Quiz 25 on Reflexes Theme and Discussion


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Quiz 25 on Reflexes Theme and Discussion preparation completed on 31-08-2009

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Quiz 25 on Reflexes Theme and Discussion

  1. 1. Reflex QuizTheme & Discussion <br />Dr. Aswini Kumar. MD<br />Professor of Medicine<br />Medical College Hospital<br />Thiruvananthapuram<br />
  2. 2. 1. Normal reflex pattern<br />.<br />Additional Points:<br />Patient Conscious<br />Higher Functions N<br />Cranial Nerves Normal<br />Tone Normal<br />No Motor Deficits<br />No Sensory Deficits<br />No Cerebellar signs<br />No Meningeal Signs<br />Conjval +<br />Corneal +<br /> Jaw -<br />Triceps ++<br />Triceps++<br />Biceps ++<br />Biceps ++<br />Abdominal<br /> + +<br /> + +<br />Supinator ++<br />Supinator ++<br />+ Cremasteric +<br />Knee +++<br />Knee +++<br />Ankle +<br />Ankle +<br />Plantar <br />Plantar<br />01<br />
  3. 3. Reflexes<br />Superficial and deep tendon reflexes play an important role in arriving at a neurological diagnosis and localization<br />Superficial reflexes are designated as present (+) or absent (-). They have perhaps more important in localization<br />Deep tendon reflexes are either <br />Absent (-) <br />present but sluggish (+), <br />present normally (++) <br />present and brisk (+++) <br />present in an exaggerated form (++++) <br />Exaggerated and with clonus (+++++)<br />
  4. 4. 2. Right HemiplegiaNeuronal Shock<br />.<br />Additional Points:<br />Patient Conscious<br />Motor Aphasia<br />UMN Facial [Right]<br />Hypotonia [Right]<br />Grade 0 power [Right]<br />No Sensory Deficits<br />No Cerebellar signs<br />No Meningeal Signs<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps ++<br />Triceps-<br />Biceps++<br />Biceps -<br />Abdominal<br /> - +<br />- +<br />Spinatore ++<br />Supinator -<br />- Cremasteric +<br />Knee +++<br />Knee -<br />Ankle +<br />Ankle -<br />Plantar <br />Plantar<br />02<br />
  5. 5. Hemiplegia<br />Hemiplegia is a condition in which upper limb and lower limb on one side of a patient&apos;s body is paralyzed<br />It is usually the result of a stroke, although other diseases affecting the hemispheres are also capable of producing it<br />Rarely it can follow processes affecting the brainstem (crossed hemiplegia) and spinal cord (without VII palsy)<br />It&apos;s a pyramidal tract lesion from the origin at the cerebral cortex down to 5th cervical segment of the spinal cord<br />During the initial few days there is loss of all neuronal functions – Neuronal shock state- important in prognosis<br />
  6. 6. 3. Left HemiplegiaPost shock <br />.<br />Additional Points:<br />Patient Conscious<br />Higher Functions N<br />Left UMN Facial<br />Clasp Knife [Left]<br />Grade 2 [Left]<br />No Sensory Deficits<br />No Cerebellar signs<br />No Meningeal Signs<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps +++<br />Triceps++<br />Biceps +++<br />Biceps ++<br />Abdominal<br /> + -<br /> + -<br />Spinatore +++<br />Supinator ++<br />+ Cremasteric -<br />Knee ++++<br />Knee +++<br />Ankle ++<br />Ankle +<br />Plantar <br />Plantar<br />03<br />
  7. 7. Causes of Hemiplegia<br />1-vascular:- stroke ((the most common cause)<br />2-infective:- encephalitis -meningitis - brain abscess<br />3-neoplastic:- glioma-meningioma<br />4-demylination:- DS disseminated sclerosis<br />5-traumatic:- cerebral lacerations<br />6-congenital:-cerebral palsy<br />7-hysterical:-absence of organic pyramidal lesion<br />8-Post-ictal :- Todd’s paralysis<br />9-Migraine :- Hemiplegic migraine<br />
  8. 8. 4. Old Right Hemiplegia<br />.<br />Additional Points:<br />Patient Conscious<br />UMN Facial [Right]<br />Tone [Right]<br />Contractures [Right]<br />Power Grade 3 [Right]<br />Patellar Clonus [Right]<br />Ankle Clonus [Right]<br />RHD MS Atrial Fib<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps ++<br />Triceps++++<br />Biceps ++<br />Biceps ++++<br />Abdominal<br /> - +<br />- +<br />Spinatore ++<br />Supinator +++<br />- Cremasteric +<br />Knee +++<br />Knee ++++<br />Ankle +<br />Ankle +++<br />Plantar <br />Plantar<br />04<br />
  9. 9. Causes of Embolic Stroke<br />Aorta:- Atheromatous Plaques (Artery to Artery Embolism)<br />Aortic Root:- Aortic Aneurysm with thrombus, Aortitis<br />Aortic Valve:- Endocarditis, Prosthetic Valve Thrombus<br />Left Ventricle:- Mural Thrombus from Post MI dyskinesia<br />Mitral Valve:- Stenosis, Endocardittis, MVR with thrombus<br />Left Atrium:- Thrombus in MS or AF or both , Myxoma, <br />Pulmonary Veins:- Pulmonary Venous Thrombosis,<br />Lung Parenchyma,: Lung Abscess, Bronchiectasis, Tumors<br />Emboli passing through lungs:- Fat , Air, Amniotic Fluid<br />Paradoxical Embolism:- Fallot’sEisenmenger Syndrome<br />
  10. 10. 5. Pseudo-bulbarPalsy<br />.<br />Conjval +<br />Corneal +<br />Jaw +++<br />Triceps +++<br />Triceps+++<br />Biceps +++<br />Biceps +++<br />Abdominal<br />- -<br /> - -<br />Spinatore +++<br />Supinator +++<br />- Cremasteric -<br />Knee ++++<br />Knee ++++<br />Ankle ++<br />Ankle++<br />Plantar<br />Plantar<br />05<br />Additional Points:<br />Patient Conscious<br />Emotional Incontinence<br />Exaggerated Gag reflex<br />Hypertonia B/L<br />Variable weakness<br />Primitive Reflexes +<br />No Cerebellar signs<br />No Meningeal Signs<br />
  11. 11. Pseudo-bulbar palsy<br />Pseudo-bulbar palsy is bilateral impairment of the function of the lower cranial nerves 9, 10, 11 and 12 which control the muscles of eating, swallowing and talking <br />It is the result of an upper motor neuron lesion to the cortico-bulbar pathways in the pyramidal tract<br />Causes<br />Vascular causes: Bilateral hemisphere infarction<br />Degenerative disorders: motor neuron disease<br />Inflammatory disorders: Multiple sclerosis<br />Malignancy: High brain stem tumors<br />Brain trauma<br />
  12. 12. 6. Parkinson’s Disease<br />.<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps ++<br />Triceps++<br />Biceps ++<br />Biceps ++<br />Abdominal<br /> + +<br /> + +<br />Spinatore ++<br />Supinator ++<br />+ Cremasteric +<br />Knee +++<br />Knee +++<br />Ankle +<br />Ankle +<br />Plantar <br />Plantar<br />06<br />Additional Points:<br />Patient Conscious<br />Expressionless face<br />Cranial Nerves Normal<br />Cog wheel rigidity<br />Generalized Hypokinesia<br />Glabellar Tap<br />Resting tremor<br />No Meningeal Signs<br />
  13. 13. Parkinson&apos;s disease<br />Parkinson&apos;s diseaseis a degenerative disorder of CNS that often impairs the sufferer&apos;s motor skills and speech<br />Parkinson&apos;s disease belongs to a group of conditions called movement disorders <br />It is characterized by muscle rigidity, tremor, slowing of physical movements, bradykinesia or akinesia<br /> The primary symptoms are the results of decreased stimulation of the motor cortex by the basal ganglia<br />It is caused by the insufficient formation and action of dopamine, which is produced by dopaminergic neurons<br />
  14. 14. 7. Lateral MedullarySyndrome [Left]<br />.<br />Conjval -<br />Corneal +<br />Jaw -<br />Triceps ++<br />Triceps++<br />Biceps ++<br />Biceps ++<br />Abdominal<br /> + +<br /> + +<br />Spinatore ++<br />Supinator ++<br />+ Cremasteric +<br />Knee +++<br />Knee +++<br />Ankle +<br />Ankle +<br />Plantar <br />Plantar<br />07<br />Additional Points:<br />Patient Conscious<br />Vertigo and ataxia<br />Vomiting and hiccups<br />Horner’s Syndrome[Left]<br />IX & X palsy [Left]<br />Pain & Temp lost Lt face<br />Pain & Temp lost Rt body<br />Cerebellar signs [Left]<br />
  15. 15. Lateral Medullary Syndrome<br />It is also called Wallenberg&apos;s syndrome and posterior inferior cerebellar artery syndrome) <br />It is caused by an infarct caused by interrupted blood supply to lateral parts of the medulla<br />Symptoms and findings are ataxia, facial pain, vertigo nystagmus, Horner‘s syndrome, diplopia and dysphagia<br />Ipsilateral pain and temp loss over face and contralateral pain and temp over body<br />The cause of this syndrome is usually the occlusion of the posterior inferior cerebellar artery (PICA) at its origin.<br />
  16. 16. 8. QuadriplegiaC3 Level<br />.<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps +++<br />Triceps+++<br />Biceps +++<br />Biceps +++<br />Abdominal<br />- -<br /> - -<br />Supinator ++<br />Supinator ++<br />- Cremasteric -<br />Knee ++++<br />Knee ++++<br />Ankle +++<br />Ankle +++<br />Plantar <br />Plantar <br />08<br />Additional Points:<br />Patient Conscious<br />Respiratory distress<br />Weakness all 4 limbs<br />HypertoniaBilateral<br />Distal &gt; proximal weakness<br />Total sensory loss below C3<br />Pectoral&Trapezius Jerk+++<br />UMN Bladder<br />
  17. 17. Quadriplegia<br />Also known as tetraplegia, it is paralysis caused by illness or injury to spinal cord resulting in weakness of all 4 limbs<br />A loss or impairment in controlling bowel and bladder, sexual function, digestion, breathing, autonomic functions<br />Sensation is usually involved in affected areas, manifesting as numbness, reduced sensation, or neuropathic pain<br />Complications: Pressure sores, osteoporosis and fractures, frozen joints, spasticity, respiratory complications and infections, autonomic dysreflexia, deep vein thrombosis<br />
  18. 18. 9. Right C5Radiculomyelopathy<br />.<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps +++<br />Triceps+++<br />Biceps ++<br />Biceps -<br />Abdominal<br />- -<br /> - -<br />Supinator ++<br />Supinator Inverted<br />- Cremasteric -<br />Knee ++++<br />Knee ++++<br />Ankle +++<br />Ankle +++<br />Plantar <br />Plantar <br />09<br />Additional Points:<br />Patient Conscious<br />Higher Functions N<br />Cranial Nerves Normal<br />Hypertonia Lower limbs<br />Shoulder abduction <br />Elbow flexion <br />Sensory loss along C5 C6 <br />UMN Bladder<br />
  19. 19. Cervical Spondylosis<br />It is degenerative arthritis of the joints between the centra of spinal vertebrae; the interfacetal joints are not involved<br />When the space between two adjacent vertebrae narrows, compression of a nerve root result in radiculopathy<br />Sensory and motor disturbances, such as severe pain in the neck, shoulder, arm, back, and/or leg, & muscle weakness <br />Less commonly, direct pressure on the cervical spinal cord may result in clinical features of quadriparesis (myelopathy)<br />Here there is global weakness, gait dysfunction, loss of balance, and loss of bowel and/or bladder control<br />
  20. 20. 10.SyringomyeliaC-8,T-1 Level<br />.<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps ++<br />Triceps++<br />Biceps ++<br />Biceps ++<br />Abdominal<br /> - -<br /> - -<br />Supinator ++<br />Supinator ++<br />- Cremasteric -<br />Knee ++++<br />Knee ++++<br />Ankle +++<br />Ankle +++<br />Plantar <br />Plantar<br />10<br />Additional Points:<br />Patient Conscious<br />HMF and Cranial Normal<br />Hypotoniadistally both ULs<br />Small muscle wasting ULs<br />Handgrip weakness B/L<br />Motor weakness both LL<br />Suspended sensory loss C8T1<br />Sensory Dissociation<br />
  21. 21. Syringomyelia<br />A cyst or cavity, called a syrinx forms within the spinal cord, expand and elongate over time, destroying the cord<br />This damage may result in pain, weakness, and stiffness in the back, shoulders, and extremities<br />The disorder generally leads to a cape-like loss of pain and temperature sensation along the back and arms<br />Some patients experience paralysis or paresis of the lower limbs temporarily or permanently<br />The symptoms typically vary depending on the extent and, the location of the syrinx within the spinal cord<br />
  22. 22. 11. ParaplegiaT-10 Level <br />.<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps ++<br />Triceps++<br />Biceps ++<br />Biceps ++<br />Abdominal<br /> + +<br /> - -<br />Supinator ++<br />Supinator ++<br />- Cremasteric -<br />Knee ++++<br />Knee ++++<br />Ankle +++<br />Ankle +++<br />Plantar <br />Plantar<br />11<br />Additional Points:<br />Patient Conscious<br />Higher Functions N<br />Cranial Nerves Normal<br />Hypertonia both LLs<br />Grade 0 both LLs<br />Beevor’s sign +<br />Sensory level at Umbilicus<br />UMN Bladder <br />
  23. 23. Acute Transverse Myelitis<br />Neurological disorder caused by an inflammatory process of the spinal cord, which can result in axonal demyelination<br />This demyelination arises idiopathically following infection, vaccination or multiple sclerosis<br />Symptoms include weakness and numbness of the limbs as well as motor, sensory, and sphincter deficits<br />A major differentiation or distinction to be made is a compression of the spinal cord in the spinal canal<br />Treatment is usually symptomatic only, corticosteroids being used with limited success<br />
  24. 24. 18.Right T11 Brown- Sequard<br />.<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps ++<br />Triceps++<br />Biceps ++<br />Biceps ++<br />Abdominal<br /> + +<br /> - +<br />Supinator ++<br />Supinator ++<br />- Cremasteric +<br />Knee +++<br />Knee -<br />Ankle +<br />Ankle-<br /> Plantar <br />Plantar<br />12<br />Additional Points:<br />Patient Conscious<br />Higher Functions N<br />Right lower limb grade 2 <br />Tone reduced right LL<br />Pain and temp lost left LL<br />Vibration and joint position lost right LL<br />Right T11 hyperaesthesia<br />
  25. 25. Brown- Sequard Syndrome<br />Loss of sensation and motor function (paralysis and ataxia) that is caused by the lateral hemi-section of the spinal cord<br />Features of a motor loss on the same side of spinal injury and loss of pain and temperature sensation on opposite side<br />Caused by a spinal cord tumor or trauma (such as a gunshot wound or puncture wound to the neck or back),<br />Other causes: ischemia (obstruction of a blood vessel), or infectious or inflammatory diseases such as tuberculosis<br />The syndrome was first described in 1850 by the British / Mauritian neurologist Charles-Édouard Brown Séquard<br />
  26. 26. 13. ParaplegiaL-1 Level - Shock<br />.<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps ++<br />Triceps++<br />Biceps ++<br />Biceps ++<br />Abdominal<br /> + +<br /> + +<br />Supinator ++<br />Supinator ++<br />-Cremasteric -<br />Knee -<br />Knee -<br />Ankle -<br />Ankle -<br />Plantar <br />Plantar<br />13<br />Additional Points:<br />Patient Conscious<br />Higher Functions N<br />Cranial Nerves Normal<br />Hypotonia LLs<br />Power grade 0 both LL<br />Total sensory loss below L1<br />No Cerebellar signs<br />UMN Bladder<br />
  27. 27. Flaccid Paraplegia<br />The area of the spinal canal which is affected in paraplegia is either the thoracic, lumbar, or sacral regions. <br />The causes range from trauma (acute spinal cord injury: transsection or compression of the cord, vertebral fractures<br />The most common cause of paraplegis (and all spinal cord injuries) is motor vehicle accidents<br />Other causes include violence, sports, cancer involving the epidural or dural space, vertebral fractures and myelitis<br />Sometimes paralysis of both legs can result from injury to the brain, or tumors like a para-sagitalmeningioma<br />
  28. 28. 14. CaudaEquinaSyndrome<br />.<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps ++<br />Triceps++<br />Biceps ++<br />Biceps ++<br />Abdominal<br /> + +<br /> + +<br />Supinator++<br />Supinator ++<br />+ Cremasteric +<br />Knee+<br />Knee -<br />Ankle -<br />Ankle -<br />Plantar -<br />Plantar-<br />14<br />Additional Points:<br />Patient Conscious<br />Higher Functions N<br />Asymmetric Wasting of LL<br />Hypotonia both LL<br />Weakness below L3<br />Patchy sensory loss below L3<br />No Cerebellar signs<br />Late Bladder involvement<br />
  29. 29. Caudaequina syndrome<br />is a condition in which there is acute loss of function of the nerve roots of the spinal canal below the termination conus<br />Caudaequina contains the nerve roots from L1-5 and S1-5. The nerve roots from L4-S4 join in the sacral plexus<br />Signs: weakness of the muscles innervated by the compressed roots, often an asymetrical paraplegia<br />Sphincter weaknesses causing urinary retention decreased anal tone; sexual dysfunction & saddle anesthesia<br />Bilateral leg pain and weakness; and bilateral absence of ankle reflexes. Pain and weakness may, however, be absent<br />
  30. 30. 15.Amyotrophic Lateral Sclerosis<br />.<br />Conjval +<br />Corneal +<br />Jaw ++<br />Triceps +++<br />Triceps+++<br />Biceps +++<br />Biceps +++<br />Abdominal<br /> + +<br /> + +<br />Spinator +++<br />Supinator +++<br />+ Cremasteric +<br />Knee ++++<br />Knee ++++<br />Ankle +++<br />Ankle +++<br />Plantar <br />Plantar <br />15<br />Additional Points:<br />Patient Conscious<br />Higher Functions N<br />Wasting hands & calf <br />Tone Increased B/L<br />Variable Weakness <br />No Sensory Deficits<br />Fasciculations present<br />No bladder involvement<br />
  31. 31. Amyotrophic lateral sclerosis<br />Amyotrophic lateral sclerosis is a form of motor neuron disease. ALS, sometimes is called Maladie de Charcot<br />It is a progressive, fatal, neurodegenerative disease caused by the degeneration of motor neurons<br />The disorder causes muscle weakness and atrophy throughout the body as both the UMN & LMN degenerate<br />The muscles gradually weaken, develop fasciculations because of denervation, and eventually atrophy <br />Cognitive function is generally spared except when ALS is associated with frontotemporal dementia<br />
  32. 32. 16. GullianBarreSyndrome <br />.<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps -<br />Triceps-<br />Biceps -<br />Biceps -<br />Abdominal<br /> - -<br /> - -<br />Supinator-<br />Supinator -<br />-Cremasteric -<br />Knee -<br />Knee -<br />Ankle-<br />Ankle -<br />Plantar --<br />Plantar --<br />16<br />Additional Points:<br />Patient Conscious<br />Higher Functions N<br />Acute Ascending paralysis<br />Markedly reduced tone<br />No Sensory Deficits<br />Single Breath Count &lt; 20<br />Bilateral LMN Facial<br />No Bladder involvement<br />
  33. 33. GullianBarre Syndrome <br />An acute inflammatory demyelinating polyneuropathy, also an autoimmune disorder affecting peripheral nervous system<br />It is frequently severe and usually exhibits as an ascending paralysis in the legs that spreads to the upper limbs <br />The face may be affected in a bilateral upper motor neuron paralysis along with complete loss of deep tendon reflexes.<br />With plasmapheresis or IVIg and supportive care, the majority of patients will regain full functional capacity<br />However, death may occur if severe pulmonary complications arise and dysautonomia are present<br />
  34. 34. 16.Peripheral Neuropathy <br />.<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps ++<br />Triceps++<br />Biceps ++<br />Biceps ++<br />Abdominal<br /> + +<br /> + +<br />Supinator -<br />Supinator -<br />+ Cremasteric +<br />Knee+<br />Knee+<br />Ankle -<br />Ankle -<br />Plantar /<br />Plantar/<br />17<br />Additional Points:<br />Patient Conscious<br />Higher Functions N<br />Cranial Nerves Normal<br />Tone Normal<br />Distal weakness UL & LL<br />Glove & Stocking sensory<br />No Cerebellar signs<br />No Meningeal Signs<br />
  35. 35. Peripheral neuropathy <br />It is the term for damage to nerves of the peripheral nervous system, either by diseases of the nerve or <br />The causes are broadly grouped as follows:<br />Genetic diseases: Charcot-Marie-Tooth syndrome<br />Metabolic/Endocrine: diabetes, porphyria, amyloidosis<br />Toxic causes: alcoholism, phenytoin, isoniazid, metals<br />Inflammatory diseases: GBS, SLE, Leprosy,  Sjögren&apos;s<br />Vitamin deficiency states: Vitamin B12, Vitamin B1<br />Others: Malignant disease, HIV, radiation, chemotherapy<br />
  36. 36. 18. MyastheniaGravis <br />.<br />Additional Points:<br />Patient Conscious<br />Higher Functions N<br />Bilateral Partial Ptosis<br />Tone Normal<br />Fatigability<br />No Sensory Deficits<br />No Cerebellar signs<br />No Meningeal Signs<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps ++<br />Triceps++<br />Biceps ++<br />Biceps ++<br />Abdominal<br /> + +<br /> + +<br />Supinator++<br />Supinator ++<br />+ Cremasteric +<br />Knee +++<br />Knee +++<br />Ankle +<br />Ankle +<br />Plantar <br />Plantar<br />18<br />
  37. 37. Myasthenia gravis <br />It is a neuromuscular disease leading to fluctuating muscle weakness and fatiguability<br />It is anautoimmune disorder, in which weakness is caused by circulating antibodies<br />These block acetylcholine receptors at the post-synaptic neuromuscular junction <br />Thus inhibiting the stimulative effect of the neurotransmitter acetylcholine. <br />Myasthenia is treated with cholinesterase inhibitors or immunosuppressants and in selected cases, thymectomy<br />
  38. 38. 19. Friedrichsataxia <br />.<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps +<br />Triceps+<br />Biceps +<br />Biceps +<br />Abdominal<br /> + +<br /> + +<br />Spinatore -<br />Supinator -<br />+ Cremasteric +<br />Knee ++<br />Knee ++<br />Ankle -<br />Ankle -<br />Plantar<br />Plantar<br />19<br />Additional Points:<br />Symptomatic before 20 years <br />Higher Functions N<br />Pescavus, kyphoscoliosis<br />H/o ataxia in family<br />Power grade 4 all limbs<br />Ataxia <br />Vibration, joint position impaired distally<br />
  39. 39. Friedrichs ataxia<br />An inherited disease that causes progressive damage to the nervous system<br />It results in symptoms ranging from gait disturbance and speech problems to heart disease<br />Ataxia results from degeneration of nerve tissue in spinal cord, in particular sensory neurons connection with cerebellum<br />The condition is named after the German physician NicholausFriedreich, who first described it in the 1860s<br />is caused by a mutation in gene FXN (formerly known as X25) that codes for frataxin, located on chromosome 9<br />
  40. 40. .<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps ++<br />Triceps++<br />Biceps ++<br />Biceps ++<br />Abdominal<br /> + +<br /> + +<br />Spinatore -<br />Supinator -<br />+ Cremasteric +<br />Knee +++<br />Knee +++<br />Ankle -<br />Ankle -<br />Plantar<br />Plantar<br />20<br />Additional Points:<br />Patient Conscious<br />Higher Functions irritable<br />Optic atrophy<br />Grade 4 power all 4 limbs<br />Loss of vibration and joint position sense<br />Megaloblastic anemia in peripheral smear<br />20. Subacute combined degeneration of spinal cord <br />
  41. 41. Subacute combined degeneration of spinal cord<br />Degeneration of the posterior and lateral columns of the spinal cord as a result of vitamin B12 deficiency<br />Also known as Lichtheim&apos;s disease, it is usually associated with pernicious anemia.<br />Patients present with weakness of legs , arms, trunk, tingling and numbness that progressively worsens<br />Bilateral spastic paresis may develop and pressure, vibration and touch sense are diminished<br />Therapy with vitamin B12 results in partial to full recovery, depending on the duration and extent of neuro-degeneration<br />
  42. 42. 21.Facioscapulo humeral dystrophy <br />.<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps -<br />Triceps-<br />Biceps -<br />Biceps -<br />Abdominal<br /> + +<br /> + +<br />Spinatore +<br />Supinator+<br />+ Cremasteric +<br />Knee +<br />Knee +<br />Ankle +<br />Ankle +<br />Plantar <br />Plantar<br />21<br />Additional Points:<br />Facial weakness, shoulder girdle weakness,winging of scapula,deltoid preserved, pseudohypertrophy present<br />Tone reduced<br />Wrist extensors grade 2, flexors grade 3<br />No Sensory Deficits<br />No Cerebellar signs<br />No Meningeal Signs<br />
  43. 43. Facioscapulo humeral dystrophy <br />Also known as Landouzy-Dejerine Disease, it is an autosomal dominant form of muscular dystrophy<br />It initially affects the skeletal muscles of the face (facio), scapula(scapulo) and upper arms (humeral)<br />Symptoms may develop in early childhood and are usually noticeable in the teenage years with 95% by age 20 years<br />A progressive skeletal muscle weakness usually develops in areas of the body; often the weakness is asymmetrical<br />Non-muscular symptoms associated with FSHD include subclinical sensorineural hearing loss & retinal telangectasias<br />
  44. 44. 22. Cerebral palsy <br />.<br />Additional Points:<br />H/O hypoxia at the time of birth<br />Non progressive weakness of LL more than UL<br />Tone Increased<br />Scissoring gait<br />No Sensory Deficits<br />Conjval +<br />Corneal +<br />Jaw+<br />Triceps +++<br />Triceps+++<br />Biceps +++<br />Biceps +++<br />Abdominal<br /> - -<br /> - -<br />Spinatore+ ++<br />Supinator+ ++<br />- Cremasteric -<br />Knee ++++<br />Knee ++++<br />Ankle ++<br />Ankle ++<br />Plantar<br />Plantar<br />22<br />
  45. 45. Cerebral palsy<br />Non-progressive motor,non-contagious conditions that cause physical disability in human development<br />Caused by damage to the motor control centers of the developing brain and can occur during pregnancy (75%)<br />Can also occur during childbirth (5%) or after birth (about 15 %) up to about age three<br />Accompanied by disturbances of sensation, perception cognition, communication, and behaviour, & by epilepsy<br />There is no known cure for CP. Medical intervention is limited to the treatment and prevention of complications<br />
  46. 46. 23. CIDP <br />.<br />Additional Points:<br />Chronic history<br />Relapsing remitting<br />Patient Conscious<br />Higher Functions N<br />Proximal and distal weakness<br />Tone reduced<br />Sensory loss distally<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps -<br />Triceps-<br />Biceps -<br />Biceps -<br />Abdominal<br /> - -<br /> - -<br />Spinatore -<br />Supinator -<br />-Cremasteric -<br />Knee -<br />Knee -<br />Ankle-<br />Ankle -<br />Plantar <br />Plantar<br />23<br />
  47. 47. Chronic inflammatory demyelinating polyneuropathy<br />It is an acquired immune-mediated inflammatory disorder of the peripheral nervous system but may be CNS involvement<br />Closely related to Guillain-Barré syndrome and it is considered the chronic counterpart of that acute disease<br />The pathologic hallmark is loss of the myelin sheath (the fatty covering that protects nerve fibers) of peripheral nerves<br />Numbing, tingling, pain, progressive muscle weakness, loss of deep tendon reflexes, fatigue, and abnormal sensations<br />Though conventional electrophysiological diagnostic criteria are not met, patient may still respond to immunomodulation<br />
  48. 48. 24. Anterior spinal artery occlusion <br />.<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps ++<br />Triceps++<br />Biceps ++<br />Biceps ++<br />Abdominal<br /> + +<br /> + +<br />Supinator ++<br />Supinator ++<br />-Cremasteric -<br />Knee -<br />Knee -<br />Ankle -<br />Ankle -<br />Plantar <br />Plantar<br />24<br />Additional Points:<br />Hyper acute onset<br />Patient Conscious<br />Higher Functions N<br />Hypotonia both LL<br />Grade 0 power LL<br />Pain and temperature lost both LL<br />Vibration and joint position preserved<br />
  49. 49. Anterior spinal artery occlusion<br />Ischemia or infarction of the spinal cord in the distribution of the anterior spinal artery, which supplies the ventral 2/3<br />Causes: Atherosclerosis of the aorta; dissection of Aortic aneurysm; dissection of the anterior spinal artery or Arteritis<br />Clinical features include weakness and loss of pain and temperature sensation below the level of injury to cord <br />It is an abrupt onset flaccid paralysis of the legs with relative sparing of position and vibratory sensation<br />It is also known as &quot;Beck&apos;s syndrome“, Sphincter control and sexual disorders are usually present<br />
  50. 50. 25. Myotonic dystrophy <br />.<br />Conjval +<br />Corneal +<br />Jaw -<br />Triceps+-<br />Triceps+<br />Biceps +<br />Biceps +<br />Abdominal<br /> + +<br /> + +<br />Supinator+<br />Supinator+<br />+ Cremasteric +<br />Knee +<br />Knee +<br />Ankle +<br />Ankle +<br />Plantar <br />Plantar<br />25<br />Additional Points:<br />Patient Conscious<br />Frontal balding<br />Bilateral Partial Ptosis<br />Hatchet facies<br />Testicular atrophy<br />Grade 4 power proximally and grade 2 distally<br />Myotonia <br />No Sensory Deficits<br />
  51. 51. Myotonic dystrophy <br />Dystrophiamyotonica, is a chronic, slowly progressing, highly variable inherited multi-systemic disease<br />It is characterized by wasting of the muscles (muscular dystrophy), and myotonia (difficulty relaxing a muscle)<br />Posterior subcapsular iridescent cataracts (opacity of the lens of the eyes), conduction defects & endocrine changes<br />DM1 also known as Steinert&apos;s disease is a congenital form; DM2 also as PROMM or proximal myotonicmyopathy<br />Most notably, the disease shows at an earlier age in successive generations, a phenomenon termed anticipation<br />
  52. 52. Thank You<br />