4 patients falling over

Mrs April

• Aged 62 • Complains of tripping up when she walks on

uneven surfaces• Falls over and comes to hospital

PMH• COPD• Vegan • Breast cancer 15 years ago

• Well nourished• Normal cranial nerves• Normal upper limbs• Lower limbs• Bilateral increased tone• Normal musculature• Clonus• Brisk reflexes

Questions

• What does this examination suggest is happening?

• Why was she tripping up?• At what level could her neurological problem

be?• What might be relevant in the past?

Spastic paraparesis

Sites of upper motor neurone lesions

Upper Motor neurone lesions

Features

• Hemiparesis• Quadraparesis• Paraparesis

Mr June

• Aged 29• History of falling over for last three weeks• Also complains of pins and needles in the tips

of fingers right hand and left footPMHAsthmaEpisode of visual loss 4 years ago which resolved

Examination

• Pupils regular but sluggish to light • Optic disc pale on left• Other cranial nerves normal• Arms normal• Left leg increased tone and clonus• Up going plantars• Brisk knee and ankle jerk

Questions

• What is the clinical finding in the patients left leg?

• What are the possible causes?• What is the most likely cause in this man?• What might be relevant in the past?• How might you proceed?

Optic atrophy

Brisk reflexes and Clonus

Mr September

• Several episodes of unexplained falls over the past 2-3 years

• Tendency to lean backwards• Noted to have slowed down and start falling

more

Examination

• Slightly dishevelled• Slow and quiet speech• Increased tone more marked on the right• Increased tone is not smooth• Normal reflexes• No sensory signs

Questions

• What might this story suggest• What are the possible causes of this problem?• Why might this patient be falling over?• This patient is also constipated why might this

be?• What is the pathological process?

Parkinsons

• Tremor• Rigidity• Bradykinesia

Mr November

• Has been falling at home for the past 3 months

• Reports some problems with swallowing past 2 weeks

• Recurrent chesty cough

Examination

Cranial nervesTongue wasted on right and protrudes to leftSpeech nasal

ArmsWasting small muscles of hands and fasiculationLegsIncreased tone bilaterally and brisk reflexes

Questions

• What do the signs in the cranial nerves suggest?

• What is this called?• What do the signs on the hands suggest?• What is the picture in the legs?• Can you suggest what might be going on?

Bulbar and Pseudobulbar palsy

Bulbar (LMN)• Wasting tongue• Tongue protrudes to weak

side• Dysarthria and sometime

dysphagia

Pseudobulbar (UMN)• No wasting • Nasal speech

Lower motor neurone signs

• Wasting• Fasiculation• Hyporeflexia

Upper motor neurone signs

• No wasting• Increased tone• Hypereflexia• Up going plantars

Amyotrophic lateral sclerosis (ALS). This is the 'classical' MND and the most common type. About 8 in 10 people with MND have this type. Symptoms tend to start in the hands and feet. The muscles tend to become stiff as well as weak at first. Progressive bulbar palsy (PBP). About 2 in 10 people with MND have this type. The muscles first affected are those used for talking, chewing and swallowing (the bulbar muscles). Progressive muscular atrophy (PMA). This is an uncommon form of MND. The small muscles of the hands and feet are usually first affected, but the muscles are not stiff. Primary lateral sclerosis (PLS). This is a rare type of MND. It mainly causes weakness in the leg muscles. Some people with this type may also develop clumsiness in the hands or develop speech problems.

Questions