EMQs in Clinical Medicine.pdf - Peshawar Medical College

Falls and loss of consciousness – answers 99
There is lack of sensation over the lateral leg below the knee (and the
entire sole of the foot) and inability to dorsiflex or evert the foot.
L
G
B
A 65-year-old man presents after a stroke with a stiff right leg that
drags forward in an arc.
Strokes give rise to upper motor neuron lesions with weakness in a
pyramidal distribution. The combination of spasticity in the leg extensors
and weakness worse in the flexors of the lower limb gives rise to this
spastic gait characterized by a stiff circumducted leg.
A broad-based high-stepping gait in a known alcoholic.
Sensory ataxia results from a loss of proprioception caused by peripheral
neuropathy (in this case secondary to alcohol abuse). Romberg’s test is
used to identify proprioceptive sensory loss by demonstrating loss of
postural control in darkness.
The patient is asked to stand with the feet together and to close his or
her eyes. If the patient is unstable, the test is said to be positive. These
patients sway and fall because they rely heavily on visual cues to
maintain postural equilibrium. This test is not pathognomonic of
proprioceptive loss because patients with bilateral vestibular damage
and some patients with cerebellar disease require visual cues to keep
their balance.
A broad-based unstable gait with veering to the right side.
Cerebellar disease affecting one hemisphere tends to cause the patient
to veer towards the side of the lesion. If cerebellar disease affects the
cerebellar midline vermis, there is truncal ataxia giving rise to difficulty
in standing and even sitting on a stool unsupported.
37 Falls and loss of consciousness
Answers: E G I C B
E
A 70-year-old man complains of several blackouts and falls every
day. The blackout lasts for several seconds and is preceded by
palpitations.
A Stokes–Adam attack is caused by transient arrhythmias that decrease
cardiac output sufficient to cause syncope. Both tachycardias and bradycardias
may be responsible. Recovery is typically quick. The patient is
characteristically pale with the syncope and becomes flushed upon
recovery.
A 65-year-old woman presented with attacks of sudden weakness
of the legs causing her to fall to the ground. There is no loss of
consciousness or confusion afterwards. She has not had any attacks
for several months now.