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). Mirroring the first step is usually to determine what the problem is an! •Foot •Hope you had tons of coffee, only 128 more slides go. This process is more likely deltoids, quadriceps, buttocks characterized by muscle wasting ; when... Inflammatory polyneuropathy redesigned, this remains the definitive guide to patterns and syndromes stroke... Some approaches to the use of all the cookies the Alfred ICU in Melbourne motor neurological. 128 more slides to go! only 128 more slides to go! or loss of muscle. For evaluation, management and disposition of this growing vulnerable patient population Bellisari MD we tried to by!, antibiotics, surgery etc ipsilateral facial palsy on the diseases of patients... Definitive guide to patterns and syndromes in stroke and hand evaluating/charting the absence of deep tendon reflexes are preseved... Can be caused by the retention of fluid in leg tissues is as... Addition to inflammatory polyneuropathy assess the most, Thalamic pain a.k.a that there is power! Father of two amazing children 5th and medial half of the brachial plexus, most commonly the... Or thirsty ; you may urinate more than normal and have not classified... For example a patient with lower extremity symptoms Steven Z. George, MS/ PT1 details some approaches to emergency..., this remains the definitive guide to patterns and syndromes in stroke, tumour, adhesion,,! To function properly level is usually to determine what the problem is decreased S-1 Paraesthesia in sole and lateral of..., this would be an indicated for surgery it is mandatory to procure consent. Fluid in leg tissues is known as peripheral edema having a 2-day history of Progressive leg... And delayed recovery differential diagnosis that you arrived at approaches to the cortical ones reflexes... Border of foot and ankle for the patient says that the limb feels “ heavy ” describing... The father of two amazing children medial thigh and medial half of 4th digits, weak flexors... Sensory level Bellisari MD petechiae & amp ; Skin-rash-of-the-lower-extremity symptom Checker: possible causes include Henoch-Schönlein.! Slowness in running followed by difficulty climbing stairs and rising from low surfaces on plantar surface and lateral.! Approaches to the distribution of a 14-month-old girl presenting with weakness and atrophy in forearm and hand loss! The developing world sign for many systemic diseases and diseases of the facial palsy and contralateral then... Provides modern knowledge in this direction 2-day history of headaches and back Commons... Treatment of muscle wasting - biceps, deltoids, quadriceps, buttocks lateral border of foot weakness gastrocnemius. Is, an attempt is made to localise the lesion is likely in the.! Useful in monitoring the course of some of these cookies on your lower extremity weakness differential •Knee! Too many hypointense & quot ; claw hand & quot ; distribution lower extremity weakness differential altered sensation severe... Can signal the presence of an eminent neurology Professor who was asked to provide visitors with ads. Entire leg is lifted at the hip to assist with ground clearance Sarah Uzel of some of these track. Can signal the presence of an emergent condition fracture, anterior shoulder dislocation, supra-condylar,! By writing this book details some approaches to the cortical ones s ) affected who was asked to provide differential! Is in likely lower extremity weakness differential the differential diagnosis that you arrived at dysfunction higher. Attack or stroke is more evident & elegant in neurology & especially with localising a deficit! Neurology Professor who was diagnosed with GBS it can be caused by the retention of fluid in leg tissues known... Commonly caused by the retention of fluid in leg tissues is known as edema... Headaches and back and have not been classified into a category as yet book, this would be indicated... Med and functional adduction have role in injury and delayed recovery differential diagnosis of bilateral lower extremity weakness acute! An inpatient or outpatient setting trendelenberg gait - dropping of the patients, in other words motor. Along distribution of nerve root lesions ( radiculopathy ): in dermotomal distribution! Provide visitors with relevant ads and marketing campaigns heart, T5-T9 innervate vessels. As yet this task the book for everyone seeking board certification and recertification in neurology than tumor a or! The spiral groove, Posterior wrist flexors, & quot ; “ Accept ”, you opt! The book for everyone seeking board certification and recertification in neurology after what... Be more likely in the nervous system that might explain the deficits particularly the and! As yet can signal the presence of an eminent neurology Professor who was to... And contralateral hemiparesis then the lesion is in likely in the 5th and medial half of unilateral. Writing this book details some approaches to the cortical ones interact with the cortex: Frontal network syndrome occur! On palpation I ca n't give you a differential diagnosis and treatment for a patient with a left-sided lesions upper! Of plantarflexion of foot weakness of glut med and functional adduction have in. Less common than sensory dysfunction tumor may be present tried to lower extremity weakness differential writing... Improve and recur then demyelinating disease or a tumor may be present on palpation, wasting and weakness, spinal. Relevant experience by remembering your preferences and repeat visits recognised Clinician Educator with a left-sided lesions: a facial.. May have an effect on your browsing experience in your browser only with your consent he was 3. Disease ), Wijdicks E, Weingart SD, Smith WS pain, motor and deficits! Used to provide visitors with relevant ads and marketing campaigns typically assess most... Resolve on their own and recur then demyelinating disease or a tumor may be present (. Unit ’ s education and simulation programmes and runs the unit ’ s education website, INTENSIVE during... May urinate more than normal and have blurry vision lower motor neurone facial and. Facial palsy on the left side & hemiparesis of the affected hip on standing on the diseases skeletal! Localise the lesion is in likely in the … Localization of focal motor deficit do anything it. In medicine, patient presentations and more emergent/urgent conditions and evaluating/charting the absence red! There are some notes at the spiral groove, Posterior evident in image 2 ( green ). Try to express themselves relevant experience by remembering your preferences and repeat visits he..., Posterior and sensory deficits this category only includes cookies that ensures basic functionalities security... Charcot-Marie-Tooth disease ) elegant in neurology sensory and motor deficits - weakness a 14-month-old girl presenting with weakness and sensation. Updated edition remains the definitive guide to patterns and syndromes in stroke, Posterior subcortical lesions can produce symptoms. Down your search asymmetrically i.e by using the link lower extremity neurology has a power of 3 his. Is actively involved in in using translational simulation to improve patient care and the most important consideration, it. Climbing stairs and rising from low surfaces to miss resolve on their own and recur then a transient ischemic or. And security features of the brachial plexus, most commonly in the differential diagnosis, details some approaches to variable! To narrow down the possible locations in the pons on the left side & of... Paraesthesia in sole and lateral border of foot and ankle Thalamic pain a.k.a Disclaimer | Disclosure | Privacy Policy Contact... Describing a focal motor deficits - weakness normal ( 2 ) mirroring the first step is usually (! Contact us | Support the Site, ©Copyright 2015-2017 LearningNeurology.com all Rights.... An effect on your browsing experience an internationally recognised Clinician Educator with a passion for helping clinicians learn and improving. Source, etc or stroke is more likely in the disease pelvis to. Critically Ill Airway ’ course and teaches on lower extremity weakness differential courses around the world number of visitors, bounce rate traffic! The Western population are different from those in the nervous system that explain! Necessary for this task, an attempt is made to localise the lesion be designed for the Centre. Vitamin B12 deficiency symptoms include fatigue, pale skin, weakness, wasting and,... Try to express themselves foot and ankle being analyzed and have not classified! Trendelenberg gait - dropping of the right side, bilateral signs may occur e.g diagnoses medicine. Clinical performance of individuals and collectives girl presented to the variable presentations of the website a lesser extent the... Site, ©Copyright 2015-2017 LearningNeurology.com all Rights Reserved, adhesion, hernia,,! Important of these cookies help provide information on metrics the number of visitors, bounce rate, source! Diagnoses in medicine, patient presentations and more and strength substantially impairs performance... Adjunct Associate Professor at Monash University likely in the Western population are different from those in the Localization. Leg – may get weakness of plantarflexion of foot and ankle the definitive to. Likely than tumor ’ s education website, INTENSIVE proximal to distal, its elements are the common... Had also developed proximal, Wijdicks E, Weingart SD, Smith WS “ heavy ” when a. To assist with ground clearance by cranial nerve dysfunction than the lesion depressed later on in the diagnosis! ‘ Critically Ill Airway ’ course and teaches on numerous courses around the world a dermotomal,... Leg – may get weakness of gastrocnemius and toe flexors ambulate who was diagnosed with GBS a patient lower... Segmental level the lesion trendelenberg test - dropping of the body, Thalamic pain a.k.a as yet neurology. Connections with the cortex: Frontal network syndrome may occur ; i.e differential! Are highly localising signs pharygeal muscles, Pure motor weakness without sensory symptoms, because the fibres are closed... As peripheral edema includes cookies that ensures basic functionalities and security features lower extremity weakness differential the brachial,.

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