Chapter 10 - Legs

Instructions: Each group of extended matching questions consists of lettered options followed by a list of numbered problems/questions. For each numbered problem/question select the one lettered option that most closely answers the question. You can use the lettered options once, more than once, or not at all.

Options:

Polymyositis
Duchenne Muscular Dystrophy
Guillain-Barre
Right hemiplegia
Cerebellar syndrome
Parkinsonism
Multiple Sclerosis
Sciatica
Motor Neurone Disease
Lateral popliteal nerve palsy
Cervical myelopathy
Peripheral neuropathy

Choose the correct diagnosis from the list of options for the following clinical scenario

Scenario 1

a)	A 56 year old man is undergoing physiotherapy. He is clearly unsteady and when he walks he tends to stagger to the right. When he walks, his feet are widely spaced apart.
Correct. This man is exhibiting an ataxic gait and his feet are spread apart to give him a broad base of support to help his balance. This is typical of a cerebellar lesion and the fact that he staggers consistently to the right suggests that the problem is within the right cerebellum (or its connecting neurones). See pages 219, 296-298.Incorrect. See pages 219, 296-298.Your answer has been saved.

Scenario 2

a)	In a clinical teaching you are asked to examine the legs of an elderly woman neurologically. Just before you start you notice a slight drooping of the patient's mouth to the right. On inspection you note that her right leg is internally rotated and the foot is plantar flexed. You discover that the tone is increased in the right leg. She moves the leg 'stiffly' and has grade 3/6 power in it. The left leg is normal. When you test her reflexes they are brisker on the right side. She also has an extensor plantar on the right side (and a normal response on the left).
Correct. This woman is exhibiting unilateral problems. The slight drooping of the mouth to the right might herald an upper motor neurone facial nerve palsy. This gives a clue to possible stroke disease. All the features on the right side are in keeping with an upper motor neurone lesion affecting the right side. The commonest cause of this is a stroke. See pages 217-219.Incorrect. See pages 217-219.Your answer has been saved.

Scenario 3

a)	In your finals examination you are asked to perform a sensory examination on a middle aged diabetic man. On inspection his legs look normal. You discover that there is diminished appreciation of light touch and pain to mid-shin level, the left level being slightly higher than the right. Proprioception is impaired at both big toes and vibration sense is absent at both left and right malleoli. You check the reflexes and the knees are only just elicited and both ankles are absent even with reinforcement. Both plantar responses are flexor.
Correct. This man has a peripheral neuropathy with sensory loss in a stocking distribution. It is likely that his diabetes is the underlying cause. See page 213.Incorrect: See page 213.Your answer has been saved.

Scenario 4

a)	You are watching a man walk into a care of the elderly outpatients department. As he approaches the door he seems to hesitate. Despite repeated encouragement from the consultant he seems to be stuck in the doorway. He then lurches forward and shuffles with increasingly rapid steps to the waiting chair. As he passes you, you notice his flexed posture.
Correct. This man has typical features of Parkinson's disease. His hesitancy at doorways is also called freezing and sufferers can be frozen for minutes. When they get going sometimes their pace quickens as they chase their centre of gravity. This is called a festinant gait. See pages: 219, 258, 400-401.Incorrect. See pages 219, 258, 400-40.Your answer has been saved.

Scenario 5

a)	You are in neurology clinic and are watching the registrar examining a 46 year old woman. She had earlier described her previous health as good although when prompted by the registrar she admitted to an episode of decreased vision in her right eye lasting about 2 weeks when she was 19 years. Now she is having difficulty walking and her legs feel stiff. On inspection the legs look normal. The registrar allows you to assess the tone which you discover is increased. The registrar then demonstrates sustained clonus at both ankles. She has grade 4/5 weakness in both legs. All her reflexes are very brisk bilaterally and both plantars are extensor. When she walks her legs appear very stiff.
Correct. This patient exhibits a spastic paraparesis with bilateral upper motor neurone signs in her legs. At this stage it is not clear what is causing this pattern of neurology except for one clue which the registrar elicited in the history. He was enquiring about past neurological dysfunction and discovered that she had significant visual impairment in her teens. This raises the possibility of Multiple Sclerosis (MS). Although this presentation is typical of MS it is still worthwhile doing further tests to exclude other disease. See pages 219-220.Incorrect. See pages 219-220.Your answer has been saved.