a 20-year-old woman with slurred speech and weakness

yesterday we briefly examined a very pleasant university student who has been unwell since earlier this year

she was alert - we did not test her higher order cognitive function

she had obvious slurring of her speech, which had been present for a month or so

we concentrated on examining her arms

we talked (again) about the importance of INSPECTION

fasciculations can be quite hard to see, especially if the light is poor and the muscles involved are small, so really have a good look - make sure you turn the lights on & adequately expose the patient (which can be done comfortably and with dignity)
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as an aside, i wanted to mention motor neurone disease - i know very little about this condition; it results in upper and lower motor neurone signs; it must be one of the worst diseases and there are no treatments, riluzole, the only drug available increases life expectancy by a few months at best (miller et al, 2007);

here is link to a video of the historian tony judt talking about the disease

he died in august
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we went on to test tone and then power

this is often done quite badly

my most useful tip (after practise a lot) would be to slow down & think about what you are doing

use the MRC grading scale

if a patient uses their muscles to move their arm (or leg) into the correct position against gravity, then they have already scored 3/5
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here is a link to another website showing you how to do a neuro exam

i particularly like the muscle action & innervation chart in the motor section

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we talked about the decreased utility of testing for inco-ordination in the context of muscle weakness
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this lady has a diagnosis of multiple sclerosis

she has had several clinical events and has had a full diagnostic work up including MRIs, LP, VEP

the visual evoked potential involves being shown a visual stimulus, eg a pattern, and then measuring electrical responses primarily from the occipital lobe using EEG

[why the occipital lobe?]

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she was actually admitted for episodes of loss of consciousness, the cause of which is not entirely clear

interestingly she is due to have a tilt table test - i mentioned my ignorance of the effects of MS on the autonomic nervous system

she is in the midst of a relapse affecting her speech, face, right arm & leg, and is due to start steroids this week

Salaam

a 52-year-old woman with tiredness and visual disturbance

yesterday rory presented an interesting case of a middle-aged woman, previously pretty well, who has become increasingly tired over recent weeks


she has also had some blurriness of vision


TIRED ALL THE TIME (TATT)


this is a common complaint but can sometimes be very difficult to diagnose


(also a common OSCE scenario)
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i could not find a specific chapter in davidsons, harrisons or my favourite symptom book tutorials in differential diagnosis (written by eric beck who invented the MRCP exam & is still involved in PDS teaching at he whitt - i was his house officer many years ago; robert souhami was dean of UCL medical school)


in my library the best i could do was a case from an excellent MRCP book (case 2.50 in PACES for MRCP by tim hall)

however, i did find a BBC radio program all about TATT, part of the very good case notes series (with a full transcript available)
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we discussed various causes:


- major organ failures (heart, kidneys, liver, lungs)
- endocrine disorders (thyroid, diabetes, also addisons, hypopit)
- cancer
- depression
- anaemia
- auto-immune type disorders (rheumatoid, lupus, GCA, polymyalgia)
- drugs, eg beta-blockers


our patient did not have any features pointing to the specific causes above?
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we did not really go through investigations in detail
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while we did not examine her, you did go through her pupillary reactions with gordon


she had an afferent pupillary defect [like this one?]

these data point to the possibility of multiple sclerosis

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we briefly talked about this mostly relapsing-remitting condition

the diagnosis requires more than one 'attack' in more than one place

the criteria i learnt have now been replaced the the mcdonald criteria which incorporate the advances MRI has brought

rory was going to update us about MS [perhaps as a comment?]

we need to review her investigations, including MR imaging & LP

[tangentially, josiah bartlett, the fictional US president in the west wing, had MS & hid it from the electorate during his first election]

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we finished by considering what we would do to learn more

reading a textbook & wikipeding were mentioned

find another patient with MS (soon) is a particularly good strategy

Salaam

sabih