EMQs in Clinical Medicine.pdf - Peshawar Medical College

92 Neurology
E
A 70-year-old woman complains of headache, drowsiness and
unsteadiness over the last couple of days. On examination she is
found to have papilloedema. She remembers falling over 3 weeks ago.
There is not always a prior history of head injury. Alcohol abuse is a risk
factor for chronic subdural haemorrhage. Neurosurgical opinion should
be sought early, although many subdural haemorrhages can be handled
conservatively because the bleeds clot spontaneously. The presence of
papilloedema indicates that the subdural bleed is increasing the intracranial
pressure. Initially the intracranial compliance is high and so the
increase in volume caused by the developing bleed causes only small
increases in intracranial pressure. However, this compliance decreases
(compensatory mechanisms to cope with increases in pressure are limiting)
and small increases in volume are associated with large increases in
intracranial pressure. This is clinically important because patients may
deteriorate very quickly and should therefore be regularly monitored.
31 Weakness in the legs
Answers: J E D B K
J
E
A 60-year-old woman complains of bilateral proximal muscle weakness
in the legs and dysphagia. On examination she has a purple rash
on her cheeks.
There are many non-neurological causes of weakness in the legs. Polymyositis
is an autoimmune disease characterized by non-suppurative
inflammation of skeletal muscle. In severe disease there can be respiratory
muscle weakness and also cardiac involvement. Creatine kinase (CK)
is usually markedly elevated. Electromyography (EMG) characteristically
shows fibrillation potentials.
A 40-year-old man presents with a recent history of progressive
weakness in the arms and legs after an episode of diarrhoea.
Examination revealed flaccid weakness of limbs with no reflexes.
Guillain–Barré syndrome describes a presentation of an ascending
polyneuropathy of unknown aetiology, which may be associated with a
preceding infection. The weakness is symmetrical and may affect proximal
muscles sooner than distal ones. Cranial nerves and the autonomic
nervous system may also be involved. Involvement of respiratory
muscles can be fatal and regular monitoring of vital capacity is important.
In these cases it is often safer to initiate ventilation sooner rather than
later. Sensory symptoms are usually mild with complaints of numbness
and tingling in the limbs.
Intravenous immunoglobulin is often used to shorten the duration of
the disease. Prognosis is good with over 85 per cent patients making a
complete or near complete recovery.