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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
352
Brisk reflexes
Some differential diagnoses and typical outline evidence
Thyrotoxicosis Suggested by: brisk reflexes in all limbs with normal
flexor plantar responses
Confirmed by: iFT4 and ddTSH levels
High level
pyramidal tract
lesion
(cervical cord,
brain stem,
bilateral internal
capsule or
diffuse bilateral
cortical lesion)
Suggested by: brisk reflexes in all limbs with extensor
plantar responses
Confirmed by: normal FT4 and TSH levels. MRI scan
appearances
Contralateral
pyramidal tract
lesion
in internal
capsule, primary
cortex, brain
stem, or
cervical cord
Suggested by: unilateral brisk reflexes in upper and
lower limb
Confirmed by: MRI of brain or cervical cord
DIMINISHED REFLEXES1
353
Diminished reflexes
Some differential diagnoses and typical outline evidence
Sensory
neuropathy
Suggested by: diminished reflexes, most marked
peripherally. Normal muscle power. Normal flexor
plantar responses
Confirmed by: nerve conduction studies
Motor
neuropathy
Suggested by: diminished reflexes, muscle wasting,
fasciculation, and weakness
Confirmed by: nerve conduction studies and normal
EMG
Primary muscle
disease
Suggested by: diminished reflexes, muscle wasting and
weakness. No fasciculation
Confirmed by: nerve conduction studies and abnormal
EMG and muscle biopsy
Cerebellar
disease
Suggested by: unilateral brisk reflexes in upper
and lower limb
Confirmed by: CT and MRI of brain posterior fossa
Posterior root
lesion in C7/C8
Suggested by: loss of triceps jerk
Confirmed by: MRI of disc space
Posterior root
lesion in C5/C6
Suggested by: Loss of biceps jerk.
Confirmed by: MRI of disc space
Posterior root
lesion in L3/L4
Suggested by: Loss of knee jerk
Confirmed by: MRI of disc space
Posterior root
lesion in S1/S2
Suggested by: Loss of ankle jerk
Confirmed by: MRI of disc space
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 13 Neurological signs
354
Gait abnormality
Some differential diagnoses and typical outline evidence
Somatization
‘functional’
cause
Suggested by: bizarre gait with exaggerated delay on
affected limb. No other physical signs of a lesion
Confirmed by: patience and careful follow-up
Contralateral
pyramidal tract
lesion
(in cerebral
hemisphere,
internal capsule,
brain stem,
or spinal cord)
Suggested by: stiff leg swung in arc. Other motor
(± sensory) localizing signs indicating level of lesion
Confirmed by: CT scan or MRI of probable site
Parkinsonism Suggested by: shuffling gait, paucity of facial expression
and movement, stiffness, tremor, etc.
Confirmed by: response to treatment by dopamine
agonist drugs, etc.
Cerebellar
lesion (tumor,
ischemia, etc.)
Suggested by: wide-based gait, inability to stand with
feet together, falling to one side (truncal ataxia). Loss
of tone and reflexes on same side as lesion
Confirmed by: MRI of posterior fossa of brain
Dorsal column
loss or periph-
eral neuropathy
(due to vitamin
B
12
deficiency,
etc.)
Suggested by: bilateral stamping, high-stepping gait,
unsteadiness made worse by closing eyes (positive
Romberg’s sign)
Confirmed by: nerve conduction studies and response
to treatment of cause (if found)
Bilateral upper
motor neuron
lesion (usually
in spinal cord)
Suggested by: “scissors” or “wading-through-mud”
gait. Bilateral leg weakness and brisk reflexes
Confirmed by: MRI of clinically probable site of lesion
GAIT ABNORMALITY1
355
Pelvic girdle
and proximal
muscle weakness
(e.g., due
to hereditary
muscular
dystrophy
Suggested by: waddling gait (hip tilts down when leg
lifted). Hypotonic limb weakness and poor reflexes
Confirmed by: EMG
Joint, bone or
muscle lesion
Suggested by: hobbling with minimal time spent on
affected limb. Tenderness and limited range of
movement
Confirmed by: X-rays and response to treatment or
resolution of cause
Lateral popliteal
nerve palsy
Suggested by: unilateral stamping, high-stepping gait
with foot drop. Flaccid weakness around ankle. Loss of
sensation of lateral lower leg
Confirmed by: nerve conduction studies
Drug effect Suggested by: wide-based gait, nystagmus, past pointing.
History of alcohol intake or other drug
Confirmed by: raised alcohol or other drug level,
improvement with withdrawal
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 13 Neurological signs
356
Difficulty in rising from chair or
squatting position
Some differential diagnoses and typical outline evidence
Polymyositis Suggested by: muscle wasting, weakness, and poor
reflexes
Confirmed by: EMG and muscle biopsy
Carcinomatous
neuromyopathy
Suggested by: muscle wasting, weakness, and poor
reflexes. Evidence of cancer (usually late stage)
Confirmed by: EMG and evidence of carcinomatosis
Thyrotoxicosis Suggested by: weight loss, tremor, sweating, anxiety,
loose bowels. iT3 or T4 and ddTSH
Confirmed by: response to treatment of thyrotoxicosis
Diabetic
amyotrophy
Suggested by: long history of diabetes mellitus
Confirmed by: nerve conduction studies and muscle
biopsy
Cushing’s
syndrome
Suggested by: facial and truncal obesity with limb
wasting
Confirmed by: high midnight cortisol, etc., and
response to treatment
Osteomalacia Suggested by: dcalcium and ialkaline phosphatase
Confirmed by: response to treatment with calcium and
vitamin D
Hereditary
dystrophy
Suggested by: evidence of primary muscle disease and
family history
Confirmed by: muscle biopsy
Chapter 14
357
GU symptoms
Urinary frequency ± dysuria 358
Incontinence of urine alone (not feces) 359
Incontinence of urine and feces 360
Painful hematuria (with dysuria) 361
Painless hematuria 362
Secondary amenorrhea 363
Excessive menstrual loss: menorrhagia 364
Intermenstrual or postcoital bleeding 365
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 14 GU symptoms
358
Urinary frequency ± dysuria
Some differential diagnoses and typical outline evidence
Urinary tract
infection (UTI)
Suggested by: vomiting, fever, abdominal pain,
initirites, white cells, and blood on urine dipstick
Confirmed by: Mid-stream urine (MSU) microscopy and
culture. Ultrasound scan for possible anatomical ab-
normality
Bladder or
urethral
calculus
Suggested by: suprapubic pain, macroscopic or
microscopic hematuria
Confirmed by: ultrasound of bladder, plain X-ray, intra-
venous urogram (IVU)
Uterine
prolapse
Suggested by: incontinent of urine, cervix observed in
lower vagina
Confirmed by: pelvic examination
Prostatic
hypertrophy
Suggested by: hesi
t
ancy, poor stream, large prostate on
rectal examination
Confirmed by: prostate-specific antigen (PSA)i, ultra-
sound of prostate gland, and response to transurethral
resection of the prostate (TURP)
Spastic bladder
due to upper
motor neuron
lesion
Suggested by: weakness, increased tone and reflexes in
lower limbs
Confirmed by: small bladder on ultrasound
INCONTINENCE OF URINE ALONE (NOT FECES)1
359
Incontinence of urine alone (not feces)
Some differential diagnoses and typical outline evidence
Prostatism Suggested by: hesitancy, dribbling, poor stream,
frequency
Confirmed by: iPSA
, ultrasound of prostate gland
Uterine prolapse Suggested by: low-volume urinary frequency
Confirmed by: pelvic examination
Urinary tract
infection (UTI)
Suggested by: dysuria, frequency, fever, vomiting,
initrites, white cells, and blood on dipstick
Confirmed by: MSU microscopy and culture. Ultra-
sound scan for possible anatomical abnormality
Weakness of
pelvic floor
muscles
Suggested by: incontinence during coughing, sneezing,
laughing
Confirmed by: Urodynamic studies
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
CHAPTER 14 GU symptoms
360
Incontinence of urine and feces
Some differential diagnoses and typical outline evidence
Neurogenic
bladder
Suggested by: paresis, low tone and diminished
reflexes in lower limbs, sensory loss in anal region
Confirmed by: small and spastic bladder (upper motor
neuron) or large and hypotonic bladder (lower motor
neuron) on ultrasound scan
Seizures Suggested by: history of loss of consciousness, tongue
biting, jerking movements
Confirmed by: clinical history, EEG
Dementia Suggested by: chronic worsening confusion, elderly,
previous strokes
Confirmed by: low mental scores, cerebral atrophy on
CT head scan
Severe
depression
Suggested by: severe lack of motivation
Confirmed by: response to treatment of depression
Fecal
impaction with
overflow
Suggested by: hard, rock-like feces in rectum
Confirmed by: response to evacuation of feces
PAINFUL HEMATURIA (WITH DYSURIA)1
361
Painful hematuria (with dysuria)
Some differential diagnoses and typical outline evidence
Urinary tract
infection
Suggested by: dysuria, frequency, ± low-grade fever ±
abdominal pain, i nitrites, white cells, and blood on
urine dipstick
Confirmed by: MSU microscopy and culture. Ultra-
sound scan for possible anatomical abnormality
Renal calculus Suggested by: dysuria, spasmodic loin-to-groin pain, no
fever
Confirmed by: urinalysis, renal ultrasound, IVU
Trauma Suggested by: dysuria, urethral catheterization, or
recent painful sexual intercourse (“honeymoon
cystitis”)
Confirmed by: history, normal MSU renal ultrasound, IVU
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
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