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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3230_Библиотеки_им_академика_М_И_Перельмана
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CHAPTER 13 Neurological signs
332
Multiple cranial nerve lesions
Some differential diagnoses and typical outline evidence
Pituitary tumor Suggested by: optic tract or chiasm lesion. Third
cranial nerve lesion
Confirmed by: CT or MRI scan appearance
Anterior
communicating
artery aneurysm
due to pituitary
tumor or
cerebral artery
aneurysm
Suggested by: optic nerve lesion, third and fourth
cranial nerve lesions
Confirmed by: CT or MRI scan appearance
Posterior
carotid artery
aneurysm
Suggested by: Fourth and fifth cranial nerve lesions
Confirmed by: CT or MRI scan appearance
Gradenigo’s
syndrome
(lesion in petrous
temporal bone)
Suggested by: fifth and sixth cranial nerve lesions
Confirmed by: MRI scan appearance
Facial canal
lesion, e.g.,
cholesteatoma
Suggested by: seventh and eighth cranial nerve lesions
alone (no fifth or sixth)
Confirmed by: CT or MRI scan appearance
Cerebellopontine
angle lesion, e.g.,
tumor
Suggested by: fifth, seventh, and eighth ± sixth cranial
nerve lesions
Confirmed by: CT or MRI scan appearance
Jugular foramen
syndrome
Suggested by: ninth, tenth, and eleventh cranial nerve
lesions
Confirmed by: MRI scan appearance
Lateral
medullary
syndrome
Suggested by: vertigo, nystagmus, fifth cranial nerve
lesion, Horner
’s syndrome, contralateral
spinothalamic loss on trunk
Confirmed by: above clinical features. MRI scan
appearance
Weber’s
syndrome
Suggested by: ipislateral third cranial nerve lesion and
contralateral hemiparesis
Confirmed by: above clinical features. MRI scan
appearance
ODD POSTURE OF ARMS AND HANDS AT REST1
333
Odd posture of arms and hands at rest
Some differential diagnoses and typical outline evidence
Internal capsule
lesion or pre-
central gyrus
and connections,
or lower
pyramidal tract
(upper motor
neuron)
Suggested by: arms flexed at elbow and wrist, and
weak. Increased tone and reflexes. Upper motor
neuron facial weakness
Confirmed by: brain CT or MRI scan appearance
T1 anterior
root lesion
Suggested by: claw hand, wasting of all small muscles of
the hand. Loss of sensation in ulnar 1.5 fingers and
ulnar border of forearm
Confirmed by: Nerve conduction study result
Ulnar nerve
lesion (below
elbow)
Suggested by: claw hand, wasting of hypothenar
eminence and dorsal guttering, especially first.
Weakness of finger abduction and adduction. Loss
of sensation in ulnar 1.5 fingers
Radial nerve
lesion (or C7
anterior root
lesion)
Suggested by: wrist drop. Inability to extend wrist and
grip. Loss of sensation over first dorsal interosseous
muscle
Confirmed by: nerve conduction study
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CHAPTER 13 Neurological signs
334
Fine tremor of hands
This is elicited by asking the patient to hold the arms out straight in front
and then placing a sheet of paper on them (to amplify fine tremor).
Some differential diagnoses and typical outline evidence
Thyrotoxicosis Suggested by: fine tremor, anxiety, tachycardia,
sweating, weight loss, goiter, increased reflexes
Confirmed by: iFT4 or FT3 and ddTSH
Anxiety state Suggested by: fine tremor, anxiety, tachycardia,
sweating, weight loss, goiter, increased reflexes
Confirmed by: normal thyroid function tests.
Improvement with sedation, psychotherapy, etc.
Alcohol
withdrawal
Suggested by: fine or coarse tremor, history of high
alcohol intake and recent withdrawal, anxiety
Confirmed by: improvement with sedation, etc.
Sympathomimetic
drugs
Suggested by: fine tremor, drug history
Confirmed by: improvement with withdrawal of drug
Benign essential
tremor
Suggested by: usually coarse tremor, long history, no
other symptoms or signs
Confirmed by: normal thyroid test results.
Improvement with beta blocker
COARSE TREMOR OF HANDS1
335
Coarse tremor of hands
This is elicited by asking the patient to hold the arms out straight in front
and extending the wrists (for asterixis or flap). Then ask the patient to
first touch his own nose and then the examiner’s finger, with the arm
extended, repetitively (for intention tremor).
Some differential diagnoses and typical outline evidence
Hepatic failure Suggested by: flapping tremor (asterixis) aggravated
when wrists extended. Spider nevi. Jaundice
Confirmed by: abnormal liver function tests and
prolonged prothrombin time
Carbon dioxide
retention
Suggested by: flapping tremor (asterixis), aggravated
when wrists extended. Muscle twitching, bounding
pulse, warm peripheries
Confirmed by: blood gases show ipCO
2
Cerebellar
disease
Suggested by: intention tremor (past pointing) when
patient attempts to touch examiner
’s finger
Confirmed by: MRI scan
Parkinsonism
due to Parkinson’s
disease, drugs
(chlorpromazine,
haloperidol,
metoclopramide,
prochlorperazine);
multisystem
atrophy,
Alzheimer’s
disease;
postencephalitis,
normal-pressure
hydrocephalus
Suggested by: resting coarse tremor (pill-rolling);
lead-pipe rigidity; expressionless face, paucity of
movement, small hand writing, rapid, shuffling
gait with small steps
Confirmed by: clinical findings, e.g., persistent blinking
when forehead tapped (e.g., glabellar tap). Clinical
improvement with appropriate treatment
Benign essential
tremor
Suggested by: usually coarse tremor, long history, no
other symptoms or signs
Confirmed by: normal thyroid test results. Improvement
with beta blocker
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 13 Neurological signs
336
Wasting of some small muscles of hand
Intermetacarpal grooves are prominent due to muscle wasting.
Some differential diagnoses and typical outline evidence
Median nerve
palsy usually
due to carpal
tunnel
syndrome
Suggested by: wasting of thenar eminence. Weakness of
thumb flexion, abduction and opposition. Unable to lift
thumb with palm upward but able to press with index
finger. Loss of sensation over palmar aspect of radial
3.5 fingers of hand
Confirmed by: nerve conduction study results
Ulnar nerve
lesion from
elbow (high)
to wrist (low)
Suggested by: wasting of hypothenar eminence. Able to
lift thumb with palm upward but unable to press with
index finger. Weakness of finger abduction and
adduction. Loss of sensation in ulnar aspect 1.5 fingers
of hand. Claw hand (in lower lesions)
Confirmed by: nerve conduction study results
T1 lesion:
anterior horn
cell or root
lesion
Suggested by: wasting of all small muscles of hand.
Unable to lift thumb with palm upward but unable to
press with index finger
Confirmed by: nerve conduction study results. MRI scan
appearance around T1 level
Motor neuron
disease
Suggested by: signs of T1 lesion, prominent
fasciculation, spastic paraparesis, wasted fasciculating
tongue, no sensory signs
Confirmed by: clinical presentation and absence of
structural abnormality on MRI scan appearance
Syringomyelia Suggested by: signs of T1 lesion, fasciculation not
prominent, burn scars, dissociated sensory loss,
Horner
’s syndrome, nystagmus. History over months
to years
Confirmed by: MRI scan appearances
Any prolonged
systemic illness
Suggested by: global muscle wasting, general
weight loss
Confirmed by: improvement in muscle wasting if
primary disease treatable
WASTING OF SOME SMALL MUSCLES OF HAND1
337
Cervical
spondylosis
compressing
nerve root
Suggested by: signs of T1 lesion, neck pain and
stiffness, and referred pain
Confirmed by: MRI scan showing root canal
compression
Tumor
compressing
nerve root
Suggested by: signs of T1 lesion, referred pain.
Progressing over months
Confirmed by: MRI scan showing root canal
compression
Brachial plexus
lesion
Suggested by: signs of T1 lesion and history of trauma
to shoulder area or birth injury
Confirmed by: nerve conduction study results
Cervical rib Suggested by: signs of T1 lesion aggravated by
movement or posture
Confirmed by: X-ray: presence of cervical rib. Relief by
surgery
Pancoast
tumor
Suggested by: signs of T1 lesion, Horner’s syndrome,
features of lung cancer (clubbing, chest signs, lymph
nodes, etc.)
Confirmed by: CXR and CT scan appearances
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CHAPTER 13 Neurological signs
338
Wasting of arm and shoulder
Loss of the rounded contour of the deltoid and biceps muscle occurs.
Fasciculation is localized twitching of the muscle. Note the patient’s facial
expression.
Some differential diagnoses and typical outline evidence
Progressive
muscular
atrophy
Suggested by: bilateral wasting of hand, arm, and
shoulder girdle with fasciculation
Confirmed by: EMG results
Motor neuron
disease
(amyotrophic
lateral sclerosis)
with anterior
horn cell
degeneration
Suggested by: initially unilateral wasting of shoulder
abductor and biceps. Weakness of speech, swallowing.
No sensory signs
Confirmed by:
EMG results
Primary muscle
disease
Suggested by: bilateral wasting of shoulder abductor
and biceps
Confirmed by: EMG findings or muscle biopsy
ABNORMALITIES OF ARM TONE1
339
Abnormalities of arm tone
This is elicited by supporting the patient’s elbow in one hand and asking
the patient to allow you to flex and extend the arm at the elbow without
assistance.
Some differential diagnoses and typical outline evidence
Cerebellar
lesion
Suggested by: tone diminished, no wasting.
Diminished reflexes. Past pointing, truncal ataxia,
nystagmus
Confirmed by: CT or MRI scan appearance of
cerebellum
Primary muscle
disease
Suggested by: tone diminished with wasting
± fasciculation
Confirmed by: EMG findings or muscle biopsy
Upper motor
neuron
Suggested by: tone increased. Brisk reflexes below
lesion
Confirmed by: CT or MRI scan of brain or spinal cord
Parkinson’s
disease
Suggested by: tone increased with cogwheel effect
(superimposed tremor). Poor facial movement,
shuffling, hesitant gait, coarse temor
Confirmed by: Response to drug therapy
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CHAPTER 13 Neurological signs
340
Weakness around the shoulder and arm
without pain
This is elicited by asking the patient to flex and extend the wrist and
elbow against resistance and to abduct, adduct, flex, and extend the
shoulder against resistance. Compare both sides.
Some differential diagnoses and typical outline evidence
C4–5 root
lesion
Suggested by: weakness of abduction at the shoulder
only (not elbow or wrist)
Confirmed by: nerve conduction studies and MRI scan
of neck
C5–6 root
lesion Erb’s
palsy
Suggested by: weakness of flexion at the shoulder and
elbow but not wrist. Arm externally rotated and
adducted behind the back (note porter’s tip position).
History of birth trauma
Confirmed by: nerve conduction studies and MRI scan
of neck
C7 root lesion Suggested by: wrist drop or weakness of grip and
extension at the elbow and wrist
Confirmed by: nerve conduction studies and MRI scan
of neck
Radial nerve
lesion
Suggested by: wrist drop or weakness of grip and
extension at the wrist but not at the elbow
Confirmed by: nerve conduction studies and history of
trauma
C8–T1 root
lesion
(Klumpke’s
paralysis)
Suggested by: arm held in adduction, paralysis or paresis
of the small muscles of the hand, loss of sensa
t
ion over
ulnar border of the hand. History of birth trauma
Confirmed by: nerve conduction studies and MRI scan
of neck
INCOORDINATION1
341
Incoordination
Incoordination on rapid wrist rotation
or hand tapping (dysdiadochokinesis)
This is often used as a screening test (i.e., if it isnormal, you can discount
any significant neuromuscular condition of the upper limbs in the absence
of other symptoms or signs).
Some differential diagnoses and typical outline evidence
Upper motor
neuron paresis
Suggested by: spastic weakness (i.e., with increased
tone) in upper limb
Confirmed by: CT scan of brain or MRI scan of neck
Lower motor
neuron paresis
Suggested by: flaccid weakness (i.e., with decreased
tone) in upper limb
Confirmed by: nerve conduction studies and MRI
scan of neck
Cerebellar
lesion
Suggested by: ataxia, past-pointing, difficulty with
finger-to-nose or heel-to-shin testing
Confirmed by: CT or MRI scan of cerebellum
Loss of
proprioreception
Suggested by: loss of joint position sense and
vibration sense
Confirmed by: nerve conduction studies
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
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