Harrison’s Book Club

1. Harrison’s Book Club Harrison’s Book Club Session Three Chapters 21-24 9/15/05

2. Chapter 21 – Weakness , Movement, Imbalance • Which of the following statements is incorrect? • Fasiculations help differentiate lower motor neuron disease from myopathy. • Flaccidity (or weakness with decreased tone) is caused by disease of the motor units. • Rigidity is increased tone, and is always present with upper motor neuron disease. • Babinski’s sign indicates upper motor neuron disease. • Absent deep tendon reflexes most likely represent upper motor neuron disease.

3. Chapter 21 – Weakness , Movement, Imbalance UMN & LMN Disease • Clasp-knife phenomenon reflects spasticity affecting antigravity muscles showing UMN disease --- T or F • Lead-pipe stiffness affects flexors more than the extensors occurring commonly in the involvement of the pyrimidal tract T or F

4. Chapter 21 – Weakness , Movement, Imbalance Paratonia- increased tone that varies irregularly • Gegenhalten (paratonia) usually results from disease of the temporal lobe T or F

5. Chapter 21 – Weakness , Movement, Imbalance UMN Disease • Fasciculations is commonly seen in UMN disease • Is associated with absent Babinski’s • Tone is spastic T or F

6. Chapter 21 – Weakness , Movement, Imbalance Hemibellismus • Due to infarction of the contra-lateral thalamic nucleus T or F

7. Chapter 22 – Numbness, Tingling, Sensory Loss CC: “ Both of my legs hurt “ HPI: A 58 y/o AAM with a history of High blood pressure, non- insulino dependent Diabetes, Hypercholesterolemia, CAD s/p CABG, CHF, Pacemaker AICD implantation and Right Carotid Endarterectomy is brought on to your office by his wife because , for the past 2-3 weeks, both of his legs are hurting . The man describes a severe leg pain that comes on after walking about 4 city blocks. His exercise tolerance has some variability. However, the patient initially noted the onset of numbness, tingling and weakness in the legs while walking downhill.

8. Chapter 22 – Numbness, Tingling, Sensory Loss He has started sitting at bus stops waiting for the pain to resolve and then walking to the next bus stop where he would again stop for a rest. The numbness and tingling increase as he walks. The patient recalls only mild , low back pain that he has had for a number of years and some intermittent nocturnal bilateral foot cramping. ROS: As per HPI . All other systems are negative. There is no change in bowel, bladder or sexual function. PMH : HTN, DM, Hypercholesterolemia, CAD, CHF. PSH: CABG in 1996, Endarterectomy in 1998 , AICD placement in 2000.

9. Chapter 22 – Numbness, Tingling, Sensory Loss SH: 40 pack years, Occasional drinker and No history of IVDA Fam Hx: HTN , Diabetes ( Mother) Medications: Aspirin 325mg, Lopressor 50mg twice daily, Vasotec 20mg daily, Lasix 40mg daily, Zocor 40mg daily , Glipizide 5mg daily and Glucophage 500mg twice daily.

10. Chapter 22 – Numbness, Tingling, Sensory Loss Physical Examination: Vitals: Temp 98, Pulse 60, Resp Rate 18 , BP 148/82. General Appearance: Overweight HEENT: No JVD, No carotid bruit , Thyroid not palpable , No Lymph nodes CVS: Regular Heart Rhythm, S1+S2 , No murmur, No gallop, Peripheral Pulses present and symmetrical. Lungs: Clear, No wheezes , No Rales Abdo: Soft , Non tender, BS X4 , No Organomegaly Neuro: CN II – XII intact , No Focal Neurologic Deficit, Normal strength and tone, Straight leg Raising test negative, DTR absent in the recumbent position but present when sitting up in the lower extremities.

11. Chapter 22 – Numbness, Tingling, Sensory Loss LABS: Hb 10.9, HCT 39.8, MCV 89,WBC 7000/mm3, Platelets 234.0000/mm3, Na+ 142, K+ 3.3, CL- 112, Bicarbonate 26, BUN 27, Creat 1.3, Glucose 152, Ca2+ 8.2 , Phosphorus 3.5 , Mg2+ 2.2 , Protein 5.5. Chest X ray : Cardiomegaly. No CHF. Pacemaker. EKG: Pacemaker drive

12. Chapter 22 – Numbness, Tingling, Sensory Loss • 1) What is the next best step in the management of this patient? • X ray of the spine • Correction of Electrolytes abnormalities • Arterial duplex of lower extremities • Ankle-brachial blood pressure ratio • CT scan of the spine with contrast • MRI of the spine • Electromyography

13. Chapter 22 – Numbness, Tingling, Sensory Loss • 2. What is the most likely diagnosis ? • Tumor involving the cauda Equina • Herniated Disc • Peripheral Vascular disease • Lumbar spinal stenosis • E. Bilateral Sciatica • 3. What is the best test in the diagnosis of the suspected condition in this particular patient? • Protein Electrophoresis • Electromyography of the lower extremities • Arteriography • MRI of the spine • CT Myelography .

14. Chapter 22 – Numbness, Tingling, Sensory Loss • 4) What is the most sensitive location to test an L5 sensory deficit ? • Heel • Medial foot • Great toe • Lateral foot • Anterolateral calf • Lateral malleolus

15. Chapter 23 – Aphasia, Memory Loss Which of the following lesions is incorrectly paired with the clinical syndrome? a tumor causing damage to the hippocampus and entorhinal cortex in a patient who cannot remember what he did yesterday an embolus to the inferior division of the MCA in a patient who cannot understand simple questions and cannot meaningfully express her thoughts infarction of the anterior perisylvian and insular cortex in a patient who is frustrated and tearful because he cannot speak fluently a tumor in the posterior perisylvian region in a patient with poor performance on the digit span and who is mistaken to be manic damage to the inferior parietal lobule and angular gyrus in a patient who cannot perform simple arithmetic, has trouble writing, and cannot distinguish between her right and left foot

16. Chapter 23 – Aphasia, Memory Loss typical lesion of limbic system causing retrograde amnesia typical lesion for Wernicke’s area in a patient with impaired comprehension typical lesion for Broca’s area in a patient with decreased fluency CORRECT ANSWER: describes a lesion to Wernicke’s area but syndrome consistent with frontal lobe disease typical lesion for patient with Gerstmann’s syndrome

17. Chapter 24 – Sleep Disorders A 36 year old African American woman came in with a chief complaint of unrefreshed sleep, excessive daytime sleepiness that was getting worse and interfering with her work. On physical examination: BP: 150/80 PR: 92/min  RR: 15/min T: 99.6F   BMI: 32 warm dry skin pink palpebral conjunctiva, pupils 2-3mmERTL moist buccal mucosa with enlarged tonsils R>L  Oropharynx: Malampati class III  supple neck with no palpable lymph nodes nor nexk masses Symmetrical chest expansion, clear breath sounds Apex beat at 5th LICS AAL, normal S1, S2 with prominent P2 soft flabby abdomen NABS, (-) hepatosplenomegaly  extremities pulses full and equal

18. Chapter 24 – Sleep Disorders Which of the following pathophysiologic mechanism does not explain the cardiac findings on this patient? a. acute Co2 retention causing chronic hypoventilation and subsequesntly pulmonary vasoconstriction b. Increase pleural pressure that causes an increase afterload causing systemic hypertension c. systemic vasoconstriction causing systemic hypertension d. pulmonary vasoconstriction thereby causing pulmonary hypertension

19. Answers Chapter – 21 (T, F), (F), (F,F,T), (T) – Dr. Faraz 21 C Dr. Locke Chapter – 22 D,D,E,C Dr. Tchokonte Chapter – 23 D Dr. Hakim Chapter – 24 B Dr. Go