSORY• Cortex• Internal Capsule• Thalamus• Pons• Medulla• Spinal Cord• Roots• Plexuses/Cords• Peripheral nerves• Receptors
![Page 81: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/81.jpg)
Take Home Messages: Shared routes
MOTOR• Cerebral Cortex• Internal Capsule• Mid Brain (peduncles)• Pons • Medulla• Spinal Cord• Nerve Roots• Plexuses• Peripheral Nerves• Motor end plates
• SENSORY• Cortex• Internal Capsule• Thalamus• Pons• Medulla• Spinal Cord• Roots• Plexuses/Cords• Peripheral nerves• Receptors
![Page 82: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/82.jpg)
Take Home Messages: Shared routes
MOTOR• Cerebral Cortex• Internal Capsule• Mid Brain (peduncles)• Pons • Medulla• Spinal Cord• Nerve Roots• Plexuses• Peripheral Nerves• Motor end plates
• SENSORY• Cortex• Internal Capsule• Thalamus• Pons• Medulla• Spinal Cord• Roots• Plexuses/Cords• Peripheral nerves• Receptors
![Page 83: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/83.jpg)
Take Home Messages: Shared routes
MOTOR• Cerebral Cortex• Internal Capsule• Mid Brain (peduncles)• Pons • Medulla• Spinal Cord• Nerve Roots• Plexuses• Peripheral Nerves• Motor end plates
• SENSORY• Cortex• Internal Capsule• Thalamus• Pons• Medulla• Spinal Cord• Roots• Plexuses/Cords• Peripheral nerves• Receptors
![Page 84: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/84.jpg)
Take Home Messages: Shared routes
MOTOR• Cerebral Cortex• Internal Capsule• Mid Brain (peduncles)• Pons • Medulla• Spinal Cord• Nerve Roots• Plexuses• Peripheral Nerves• Motor end plates
• SENSORY• Cortex• Internal Capsule• Thalamus• Pons• Medulla• Spinal Cord• Roots• Plexuses/Cords• Peripheral nerves• Receptors
![Page 85: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/85.jpg)
Take Home Messages: Shared routes
MOTOR• Cerebral Cortex• Internal Capsule• Mid Brain (peduncles)• Pons • Medulla• Spinal Cord• Nerve Roots• Plexuses• Peripheral Nerves• Motor end plates
• SENSORY• Cortex• Internal Capsule• Thalamus• Pons• Medulla• Spinal Cord• Roots• Plexuses/Cords• Peripheral nerves• Receptors
![Page 86: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/86.jpg)
Take Home Messages: Shared routes
MOTOR• Cerebral Cortex• Internal Capsule• Mid Brain (peduncles)• Pons • Medulla• Spinal Cord• Nerve Roots• Plexuses• Peripheral Nerves• Motor end plates
• SENSORY• Cortex• Internal Capsule• Thalamus• Pons• Medulla• Spinal Cord• Roots• Plexuses/Cords• Peripheral nerves• Receptors
![Page 87: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/87.jpg)
Take Home Messages: Shared routes
MOTOR• Cerebral Cortex• Internal Capsule• Mid Brain (peduncles)• Pons • Medulla• Spinal Cord• Nerve Roots• Plexuses• Peripheral Nerves• Motor end plates
• SENSORY• Cortex• Internal Capsule• Thalamus• Pons• Medulla• Spinal Cord• Roots• Plexuses/Cords• Peripheral nerves• Receptors
![Page 88: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/88.jpg)
Take Home Messages: Shared routes
MOTOR• Cerebral Cortex• Internal Capsule• Mid Brain (peduncles)• Pons • Medulla• Spinal Cord• Nerve Roots• Plexuses• Peripheral Nerves• Motor end plates
• SENSORY• Cortex• Internal Capsule• Thalamus• Pons• Medulla• Spinal Cord• Roots• Plexuses/Cords• Peripheral nerves• Receptors
![Page 89: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/89.jpg)
Take Home Messages: Shared routes
MOTOR• Cerebral Cortex• Internal Capsule• Mid Brain (peduncles)• Pons • Medulla• Spinal Cord• Nerve Roots• Plexuses• Peripheral Nerves• Motor end plates
• SENSORY• Cortex• Internal Capsule• Thalamus• Pons• Medulla• Spinal Cord• Roots• Plexuses/Cords• Peripheral nerves• Receptors
![Page 90: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/90.jpg)
Take Home Messages: Shared routes
MOTOR• Cerebral Cortex• Internal Capsule• Mid Brain (peduncles)• Pons • Medulla• Spinal Cord• Nerve Roots• Plexuses• Peripheral Nerves• Motor end plates
• SENSORY• Cortex• Internal Capsule• Thalamus• Pons• Medulla• Spinal Cord• Roots• Plexuses/Cords• Peripheral nerves• Receptors
![Page 91: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/91.jpg)
Take Home Messages: Different Directions
• MOTOR- Descending . SENSORY -Ascending
![Page 92: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/92.jpg)
Take Home Messages- Motor System
Motor System consists of 2 neurons (UMN &LMN)
• Pyramidal Tract (UMN) .• Motor Unit (LMN)
• Extrapyramidal Tracts
• Cerebellar Pathway
![Page 93: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/93.jpg)
Take Home Messages –Motor System
Only 1st Order neurons cross (UMN)
• Lesions before the crossing of pyramidal tract cause contra-lateral features
• Lesions after the crossing of pyramidal tract cause ipsi-lateral features
![Page 94: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/94.jpg)
Take Home Messages –Motor System
• Alteration in bulk, tone, power and reflexes help in pattern recognition and to differentiate between UMN and LMN lesions
Motor testing is objective
More accurate
![Page 95: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/95.jpg)
Take Home Messages –Motor System
• Alteration in bulk, tone, power and reflexes help in pattern recognition and to differentiate between UMN and LMN lesions
Motor testing is objective
More accurate
![Page 96: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/96.jpg)
Take Home Messages –Sensory System
Sensory System consists of
• 3 neurons (1st, 2nd and 3rd order neurons) and
• 2 Pathways- carrying different sensations
• Spinothalamic
• Dorsal Columns
Beyond Thalamus the pathways merge
![Page 97: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/97.jpg)
Take Home Messages –Sensory System
Sensory System consists of
• 3 neurons (1st, 2nd and 3rd order neurons)
• 2 Pathways- carrying different sensations
• Spinothalamic
• Dorsal Columns
Beyond Thalamus the pathways merge
![Page 98: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/98.jpg)
Take Home Messages –Sensory System
Sensory System consists of
• 3 neurons (1st, 2nd and 3rd order neurons)
• 2 Pathways- carrying different sensations
• Spinothalamic
• Dorsal Columns
Beyond Thalamus the pathways merge
![Page 99: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/99.jpg)
Take Home Messages –Sensory System
Sensory System consists of
• 3 neurons (1st, 2nd and 3rd order neurons)
• 2 Pathways- carrying different sensations
• Spinothalamic
• Dorsal Columns
Beyond Thalamus the pathways merge
![Page 100: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/100.jpg)
Take Home Messages –Sensory System
Only 2nd order neurons cross in both pathways
• Spinothalamic- at spinal level
• Dorsal Columns –at medulla
• Lesions before the crossing cause ipsi-lateral features
• Lesions after the crossing cause contra-lateral features
• Throughout the length of the spinal cord, both sensory pathways run on different sides of the cord
• Complete anesthesia is a rare finding
![Page 101: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/101.jpg)
Take Home Messages –Sensory System
Only 2nd order neurons cross in both pathways
• Spinothalamic- at spinal level
• Dorsal Columns –at medulla
• Lesions before the crossing cause ipsi-lateral features
• Lesions after the crossing cause contra-lateral features
• Throughout the length of the spinal cord, both sensory pathways run on different sides of the cord
• Complete anesthesia is a rare finding
![Page 102: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/102.jpg)
Take Home Messages –Sensory System
Only 2nd order neurons cross in both pathways
• Spinothalamic- at spinal level
• Dorsal Columns –at medulla
• Lesions before the crossing cause ipsi-lateral features
• Lesions after the crossing cause contra-lateral features
• Throughout the length of the spinal cord, both sensory pathways run on different sides of the cord
• Complete anesthesia is a rare finding
![Page 103: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/103.jpg)
Take Home Messages –Sensory System
Only 2nd order neurons cross in both pathways
• Spinothalamic- at spinal level
• Dorsal Columns –at medulla
• Lesions before the crossing cause ipsi-lateral features
• Lesions after the crossing cause contra-lateral features
• Throughout the length of the spinal cord, both sensory pathways run on different sides of the cord
• Complete anesthesia is a rare finding
![Page 104: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/104.jpg)
Take Home Messages –Sensory System
Only 2nd order neurons cross in both pathways
• Spinothalamic- at spinal level
• Dorsal Columns –at medulla
• Lesions before the crossing cause ipsi-lateral features
• Lesions after the crossing cause contra-lateral features
• Throughout the length of the spinal cord, both sensory pathways run on different sides of the cord
• Complete anesthesia is a rare finding
![Page 105: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/105.jpg)
Take Home Messages –Sensory System
• Clinical features help in pattern recognition and differentiate Dorsal Column from Spinothalamic lesions.
Sensory testing is subjective
Less accurate
![Page 106: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/106.jpg)
Take Home Messages –Sensory System
• Clinical features help in pattern recognition and differentiate Dorsal Column from Spinothalamic lesions.
Sensory testing is subjective
Less accurate
![Page 107: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/107.jpg)
Take Home Messages – Motor & Sensory • Gait is an important clue to localization
• Being part of the reflex arc, involvement of reflexes is seen in both
• Accompanying features (motor/sensory/ cranial nerve/ cerebellar/EPS/ autonomic) also help in localisation
• Temporal profile and other history give clue to the etiology
![Page 108: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/108.jpg)
Take Home Messages – Motor & Sensory • Gait is an important clue to localization
• Being part of the reflex arc, involvement of reflexes is seen in both
• Accompanying features (motor/sensory/ cranial nerve/ cerebellar/EPS/ autonomic) also help in localisation
• Temporal profile and other history give clue to the etiology
![Page 109: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/109.jpg)
Take Home Messages – Motor & Sensory • Gait is an important clue to localization
• Being part of the reflex arc, involvement of reflexes is seen in both
• Accompanying features (motor/sensory/ cranial nerve/ cerebellar/EPS/ autonomic) also help in localisation
• Temporal profile and other history give clue to the etiology
![Page 110: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/110.jpg)
Take Home Messages – Motor & Sensory • Gait is an important clue to localization
• Being part of the reflex arc, involvement of reflexes is seen in both
• Accompanying features (motor/sensory/ cranial nerve/ cerebellar/EPS/ autonomic) also help in localisation
• Temporal profile and other history give clue to the etiology
![Page 111: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/111.jpg)
Case1 : 25 year old soldier on leaveBrought by relatives
• Weakness of all 4 limbs X 5 days• Difficulty in breathing X 1 day
• Noticed weakness of left LL on waking up. A few hours later similar complaint started in the right LL. A day later same problem developed in the upper limbs too. There has been rapid worsening. For the past 2 days he is unable to get up from the bed. Since yesterday he has developed difficulty in breathing. No cough……
• No sensory complaints. No suggestion of cranial nerve involvement/ seizures/ bowel & bladder disturbances
• Diarrheal illness 2 weeks ago
![Page 112: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/112.jpg)
25 year old soldier on leave
• Clinically- T 99 degree F• Pulse 120/ min• BP 160/100• Tachypnea- shallow respiration• Chest expansion 1 cm
• Wasting• Decreased tone• Grade 0 to 2 power• Areflexia- all 4 limbs
![Page 113: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/113.jpg)
25 year old soldier
• Where &
• What is the lesion ?
![Page 114: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/114.jpg)
25 year old soldier
• Acute, Asymmetric, Areflexic, Quadriparesis(Polyradiculopathy)
• Post infective
Gullian Barre Syndrome
![Page 115: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/115.jpg)
25 year old soldier
• What are the urgencies?
![Page 116: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/116.jpg)
25 year old soldier
• Respiratory Neuromuscular Failure
• Dysautonomia
![Page 117: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/117.jpg)
Case 2: 30 year old lady
• Burning pain like a band on the right side of the chest X 2 days
• Few blisters over the same area- this morning
• What?
• Where?
![Page 118: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/118.jpg)
Case 3: 45 year old Hypertensive
• Weakness left side of body X 6 hours
• Sudden onset, while sitting at the table, progressed rapidly over 1 hour, no improvement
• Where is the lesion?
• What is the lesion?
![Page 119: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/119.jpg)
Case 3: 45 year old Hypertensive
What if-
• Was irregular with medication ?
• Had an argument with his wife ?
• Had intense headache preceding the event ?
• Had a seizure (focal with secondary generalization) on the way to the hospital ?
![Page 120: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/120.jpg)
Case 3: 45 year old Hypertensive
• BP 200/120 mm
• Pulse 56/ min regular
• Resp20/ min
• Altered sensorium
• Bulk & tone- equal
• Left sided hemiparesis; power grade I
• Exaggerated deep tendon jerks• Neck stiffness
![Page 121: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/121.jpg)
Diagnosis
• Right Sided Hemiparesis
• Intracerebral Hemorrhage
• Hypertensive Etiology
![Page 122: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/122.jpg)
Case 4: 18 year old girl
• Fever X 1 Month
• Backache X 1 month
• Numbness and weakness of both lower limbs X 7 Days
• Severe burning pain around the middle X 7 Days
• Inability to control urination X 2 Days
![Page 123: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/123.jpg)
Case 4: 18 year old girl
• Thin built, poorly nourished
• T 100 degree F
• P 110/ min
• BP, Resp- N
• Pallor +
• Cervical matted lymphadenopathy +
• Smell of urine+
![Page 124: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/124.jpg)
Case 4: 18 year old girl
Motor:
• Lower Limbs
• Bulk equal
• Tone increased in both lower limbs
• Power grade 0 to 1
• Reflexes – Brisk knee jerks and ankle jerks with ankle clonus
• Plantars extensors
• Upper limbs normal
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Case 4: 18 year old girl
• Sensory:
• All modalities of sensation diminished below the umbilical level
• Definite upper level
• Band of hyperaesthesia at the level
• Abdominal reflexes - absent
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Case 4: 18 year old girl
• Where ?
• What ?
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Case 2:55 year old diabetic
• Tingling & numbness both lower limbs X 2M
• Tingling & numbness both upper limbs X 1M
• Weakness in both lower limbs X 1 month
• What is the lesion?
• Where is the lesion?
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Case 2:55 year old diabetic
• Control has been poor
• Has been having indigestion
• He is a strict vegetarian
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Case 2:55 year old diabetic
• Vitals normal
• Pallor
• Hypovitaminosis
• Mild pitting edema
• Trophic ulcers on feet
![Page 130: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/130.jpg)
Case 2:55 year old diabeticSensory: Glove and Stocking distribution of sensory loss -Pain, Temp,
touch, proprioception and vibration (variable levels)
Motor system: LL• Bulk & Tone – equal on both sides• Power -grade IV in lower limbs• Ankle Jerks- absent• Knee Jerks –normalUL
Normal
![Page 131: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/131.jpg)
Case 2:55 year old diabetic
• What if she had additional weakness and stiffness in lower limbs with bladder complaints of frequency and incontinence?
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Case 2:55 year old diabetic
And-
• Bulk – equal on both sides
• Tone increased in thigh muscles
• Grade IV weakness in both lower limbs
• Ankle jerks absent
• Knee Jerks brisk with clonus
• Plantars extensors
• Bladder incontinence – empty bladder
![Page 133: Approach to a case of motor and sensory disorders](https://reader030.fdocuments.us/reader030/viewer/2022032421/55a74e691a28aba5638b46bf/html5/thumbnails/133.jpg)
Diagnosis
• Peripheral Neuropathy
• Myelopathy
• Diabetes and Nutritional etiology