Medical Case Study: Weakness and Gait Change

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Questions and Answers

What is the most likely cause of the patient's gait disturbance?

Osteoarthritis

Vitamin B12 deficiency

Cervical spinal cord compression (correct)

Diabetic neuropathy

What is the significance of the patient's difficulty with fine motor skills?

It is a symptom of peripheral neuropathy

It is a side effect of diabetes medication

It is a sign of cognitive impairment

It is a manifestation of upper motor neuron dysfunction (correct)

What is the most likely explanation for the patient's urinary urgency and constipation?

Osteoarthritis

Spinal cord compression (correct)

Vitamin B12 deficiency

Diabetic autonomic neuropathy

What is the role of electromyography and nerve conduction studies in this patient's evaluation?

To rule out peripheral neuropathy Signup and view all the answers

What is the most appropriate next step in the evaluation of this patient?

Obtain MRI of cervical spine Signup and view all the answers

What is the percentage of bilateral cases in Subdural Hematoma?

15% Signup and view all the answers

What is the primary cause of Subdural Hematoma?

Head trauma Signup and view all the answers

What is the significance of the patient's history of falls?

It is a consequence of gait disturbance Signup and view all the answers

What is the most common symptom of Chronic Subdural Hematoma?

Headache Signup and view all the answers

What is the recommended treatment for patients with Chronic Subdural Hematoma who are asymptomatic?

Clinical monitoring Signup and view all the answers

What is the age range when Multiple Sclerosis is most common?

16-40 years old Signup and view all the answers

What is the approximate cost of Multiple Sclerosis per patient per year?

$41,000 Signup and view all the answers

What is the prevalence of Multiple Sclerosis worldwide?

2.5 million Signup and view all the answers

What is the ratio of Multiple Sclerosis cases in women to men?

2:1 Signup and view all the answers

What percentage of patients with myasthenia gravis experience spontaneous improvement before steroids?

33% Signup and view all the answers

At what stage of the disease does muscle atrophy typically occur?

After 15-20 years of onset Signup and view all the answers

What percentage of patients with myasthenia gravis experience severe exacerbation or MG crisis within the first year?

20% Signup and view all the answers

What is the most common age of onset for myasthenia gravis in women?

Second and third decades Signup and view all the answers

What is the typical pattern of weakness in myasthenia gravis?

Less in the morning, worsening as the day progresses Signup and view all the answers

What percentage of patients with myasthenia gravis develop generalized disease within the first two years of ocular symptoms?

75% Signup and view all the answers

What is the initial symptom in approximately 17% of patients with myasthenia gravis?

Oropharyngeal muscle weakness Signup and view all the answers

What percentage of patients with myasthenia gravis reach maximum severity within the first year?

67% Signup and view all the answers

Which of the following conditions can trigger myasthenia gravis?

Both a and b Signup and view all the answers

What is the purpose of giving Edrophonium chloride (Tensilon) IV in the diagnosis of myasthenia gravis?

To increase the levels of acetylcholine at the neuromuscular junction Signup and view all the answers

What is the main goal of collaborative treatment in myasthenia gravis?

To control symptoms and maintain functional ability Signup and view all the answers

Which of the following is NOT a treatment option for myasthenia gravis?

Dialysis Signup and view all the answers

What is the purpose of EMG (nerve conduction) tests in the diagnosis of myasthenia gravis?

To demonstrate decrements of the muscle action potential Signup and view all the answers

What is the effect of spontaneous improvement or remission in myasthenia gravis?

It makes treatment less effective Signup and view all the answers

What is the purpose of giving High-dose IV Immune Globulin in myasthenia gravis?

To temporarily modify the immune system Signup and view all the answers

What is the benefit of thymectomy in myasthenia gravis?

It reduces symptoms in more than 70% of clients without thymoma Signup and view all the answers

What is the primary goal of identifying the specific cause of musculoskeletal pain?

To develop an effective treatment plan Signup and view all the answers

What is the gold standard for determining the cause of musculoskeletal pain?

Physical examination complemented by a good history Signup and view all the answers

What is a potential indicator of a systemic process in an adult patient with musculoskeletal pain?

Pain in multiple joints Signup and view all the answers

What is an important question to ask during the history-taking component of a musculoskeletal pain evaluation?

What brings on the pain? Signup and view all the answers

What is a key component of a thorough physical examination for investigating musculoskeletal issues?

All of the above Signup and view all the answers

What is a potential characteristic of musculoskeletal pain in older adults?

Multiple mechanical problems may occur in different sites of the body Signup and view all the answers

What is an important aspect of evaluating neck pain?

All of the above Signup and view all the answers

What is a key principle of evidence-based management of musculoskeletal problems?

Tailoring treatment to the specific cause of the pain Signup and view all the answers

Study Notes

Case 1

The patient is a woman who has experienced changes in her gait over the last 6 months, now using a walker, and has fallen once a month ago on uneven pavement.
She complains of weakness and lousiness in her legs with no pain in her lower extremities.
Her medical history includes diabetes mellitus, osteoarthritis, and CAD.

Review of Systems

The patient experiences increased urinary urgency and constipation.
She has difficulty opening jars and buttoning blouses.

Physical Examination

The patient has impaired fine motor skills in her hands.
She exhibits bilateral hyperreflexia in her ankles and patella.
The Romberg test is positive.

Diagnostic Evaluation

The next appropriate evaluation for the patient would be to measure her serum vitamin B12 level.

Subdural Hematoma

A subdural hematoma is a collection of blood between the dura and the arachnoid.
It is usually caused by head trauma, which may be mild, especially in older adults.
The incidence of chronic subdural hematoma increases with age.
Symptoms may include headache, slight to severe cognitive impairment, hemiparesis, seizures, and focal neurologic signs.
Neuroimaging shows extra-axial blood collection.

Treatment of Chronic SDH

If the patient's condition is worsening, removal of the clot may be attempted.
If the patient's condition is improving, clinical monitoring is appropriate, as the hematoma may shrink and disappear without surgery.

Multiple Sclerosis

The objectives of this module are to recognize the features of MS, understand and apply diagnostic criteria, and understand symptom management and disease management pharmacologic modalities for MS.
Prevalence: 2.5 million worldwide, 400,000 in the US, with an annual cost of $41,000 per patient.
Incidence: 2/3 more cases in women than men, typically occurring in the 2nd or 3rd decade of life (16-40 years old).
Diagnostic criteria include prevalence, incidence, subtype, and management.

Myasthenia Gravis

MG occurs at any age, in both genders, and begins insidiously.
Second and third decades are the most common age of onset in women, while seventh and eighth decades are the most common in men.
Patients complain of specific muscle weakness, not generalized fatigue.
Ptosis or diplopia are initial symptoms in 65% of patients.
Oropharyngeal muscle weakness is the initial symptom in 17% of patients.
Limb weakness is a presenting symptom in only 10% of cases.
Severity of weakness fluctuates during the day, worsening as the day progresses, especially after prolonged use of affected muscles.

Presentation (continued)

Before steroids, near 1/3 of patients improved spontaneously, 1/3 became worse, and 1/3 died.
Ocular myasthenia: if progressing to generalized MG, usually does so within the first two years after onset.
After 15 to 20 years, weakness becomes fixed—the “Burnt-Out-Stage”—with muscle atrophy.

Diagnostics

EMG (nerve conduction) tests: demonstrate decrements of the muscle action potential due to impaired nerve-to-muscle transmission.
Diagnosis: ANA (blood test for presence of immune molecules or acetylcholine receptor antibodies), and Tensilon IV (Edrophonium chloride).

Treatment

Control symptoms, maintain functional ability, and prevent complications.
Collaborative treatment goals: PT, OT, Speech, thymectomy, plasmapheresis, high-dose IV immune globulin.
CHE inhibitors: Mestinon (Pyridostigmine bromide) is the drug of choice.

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Description

A patient presents with a 6-month history of gait change, weakness, and recent fall. Review of systems reveals urinary urgency, constipation, and difficulty with fine motor tasks. Medical history includes diabetes, osteoarthritis, and CAD.