Medical Case Study: Weakness and Gait Change

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.