KIMS 2016 student 1 (Learning point: Format of case log discussion) :
1) Do we have to summarize the case and then answer the questions or directly start answering the questions?
Answer:
Do as in the previous format where you begin by creating a new log book post in your current weblog (complete online learning portfolio that you will use life long) for each of the three cases and clarify stating for each case your learning objectives such as:
"I've been given these three cases data here
https://medicinedepartment.blogspot.com/2020/05/case-based-online-learning-assignment.html?m=1 to solve in an attempt to understand the topic of "paraparesis."
This may develop my competency in
a) reading and comprehending clinical data related to "paraparesis" including history, clinical findings, investigations
b) come up with a diagnosis such as:
1) Anatomical location of the root cause
2) Physiological functional disability
3) Biochemical abnormalities that could be a root cause at a molecular level
4) Pathology that could reflect the root cause at a cellular level
c) a treatment plan for each of these patients of paraparesis that can have a pharmacological and non pharmacological component.
And
d) learning the scientific basis of diagnostic and therapeutic approach in terms of past collective experiences and experiments (aka evidence based medicine)
The first step to developing these competencies after reading and comprehending each patient data will be to
a) create a problem list for each patient in order of the patient's perceived priority
b) Discuss the root causes for the problem as described above in terms of anatomy, biochemistry and pathology, microbiology
and
c) discuss possible solutions to tackle these root causes from upstream (soil from which the roots begin) or downstream (to treating the stem and branches aka palliation) in terms of pharmacological (medicinal) and non pharmacological (such as prosthetics, implants) both in historical terms (past dominant treatments for the same cause and it's current evolution) as well as recent advances ( ongoing trials and innovative approaches even at a hypothetical stage).
KIMS 2016 student 2 (Learning point: How to write and represent our work in an original manner and avoid plagiarism) :
[5/22, 1:01 PM] KIMs 2016: I'm trying to fix the alignment of the text sir. There's some problem with it.
[5/22, 1:30 PM] Rakesh Biswas: But there are issues in your write up with copy pasting from uptodate.
Every statement in the text needs to cite a journal paper to support it. Not something like a blanket reference to uptodate. Uptodate people can sue for plagiarism if they see it. 🙂
[5/22, 1:31 PM] KIMs 2016: Oh no. What do you suggest I do?
[5/22, 1:31 PM] Rakesh Biswas: Overall it's very well done.
Maybe you could also just add a few sentences on how you obtained the text that were not your own original thoughts then it would be good to go
[5/22, 1:33 PM] KIMs 2016: Would that be the parts I quoted from UpToDate articles?
[5/22, 1:33 PM] Rakesh Biswas: By rules only one or two sentences can be quoted from a reference and they should be indicated by "...".
Anything more than that has to be paraphrased.
[5/22, 1:34 PM] Rakesh Biswas: Yes which ever parts you quoted from wherever that didn't originate from your original thoughts. Very difficult to keep track I know but this is how we train ourselves to do it right 👍
[5/22, 1:36 PM] KIMs 2016: Yes sir. Most of them are original. I wrote it after reading from various textbooks and video resources. I'll paraphrase the other parts which were copy pasted and redo them.
[5/22, 1:37 PM] Rakesh Biswas: It would be great if you can mention all those resources that you read in your learning and sharing journey 👍
[5/22, 1:37 PM] KIMs 2016: Okay sir I will do so
[5/22, 1:42 PM] KIMs 2016: I'm enjoying learning from real patients, it's motivating us to read up. But the entire process of reading, comprehending and interpreting the case and furthermore studying the material related to it and then penning it down using our own thoughts from our learning experience, for each case is taking a lot of time.
[5/22, 1:44 PM] Rakesh Biswas: Yes. Deep learning always takes time but is long lasting 🙂
[5/22, 3:39 PM] KIMs 2016: I just realised how so many of us are unknowingly plagiarising. Thanks for pointing it out, Sir. As you mentioned, US schools would've failed or suspended us for plagiarism. This is the first time we are learning how to write essays and research papers as it's not included in our curriculum. I hope to learn from this and follow the rules of paraphrasing and citing to avoid plagiarism in the future papers I submit.
[5/22, 3:45 PM] KIMs 2016: https://www.youtube.com/channel/UCrDcofIg9AJ3Ky3BGuMnqqw
I found this YouTube channel which has some useful videos which range from topics such as the Various types of Plagiarism, How to avoid Plagiarism, How to Paraphrase and The Review of literature.
KIMs 2016 student 3:
2) [5/20, 8:55 AM] Sir in this case
https://vaish7.blogspot.com/2020/05/medicine.html?m=1, the patient didn’t have fever or any symptoms of inflammation how would we think of TB?
[5/20, 9:17 AM]: That's the idea of differential diagnosis.
One discusses the differentials to capture something the current symptoms wouldn't allow us to think of from what is currently known.
[5/20, 8:54 AM] +91 0: https://vaish7.blogspot.com/2020/05/medicine.html?m=1
[5/20, 11:03 AM] +91 : Why haven’t we done a Lumbar puncture in the above patient sir?
[5/20, 4:40 PM] Rakesh Biswas: Alright. How do you think it would have helped if we did the lumber puncture? What were you expecting to find in it?
[5/20, 4:40 PM] : Lymphocyte?
To confirm TB
[5/20, 4:59 PM] Rakesh Biswas: How many are normal in CSF?
How does TB lead to lymphocytosis in CSF?
[5/20, 5:04 PM] : Less than 5 per ml is normal in CSF
Meningeal inflammation sir.
[5/20, 5:07 PM] Rakesh Biswas: So are you suspecting meningitis here? Does this patient of paraparesis have any sign of meningitis? What signs would you look for?
[5/20, 5:49 PM] +91: Kernigs sign
[5/20, 6:26 PM] Rakesh Biswas: So does this patient have any signs and symptoms of meningitis to merit an LP. You can even ask the intern. I can share her number if you want. You can message her or better is ask her in her log book comment box
[5/20, 7:16 PM] : No sir.
[5/20, 7:16 PM] : Yes sir I’ll ask her.
[5/20, 8:05 PM] Rakesh Biswas: 👍keep your questions coming. These are important to score learning points
[5/20, 8:55 PM] +91: Sir is it falx cerebri tuberculoma?
[5/20, 8:57 PM] Rakesh Biswas: Are there descriptions of such a location being affected by mycobacteria in the past on your review of literature?
[5/20, 8:57 PM]: Yes sir
[5/20, 8:57 PM]: It says there are 3 cases reported as now.
[5/20, 8:59 PM] Rakesh Biswas: Share those cases and check out the similarities with our patient
[5/20, 9:03 PM]: The patient had monoperesis because it was unilateral.
[5/20, 9:03 PM] Rakesh Biswas: Tell me the similarities and dissimilarities and always share the links to articles as we can't share the PDFs in your log book comment box or the FAQ learning points page
[5/20, 9:04 PM]: http://www.roneurosurgery.eu/atdoc/CucuA_Falx.pdf
[5/20, 9:06 PM] : Sir he had monoplegia initially
Later developed seizure which our patient didn’t.
CT revealed edema and a tumor like mass near the falx cerebri.
[5/20, 9:08 PM] Rakesh Biswas: Was the second line similar to our current patient?
[5/20, 9:17 PM] Yes sir
[5/20, 9:17 PM] He had meningeal enhancement and edema.
[5/20, 10:51 PM] Rakesh Biswas: Yes but is that same as having a tumor like mass near the falx?
[5/20, 8:57 PM] Rakesh Biswas: Are there descriptions of such a location being affected by mycobacteria in the past on your review of literature?
[5/20, 8:57 PM] : Yes sir
[5/20, 8:57 PM]: It says there are 3 cases reported as now.
[5/20, 8:59 PM] Rakesh Biswas: Share those cases and check out the similarities with our patient
[5/20, 9:03 PM] Rakesh Biswas: Tell me the similarities and dissimilarities and always share the links to articles as we can't share the PDFs in your log book comment box or the FAQ learning points page
[5/20, 9:04 PM] : http://www.roneurosurgery.eu/atdoc/CucuA_Falx.pdf
[5/20, 9:06 PM] Kims 2016: Sir he had monoplegia initially
Later developed seizure which our patient didn’t.
CT revealed edema and a tumor like mass near the falx cerebri.
[5/20, 9:08 PM] Rakesh Biswas: Was the second line similar to our current patient?
[5/20, 9:17 PM] Kims 2016: Yes sir
[5/20, 9:17 PM] Kims 2016: He had meningeal enhancement and edema.
[5/20, 10:51 PM] Rakesh Biswas: Yes but is that same as having a tumor like mass near the falx?
[5/20, 11:11 PM] Kims 2016: Enhancing lesion is tumor like?
[5/20, 11:13 PM] Rakesh Biswas: Not as seen in the mri of our patient? Check out how a tumor enhancement looks like
[5/20, 11:15 PM] Kims 2016: There’s a diffuse enhancement in our patient
[5/20, 11:22 PM] Rakesh Biswas: Is that what happens in tumors?
[5/20, 11:22 PM] Kims 2016: No sir.
[5/20, 11:23 PM] Rakesh Biswas: Was contrast enhancement demonstrated in our patient's mri study? Was our patient given contrast?
[5/20, 11:24 PM] Kims 2016: The blog says there was significant enhancement
[5/20, 11:27 PM] Rakesh Biswas: Please clarify this with the intern who wrote that web log
[5/21, 8:18 AM] Kims 2016: Okay sir
[5/21, 8:49 AM] Kims 2016: Sir another doubt,
When we did an Xray abdomen and it showed psoas abscess on the right why didn’t we assume it to be the reason for the lower limb weakness and did an MRI?
[5/21, 8:54 AM] Rakesh Biswas: They happened at the same time but tell me what are your thoughts on the anatomical location of his lesion that is actually causing his paraparesis?
[5/21, 8:56 AM] Kims 2016: Psoas abscess compressing the nerves of the cord.
[5/21, 8:57 AM] Kims 2016 : It can also be because of the ring enhancing lesions of the cerebrum.
[5/21, 8:57 AM] Rakesh Biswas: Which part of the cord? Where is the psoas located and how does it compress the cord?
[5/21, 8:58 AM] Kims 2016: Not the cord but the nerves arising from the cord.
L4 and L5
[5/21, 8:58 AM] Rakesh Biswas: Which is the exact location? You can't say the paraparesis is both UMN as well as LMN?
[5/21, 8:59 AM] Kims 2016: Parasaggital?
[5/21, 9:01 AM] Kims 2016: It can be both.
[5/21, 9:03 AM] Kims 2016: In ALS, Neurodegenration, Spastic paraplegia
[5/21, 9:08 AM] Rakesh Biswas: What clinical signs does he have? Does he have both UMN and LMN signs?
[5/21, 9:09 AM] Kims 2016: UMN - Hypotonia, Absent reflexes
[5/21, 9:10 AM] Rakesh Biswas: 😳
[5/21, 9:12 AM] Kims 2016: LMN sir😬 sorryy
"[5/21, 9:13 AM] Rakesh Biswas: He has hypotonia and absent reflexes? 😳🤔
[5/21, 9:13 AM] Kims 2016 : Ankle clonus was absent
[5/21, 9:15 AM] Kims 2016 : And in the examination she wrote hypotonia in lower limbs.
[5/21, 9:42 AM] Rakesh Biswas: Which patient are you talking about? This one with psoas abscess? 🤔
Can you share the link to the case you are discussing?
[5/21, 9:42 AM] Kims 2016 : https://vaish7.blogspot.com/2020/05/medicine.html?m=1
[5/21, 9:42 AM] Kims 2016: This one sir.
[5/21, 9:49 AM] Rakesh Biswas: Yes but what about the reflexes?
[5/21, 9:50 AM] Kims 2016: Reflexes were present sir.
[5/21, 9:51 AM] Rakesh Biswas: Then can it be LMN?
[5/21, 9:51 AM] Kims 2016: No sir
But the reflexes were not exaggerated also
And there was hypotonia.
[5/21, 9:54 AM] Rakesh Biswas: Can a paraparesis be due to LMN as long as reflexes are normal even if the patient has hypotonia. Please ask the intern to change the entry of the reflexes as many observers thought they were exaggerated because they could be elicited with the fingers without the hammer. Check out the discussion videos around this patient but better do that in the end because then you won't have many questions left 🙂
Keep the questions coming. This is the best way to active learning
[5/21, 9:56 AM] Kims 2016 : It is UMN sir?
[5/21, 9:56 AM] Kims 2016: Yes sir I will ask.
[5/21, 9:57 AM] Rakesh Biswas: Where does the UMN start and where does it end and where in that path is the lesion located in this patient?
[5/21, 9:58 AM] Kims 2016 : Motor cortex to the spinal cord
[5/21, 9:58 AM] Kims 2016: Cerebral cortex?
[5/21, 10:02 AM] Rakesh Biswas: How do you explain paraparesis with the cerebral cortical lesion? Bilateral cerebral cortex? Which part of the cerebral cortex?
[5/21, 10:03 AM] Kims 2016l: ACA territory sir
Medial side
[5/21, 10:04 AM] Rakesh Biswas: Both sides? Why and how the paraparesis?
[5/21, 10:04 AM] Kims 2016: Vasculitis?
[5/21, 10:09 AM] Rakesh Biswas: Which side ACA?
How does it cause paraparesis?
[5/21, 10:10 AM] Rakesh Biswas: Cause for ACA blockage due to ACA vasculitis? How did the mycobacteria in the psoas manage to do that?
[5/21, 10:11 AM] Kims 2016: Bilateral
[5/21, 10:11 AM] Rakesh Biswas: Ok
Answer the next questions
[5/21, 10:12 AM] Kims 2016: Blood borne spread sir?
[5/21, 10:14 AM] Rakesh Biswas: Second question was how does it cause paraparesis
[5/21, 10:16 AM] Kims 2016: Because of infarction?
[5/21, 10:18 AM] Rakesh Biswas: No I meant how does affecting that area of brain cause paraparesis
[5/21, 10:18 AM] Kims 2016: It’s affecting the motor areas of cortex
[5/21, 10:20 AM] Rakesh Biswas: The motor area is large. Can you share a weblink to an image showing the different motor areas such as leg area, hand area, face etc in one single image?
[5/21, 10:20 AM] Kims 2016: Legs according to hommunculus is on the medial side.
[5/21, 10:23 AM] Rakesh Biswas: Share a coronal section of the motor homunculus
[5/21, 10:24 AM] Rakesh Biswas: And share links because one can't enter images without reference into a blog
[5/21, 10:25 AM] Rakesh Biswas: Make it a habit to share links rather than stolen images 👍
[5/21, 10:26 AM] Kims 2016: https://www.alamy.com/cortical-homunculus-illustration-image245864436.html
[5/21, 10:47 AM] Kims 2016: So isn’t it the reason sir?
[5/21, 11:12 AM] Rakesh Biswas: Yes it is. Can you find if anyone else has reported this happening in other patients of tuberculosis?
[5/21, 11:26 AM] Kims 2016: Yes sir I’ll check.
[5/21, 11:26 AM] Kims 2016 A Vaishnavi: Sir the videos that are being uploaded on YouTube are not clear.
We aren’t able to hear anything.
[5/21, 11:28 AM] Rakesh Biswas: Yes. We need some of you people here to come here and become videographers. 😅
[5/21, 11:31 AM] Kims 2016 : 😁we’ll come soon sir.
[5/21, 11:42 AM] Kims 2016: Sir the isolated cns angiitis is itself very rare and till now no proper research was done sir.
[5/21, 11:56 AM] Kims 2016: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606267/
[5/21, 12:49 PM] Kims 2016: Sir in this case
Scabies serology was negative
So can we attribute the rash to peripheral neuropathy?
[5/21, 5:00 PM] Rakesh Biswas: Quote the relevant portion that will be useful to read in the context of our current discussion
[5/21, 5:00 PM] Rakesh Biswas: But we are not thinking of isolated CNS angiitis here but tubercular CNS vasculitis?
[5/21, 5:01 PM] Rakesh Biswas: Scabies serology? 😳🤔
[5/21, 5:04 PM] Rakesh Biswas: Ask Hitesh to share the report.
[5/21, 5:04 PM] Rakesh Biswas: What about searching for tubercular CNS vasculitis
[5/21, 5:05 PM] Kims 2016: There’s one retrospective study sir
But that was as a complication oc tubercular meningitis
[5/21, 5:05 PM] Kims 2016: Okay sir.
[5/21, 8:09 PM] Rakesh Biswas: [5/21, 5:33 PM] Hitesh Kims Intern: It's not scabies serology sir
[5/21, 5:36 PM] Hitesh Kims Intern: There what I mean was as he was not having any itching we thought of immunocompromised state due to viral infection as the reason for no itching and paraperesis but retroviral serology came as negative sir
[5/21, 8:10 PM] Rakesh Biswas: There is probably no such thing as scabies serology.
How is it diagnosed?
[5/21, 8:34 PM] Kims 2016: 😬
[5/21, 8:34 PM] Kims 2016: Sir it was written serology negative
So
[5/21, 8:36 PM] Rakesh Biswas: Yes he meant retroviral serology.
So find out and tell us how is the diagnosis of scabies confirmed
[5/21, 9:51 PM] Kims 2016: Okay sir"
KIMs student 4:
[5/22, 10:46 AM] : Gud Morning Sir,
In our case of 23 yr patient with lower limb weakness
Why was an MRI of spine not done?
It is also possible that he might have Potts paraplegia, Presence of Ankle clonus and exaggerated DTR are earliest neurological signs indicating a SC compression.
[5/22, 10:48 AM] : Also it would be better to have an Orthopedic opinion to rule out Potts paraplegia. Because if it is there and is not identified it would involve Bowel and Bladder in long term and if it's Potts paraplegia it can be managed surgically.
[5/22, 10:50 AM] : Also Gait is to be evaluated to see if there is any TB spondylitis
[5/22, 4:28 PM] Rakesh Sir KIMS: Orthopedic opinion for Potts paraplegia? 😅
Well their opinion is only asked if we want them to operate, otherwise we need to make the diagnosis for them ourselves first
[5/22, 4:30 PM] Rakesh Sir KIMS: Ask Hitesh to share with you the MR spine images.
The MRI spine lumbar vertebral involvement is mentioned in his mri report that is already in the log.
However that may not be causing his paraparesis. Can you tell why?
[5/22, 4:31 PM] Rakesh Sir KIMS: Ask Hitesh to share his gait video or at least mention what was his gait like
[5/22, 4:31 PM] : Sure sir
[5/22, 4:31 PM] : May be it's not compressing the cord
[5/22, 4:32 PM] Rakesh Sir KIMS: Ok so back to the first question
[5/22, 4:33 PM] : Sir but the lesion is definitely peripheral na Sir
[5/22, 4:34 PM] : If it's a central lesion the presentation would be far different with involvement of other structures
[5/22, 4:35 PM] : There is a chace of disc inflammation spondylodiscitis
[5/22, 4:35 PM] : But that is usually more common in immunocompromised patients
[5/22, 4:35 PM] : I think we also need to assess the patients HIV status tooo
[5/22, 4:36 PM] : To consider few other differentials
[5/22, 4:43 PM] Rakesh Sir KIMS: Yes so the most basic thing in mbbs neurology that we need to learn to distinguish is between peripheral LMN lesion and central UMN lesion.
What does his clinical features suggest?
[5/22, 4:46 PM] : Sir
From the Nervous system examination mentioned above it is evident that there is
•B/L Hypotonia, Suggestive of LMN lesions
•Hyper reflexia of Knee and Ankle reflex suggestive of lesion UMN lesion above L3,L4
• Ankle clonus, suggestive of UMN lesion above S1,S2
[5/22, 4:47 PM] : I think there is lesion just above L3,L4 in the spinal cord that reflects as UMN lesion for the levels below it.
[5/22, 4:50 PM] Rakesh Sir KIMS: Good above L3, L4 where?
[5/22, 4:59 PM] : Just above L3,L4 but not likely disturbing the L2
Because if L2 in involved in the lesion then
There should be sensory loss on antero lateral aspect of thigh upto level of knee(Lateral cutaneous nerve of thigh-L2,3)
Also loss of sensation over the medial aspect of thigh( Obturator nerve-L2,3,4)
[5/22, 5:00 PM] : As there is no sensory deficit it is likely that the sensations are preserved due to normal L2
[5/22, 5:04 PM] : Also involvement of L3,4 explain the weakness in lower limb caused due to loss of motor fibers of obturator nerve to thigh muscle
(5/22, 11:00 PM) : RB
So you mean the lesion is in the L2-3, spinal cord segment or L2 and L3 vertebra? What have they mentioned in the MRI spine report about which vertebra is involved?
Also what if I told you that his upper limb reflexes are so exaggerated that we could actually elicit the reflex with our fingers?
Student 5 kims 2016:
"[5/22, 4:12 PM] Rakesh Biswas:
"Anatomical location of the root cause could be in the Spinal cord?"
Where is the exact level in the spinal cord? Is it in the cervical, thoracic or lumbosacral segments? 🤔
[5/22, 4:19 PM] 2016 Kims: Lumbosacral segments sir
[5/22, 4:21 PM] 2016 Kims: But it could be lower thoracic and upper lumbar sir.
[5/22, 4:23 PM] 2016 Kims: I think we need more Data to confirm it sir. MRI spine should also be done
[5/22, 4:23 PM] Rakesh Biswas: What if I told you that the patient's upper limb reflexes were elicitable by me by just tapping with my fingers and even his biceps was jumping bilaterally
[5/22, 4:25 PM] 2016 Kims: Then it could be a upper motor neuron lesion sir. If it’s exaggerated then maybe it could be a UMN lesion
[5/22, 4:26 PM] 2016 Kims: His babinski sign is also positive
[5/22, 4:27 PM] 2016 Kims: But since he has hypotonia I thought it couldn’t be UMN
[5/22, 4:39 PM] Rakesh Biswas: In the stage of acute neuronal shock one can still have hypotonia in UMN
[5/22, 4:40 PM] 2016 Kims: Yes sir so how do we know that it a stage of acute neuronal shock?
[5/22, 4:49 PM] Rakesh Biswas: If the UMN findings such as hyperreflexia predominate you think of UMN with hypotonia due to acute neuronal shock.
If LMN findings such as areflexia predominates you think of hypotonia due to LMN
[5/22, 4:50 PM] 2016 Kims: Okay sir.
Thank you. So this could be a state of UMN lesion with hypotonia due to acute neuronal shock
[5/22, 4:51 PM] Rakesh Biswas: Yes and where is the UMN lesion located?
[5/22, 4:53 PM] 2016 Kims: I think it’s above the anterior horn cell in spinal cord
[5/22, 4:55 PM] 2016 Kims: Sir in the video you said it could be parasagittal meningioma but then the lesion should be in cerebral cortex for that
[5/22, 4:55 PM] 2016 Kims: And he does not have any features suggestive of cortical lesion like aphasia
[5/22, 4:56 PM] Rakesh Biswas: Where are anterior horn cells in spinal cord? 😅
[5/22, 4:57 PM] Rakesh Biswas: Are the areas of aphasia located all over the cortex? Is the leg area same as the speech area? 😅
[5/22, 4:58 PM] Rakesh Biswas: You will find anterior horn cells at every section you take of the spinal cord
[5/22, 4:58 PM] 2016 Kims: Oh yes sir. Sorry sir 😅
[5/22, 4:58 PM] 2016 Kims: I think the lesion is at the level of lower thoracic and upper lumbar vertebrae
[5/22, 4:59 PM] 2016 Kims: No sir. 😅
[5/22, 4:59 PM] 2016 Kims: It’s speech areas are brocas and wernickes
[5/22, 5:00 PM] 2016 Kims: So it could be parasaggital meningioma then?
[5/22, 5:06 PM] Rakesh Biswas: What about this then? 👆
[5/22, 5:08 PM] Rakesh Biswas: How do you explain the gluteal abscess and the mei report mentioning other things in that vertebral region?
[5/22, 5:13 PM] 2016 Kims: Sir i think that is a cold abscess.
Yeah then lesion is in lumbosacral region sir that could explain the abscess.
[5/22, 5:39 PM] Rakesh Biswas: So is the vertebral lesion producing any neurological signs?
[5/22, 7:07 PM] 2016 Kims: Yes sir I think it’s compressing upon the cord and causing the upper motor neuron signs i.e. hypotonia and exaggeration of reflexes
[5/22, 7:08 PM] 2016 Kims: Sir should I change it in my blog then ? That the reflexes are exaggerated
[5/22, 7:46 PM] Rakesh Biswas: Yes instead of deleting the previous you can add this as an edit
[5/22, 7:47 PM] Rakesh Biswas: But then where in the cord will the compression produce the paraparesis he is having?
[5/22, 8:03 PM] 2016 Kims: Okay sir. I will do that
[5/22, 8:04 PM] 2016 Kims: Sir because psoas muscle is supplied by L2,L3,L4 nerve roots so maybe the compression is over there
[5/22, 8:22 PM] Rakesh Biswas: So if the nerve root is compressed what will it look like? UMN or LMN?
[5/22, 9:02 PM] 2016 Kims: LMN sir
[5/22, 9:04 PM] Rakesh Biswas: And what are the dominant clinical signs in your patient suggestive of?
[5/22, 9:36 PM] Kims: So if the nerve root is compressed what will it look like? UMN or LMN?
[5/22, 9:36 PM] 2016 Kims: LMN sir
[5/22, 10:10 PM] Rakesh Biswas: So then the nerve root is spared ?"
1) Do we have to summarize the case and then answer the questions or directly start answering the questions?
Answer:
Do as in the previous format where you begin by creating a new log book post in your current weblog (complete online learning portfolio that you will use life long) for each of the three cases and clarify stating for each case your learning objectives such as:
"I've been given these three cases data here
https://medicinedepartment.blogspot.com/2020/05/case-based-online-learning-assignment.html?m=1 to solve in an attempt to understand the topic of "paraparesis."
This may develop my competency in
a) reading and comprehending clinical data related to "paraparesis" including history, clinical findings, investigations
b) come up with a diagnosis such as:
1) Anatomical location of the root cause
2) Physiological functional disability
3) Biochemical abnormalities that could be a root cause at a molecular level
4) Pathology that could reflect the root cause at a cellular level
c) a treatment plan for each of these patients of paraparesis that can have a pharmacological and non pharmacological component.
And
d) learning the scientific basis of diagnostic and therapeutic approach in terms of past collective experiences and experiments (aka evidence based medicine)
The first step to developing these competencies after reading and comprehending each patient data will be to
a) create a problem list for each patient in order of the patient's perceived priority
b) Discuss the root causes for the problem as described above in terms of anatomy, biochemistry and pathology, microbiology
and
c) discuss possible solutions to tackle these root causes from upstream (soil from which the roots begin) or downstream (to treating the stem and branches aka palliation) in terms of pharmacological (medicinal) and non pharmacological (such as prosthetics, implants) both in historical terms (past dominant treatments for the same cause and it's current evolution) as well as recent advances ( ongoing trials and innovative approaches even at a hypothetical stage).
KIMS 2016 student 2 (Learning point: How to write and represent our work in an original manner and avoid plagiarism) :
[5/22, 1:01 PM] KIMs 2016: I'm trying to fix the alignment of the text sir. There's some problem with it.
[5/22, 1:30 PM] Rakesh Biswas: But there are issues in your write up with copy pasting from uptodate.
Every statement in the text needs to cite a journal paper to support it. Not something like a blanket reference to uptodate. Uptodate people can sue for plagiarism if they see it. 🙂
[5/22, 1:31 PM] KIMs 2016: Oh no. What do you suggest I do?
[5/22, 1:31 PM] Rakesh Biswas: Overall it's very well done.
Maybe you could also just add a few sentences on how you obtained the text that were not your own original thoughts then it would be good to go
[5/22, 1:33 PM] KIMs 2016: Would that be the parts I quoted from UpToDate articles?
[5/22, 1:33 PM] Rakesh Biswas: By rules only one or two sentences can be quoted from a reference and they should be indicated by "...".
Anything more than that has to be paraphrased.
[5/22, 1:34 PM] Rakesh Biswas: Yes which ever parts you quoted from wherever that didn't originate from your original thoughts. Very difficult to keep track I know but this is how we train ourselves to do it right 👍
[5/22, 1:36 PM] KIMs 2016: Yes sir. Most of them are original. I wrote it after reading from various textbooks and video resources. I'll paraphrase the other parts which were copy pasted and redo them.
[5/22, 1:37 PM] Rakesh Biswas: It would be great if you can mention all those resources that you read in your learning and sharing journey 👍
[5/22, 1:37 PM] KIMs 2016: Okay sir I will do so
[5/22, 1:42 PM] KIMs 2016: I'm enjoying learning from real patients, it's motivating us to read up. But the entire process of reading, comprehending and interpreting the case and furthermore studying the material related to it and then penning it down using our own thoughts from our learning experience, for each case is taking a lot of time.
[5/22, 1:44 PM] Rakesh Biswas: Yes. Deep learning always takes time but is long lasting 🙂
[5/22, 3:39 PM] KIMs 2016: I just realised how so many of us are unknowingly plagiarising. Thanks for pointing it out, Sir. As you mentioned, US schools would've failed or suspended us for plagiarism. This is the first time we are learning how to write essays and research papers as it's not included in our curriculum. I hope to learn from this and follow the rules of paraphrasing and citing to avoid plagiarism in the future papers I submit.
[5/22, 3:45 PM] KIMs 2016: https://www.youtube.com/channel/UCrDcofIg9AJ3Ky3BGuMnqqw
I found this YouTube channel which has some useful videos which range from topics such as the Various types of Plagiarism, How to avoid Plagiarism, How to Paraphrase and The Review of literature.
Paraparesis Case based questions and conversational learning points:
KIMs 2016 student 3:
2) [5/20, 8:55 AM] Sir in this case
https://vaish7.blogspot.com/2020/05/medicine.html?m=1, the patient didn’t have fever or any symptoms of inflammation how would we think of TB?
[5/20, 9:17 AM]: That's the idea of differential diagnosis.
One discusses the differentials to capture something the current symptoms wouldn't allow us to think of from what is currently known.
[5/20, 8:54 AM] +91 0: https://vaish7.blogspot.com/2020/05/medicine.html?m=1
[5/20, 11:03 AM] +91 : Why haven’t we done a Lumbar puncture in the above patient sir?
[5/20, 4:40 PM] Rakesh Biswas: Alright. How do you think it would have helped if we did the lumber puncture? What were you expecting to find in it?
[5/20, 4:40 PM] : Lymphocyte?
To confirm TB
[5/20, 4:59 PM] Rakesh Biswas: How many are normal in CSF?
How does TB lead to lymphocytosis in CSF?
[5/20, 5:04 PM] : Less than 5 per ml is normal in CSF
Meningeal inflammation sir.
[5/20, 5:07 PM] Rakesh Biswas: So are you suspecting meningitis here? Does this patient of paraparesis have any sign of meningitis? What signs would you look for?
[5/20, 5:49 PM] +91: Kernigs sign
[5/20, 6:26 PM] Rakesh Biswas: So does this patient have any signs and symptoms of meningitis to merit an LP. You can even ask the intern. I can share her number if you want. You can message her or better is ask her in her log book comment box
[5/20, 7:16 PM] : No sir.
[5/20, 7:16 PM] : Yes sir I’ll ask her.
[5/20, 8:05 PM] Rakesh Biswas: 👍keep your questions coming. These are important to score learning points
[5/20, 8:55 PM] +91: Sir is it falx cerebri tuberculoma?
[5/20, 8:57 PM] Rakesh Biswas: Are there descriptions of such a location being affected by mycobacteria in the past on your review of literature?
[5/20, 8:57 PM]: Yes sir
[5/20, 8:57 PM]: It says there are 3 cases reported as now.
[5/20, 8:59 PM] Rakesh Biswas: Share those cases and check out the similarities with our patient
[5/20, 9:03 PM]: The patient had monoperesis because it was unilateral.
[5/20, 9:03 PM] Rakesh Biswas: Tell me the similarities and dissimilarities and always share the links to articles as we can't share the PDFs in your log book comment box or the FAQ learning points page
[5/20, 9:04 PM]: http://www.roneurosurgery.eu/atdoc/CucuA_Falx.pdf
[5/20, 9:06 PM] : Sir he had monoplegia initially
Later developed seizure which our patient didn’t.
CT revealed edema and a tumor like mass near the falx cerebri.
[5/20, 9:08 PM] Rakesh Biswas: Was the second line similar to our current patient?
[5/20, 9:17 PM] Yes sir
[5/20, 9:17 PM] He had meningeal enhancement and edema.
[5/20, 10:51 PM] Rakesh Biswas: Yes but is that same as having a tumor like mass near the falx?
[5/20, 8:57 PM] Rakesh Biswas: Are there descriptions of such a location being affected by mycobacteria in the past on your review of literature?
[5/20, 8:57 PM] : Yes sir
[5/20, 8:57 PM]: It says there are 3 cases reported as now.
[5/20, 8:59 PM] Rakesh Biswas: Share those cases and check out the similarities with our patient
[5/20, 9:03 PM] Rakesh Biswas: Tell me the similarities and dissimilarities and always share the links to articles as we can't share the PDFs in your log book comment box or the FAQ learning points page
[5/20, 9:04 PM] : http://www.roneurosurgery.eu/atdoc/CucuA_Falx.pdf
[5/20, 9:06 PM] Kims 2016: Sir he had monoplegia initially
Later developed seizure which our patient didn’t.
CT revealed edema and a tumor like mass near the falx cerebri.
[5/20, 9:08 PM] Rakesh Biswas: Was the second line similar to our current patient?
[5/20, 9:17 PM] Kims 2016: Yes sir
[5/20, 9:17 PM] Kims 2016: He had meningeal enhancement and edema.
[5/20, 10:51 PM] Rakesh Biswas: Yes but is that same as having a tumor like mass near the falx?
[5/20, 11:11 PM] Kims 2016: Enhancing lesion is tumor like?
[5/20, 11:13 PM] Rakesh Biswas: Not as seen in the mri of our patient? Check out how a tumor enhancement looks like
[5/20, 11:15 PM] Kims 2016: There’s a diffuse enhancement in our patient
[5/20, 11:22 PM] Rakesh Biswas: Is that what happens in tumors?
[5/20, 11:22 PM] Kims 2016: No sir.
[5/20, 11:23 PM] Rakesh Biswas: Was contrast enhancement demonstrated in our patient's mri study? Was our patient given contrast?
[5/20, 11:24 PM] Kims 2016: The blog says there was significant enhancement
[5/20, 11:27 PM] Rakesh Biswas: Please clarify this with the intern who wrote that web log
[5/21, 8:18 AM] Kims 2016: Okay sir
[5/21, 8:49 AM] Kims 2016: Sir another doubt,
When we did an Xray abdomen and it showed psoas abscess on the right why didn’t we assume it to be the reason for the lower limb weakness and did an MRI?
[5/21, 8:54 AM] Rakesh Biswas: They happened at the same time but tell me what are your thoughts on the anatomical location of his lesion that is actually causing his paraparesis?
[5/21, 8:56 AM] Kims 2016: Psoas abscess compressing the nerves of the cord.
[5/21, 8:57 AM] Kims 2016 : It can also be because of the ring enhancing lesions of the cerebrum.
[5/21, 8:57 AM] Rakesh Biswas: Which part of the cord? Where is the psoas located and how does it compress the cord?
[5/21, 8:58 AM] Kims 2016: Not the cord but the nerves arising from the cord.
L4 and L5
[5/21, 8:58 AM] Rakesh Biswas: Which is the exact location? You can't say the paraparesis is both UMN as well as LMN?
[5/21, 8:59 AM] Kims 2016: Parasaggital?
[5/21, 9:01 AM] Kims 2016: It can be both.
[5/21, 9:03 AM] Kims 2016: In ALS, Neurodegenration, Spastic paraplegia
[5/21, 9:08 AM] Rakesh Biswas: What clinical signs does he have? Does he have both UMN and LMN signs?
[5/21, 9:09 AM] Kims 2016: UMN - Hypotonia, Absent reflexes
[5/21, 9:10 AM] Rakesh Biswas: 😳
[5/21, 9:12 AM] Kims 2016: LMN sir😬 sorryy
"[5/21, 9:13 AM] Rakesh Biswas: He has hypotonia and absent reflexes? 😳🤔
[5/21, 9:13 AM] Kims 2016 : Ankle clonus was absent
[5/21, 9:15 AM] Kims 2016 : And in the examination she wrote hypotonia in lower limbs.
[5/21, 9:42 AM] Rakesh Biswas: Which patient are you talking about? This one with psoas abscess? 🤔
Can you share the link to the case you are discussing?
[5/21, 9:42 AM] Kims 2016 : https://vaish7.blogspot.com/2020/05/medicine.html?m=1
[5/21, 9:42 AM] Kims 2016: This one sir.
[5/21, 9:49 AM] Rakesh Biswas: Yes but what about the reflexes?
[5/21, 9:50 AM] Kims 2016: Reflexes were present sir.
[5/21, 9:51 AM] Rakesh Biswas: Then can it be LMN?
[5/21, 9:51 AM] Kims 2016: No sir
But the reflexes were not exaggerated also
And there was hypotonia.
[5/21, 9:54 AM] Rakesh Biswas: Can a paraparesis be due to LMN as long as reflexes are normal even if the patient has hypotonia. Please ask the intern to change the entry of the reflexes as many observers thought they were exaggerated because they could be elicited with the fingers without the hammer. Check out the discussion videos around this patient but better do that in the end because then you won't have many questions left 🙂
Keep the questions coming. This is the best way to active learning
[5/21, 9:56 AM] Kims 2016 : It is UMN sir?
[5/21, 9:56 AM] Kims 2016: Yes sir I will ask.
[5/21, 9:57 AM] Rakesh Biswas: Where does the UMN start and where does it end and where in that path is the lesion located in this patient?
[5/21, 9:58 AM] Kims 2016 : Motor cortex to the spinal cord
[5/21, 9:58 AM] Kims 2016: Cerebral cortex?
[5/21, 10:02 AM] Rakesh Biswas: How do you explain paraparesis with the cerebral cortical lesion? Bilateral cerebral cortex? Which part of the cerebral cortex?
[5/21, 10:03 AM] Kims 2016l: ACA territory sir
Medial side
[5/21, 10:04 AM] Rakesh Biswas: Both sides? Why and how the paraparesis?
[5/21, 10:04 AM] Kims 2016: Vasculitis?
[5/21, 10:09 AM] Rakesh Biswas: Which side ACA?
How does it cause paraparesis?
[5/21, 10:10 AM] Rakesh Biswas: Cause for ACA blockage due to ACA vasculitis? How did the mycobacteria in the psoas manage to do that?
[5/21, 10:11 AM] Kims 2016: Bilateral
[5/21, 10:11 AM] Rakesh Biswas: Ok
Answer the next questions
[5/21, 10:12 AM] Kims 2016: Blood borne spread sir?
[5/21, 10:14 AM] Rakesh Biswas: Second question was how does it cause paraparesis
[5/21, 10:16 AM] Kims 2016: Because of infarction?
[5/21, 10:18 AM] Rakesh Biswas: No I meant how does affecting that area of brain cause paraparesis
[5/21, 10:18 AM] Kims 2016: It’s affecting the motor areas of cortex
[5/21, 10:20 AM] Rakesh Biswas: The motor area is large. Can you share a weblink to an image showing the different motor areas such as leg area, hand area, face etc in one single image?
[5/21, 10:20 AM] Kims 2016: Legs according to hommunculus is on the medial side.
[5/21, 10:23 AM] Rakesh Biswas: Share a coronal section of the motor homunculus
[5/21, 10:24 AM] Rakesh Biswas: And share links because one can't enter images without reference into a blog
[5/21, 10:25 AM] Rakesh Biswas: Make it a habit to share links rather than stolen images 👍
[5/21, 10:26 AM] Kims 2016: https://www.alamy.com/cortical-homunculus-illustration-image245864436.html
[5/21, 10:47 AM] Kims 2016: So isn’t it the reason sir?
[5/21, 11:12 AM] Rakesh Biswas: Yes it is. Can you find if anyone else has reported this happening in other patients of tuberculosis?
[5/21, 11:26 AM] Kims 2016: Yes sir I’ll check.
[5/21, 11:26 AM] Kims 2016 A Vaishnavi: Sir the videos that are being uploaded on YouTube are not clear.
We aren’t able to hear anything.
[5/21, 11:28 AM] Rakesh Biswas: Yes. We need some of you people here to come here and become videographers. 😅
[5/21, 11:31 AM] Kims 2016 : 😁we’ll come soon sir.
[5/21, 11:42 AM] Kims 2016: Sir the isolated cns angiitis is itself very rare and till now no proper research was done sir.
[5/21, 11:56 AM] Kims 2016: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4606267/
[5/21, 12:49 PM] Kims 2016: Sir in this case
Scabies serology was negative
So can we attribute the rash to peripheral neuropathy?
[5/21, 5:00 PM] Rakesh Biswas: Quote the relevant portion that will be useful to read in the context of our current discussion
[5/21, 5:00 PM] Rakesh Biswas: But we are not thinking of isolated CNS angiitis here but tubercular CNS vasculitis?
[5/21, 5:01 PM] Rakesh Biswas: Scabies serology? 😳🤔
[5/21, 5:04 PM] Rakesh Biswas: Ask Hitesh to share the report.
[5/21, 5:04 PM] Rakesh Biswas: What about searching for tubercular CNS vasculitis
[5/21, 5:05 PM] Kims 2016: There’s one retrospective study sir
But that was as a complication oc tubercular meningitis
[5/21, 5:05 PM] Kims 2016: Okay sir.
[5/21, 8:09 PM] Rakesh Biswas: [5/21, 5:33 PM] Hitesh Kims Intern: It's not scabies serology sir
[5/21, 5:36 PM] Hitesh Kims Intern: There what I mean was as he was not having any itching we thought of immunocompromised state due to viral infection as the reason for no itching and paraperesis but retroviral serology came as negative sir
[5/21, 8:10 PM] Rakesh Biswas: There is probably no such thing as scabies serology.
How is it diagnosed?
[5/21, 8:34 PM] Kims 2016: 😬
[5/21, 8:34 PM] Kims 2016: Sir it was written serology negative
So
[5/21, 8:36 PM] Rakesh Biswas: Yes he meant retroviral serology.
So find out and tell us how is the diagnosis of scabies confirmed
[5/21, 9:51 PM] Kims 2016: Okay sir"
KIMs student 4:
[5/22, 10:46 AM] : Gud Morning Sir,
In our case of 23 yr patient with lower limb weakness
Why was an MRI of spine not done?
It is also possible that he might have Potts paraplegia, Presence of Ankle clonus and exaggerated DTR are earliest neurological signs indicating a SC compression.
[5/22, 10:48 AM] : Also it would be better to have an Orthopedic opinion to rule out Potts paraplegia. Because if it is there and is not identified it would involve Bowel and Bladder in long term and if it's Potts paraplegia it can be managed surgically.
[5/22, 10:50 AM] : Also Gait is to be evaluated to see if there is any TB spondylitis
[5/22, 4:28 PM] Rakesh Sir KIMS: Orthopedic opinion for Potts paraplegia? 😅
Well their opinion is only asked if we want them to operate, otherwise we need to make the diagnosis for them ourselves first
[5/22, 4:30 PM] Rakesh Sir KIMS: Ask Hitesh to share with you the MR spine images.
The MRI spine lumbar vertebral involvement is mentioned in his mri report that is already in the log.
However that may not be causing his paraparesis. Can you tell why?
[5/22, 4:31 PM] Rakesh Sir KIMS: Ask Hitesh to share his gait video or at least mention what was his gait like
[5/22, 4:31 PM] : Sure sir
[5/22, 4:31 PM] : May be it's not compressing the cord
[5/22, 4:32 PM] Rakesh Sir KIMS: Ok so back to the first question
[5/22, 4:33 PM] : Sir but the lesion is definitely peripheral na Sir
[5/22, 4:34 PM] : If it's a central lesion the presentation would be far different with involvement of other structures
[5/22, 4:35 PM] : There is a chace of disc inflammation spondylodiscitis
[5/22, 4:35 PM] : But that is usually more common in immunocompromised patients
[5/22, 4:35 PM] : I think we also need to assess the patients HIV status tooo
[5/22, 4:36 PM] : To consider few other differentials
[5/22, 4:43 PM] Rakesh Sir KIMS: Yes so the most basic thing in mbbs neurology that we need to learn to distinguish is between peripheral LMN lesion and central UMN lesion.
What does his clinical features suggest?
[5/22, 4:46 PM] : Sir
From the Nervous system examination mentioned above it is evident that there is
•B/L Hypotonia, Suggestive of LMN lesions
•Hyper reflexia of Knee and Ankle reflex suggestive of lesion UMN lesion above L3,L4
• Ankle clonus, suggestive of UMN lesion above S1,S2
[5/22, 4:47 PM] : I think there is lesion just above L3,L4 in the spinal cord that reflects as UMN lesion for the levels below it.
[5/22, 4:50 PM] Rakesh Sir KIMS: Good above L3, L4 where?
[5/22, 4:59 PM] : Just above L3,L4 but not likely disturbing the L2
Because if L2 in involved in the lesion then
There should be sensory loss on antero lateral aspect of thigh upto level of knee(Lateral cutaneous nerve of thigh-L2,3)
Also loss of sensation over the medial aspect of thigh( Obturator nerve-L2,3,4)
[5/22, 5:00 PM] : As there is no sensory deficit it is likely that the sensations are preserved due to normal L2
[5/22, 5:04 PM] : Also involvement of L3,4 explain the weakness in lower limb caused due to loss of motor fibers of obturator nerve to thigh muscle
(5/22, 11:00 PM) : RB
So you mean the lesion is in the L2-3, spinal cord segment or L2 and L3 vertebra? What have they mentioned in the MRI spine report about which vertebra is involved?
Also what if I told you that his upper limb reflexes are so exaggerated that we could actually elicit the reflex with our fingers?
Student 5 kims 2016:
"[5/22, 4:12 PM] Rakesh Biswas:
"Anatomical location of the root cause could be in the Spinal cord?"
Where is the exact level in the spinal cord? Is it in the cervical, thoracic or lumbosacral segments? 🤔
[5/22, 4:19 PM] 2016 Kims: Lumbosacral segments sir
[5/22, 4:21 PM] 2016 Kims: But it could be lower thoracic and upper lumbar sir.
[5/22, 4:23 PM] 2016 Kims: I think we need more Data to confirm it sir. MRI spine should also be done
[5/22, 4:23 PM] Rakesh Biswas: What if I told you that the patient's upper limb reflexes were elicitable by me by just tapping with my fingers and even his biceps was jumping bilaterally
[5/22, 4:25 PM] 2016 Kims: Then it could be a upper motor neuron lesion sir. If it’s exaggerated then maybe it could be a UMN lesion
[5/22, 4:26 PM] 2016 Kims: His babinski sign is also positive
[5/22, 4:27 PM] 2016 Kims: But since he has hypotonia I thought it couldn’t be UMN
[5/22, 4:39 PM] Rakesh Biswas: In the stage of acute neuronal shock one can still have hypotonia in UMN
[5/22, 4:40 PM] 2016 Kims: Yes sir so how do we know that it a stage of acute neuronal shock?
[5/22, 4:49 PM] Rakesh Biswas: If the UMN findings such as hyperreflexia predominate you think of UMN with hypotonia due to acute neuronal shock.
If LMN findings such as areflexia predominates you think of hypotonia due to LMN
[5/22, 4:50 PM] 2016 Kims: Okay sir.
Thank you. So this could be a state of UMN lesion with hypotonia due to acute neuronal shock
[5/22, 4:51 PM] Rakesh Biswas: Yes and where is the UMN lesion located?
[5/22, 4:53 PM] 2016 Kims: I think it’s above the anterior horn cell in spinal cord
[5/22, 4:55 PM] 2016 Kims: Sir in the video you said it could be parasagittal meningioma but then the lesion should be in cerebral cortex for that
[5/22, 4:55 PM] 2016 Kims: And he does not have any features suggestive of cortical lesion like aphasia
[5/22, 4:56 PM] Rakesh Biswas: Where are anterior horn cells in spinal cord? 😅
[5/22, 4:57 PM] Rakesh Biswas: Are the areas of aphasia located all over the cortex? Is the leg area same as the speech area? 😅
[5/22, 4:58 PM] Rakesh Biswas: You will find anterior horn cells at every section you take of the spinal cord
[5/22, 4:58 PM] 2016 Kims: Oh yes sir. Sorry sir 😅
[5/22, 4:58 PM] 2016 Kims: I think the lesion is at the level of lower thoracic and upper lumbar vertebrae
[5/22, 4:59 PM] 2016 Kims: No sir. 😅
[5/22, 4:59 PM] 2016 Kims: It’s speech areas are brocas and wernickes
[5/22, 5:00 PM] 2016 Kims: So it could be parasaggital meningioma then?
[5/22, 5:06 PM] Rakesh Biswas: What about this then? 👆
[5/22, 5:08 PM] Rakesh Biswas: How do you explain the gluteal abscess and the mei report mentioning other things in that vertebral region?
[5/22, 5:13 PM] 2016 Kims: Sir i think that is a cold abscess.
Yeah then lesion is in lumbosacral region sir that could explain the abscess.
[5/22, 5:39 PM] Rakesh Biswas: So is the vertebral lesion producing any neurological signs?
[5/22, 7:07 PM] 2016 Kims: Yes sir I think it’s compressing upon the cord and causing the upper motor neuron signs i.e. hypotonia and exaggeration of reflexes
[5/22, 7:08 PM] 2016 Kims: Sir should I change it in my blog then ? That the reflexes are exaggerated
[5/22, 7:46 PM] Rakesh Biswas: Yes instead of deleting the previous you can add this as an edit
[5/22, 7:47 PM] Rakesh Biswas: But then where in the cord will the compression produce the paraparesis he is having?
[5/22, 8:03 PM] 2016 Kims: Okay sir. I will do that
[5/22, 8:04 PM] 2016 Kims: Sir because psoas muscle is supplied by L2,L3,L4 nerve roots so maybe the compression is over there
[5/22, 8:22 PM] Rakesh Biswas: So if the nerve root is compressed what will it look like? UMN or LMN?
[5/22, 9:02 PM] 2016 Kims: LMN sir
[5/22, 9:04 PM] Rakesh Biswas: And what are the dominant clinical signs in your patient suggestive of?
[5/22, 9:36 PM] Kims: So if the nerve root is compressed what will it look like? UMN or LMN?
[5/22, 9:36 PM] 2016 Kims: LMN sir
[5/22, 10:10 PM] Rakesh Biswas: So then the nerve root is spared ?"
No comments:
Post a Comment