This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Physical Examination:Vital signs: BT 37 º C , PR 100 /min, BP 159/95 mmHg,
RR 20 /minGA: A Thai middle aged male, good consciousnessSkin and appendages: No rash, hyperpigmented skin at
sun-exposure areas (as pictures)
HEENT: Not pale conjunctivae , no icteric sclerae, no cervical and axillary lymphadenopathy.
Pulmonary system: Equal breath sound, no adventitious sound
CVS: Regular rhythm, normal S1S2, no murmur, PMI at 5th ICS MCL
Abdomen: Normal contour; soft, not tender; normoactive bowel sound; liver 1 cm. below RCM with span 12 cm., blunt edge, rubbery consistency; spleen just palpated
Extremities: Mild pitting edema at dorsum of feet
Neurological Examination:
Good consciousness, cooperative
Cranial nerve: Pupils 3 mm. with reaction to light; no exudates or hemorrhages; other CNs were normal
Motor Upper extremities No fasciculation, no atrophy Tone: Normal
Power: grade V all Reflex: 2+ all
Lower extremitiesNo fasciculation, no atrophy Tone: mild hypotoniaPower:
EHL, Tibialis anterior (Rt./Lt.): I/II
Finger flexors (Rt./Lt): I/II
Ankle extensor (Rt./Lt.): I/III
Ankle flexor (Rt./Lt.): I/II
Ankle inversion (Rt./Lt.): II/III
Ankle eversion (Rt./Lt.): II/III
Reflex: 0+ all
Babinski’s sign: Plantar responseClonus: Negative
SensoryUpper extremities
Pinprick sensation: Normal
Proprioception: Normal
Lower extremities
Pinprick sensation: Decreased all toes
Proprioception: Loss of joint position sensation of both feet;
Romberg: positive
Hyperesthesia of both plantar sides
ANSAnal sphincter tone: Normal
Anal reflex: Normal
CerebellumFTN: normal, no dysdiadocokynesia, no trunkal ataxia
Tandem gait: can’t be evaluated
No meningeal sign
2+2+
2+
2+
2+
2+
00
00
Motor : weaknesshypotoniaPinprick
Proprioception / Hyperesthesia
Problems• Neurological
– Abnormal sensation of lower extremities• Pinprick
• Hyperesthesia
• Proprioception
– Motor weakness of lower extremities R>L and hypotonia
– Areflexia
• Non neurological– Weight loss
– Hyperpigmentation
– Hepatosplenomegaly
– Hyperuricemia (Hx)
The Nervous system• CNS
– Brain
– Spinal cord
• PNS
– Nerve
• Nerve root (Cauda equina)
• LS Plexus
• Peripheral nerve
– Mononeuropathy
– Multiple mononeuropathy
– Polyneuropathy
– NMJ, Muscle
ANS spared
Non root distribution
Discrepancy of motor,
sensory
Infiltrative ?Immune ?
Asymmetry
Hx and PE
Multifocal neuropathy
Mononeuropathy
Peripheral neuropathy
EMG
Axonal
Demyelination
Approach to Peripheral Nerve Disease
Axonopathy Demyelination
Motor Distal Proxima/ Distal
Sensory (pinprick)
Distal, Gloves and stockings
Not well demarcated
Proprioception Intact Impaired
Reflexes Decreased distal
Decreased generalized
Autonomic May involve Rarely
Length dependent
Axonopathy VS Demyelination
Impression:
Bilateral sural sensory, bilateral tibial, peroneal motor responses were absent.
Right median, ulnar motor responses showed prolonged distal latencies; slow
conduction velocities; prolonged F wave latencies.
The above studies are consistent with severe demyelinating polyneuropathies; lower extremities more affected than upper.
Mild-to-moderate hepatomegaly with mild increased echogenicity of liver parenchyma, no space-taking lesions, and no intrahepatic and common bile duct dilatation; no gall stone; moderate splenomegaly with mild increased echogenicity; no ascites; and no lymphadenopathy
Echocardiography:
All valvular structures appeared normal.
All cardiac chambers were not dilated. Good LV systolic function (LVEF 80% by Teich) without RWMA. RV normal contraction.
Doppler and color flow study showed normal.
Neither intracardiac thrombus nor pericardial effusion was detected.
P olyneuropathy
O rganomegaly (liver, spleen, lymph nodes,
cardiomyopathy)
E ndocrinopathy (diabetes mellitus, hypothyroidism,