This document provides an overview of peripheral neuropathy (PN), including:
- PN most commonly presents as a length-dependent, symmetric sensorimotor polyneuropathy affecting the distal portions of limbs more than proximal.
- The clinical exam evaluates superficial sensation, deep sensation, motor function, and autonomic involvement. Sensory testing assesses patterns, distributions, and cortical sensation when possible.
- Common causes of PN include diabetes, paraproteinemias, alcoholism, renal failure, vitamin deficiencies, and some infectious diseases. A thorough history helps determine the temporal pattern and potential etiologies.
This ppt describes various movement disorders found commonly in elderly persons. It also describes hyper and hypokinetic disorder categorization with cause and pathophysiology of movement disorders.
This ppt describes various movement disorders found commonly in elderly persons. It also describes hyper and hypokinetic disorder categorization with cause and pathophysiology of movement disorders.
Detailed description of clinical examination of higher mental functions like conscoiusness, cognition, memory, pereception,etc. in neurological conditions.
Amyotrophic lateral sclerosis (ALS), AKA "Lou Gehrig's Disease," is a progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord. Motor neurons reach from the brain to the spinal cord and from the spinal cord to the muscles throughout the body. The progressive degeneration of the motor neurons in ALS eventually leads to their death. When the motor neurons die, the ability of the brain to initiate and control muscle movement is lost. With voluntary muscle action progressively affected, patients in the later stages of the disease may become totally paralyzed.
Detailed description of clinical examination of higher mental functions like conscoiusness, cognition, memory, pereception,etc. in neurological conditions.
Amyotrophic lateral sclerosis (ALS), AKA "Lou Gehrig's Disease," is a progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord. Motor neurons reach from the brain to the spinal cord and from the spinal cord to the muscles throughout the body. The progressive degeneration of the motor neurons in ALS eventually leads to their death. When the motor neurons die, the ability of the brain to initiate and control muscle movement is lost. With voluntary muscle action progressively affected, patients in the later stages of the disease may become totally paralyzed.
SYBPO - Orthotics.This presentation consists of all the pathological reasons affecting the lower extremity causing various deformities. it consists of Cerebral Palsy, polio, CDH etc.
Diabetic Peripheral Neuropathy and Vitamin B12 IssueUsama Ragab
Diabetic Peripheral Neuropathy and Vitamin B12 Issue
By Dr. Usama Ragab Youssif
Diabetic neuropathies are the most prevalent chronic complications of diabetes
Central and Peripheral Precocious PubertyUsama Ragab
Precocious Puberty
By Dr. Usama Ragab Youssif
Precocious puberty (PP) is defined as the development of pubertal changes (2ry sexual characters), at an age younger than the accepted lower limits for age of onset of puberty.
Algorithms for Diabetes Management for StudentsUsama Ragab
Algorithms for Diabetes Management for Students
By Usama Ragab Youssif
Lecturer of Medicine - Zagazig University
Agenda
Type 2 Diabetes 101
Incretin based therapy
Algorithms of management
Email: usamaragab@medicine.zu.edu.eg, usama.ragab.zu@gmail.com
SlideShare: https://www.slideshare.net/dr4spring/
Facebook: https://www.facebook.com/doc.usama
Facebook Clinic: https://www.facebook.com/usamaclinic
Mobile: 00201000035863
Classification & Diagnosis of Diabetes.pptx
By Dr. Usama Ragab Youssif
Lecturer of Internal Medicine Zagazig University
Email: usamaragab@medicine.zu.edu.eg, usama.ragab.zu@gmail.com
SlideShare: https://www.slideshare.net/dr4spring/
Facebook: https://www.facebook.com/doc.usama
Facebook Clinic: https://www.facebook.com/usamaclinic
Mobile: 00201000035863
Renal System - History Taking
By Dr. Usama Ragab Youssif
Lecturer of Medicine, Zagazig University
Email: usamaragab@medicine.zu.edu.eg, usama.ragab.zu@gmail.com
SlideShare: https://www.slideshare.net/dr4spring/
Facebook: https://www.facebook.com/doc.usama
Facebook Clinic: https://www.facebook.com/usamaclinic
Mobile: 00201000035863
Clinical Endocrinology Round
By Dr. Usama Ragab Youssif
Lecturer of Medicine
Zagazig University
Acromegaly
Cushing
Diabetes
Thyroid
Addison
Techniques and clinical insights
Functional Bowel Disorders
By Dr. Usama Ragab
Esophageal Disorders
Gastroduodenal Disorders
Bowel disorders
Centrally Mediated Disorders of GI Pain
Gallbladder and Sphincter of Oddi Disorders
Anorectal disorders
Childhood Functional GI Disorders: Neonate/Toddler
Childhood Functional GI Disorders: Child/Adolescent
Heat, Cold and High Altitude Related illnessUsama Ragab
Heat, Cold and High Altitude Related illness
By Dr Usama Ragab
Lecturer of Medicine
Topics are heat and cold related illness and high altitude medical disorders
Imeglimin, What is new?
By Dr. Usama Ragab Youssif
Lecturer of Medicine - Zagazig University
Agenda
Mitochondrial function and dysfunction
Mitochondrial (dys)function in diabetes
Diabetes core defects and Imeglimin
Imeglimin drug development and approval
Imeglimin and Heart
Diabetes and Gut interplay
By Dr. Usama Ragab Youssif
In Gastro Canal Association Annual Conference
Agenda
Diabetes as the main player
Gut as the main player
Diabetes and gut in a separate game
Gut as game changer
Tips and tricks: diabetes drugs
Guidelines in Obesity management
By Dr. Usama Ragab Youssif
Obesity-related counseling should be offered to those with BMI ≥25 kg/m2
A 3% to 5% weight loss can result in meaningful reductions in triglycerides, blood glucose, hemoglobin A1c, and the risk of developing type 2 diabetes
Set an initial weight loss goal of 5% to 10% of current body weight over 6 mo
After 6 mo, focus on weight maintenance before attempting further weight loss
Participating in a weight loss program long-term can help improve weight maintenance
Intensification Options after basal Insulin RevisitedUsama Ragab
Intensification Options revisited
By Dr. Usama Ragab Youssif
Add an OAD
Add a short-acting insulin at mealtime
Switch to premixed insulins
Novel insulin combinations
Basal insulin/GLP-1 RA combinations
Insulin Lispro Revisited
By Dr. Usama Ragab Youssif
The discovery of insulin was one of the most dramatic and important milestones in medicine - a Nobel Prize-winning moment in science.
Thyroid and Pregnancy, Review of PhysiologyUsama Ragab
Thyroid and Pregnancy
Facts and Messages
A series of changes in thyroid hormone economy take place in normal pregnancy.
As a result of these changes, thyroid hormone levels in pregnancy differ from those in the non-pregnant state.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
5. Peripheral neurology
• Root: Radiculopathy
• Multiple roots: Polyradiculopathy
• Plexus: Plexopathy
• Individual peripheral nerves:
Mononeuropathy
• Multiple, multifocal: mononeuritis
multiplex
Affection
of any
part of
the PNS
6.
7. Definition of neuropathy
• Generalized term including disorders of any cause affecting PNS
• May involve sensory nerves, motor nerves, autonomic or any combo
• May affect one nerve (mononeuropathy), several nerves together
(polyneuropathy) or several nerves not contiguous (Mononeuropathy
multiplex)
• Further classified into those that primarily affect the cell body (e.g.,
neuronopathy or ganglionopathy), myelin (myelinopathy), and the axon
(axonopathy)
10. Mononeuropathy
• Focal involvement of a single nerve and implies
a local process:
Direct trauma
compression or entrapment
vascular lesions
neoplastic compression or infiltration
12. Polyneuropathy
• Characterized by symmetrical, distal motor and
sensory deficits that have a graded increase in
severity distally and by distal attenuation of
reflexes
• Rarely predominantly proximal: (e.g., acute
intermittent porphyria).
• The sensory deficits generally follow a length-
dependent stocking-glove pattern
13. Most common causes
Disease Prevalence
Diabetes 11 – 41% (depends on duration, type &
control)
Paraproteinaemia 9 – 10%
Alcohol misuse 7%
CKD 4%
Vitamin B-12 deficiency 3.6%
HIV infection 16% (depending on the population studied,
usually much lower)
Chronic idiopathic axonal neuropathy 10 – 40% of different hospital series
BMJ 2010:341:c6100
14. Importance of history
• The temporal course of a neuropathy varies, based on the etiology:
With trauma or ischemic infarction, the onset will be acute, with
the most severe symptoms at onset.
Inflammatory and some metabolic neuropathies have a subacute
course extending over days to weeks.
A chronic course over weeks to months is the hallmark of most
toxic and metabolic neuropathies.
15. Importance of history (cont.)
• A chronic, slowly progressive neuropathy over many years occurs
with most hereditary neuropathies or with chronic inflammatory
demyelinating polyradiculoneuropathy (CIDP).
• Neuropathies with a relapsing and remitting course include CIDP,
acute porphyria, Refsum's disease, hereditary neuropathy with
liability to pressure palsies (HNPP), familial brachial plexus
neuropathy, and repeated episodes of toxin exposure.
16. Importance of history (cont.)
• Ischemic neuropathies often have pain as a prominent feature.
• Small-fiber neuropathies often present with burning pain, lightning-
like or lancinating pain, aching, or uncomfortable paresthesias
(dysesthesias).
• Careful past medical history, looking for systemic diseases that can be
associated with neuropathy, such as diabetes or hypothyroidism
17. The clinical response to sensory nerve injury
Loss of function
-ve symptoms
Disordered Function
+ve symptoms
Sensory “Large Fiber” ↓ Vibration
↓ Proprioception
Hyporeflexia
Sensory ataxia
Paresthesias
Sensory “Small Fiber” ↓ Pain
↓ Temperature
Dysesthesias
Allodynia
18. The clinical response to motor nerve injury
Loss of function
-ve symptoms
Disordered Function
+ve symptoms
Motor “Large Fiber” Wasting
Hypotonia
Weakness
Hyporeflexia
Orthopedic deformity
Fasciculation
Cramps
19. The clinical response to autonomic nerve injury
Loss of function
-ve symptoms
Disordered Function
+ve symptoms
Autonomic
nerves
↓ Sweating
Hypotension
Urinary retention
Impotence
Vascular color changes
↑ Sweating
Hypertension
21. Length-dependent
(Distal) Sensorimotor PN
• Most prevalent pattern
• Clinically symmetric:
Stocking, glove sensory loss
• Proprioception generally preserved
unless severe
• Weakness distal > proximal
• DTRs reduced distally > proximally
22. Peripheral Neuropathy –
Clinical Wise
• It will present by the 3 following
manifestations in difference combinations:
Motor
Sensory
Autonomic
23. Regardless of the cause of the
polyneuropathy, the clinical picture is
essentially the same; variations
depend on whether the motor,
sensory or autonomic features
predominate
24. Prominent motor or sensory neuropathy
Motor neuropathy Sensory Neuropathy
GBS Alcoholic neuropathy
Lead poisoning Arsenic neuropathy
Diphtheric neuropathy Leprotic neuropathy
Porphyria Diabetic neuropathy
Vitamin Deficiency
25. Sensory system in PN
1. History: pain and paresthesia in the limbs, specially distally.
2. Examination:
- Superficial sensory impairment of the stock and glove
nature.
- Deep sensory loss specially distally with absence of deep
reflexes
26. Sensory affection
Superficial Sensation Deep Sensation
Component Pain
Touch
Temperature
Muscles
Irritation Pain, paresthesia Tender muscle
Destruction Lost superficial sensation Lost deep reflexes
Sensory ataxia
31. How to…
1. Compare side by side
2. Compare above and below in same side
3. Compare distal and proximal in same limb
4. Circumferential comparison
32. Compare Side by side
• Compare both sides of body between right
& left side; starting with healthy side
At the level of: Head, trunk (chest), UL
(arm), LL (Leg)
Value: Hemi-anesthesia (hemiplegia)
33. Compare above and below in same side
• Compare between Head, trunk (chest, abdomen), UL
(arm), LL (Leg) of same side and after finishing do the
opposite side:
Better UL (arm) & upper trunk (chest), less in
lower trunk (abdomen) & LL (Leg)= extra-
medullary lesion- sensory level of paraplegia
(detect the level)
Better in LL (Leg) & lower trunk (abdomen) less in
upper trunk (chest) & UL (arm)= intramedullary
lesion (jacket sensory loss)
34. Compare distal and proximal in
same limb
• Compare distal with proximal part of the
same limb, after finishing do the opposite
side:
Value: detect the level of stocking &
glove hypoesthesia in peripheral
neuropath
35. Circumferential
comparison
• Circumferential comparison
between lateral, medial, posterior
aspects of the limb, after
finishing do the opposite side:
If sensation is defective in one
dermatome: radicular sensory
loss in that dermatome as in
cauda equina
36. If the 4 above screening
tests were normal =
intact superficial
sensation
37. Dermatomal distribution
C2 Angle of jaw, lateral neck.
C3,4 Shoulder, down manubrium.
C5 Lateral aspect of arm.
C6 Lateral aspect of the forearm, thenar eminence & thumb.
C7 Middle aspect of the forearm, middle of the palm, middle 3 fingers.
C8 Medial aspect of forearm, hypothenar eminence & little finger.
T1 Medial aspect of arm.
T2 → T7 Thorax (T4 = nipple).
T8 → T12 Abdomen (T10= umbilicus), (T6= costal margin), (T12= inguinal ligament).
38. Dermatomal distribution (cont.)
L1 Upper 1/3 front of thigh.
L2 Middle 1/3 front of thigh.
L3 Lower 1/3 front thigh.
L4 Anterolateral aspect of thigh, front of knee, anteromedial aspect of leg,medial aspect
of foot & big toe.
L5 Lateral aspect of thigh, lateral aspect of leg, middle 1/3 of dorsum of foot & middle 3
toes.
S1 Posterolateral aspect of thigh & leg, lateral 1/3 of dorsum of foot & little toe.
S2 Posterior aspect of thigh, leg & sole of the foot.
S3,4,5 Anal, perianal & gluteal region (saddle shaped area) in concentric manner.
43. Vibration sense
• Tuning fork 128
• Start on forehead to test thalamus
Upper limbs Lower limbs
• Styloid process of
radius: PN
• Clavicle: posterior
column (PC)
• Forehead: thalamus
Medial malleolus: PN
ASIS: PC
Forehead: thalamus
44. Muscle sense
• Squeeze the calf muscle.
• Loss of muscle sense. Called Abadie's sign
as in neurosyphilis
• Tender calf muscle in:
Diabetic P.N.
Nutritional P.N.
D.V.T.
Myositis
GBS
45. Joint (Position) sense
• First learn the patient: position
and whether finger is moved or
not
• Ask patient to close his eye and
test position and movement
• Caught finger or toe gently
46. Nerve sensation
• By pressing the ulnar nerve
and the lateral popliteal nerve
against the bones.
• Normally, it results in an
electric like sensation.
47. Romberg sign
• Ask the patient to stand with the heels
together, 1st with his eyes open, then with
his eyes closed.
• Note any swaying or loss of balance.
• If present:
With eyes open or closed = cerebellar
ataxia.
Only with closed eyes = sensory
ataxia.
50. Cortical sensation
• They are only examined when the superficial and deep sensation are
intact with open and closed eyes.
1. Tactile localization
2. Two-points discrimination
3. Stereognosis
4. Graphesthesia
5. Perceptual rivalry
51. Don’t forget to ask patient to close his eye
They are tested on healthy side
57. Motor affection in PN
1. Weakness or paralysis of LMN nature (wasting, hypotonia,
hyporeflexia ...).
2. The weakness and wasting are:
- Bilateral and symmetrical.
- Affecting L.L. more than U.L.
- Affecting distal muscles more than proximal muscles.
- Affecting extensors more than flexors, affecting
adductors more than abductors
58. Motor affection in PN (cont.)
3. The weakness in the extensors of the distal group of muscles
leads to bilateral foot drop and wrist drop.
4. The ankle reflex is lost while the knee reflex is preserved.
5. The cranial nerves may be affected specially CN 3, 6, 7 and
10.
6. The gait is high steppage due to the foot drop.
61. Reflexes in peripheral neuropathy
• It should be differentiated from deep
sensory loss
• In PN: there is loss of distal reflexes and
preserved proximal one
• Example: lost ankle preserved knee
reflex
Rate of onset and progression
Symmetrical or asymmetrical at onset
Proximal vs Distal
Motor symptoms (e.g. weakness, wasting, tremor, fatigue)
Pain
Adequacy of diet (e.g. bariatric surgery, fads)
Autonomic dsyfunction (e.g. orthostatic dizziness, erectile dysfunction, constipation, nocturnal diarrhea)
DTRs= deep tendon reflexes
Small fiber sensory neuropathy (SFSN) is a disorder in which only the small sensory cutaneous nerves are affected. The majority of patients experience sensory disturbances that start in the feet and progress upwards. These patients have what is called a length-dependent SFSN.
Length-dependent polyneuropathies primarily affect the longest nerves first and represent a prototypic form of a primary axonal neuropathy.
Compare both sides leg to leg, arm to arm & face to face.
Compare on each side, the L.L. with the trunk, with the U.L. & with the face.
In case of hyposthesia in a limb, test all around it to differentiate between radicular sensory loss & glove & stock hyposthesia.
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Face: start with C2 then 3 areas of trigeminal
Leg → Arm → Face
Leg:Leg → Arm:Arm → Face:Face
Leg: proximal & distal
Arm: proximal & distal
Leg & arm circumference
Sensory level:
Very important in paraplegia and PN
Not done in hemihyposthesia and Normal person
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Start with C2
1. Compare right with left at (face - upper limb - lower limb) →↓ in one side in hemiplegia.
2. Compare the same side at (face - upper limb - trunk - lower limb)
Jacket of sensory loss in intramedullary compression paraplegia.
Decrease sensation in lower limb in extramedullary compression paraplegia.
3. Compare proximal with distal (PN).
4. Level.
5. Circumferential to detect radiculopathy
------------------------
Face: start with C2 then 3 areas of trigeminal
Leg → Arm → Face
Leg:Leg → Arm:Arm → Face:Face
Leg: proximal & distal
Arm: proximal & distal
Leg & arm circumference: to detect radiculopathy
Sensory level:
Very important in paraplegia and PN
Not done in hemihyposthesia and Normal person
Dermatomes are areas of skin on your body that rely on specific nerve connections on your spine. In this way, dermatomes are much like a map.
There are 8 cervical segments & only 7 cervical vertebra.
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The five groups of spinal nerves are:
Cervical nerves. There are eight pairs of these cervical nerves, numbered C1 through C8. They originate from your neck.
Thoracic nerves. You have 12 pairs of thoracic nerves that are numbered T1 through T12. They originate in the part of your spine that makes up your torso.
Lumbar nerves. There are five pairs of lumbar spinal nerves, designated L1 through L5. They come from the part of your spine that makes up your lower back.
Sacral nerves. Like the lumbar spinal nerves, you also have five pairs of sacral spinal nerves. They’re associated with your sacrum, which is one of the bones found in your pelvis.
Coccygeal nerves. You only have a single pair of coccygeal spinal nerves. This pair of nerves originates from the area of your coccyx, or tailbone.
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Your body has 30 dermatomes. You may have noticed that this is one less than the number of spinal nerves. This is because the C1 spinal nerve typically doesn’t have a sensory root. As a result, dermatomes begin with spinal nerve C2. Dermatomes have a segmented distribution throughout your body. The exact dermatome pattern can actually vary from person to person. Some overlap between neighboring dermatomes may also occur.
Because your spinal nerves exit your spine laterally, dermatomes associated with your torso and core are distributed horizontally. When viewed on a body map, they appear very much like stacked discs.
The dermatome pattern in the limbs is slightly different. This is due to the shape of the limbs as compared with the rest of the body. In general, dermatomes associated with your limbs run vertically along the long axis of the limbs, such as down your leg.
Vibration sensation: using tuning fork 128
Place the vibrating fork over the bony prominences: medial malleouls - anterior tibial tubercle - anterior superior iliac spine (ASIS) - styloid process & clavicle.
Ask the patient if he feels the fork's vibrations & if they are felt equally on all sites if V.S. is diminished or lost over medial malleolus, check A.S.I.S., if lost, It suggest posterior column lesion, if intact, it suggests P.N. lesion.
Joint sense (sense of position and movement): first show the patient with his eyes open, the position of his big toe (dorsi-flexed), then with his eyes closed, move the big toe and ask him if he feels it moving and if so in which direction.
The big toe should be caught gently, from the sides.
Ask the patient to close his eyes, then prick his finger & ask him to localize the site of the prick.
With his eyes closed, the patient is asked to recognize a familiar object placed in his hand.
With his eyes closed, the patient is asked to recognize a number or letter drawn over his palm.
Normally if you deliver 2 simultaneous pin pricks at 2 corresponding sites of the body, both pricks are felt; in cortical sensory loss, only the prick on the healthy side is felt.