Tuesday, January 9, 2018

Approach to patient presenting with Numb toes - History and Examination

A middle aged man has developed numbness and tingling in his toes and feet, and more recently his fingertips. He also complains that he trips up more frequently.

Clinical Approach: This man has distal sensory symptoms and motor symptoms.  Here it is important to decide whether this is due to a peripheral cause ,  central or a combination of both.

Clinical History :
1. Is this an urgent case? Ask about the duration of symptoms and rate of progression.  Any worrying associated symptoms like loss of sphincter control or difficulty in breathing.

2. Differentiating between peripheral and central nervous system dysfunction:

A peripheral nervous system dysfunction is characterized by
  • tingling, numbness and burning in feet.  
  • Numb fingers. 
  • Foot drop
  • Difficulty in rising from a chair
  • Difficulty in going up and down stairs.  
A spinal cord lesion is characterized by
  • Legs and feet feeling stiff and heavy. 
  • Clumsy stiff hands
  • Sphincter disturbances. 
3. Duration of symptoms may help determine the cause of neuropathy.  

4. Any associated pain.

Past History: Ask specifically about:
  • Diabetes mellitus 
  • Alcohol intake 
  • Current medications
  • Dietary history 
  • Pernicious anemia 
  • Hypothyroidism 
  • Weight loss 
  • Smoking 
  • Neck trauma 
  • Rheumatoid arthritis. 
Clinical Examination: 
1. Signs in case of peripheral nervous system disorder 
  • Distal weakness 
  • Absent ankle reflexes
  • Stocking distribution sensory loss
  • Muscle wasting (if severe) 
2. Signs in case of central nervous system disorder 
  • Spastic tone
  • Weakness both proximal and dismally, but predominantly in leg flexor
  • Brisk reflexes 
  • Extensor plantars
  • Possible sensory level 

3. Is is important to check if the signs are symmetrical?

  • Asymmetry in the context of an upper motor neurone syndrome would represent a Brown-Sequard syndrome with loss of proprioception ispilateral to the weak leg, and loss of pain and temperature sensation contralateral to the weak leg. 
  • Asymmetric lower motor neurone findings suggest mononeuritis multiplex or entrapment neuropathic..
4. Check for associated cranial nerve pansies
  • Deafness in CN VIII
  • Bilateral facial weakness in Guillain-Barre syndrome and Sarcoidosis 
  • Malignant infiltration of the basal meninges may lead to multiple cranial nerve palsies. 
5. General Examination :
Look and check if the patient is systemically well? 
  • Cachexia may suggest malignancy or alcoholism 
  • Vasculitic rash in systemic vasculitis 
  • Look for signs of hypothyroidism 
  • Check 

Monday, November 27, 2017

Nausea And Weight Loss In A 45 Year old Alcoholic... Case Study

A 45 years old man consults his general practitioner (GP) with a 6-month history of reduced appetite
and a weight loss, from 78 to 71 kg. During the last 3 months he has had intermittent nausea, especially in the mornings, and in the last 3 months the morning nausea has been accompanied by vomiting on several occasions. For 1 month he has noted swelling of his ankles. Despite his weight loss he has recently noticed his trousers getting tighter. He has had no abdominal pain. He has no relevant past history and knows no family history as he was adopted.
He takes no medication. From the age of 18 he has smoked 5–6 cigarettes daily and drunk 15–20 units of alcohol per week. He has been a chef all his working life, without exception in fashionable restaurants. He now lives alone as his wife left him 1 year ago.

He has plethoric features. There is pitting oedema of his ankles. He appears to have lost weight from his limbs, but not his trunk. He has nine spider naevi on his upper trunk.
His pulse is normal, and the rate is 92/min. His jugular venous pressure (JVP) is not raised, and his blood pressure is 146/84 mmHg.
The cardiovascular and respiratory systems are normal.
The abdomen is distended. He has no palpable masses, but there is shifting dullness and a fluid thrill

Haemoglobin = 12.6 g/dL (normal = 13.3–17.7 g/dL)
White cell count = 10.2 × 109/L (normal = 3.9–10.6 × 109/L)
Platelets = 121 × 109/L (normal = 150–440 × 109/L)
Sodium = 131 mmol/L (normal = 135–145 mmol/L)
Potassium = 4.2 mmol/L(normal = 3.5–5.0 mmol/L)
Urea = 2.2 mmol/L (normal = 2.5–6.7 mmol/L)
Creatinine  = 101 μmol/L (normal = 70–120 μmol/L)
Total protein = 48 g/L (normal = 60–80 g/L)
Albumin = 26 g/L (normal = 35–50 g/L)
Bilirubin =  25 mmol/L (normal = 3–17 mmol/L)
Alanine transaminase = 276 IU/L (normal = 5–35 IU/L)
Gamma-glutamyl transaminase = 873 IU/L (normal = 11–51 IU/L)
Alkaline phosphatase = 351 IU/L (normal = 30–300 IU/L)
International normalised ratio (INR) = 1.4 (normal = 0.9–1.2)

Urinalysis: no protein; no blood

• What is the diagnosis?
• How would you manage this patient?

Thursday, September 28, 2017

Regarding Rotator Cuff Injury...

A 23-year-old man presents following a fall onto his left shoulder whilst playing rugby. He complains of pain throughout the shoulder and on examination has weakness when testing internal rotation of the arm compared to the contralateral side.
Radiographs are negative.

Injury to which tendon would explain his symptoms?
A Deltoid
B Infraspinatus
C Subscapularis
D Supraspinatus
E Teres minor


A first-time mother brings in her 5-day-old baby for a well-child visit....

A first-time mother brings in her 5-day-old baby for a well-child visit. The nurse weighs the infant and reports a weight of 7 lb 5 oz to the mother. The mother looks concerned and tells the nurse that her baby weighed 7 lb 10 oz when she was discharged 4 days ago.

The nurse’s best response to the mother is:
A. “I will let the doctor know, and he will talk with you about possible causes of your infant’s weight loss.”
B. “A weight loss of a few ounces is common among newborns, especially for breastfeeding mothers.”
C. “I can tell you are a first-time mother. Don’t worry; we will find out why she is losing weight.”
D. “Maybe she isn’t getting enough milk. How often are you breastfeeding her?”


Wednesday, September 27, 2017

A 40 Year old patient presenting with nausea, vomiting and abnormal liver function tests...

A 40-year-old school teacher develops nausea and vomiting at the beginning of the fall semester. Over the summer she had taught preschool children in a small town in Mexico. She is sexually active, but has not used intravenous drugs and has not received blood products.
Physical examination reveals scleral icterus, right upper quadrant tenderness, and a palpable liver. Liver function tests show aspartate aminotransferase of 750 U/L (normal < 40) and alanineaminotransferase of 1020 U/L (normal < 45). The bilirubin is 13 mg/dL (normal < 1.4) and the alkaline phosphatase is normal.

What further diagnostic test is most likely to be helpful?
a. Liver biopsy
b. Abdominal ultrasound
c. IgM antibody to hepatitis A
d. Antibody to hepatitis B surface antigen
e. Determination of hepatitis C RNA


Monday, September 25, 2017

Aortic Regurgitation - History, Examination And Study Questions & Answers

Clinical History
· Patients may be asymptomatic (but may have normal or depressed left ventricular function).
· Dyspnoea and fatigue (due to left ventricular impairment and low cardiac output initially on exertion).
· Symptoms of left ventricular failure in later stages.
· Angina pectoris is less common than in aortic stenosis; it usually indicates coronary artery disease.


1. Pulse
· Collapsing pulse (large volume, rapid fall with low diastolic pressure).
· Visible carotid pulsation in neck (dancing carotids or Corrigan's sign).
· Capillary pulsation in fingernails (Quincke's sign).
· A booming sound heard over femorals ('pistol-shot' femorals or Traube's sign).
· To and fro systolic and diastolic murmur produced by compression of femorals by stethoscope
(Duroziez's sign or murmur).

2. Heart

· Heart sounds are usually normal.
· Apex beat is displaced outwards and is forceful.
· Third heart sound (in early systole with bicuspid aortic valve).
· Early diastolic, high-pitched murmur is heard at the left sternal edge with the diaphragm - if not
readily apparent, it is important to sit the patient forward and auscultate with the patient's breath held
at the end of expiration. When the ascending aorta is dilated and displaced to the right, the murmur
may be heard along the right sternal border as well.
· An ejection systolic murmur may be heard at the base of the heart in severe aortic regurgitation
(without aortic stenosis). This murmur may be as loud as grade 5 or 6, and underlying organic stenosis can be ruled out only by investigations.
· Ejection click suggests underlying bicuspid aortic valve.
· Mid-diastolic murmur of Austin Flint may be heard at the apex. It is typically low-pitched, similar to the murmur of mitral stenosis but without a preceding opening snap.
· Loud pulmonary component of second sound (suggests pulmonary hypertension).

3. General examination
· Head nodding in time with the heart beat (de Musset's sign) may be present.
· Visible carotid pulsation may be obvious in the neck - dancing carotids or Corrigan's sign.
· Check the blood pressure (wide pulse pressure).
· Look for systolic pulsations of the uvula (Muller's sign).
· Check pupils for Argyll Robertson pupil of syphilis.
· Look for stigmata of Marfan's syndrome - high arched palate, arm span greater than height.
· Check joints for ankylosing spondylitis and rheumatoid arthritis.