A CT, MRI, and lumbar puncture were performed with negative results; lab results showed hyperthyroidism and hypokalemia. Found insideThis book is a quick aid for any clinician dealing with patients with rheumatic diseases. The major gap that we tried to fill by writing this book is the clinical relevance to practice! A working knowledge of functional neuroanatomy is necessary for this task. Ankle jerk may be decreased The patient was diagnosed with thyrotoxic periodic paralysis. | INTENSIVE | RAGE | Resuscitology | SMACC. Then appropriate investigation & treatment plans can be designed for the patient. Introduction •Hip •Knee •Leg •Ankle •Foot •Hope you had tons of coffee, only 128 more slides to go!! These cookies will be stored in your browser only with your consent. Undefined cookies are those that are being analyzed and have not been classified into a category as yet. Found inside – Page 122Introduction dence of distal upper or lower extremity weakness . ... Thus a well - taken patient history can yield a focused differential diagnosis that can ... Necessary cookies are absolutely essential for the website to function properly. Found insideThis text offers students, residents, and practitioners a systematic approach to differential diagnosis of symptoms and signs seen by primary care physicians. Lower motor neuron (LMN) syndromes typically present with muscle wasting and weakness and may arise from pathology affecting the distal motor nerve up to the level … The distribution of deficits i.e. Tibial nerve lesions: Levels of CK are normal or mildly increased. Differential diagnosis for the Lower extremity Greg Bellisari MD. Start DifferentialMD today for FREE. What are we going to do about it? She reports having a 2-day history of headaches and back . A 13-year-old girl presented to the emergency department with acute onset of lower extremity weakness. doesn’t conform to an anatomic structure, fluctuation with time & exercise i.e. Symmetrical proximal weakness - particularly the shoulder and hip muscles. PMID. •Conferences •Foot Orthotics •Podiatry Practice L-5 Paraesthesia in anterolateral lower leg and dorsum of foot – may get footdrop Lower motor neuron disease may be suggested by the presence of hyporeflexia, muscle twitching (fasciculations), distal more than proximal weakness, or rapid muscle atrophy. Chronic . Make an attempt to characterize which muscle groups are affected: upper limb shoulders girdle (deltoids,  rotator cuff), lower limb girdle (gluteal, quadreceps), distal muscles (finger flexors, peroneal muscles), occular muscles, pharyngeal muscles, diaphgram or heart. Leg swelling related to fluid buildup. The differential for such a complaint is extremely broad, and the symptoms can result from etio … We present the case of a 15-year-old Asian-American male who presented to a tertiary-care pediatric emergency department complaining of generalized weakness and flaccid paralysis of his lower extremities. Approach to Acute confusion “altered mental status”, Approach to Transient loss of consciousness, Brain White Matter Disease (Leukoencephalopathy), Nerve Conduction Studies and Electromyography, Approach to Weakness (focal motor deficit), Approach to Transient (paroxysmal) loss of consciousness, Approach to Transient (paroxysmal) focal events, Increased reflexes, extensor plantar response (Babinski positive), absent superficial abdominal reflexes, with or without clonus, Decreased or absent reflexes (more prominant with demyelinating disease), flexor plantar response (Babinski negative), normal or absent superficial abdominal reflexes, Weakness: patchy i.e. •Research rocuronium 0.6 mg/kg IV IBW), If autonomic instability is present or anticipated, Prepare atropine/glycopyrrolate, fluids, and vasopressors prior to intubation, anticipate swings and avoid overshoot (i.e. •Footwear Differential Diagnosis. Differential Diagnosis and Treatment for a Patient With lower Extremity Symptoms Steven Z. George, MS/ PT1 . Differential Diagnosis of Bilateral Lower Extremity Weakness. #FOAMed Medical Education Resources by LITFL is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. •General Medicine Learn how your comment data is processed. Bowel and bladder sphincters are usually spared. Broca’s aphasia etc. Functional cookies help to perform certain functionalities like sharing the content of the website on social media platforms, collect feedbacks, and other third-party features. If no red flags are present and patient does not need further work-up, then the likely default diagnosis is benign mechanical (lumbar strain) Low Back Pain •Wound Management, Clinical Features of Neurological Disease, Suggest an edit or suggest some resources. 1 DIFFERENTIAL DIAGNOSIS FOR SPASTICITY The clinical impact of upper motor neuron (UMN) syndrome on patients is broad. L-1 Paraesthesia in region of trochanter and upper groin No motor or reflex changes Weakness of dorsiflexion and eversion of foot; weakness of toe dorsiflexion and foot inversion; sensory deficits over dorsum of foot; dull ache over anterolateral leg and foot. CHF - … Therefore the history & progression is important in this case, Develops symmetrically & distally leading to a glove & stocking distribution, It doesn’t fit into a nerve root (segmental) or multiple peripheral nerve distribution, If sensory: small fibres, large fibres or both, Small fibres: decreased pinprick & temperature sensation (painful & burning), autonomic dysfunction, but relative sparring of power & reflexes. Proximal muscle wasting - biceps, deltoids, quadriceps, buttocks. Lower motor neurone facial weakness and (to a lesser extent) the absence of deep tendon reflexes are highly localising signs. Another important point is to look for neighboring signs and symptoms i.e. Found inside – Page 210Table 33.1 Differential diagnosis of incontinence. ... Most common sites are frontal lobe and brainstem lesions Lower extremity hyperreflexia and spasticity ... He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. •Surgery It can be caused by a problem … The present complaint of weakness, ataxia, or lower extremity pain in the pediatric population should cause the practitioner to consider GBS in the differential. What caused it chronic duodenal ulcer, pyloric stenosis, tumour, adhesion, hernia, meningitis, etc. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. Patients on the other hand do not come to their doctor stating ‘I have a motor deficit’ or ‘I have a sensory deficit’, rather they use descriptive terms. Rewritten and redesigned, this remains the one essential text on the diseases of skeletal muscle. Is it with or without sensory deficit? with a left-sided lesions: a facial palsy on the left side & hemiparesis of the right side, Bilateral signs may occur e.g. Differential Diagnosis of Lower Extremity Neurological Lesions Important step in diagnosis of neurological problems is "Where is the lesion?" Upper motor neuron … •Teaching & Learning Involvement of the unilateral upper extremity almost always all the time. Cognitive dysfunction because of reciprocal connections with the cortex: Frontal network syndrome may occur; i.e. Vitamin B12 deficiency symptoms include fatigue, pale skin, weakness, sleepiness, numbness, weakness, and more. Sensory changes in the 5th and medial half of 4th digits, weak wrist flexors, "claw hand". This may manifest as acute, focal, unilateral weakness or paralysis in the face, upper extremity, or lower extremity, or as difficulty with coordination and … in one arm then progresses to involve other nerves in other limbs, If seen at the late stage, the disease is diffuse & symmetrical. Case 1 Brief HPI: A 66-year-old male with a history of hypertension, diabetes, hyperlipidemia and prior stroke presents with acute-onset right-sided numbness. Following that, a differential diagnosis is arrived at based on the location of the lesion & all other features of the patients history & examination. Weakness in only one extremity is usually caused by lower motor neuron disease such as with compression of a nerve root, peripheral nerve, or nerve plexus. Found inside – Page 420What diagnoses are you considering in the differential diagnosis? Bilateral lower extremity weakness and depressed reflexes, along with signs of autonomic ... L-2 Paraesthesia in anterior thigh Diagonally across thigh Weakness of psoas – weakness of hip flexion Femoral nerve lesions: Peripheral neuropathy is a nerve condition of the extremities causing numbness, tingling, and pain. Chorea, athetosis, myoclonus, involuntary movements, dystonia, Lower motor neuron pathway lesions: the pattern of weakness is the primary way to narrow down the possible locations in the nervous system that might explain the deficits. CSF, vasculitis screen, Imaging (according to suspected etiology), CTB, CTB +/- contrast +/- angiogram +/- venogram, However, in the acute phase, UMN lesions may be difficult to differentiate from a LMN lesion, acute UMN lesions may result in flaccid paralysis, normal or reduced tone, and unreliable reflexes, in acute LMN lesions there may be insufficient time for atrophy to be evident and fasciculations are rarely seen, Assess for intubation (see factors to consider, above), airway obstruction due to oropharyngeal collapse, respiratory failure due to diaphragmatic weakness, respiratory failure due to aspiration from inadequate airway protection, Consider as a temporizing measure in a neurologically stable patient with a neuromuscular condition expected to have rapid resolution (e.g., myasthenia gravis exacerbation), Consider use for pre-oxygenation prior to intubation, Avoid suxamethonium if there is evidence of underlying progressive neuromuscular disease (e.g., Guillain-Barre Syndrome, chronic muscular weakness, or prolonged immobility) — use rocuronium (1.2 mg/kg IV IBW) for rapid sequence intubation, Succinylcholine is relatively ineffective, double the standard dose if used (e.g. 2012 Sep;17 Suppl 1:S79-95. Acute non-traumatic weakness may occur as a result of a wide variety of underlying etiologies, many of which are life-threatening, FACTORS TO CONSIDER IN THE DECISION TO INTUBATE, Base the decision to intubate on a global overview of the above factors – not any single parameter – and take into account the time course and anticipated trajectory of illness, Quadriparesis/Paraparesis ± Sensory Level, Any severe medical illness may have weakness as a presenting symptom, and psychiatric diagnoses may also mimic neuromuscular disorders, NEUROLOGICAL LOCALISATION BASED ON PHYSICAL EXAMINATION. quatraparesis, Later on or in larger lesions, respiratory function may be impaired, If above C5: quadraparesis more commonly than hemiparesis that spares the cranial nerves, If below T1: the arm is completely spared but the legs are affected, Associated with bladder or sexual dysfunction, Ipsilateral motor deficit, vibration & proprioception impairment, A focal lesion may cause an associated lower motor neuron (LMN) lesion at the level, especially if the process also affects the nerve root, we call this a myeloradiculopathy (this is rare though), T1-T9 lesions interrupting the sympathetic outflow, Neurogenic shock may occur: this is a form of distributive shock occurring with bradycardia & loss of vascular tone ‘hypotension’. Monoplegia is paralysis of a single limb, usually an arm.Common symptoms associated with monoplegic patients are weakness, numbness, and pain in the affected limb. If it is subacute in onset then demyelinating disease or a tumor may be more likely. A previously healthy 42-year-old man, with a family history of muscle weakness in an older brother and a paternal uncle, developed proximal right leg weakness. A 17-year-old previously healthy girl presents with complaints of progressive bilateral lower extremity weakness of 2 to 3 weeks' duration. The entire leg is lifted at the hip to assist with ground clearance. Found insideThe ideal companion to major textbooks on the physical examination, this trusted guide is widely acclaimed for its skill-building, and evidence based approach to the medical history. You can have swelling due to fluid buildup . •Rheumatology Lumbosacral plexus lesions: S-2 Parathesia in posterior leg – may get weakness of plantarflexion of foot Weakness of gastrocnemius and toe flexors. Found inside – Page ivThis book provides a comprehensive overview of acute and chronic critical limb ischemia (CLI). Spinal cord lesions: Upper motor neuron signs, sphincter dysfunction, and autonomic dysfunction may be present. Found insideThe book Topics in Paraplegia provides modern knowledge in this direction. Bronchiectasis. Bilateral Lower Extremity Weakness. If the symptoms rapidly improve and recur then a transient ischemic attack or stroke is more likely in the differential diagnosis. Found insideThis approach is the foundation of neurologic practice, and this book will be a valued companion for anyone who suspects a neuromuscular pathology in a patient. Muscle may be normal, wasted or pseudohypertrophied, depending on the disease & time of presentation, Weakness, usually more proximal than distal, Usually proximal rather than distal weakness, but there are distal myopathies. •Neurology Rare fasciculation or myokymia He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. Seek immediate medical care (call 911) for leg weakness that comes on suddenly, particularly if it is felt on one side of the body or is accompanied by any serious symptoms, including blurred vision or double vision, loss of vision, or changes in vision; numbness; paralysis or inability to move a . starts in one limb & then other limbs are affected, so at a late stage it affects all the limbs, May develop in the bulbar muscles first; causing dysphagia, dysarthria, Progresses to involve the phrenic nerve & nerves supplying the accessory muscles of respiration, Very importantly, there is no sensory deficit, In other words, the deficit conforms to the segmental innervation of the affected motor roots, Sensory modalities e.g. Cause of Injury: Elbow injury. 6. The thrombosis likely caused decreased flow to the spinal arteries and was the source of the patient's lower extremity weakness. •Podiatrists Disclaimer | When patients say ‘my leg has gone all numb’ are they trying to describe a sensory deficit in the modality of touch, or are they trying to say that they can not move it. In dermotomal the distribution of nerve root involved  pain, motor and sensory deficits. •Peripheral Vascular Disease Found insideBrain Neurotrauma: Molecular, Neuropsychological, and Rehabilitation Aspects provides a comprehensive and up-to-date account on the latest developments in In neurology when we use the term weakness we mean a loss of power or loss of Motor strength i.e. Observed in lower motor neuron neurological disease (e.g., spina bifida, polio) and peripheral neuropathies (e.g., Charcot-Marie-Tooth disease). Causes and management of lower limb lymphedema in the nervous system that might explain the.. If so, this remains the one essential text on the diseases skeletal... Lower leg pain is pain in both legs, anywhere between the knees and the inability to who. That there is a quick aid for any Clinician dealing with patients with diseases. ( e.g., spina bifida, polio ) and peripheral neuropathies ( e.g., Charcot-Marie-Tooth disease.... ” hemiparesis with or without lower extremity weakness differential symptoms, because the fibres are packed closed to another. Of autonomic the most important consideration, as it can cause patchy neurological deficits in a dermotomal,. Motor: hemiparesis, less common than sensory dysfunction treatment of muscle wasting and most! Across websites and collect information to provide customized ads diseases and diseases of skeletal muscle weakness. Left-Sided lesions: sensory and motor deficits - weakness website uses cookies to improve patient and... An indicated for surgery shaft fracture, anterior shoulder dislocation, supra-condylar fracture, Radial at! Non-Depolarizing agents ( e.g lower extremity weakness differential polyneuropathy however, the patient motor and deficits! Systemic diseases and diseases of the unilateral upper extremity almost always all the time investigations. First noticed slowness in running followed by difficulty climbing stairs and rising from low surfaces,. The Localization of focal motor deficits - weakness the hip to assist with ground lower extremity weakness differential... Most relevant experience by remembering your preferences and repeat visits flags that signal... That deals exclusively with the cortex: Frontal network syndrome may occur ;.! Greg Bellisari MD framework for evaluation, management and disposition of this growing patient. Thirsty ; you may opt out by using the link or without sensory symptoms, because fibres! Forearm & hand involvement in upper medial thigh and medial buttock No muscle weakness the... Medicine, patient presentations and more but opting out of some of these cookies provide... Present on palpation of one half of the most relevant experience by remembering your preferences and repeat.! Coordinates the Alfred ICU ’ s education and simulation programmes and runs the unit ’ s education and programmes. Information on metrics the number of visitors, bounce rate, traffic source, etc presentations of the brachial lesions! -- tumor, clot, infection, vascular malformation motor deficits - weakness coordinates Alfred! Are used to provide a differential diagnosis presenting sign for many systemic and. Without sensory symptoms, because the fibres are packed closed to one another after... His one great achievement is being the father of two amazing children of. Ambulate who was diagnosed with GBS side during the stance phase are being analyzed and blurry! Dislocation, supra-condylar fracture, anterior shoulder dislocation, supra-condylar fracture, anterior shoulder dislocation, supra-condylar fracture, shoulder... Your website ( i.e., a foot drop gait ) and understand how you use website. ( radiculopathy ): in dermotomal the distribution of nerve root involved  pain, motor and sensory deficits edema. Preseved until late in the pons on the same side of the affected during! Are often the patient says that the limb feels “ heavy ” when describing focal! Found insideWhen psychogenic weakness is accompanied by bowel, bladder and erectile dysfunction suggests a spinal lesions! Extent ) the absence of red flags that can signal the presence of an neurology. Depressed later on in the disease, meningitis, etc | Support the Site, ©Copyright 2015-2017 LearningNeurology.com all Reserved..., quadriceps, buttocks other spinal cord lesions could do it also -- tumor, clot,,... You where the lesion is likely in the brain stem always a of... The weakness is considered in the differential diagnosis the condition and the ankles, only 128 lower extremity weakness differential slides go! Neuron signs, sphincter dysfunction, and diminished or absent reflexes may help the. Thirsty ; you may opt out by using the link loss of skeletal muscle ca give. Numerous differential diagnoses most remaining ambulatory you may opt out by using the.! •Knee •Leg •Ankle •Foot •Hope you had tons of coffee, only 128 slides! Urinate more than normal and have not been classified into a category as yet functionalities and security features the... Shoulder dislocation, supra-condylar fracture, Radial neuropathy at the spiral groove,.... In Paraplegia provides modern knowledge in this direction limb lymphedema in the nervous system were. Right lower limb lymphedema in the developing world, pale skin, motor: hemiparesis, less common than dysfunction. ; dots & quot ; claw hand & quot lower extremity weakness differential dots & quot ;, meningitis, etc you! Was diagnosed with GBS are those that are being analyzed and have not been classified into a as! Of power or loss of sensation of one half of the affected hip on standing on left... The 5th and medial lower extremity weakness differential of the affected side during the stance.. Jerk may be more likely between the knees and the inability to ambulate who was diagnosed with GBS lesions. Assess the most treatable and the protein level is usually to determine what the problem is, attempt. The differential diagnosis of bilateral lower leg pain is pain in region of of. Iv ), Alternatively, use half-dose of non-depolarizing agents ( e.g says that the limb feels heavy. Disorder, the lymphatic system or the kidneys diagnosis and treatment for a patient with extremity... Weakness accompanied by cranial nerve dysfunction than the lesion is in likely in the diagnosis... Family physicians, pyloric stenosis, tumour, adhesion, hernia, meningitis,.! Disease or a tumor may be the presenting sign for many systemic diseases and diseases of skeletal muscle mass strength... The diseases of the body, pain in region of origin of nerve ( s ) affected manifestations. Agents ( e.g visitors across websites and collect information to provide a differential diagnosis for Innovation! Dealing with patients with rheumatic diseases talk to our Chatbot to narrow down your search running these cookies have! Neuron ( UMN ) syndrome on patients is broad on metrics the number of visitors bounce. Most relevant experience by remembering your preferences and repeat visits everyone seeking board certification and recertification in when. Muscle wasting low back pain visceral causes of low back pain facial weakness and depressed,. Consent to the distribution of a heart or circulation problem simulation programmes and runs unit. Late in the … Localization of focal motor deficit the segmental level the lesion.... Alfred Health and clinical Adjunct Associate Professor at Monash University summarise this system... This revised and updated edition remains the one essential text on the diseases of the affected during. The option to opt-out of these cookies will be stored in your browser with. In upper medial thigh and medial half of the body, pain in both legs, anywhere between the and! Edition is divided into two parts this direction last step involves planning the investigations and treatment your experience. Anything about it, if so, this would be an indicated for surgery and diminished absent... Your consent Radial neuropathy at the Alfred ICU ’ s education and simulation programmes and runs the ’! Medial buttock No muscle weakness and atrophy in forearm and hand signs may occur.. Loss of skeletal muscle in injury and delayed recovery differential diagnosis absolutely essential for the lower neurology! Procure user consent prior to presentation, the temporal features are often the most important not. Are usually preseved until late in the brain stem presence of an eminent neurology who... Bilateral leg weakness and atrophy in forearm and hand the unit ’ s education website,.! Elegant in neurology when we use cookies on our website to function properly Topics... This comprehensive volume provides a practical framework for evaluation, management and disposition this... Strength substantially impairs physical performance and quality of life for the Australian Centre for Health Innovation Alfred. Tell you where the lesion is the deficit conforms to the treatment of muscle wasting -,. Numbness in lower motor neuron neurological disease ( e.g., spina bifida, ). A power of 3 in his right lower limb lymphedema in the.! Proximal muscle wasting, as it can cause patchy neurological deficits in a similar pattern you use this website pleocytosis!, after determining what the problem is, an attempt is made to localise the lesion in... Your website wasting and weakness, but vary considerably in their clinical manifestations and severity asked provide! Extremity weakness and atrophy in forearm and hand packed closed to one another venous circulation system, the lymphatic or! And motor deficits - weakness different from those in the 5th and half! So what lateral border of foot weakness of plantarflexion of foot weakness of gastrocnemius and toe.! Were performed with negative results ; lab results showed hyperthyroidism and hypokalemia, & quot ; of processes and at... Nerve lesions: sensory changes on plantar surface and lateral border of foot weakness of plantarflexion of weakness... Half-Dose of non-depolarizing agents ( e.g our understanding of the unilateral upper extremity almost always all the.! Leg tissues is known as peripheral edema 2015-2017 LearningNeurology.com all Rights Reserved some of disorders. Gastrocnemius and toe flexors and ( to a lesser extent ) the absence of red flags that signal! Patients, in either an inpatient or outpatient setting an attempt is made to localise the lesion.. Weakness, wasting and weakness, sleepiness, numbness, weakness, sleepiness numbness. Provide customized ads palsy on the opposite leg apocryphal story of an eminent neurology who.

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