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R. Rasarus, M.B. B.CH. B.A.O., M.B.B.Ch., Ph.D.
Program Director, Alpert Medical School at Brown University
After a complete neurologic investigation, his family was told that he would be paralyzed from the waist downward for the rest of his life. The neurologist outlined to the medical personnel the importance of preventing complications in these cases. The common complications are the following: (a) urinary infection, (b) bedsores, (c) nutritional deficiency, (d) muscular spasms, and (e) pain. Using your knowledge of neuroanatomy, explain the underlying reasons for these complications. How long after the accident do you think it would be possible to give an accurate prognosis in this patient? A 67-year-old man was brought to the neurology clinic by his daughter because she had noticed that his right arm had a tremor. Apparently, this had started about 6 months previously and was becoming steadily worse. When questioned, the patient said he noticed that the muscles of his limbs sometimes felt stiff, but he had attributed this to old age. It was noticed that while talking, the patient rarely smiled and then only with difficulty. When asked to walk,the patient was seen to have normal posture and gait, although he tended to hold his right arm flexed at the elbow joint. When he was sitting, it was noted that the fingers of the right hand were alternately contracting and relaxing, and there was a fine tremor involving the wrist and elbow on the right side. When he was asked to hold a book in his right hand,the tremor stopped momentarily,but it started again immediately after the book was placed on the table. The daughter said that when her father falls asleep, the tremor stops immediately. On examination, it was found that the passive movements of the right elbow and wrist showed an increase in tone, and there was some cogwheel rigidity. There was no sensory loss, either cutaneous or deep sensibility, and the reflexes were normal. Name a center in the central nervous system that may be responsible for the following clinical signs: (a) intention tremor, (b) athetosis, (c) chorea, (d) dystonia, and (e) hemiballismus. This patient was suffering from spondylosis, which is a general term used for degenerative changes in the vertebral column caused by osteoarthritis. In the cervical region, the growth of osteophytes was exerting pressure on the anterior and posterior roots of the fifth and sixth spinal nerves. As the result of repeated Answers and Explanations to Clinical Problem Solving 179 trauma and of aging, degenerative changes occurred at the articulating surfaces of the fourth, fifth, and sixth cervical vertebrae. Extensive spur formation resulted in narrowing of the intervertebral foramina with pressure on the nerve roots. The burning pain, hyperesthesia, and partial analgesia were due to pressure on the posterior roots, and weakness, wasting, and fasciculation of the deltoid and biceps brachii muscles were due to pressure on the anterior roots. Movements of the neck presumably intensified the symptoms by exerting further traction or pressure on the nerve roots. Coughing or sneezing raised the pressure within the vertebral canal and resulted in further pressure on the nerve roots. The patient was operated on and a laminectomy of the third, fourth, and fifth thoracic vertebrae was carried out. At the level of the fourth thoracic vertebra, a small swelling was seen on the posterior surface of the spinal cord; it was attached to the dura mater. The tumor was easily removed, and the patient successfully recovered from the operation. There was a progressive recovery in the power of the lower limbs, with the patient walking without a stick. This patient emphasizes the importance of making an early, accurate diagnosis because benign extramedullary spinal tumors are readily treatable. The lateral spinal thalamic tracts are responsible for the conduction of pain impulses up the spinal cord.
Again, we are mindful of associated injuries such as rib fracture that existed in some patients and needle depth into the pleura may be restricted in obese patients or with subcutaneous haematoma. Imaging technique is usually used to confirm diagnosis of pneumothorax but clinical evaluation should be the determinant for assisting initial diagnosis and subsequent [19] management modalities. Adoption of widespread digital imaging should be taken with caution as small pneumothorax may not be apparent immediately. Again a number of conditions can increase lucency in radiographs other than pneumothorax such Page 135 Vol. An expiratory chest X-ray and lateral decubitus films are sensitive in picking small pneumothorax with the former, owing to compressing the lungs thereby increasing 23 24 its density. Winter and Smethrust reported a new way of simultaneous sternal percussion with chest auscultation to detect pneumothorax in their 1999 case series which helped in two of three patients that had inconclusive chest radiographs. However, the sensitivity accuracy is reproducible, has validity and is important in screening pneumothorax while poor specificity may "matter less if over-treatment rarely results in adverse effect but may be a serious disadvantage if treatment is highly toxic"25 which also influences the negative predictive value. High sensitivity is important for a screening test where a missed 25 diagnosis has serious consequences. A prospective controlled blind comparison of the test under study and the reference test in a consecutive series of relevant clinical population is the optimal design for assessing the accuracy of a diagnostic test, but the largest effect of over estimation of diagnostic accuracy was found in case-control studies in which a group with the disease is compared to normal patients that were not part of a relevant control clinical population. Incidence of primary spontaneous pneumothorax (psp) is 18 in 27 100,000 in males, 6 /100,000 in females, despite a very high sensitivity and specificity,8therefore; a very specific test follows a very positive sensitivity test. Limitation of this study could be the presence of occult pneumothorax, relatively small sample size, slight comparative group though only two patients were nontrauma cases and further work could increase the reliability of our findings. Conclusion Our technique makes emphasis on diagnostic needle thoracentesis and was able to achieve good accuracy in confirmation of pneumothorax with only minor pains exhibited in about 4 patients. Also at times where radiological confirmation may be inconclusive, obscured by chest wall contusion or subcutaneous haematoma and in patients that are critically ill to warrant erect chest films. A role for lateral needle aspiration in emergency decompression of spontaneous pneumothorax. Pleural procedures and thoracic ultrasound: British Thoracic Society pleural disease guideline 2010. Management of emergency department patients with primary spontaneous pneumothorax: needle aspiration or tube thoracostomy. Management of spontaneous pneumothorax: British thoracic society pleural disease guideline 2010. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. Notable are the "Generation Y" female doctors, whose peculiar characteristics distinguished them. Objectives - this study aimed to identify the expectations and challenges faced by female millennial doctors, brought about by misunderstanding of their peculiar needs as a generation. Methods: this was a descriptive, cross sectional study, involving 108 participants selected by cluster sampling technique. A pretested, interviewer administered questionnaire was used to collect data that was analyzed using Epi-info statistical software; version 3. Conclusion: the study demonstrated that some work related challenges impact negatively on the family. This includes general quality of family life including happiness and family health. Therefore, the Government and relevant institutions at all levels should revise policies that promote work family balance for the female worker. A culture of interactions and mentorship between the older and younger doctors; particularly female doctors should also be encouraged. They are a younger generation compared to the generation X (1965-1980), baby boomers (1946-1964) and traditionalists (born before 1946). This is evidenced by several advances in technology and the constant acquisition of new skills by the physician. Y female physician is peculiar because in addition to these, other challenges which are gender related greatly influence her work effectiveness and efficiency. The reasons for the challenges in this group include technological advancements and the generational gap between them and the older 1 generations.
In general, sensory symptoms precede sensory signs, and the sensory examination may not be revealing early on in the course of an illness that produces sensory dysfunction. In general, the examiner looks for a proximal-to-distal gradient, or for findings in the distribution of a specific nerve or nerve root. The sensory examination is divided into three parts: primary modalities, cortico-sensory modalities, and functional testing (the Romberg test). Primary Modalities Protopathic sensation Examples of protopathic sensation include poorly localized touch, pain and temperature perception. These modalities are carried by small, unmyelinated fibers, travel contralaterally in the lateral spinothalamic tracts in the spinal cord, and are ultimately processed in the brain stem reticular formation and in the thalamus. The "prickly" sensation may be reported by the patient as diminished, absent or heightened in the affected areas. Temperature: this can be assessed with a cool tuning fork, or with test tubes filled with cold or hot water. Epicritic sensation Examples of epicritic sensation include fine, discriminative touch, vibration, and proprioception (position sense). These modalities are generally subserved by encapsulated nerve endings and are carried by large, myelinated nerve fibers, ascending ipsilaterally in the dorsal columns in the spinal cord. This information then crosses in the medulla, projects to the thalamus and is ultimately processed in the primary sensory cortex. If vibratory perception is absent distally, more proximal joints are assessed in a similar fashion. Cortico-sensory Modalities these are more complex forms of sensation that require significant cortical processing. Four different cortico-sensory modalities are typically evaluated: stereognosis, graphesthesia, twopoint discrimination, and double simultaneous stimulation. To evaluate this modality, objects such as a safety pin or coin are placed in the hand of a patient for identification. Two Point Discrimination: the ability to localize and discriminate between two points that are close together. This is typically tested on the tip of the index finger with a paper clip that is bent open. The examiner applies both ends of the clip, keeping them several millimeters apart and moving them closer and closer together. Normal subjects have a detection threshold of 2 mm at the tip of the index finger. Double Simultaneous Stimulation: A normal subject should be able to localize two stimuli that are applied simultaneously to different parts of the body. Patients with a parietal lobe lesion have a phenomenon known as extinction in which they consistently fail to identify a stimulus on the side of the body contralateral to a parietal lobe lesion, when it is presented simultaneously with a stimulus on the opposite side of the body. In a broad sense, extinction to double simultaneous stimuli is a type of agnosia known as sensory neglect. To test for extinction, the right and left sides of the body are touched at the same time and the patient is asked to localize both stimuli with the eyes closed. This test is performed by asking the patient to stand with his/her feet together and then close the eyes. The patient is then observed to see if balance can be maintained with the eyes closed. Recall that three systems are routinely used to maintain balance, namely proprioception, the vestibular apparatus and vision. If balance is maintained with the eyes closed, this implies integrity of both the vestibular apparatus and proprioception. The Romberg test can only be performed if the patient is able to stand well with feet together and eyes open. If the patient cannot do this well, a lesion of the cerebellum is suspected; the Romberg test cannot be performed under these circumstances.
There was slight but definite weakness and increased tone of the muscles of the right leg. Examination of the right shoe showed evidence of increased wear beneath the right toes. Given that this patient had a cerebrovascular lesion involving the cerebral cortex, which area of the cortex was involved to cause these symptoms? A small piece of shrapnel entered the right side of his skull over the precentral gyrus. Five years later, he was examined by a physician during a routine physical checkup and was found to have weakness of the left leg. Explain why it is that most patients with damage to the motor area of the cerebral cortex have spastic muscle paralysis, while a few patients retain normal muscle tone. A distinguished neurobiologist gave a lecture on the physiology of the cerebral cortex to the freshman medical student class. Having reviewed the structure of the different areas of the cerebral cortex and the functional localization of the cerebral cortex, he stated that our knowledge of the cytoarchitecture of the human cerebral cortex has contributed very little to our understanding of the normal functional activity of the cerebral cortex. An 18-year-old boy received a gunshot wound that severely damaged his left precentral gyrus. The patient, however, still possessed some coarse voluntary movements of the right shoulder, hip, and knee. A 53-year-old professor and chairman of a department of anatomy received a severe head injury while rock climbing. After convalescing from his accident, the professor returned to his position in the medical school. Finally, he was removed from office after being found one morning urinating into the trash basket in one of the classrooms. A 50-year-old woman with a cerebrovascular lesion, on questioning, was found to experience difficulty in understanding spoken speech, although she fully understood written speech. A 62-year-old man, on recovering from a stroke, was found to have difficulty in understanding written speech (alexia) but could easily understand spoken speech and written symbols. What is understood by the following terms: (a) coma, (b) sleep, and (c) electroencephalogram? Name three neurologic conditions in which the diagnosis may be assisted by the use of an electroencephalogram. In the motor cortex in the precentral gyrus, there is a lack of granular cells in the second and fourth layers, and in the somesthetic cortex in the postcentral gyrus,there is a lack of pyramidal cells in the third and fifth layers. This is the somesthetic association area, where the sensations of touch, pressure, and proprioception are integrated. It is essential that the patient be allowed to finger the object so that these different sensations can be appreciated. The damage to the pyramidal cells that give origin to the corticospinal fibers was responsible for the right-sided paralysis. The increased tone of the paralyzed muscles was due to the loss of inhibition caused by involvement of the extrapyramidal fibers (see p. Destructive lesions of the frontal eye field of the left cerebral hemisphere caused the two eyes to deviate to the side of the lesion and an inability to turn the eyes to the opposite side. The frontal eye field is thought to control voluntary scanning movements of the eye and is independent of visual stimuli. A small discrete lesion of the primary motor cortex results in little change in muscle tone. Larger lesions involving the primary and secondary motor areas, which are the most common, result in muscle spasm. As the result of the patient and extensive histologic research of Brodmann, Campbell, Economo, and the Vogts, it has been possible to divide the cerebral cortex into areas that have a different microscopic arrangement and different types of cells. Because the functional significance of many areas of the human cerebral cortex is not known,it has not been possible to closely correlate structure with function. In general,it can be said that the motor cortices are thicker than the sensory cortices and that the motor cortex has less prominent second and fourth granular layers and has large pyramidal cells in the fifth layer.