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81yr old with SOB and shaking

81yr old with SOB and shaking. Dr. A. Waterfield. Pertinent History and Physical Exam. Awake and alert in no respiratory distress Negative neurological exam Tenderness upon palpation of right lumbar para spinal muscles with spasm Witnessed right sided trunk fasciculations.

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81yr old with SOB and shaking

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  1. 81yr old with SOB and shaking Dr. A. Waterfield

  2. Pertinent History and Physical Exam • Awake and alert in no respiratory distress • Negative neurological exam • Tenderness upon palpation of right lumbar para spinal muscles with spasm • Witnessed right sided trunk fasciculations • Right sided abdominal shaking (for the past year) • New generalized weakness (the reason for the visit) • SOB with shaking and exertion (for past 3 months) • Low back pain with spasm • 81yr old

  3. Pertinent Testing and Radiology • Elevated left hemidiaphragm • Negative EEG during fasciculations • Spinal cord impingement at T9-T10 • C3-6 degeneration with stenosis • CT Head normal

  4. Differential Diagnosis • Traumatic( cervical spinal injury, cervical spondylosis, spinal shock, nerve root avulsion, peripheral neuropathy, fractures, cord compression) • Infectious (poliomyelitis, transmyelitis, epidural abscess, syphilis, Lyme disease, pneumonia, herpes zoster) • Lesions (spinal tumors, metastatic cancer, syringomyelia, phrenic nerve compression tumor, spinal cord infarction) • Degeneration (ALS, poliomyelitis, Multiple Sclerosis, Gillian-Barre, Myasthenia gravis) • Inflammatory (polymyalgia)

  5. The thought process begins! Fasciculations and Weakness…..and the patient is 81yrs old Motor Neuron Disease

  6. MND Upper Motor Neuron Lower Motor Neuron Fasciculations Weakness Muscle Atrophy Hypotonia Hyporeflexia Flaccid paralysis • Weakness • Hypertonia • Hyperreflexia • Spasticity • Babinski sign

  7. Motor Neuron Disease • **Amyotrophiclateralsclerosis: upper and lower motor neuron symptoms • Progressive bulbar palsy: doesn't fit the symptoms • Primary lateral sclerosis: upper motor neuron symptoms (doesn't fit) • **Progressive muscular atrophy: lower motor neurons symptoms • **Post-polio syndrome: upper and lower motor neuron symptoms

  8. ALS vs. PPS vs. PMA • ALS is usually more rapidly progressing and PPS is slower, PMA is slower • Patient is slowly progressing • ALS usually has overt UMN and LMN signs but progressive musculature atrophy form is slower and can have only LMN signs in the beginning as well as PPS • ALS can have frontotemporal dementia component • PPS requires a previous polio diagnosis • There is no mention of this in his history

  9. ALS vs. PPS vs. PMA • Patients age puts him in the time frame for having hx of Polio • PPS criteria included gradual weakness and abnormal muscle fatigability for at least 1yr but usually would present earlier • There is degeneration of cervical spine that could be consistent with hx of poliomyelitis • PMA is also usually present at an earlier age

  10. Best educated guess… • Considering that patient does not have a history of polio and is 81yrs old which is most likely not PMA, I conclude that this patient has…. • ALS

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