Neuro2: Movement Disorders Cases

Front 1

A 13-year-old white male presents with a two-year history of progressive weaknesses in both upper and lower extremities. He finds it difficult to lift heavy objects off a shelf. When sitting on the floor he has to hold onto objects such as a chair to pull himself up. On examination, there is significant wasting of muscles in the shoulders, upper arms, and hips. There is significant weakness on muscle testing. On tapping the knee tendon there is a contraction of the quadriceps muscle in the leg, and on tapping the biceps tendon there is a contraction of the biceps muscle in the arm. No fasciculations are noted. There is normal muscle tone detected by passive movement through the joints.

Back 1

WEAKNESS (so UMN, LMN, peripheral n., muscle, NMJ)

Atrophy + (NOT UMN or NMJ)

Reflexes present and not high or low (NOT UMN, NOT LMN)

NO fasciculations (NOT peripheral n.)

Weakness, normal reflexes with atrophy suggests muscular disorder

Front 2

A 67-year-old female presents with complaints of clumsiness in her arms. She notices this when she attempts to bring a cup of water to her lips. As she does, so she develops shaking and spills the contents. Also, she notices some incoordination in her walking. Her speech has become somewhat slurred. On examination, (in contrast to first case) there is normal strength in her arms, legs, and articulatory muscles. When the tendon at the knee is tapped, the quadriceps muscles contracts, and when the tendon at the biceps is tapped, the biceps muscles contract. There is no atrophy or wasting (in contrast to first case). At rest, there are no unusual movements. When she brings the tip of her finger to the tip of her nose there are coarse, jerking movements which get worse as her finger approaches her nose. No fasciculations are noted. There is normal muscle tone. Unlike case 1, she has no weakness.

Back 2

NO WEAKNESS (so think cerebellum, basal ganglia, associtation cortex)

Tremor +, gait issues, speech slurred, Nothing abnormal AT REST (would have suggested basal ganglia), trajectory issues

Strength normal, reflexes normal, NO atrophy,


Cerebellum issue

Front 3

A 22-year-old white female presents with complaints of fatigue. She states that she feels her normal self upon awakening but through the course of the day she becomes increasingly weak. She notices that when she tries to hold an object with her arms extended, she can only do so for a short period of time after which the muscles seem to “give way”. When she begins to speak, her speech is normal. After a few sentences, however, her speech becomes slurred and harder to hear. On examination, the muscle strength is normal at first, but with sustained contraction the muscles become weaker. There is no atrophy or wasting. There are no abnormal movements. No fasciculations are noted. The muscle tone is normal. Tapping on the knee or biceps tendon produces a normal muscle contraction reflex.

Back 3

Fatigue, weakness + (UMN, LMN, muscle, peripheral n, NMJ)

Weakness with activity

Strength norm at first, NO atrophy (not muscle), no fasciculations (not LMN), Normal reflexes (NOT UMN, LMN, peripheral n.)

Must be NMJ issue

Myasthenia gravis

Front 4

A 72-year-old white male is brought to the emergency room because of a sudden onset of weakness on his left side. He noted that the left arm felt "clumsy." His wife noted that he tended to drag his left leg while walking. Also, she noted that the left corner of his mouth appeared to droop. On examination, there is significant weakness in the patient's left upper and lower extremity. Left hand movements are slow and labored. Tapping on the tendons of the knee and biceps resulted in an exaggerated and brisk response on the left side but is normal on the right (exaggerated reflex). Muscle tone was increased on the left side compared to the right (increased resistance). No atrophy was noted. No fasciculations were noted. No abnormal movements were noted. Unlike case 1 and 3, has exaggerated muscle tone and reflexes.

Back 4

Left sided weakness (UMN, LMN, peripheral n., muscle, NMJ)

Arm issue (MCA maybe), Weakness in both upper and lower extremity (NOT JUST MCA)

EXAGGERATED REFLEXES (not LMN, not peripheral n.), NO atrophy (not muscle)

UMN disorder (probably corticospinal tract loss)

Front 5

- A 55-year-old male presents with complaints of slowing down in his movements. He found that it takes him longer to dress and eat. His wife complains that he tends to fall behind when they go for a walk. His voice has become softer. On examination the patient has normal strength. There is no atrophy. There are no fasciculations. The muscle tone is increased but with a particular "ratchety" or cogwheel character. Rapid tapping of his forefinger to his thumb is slower than would be expected. When walking, he does not swing his left arm. There appears to be a paucity of facial expression and his speech sounds slurred. Tapping on the muscle tendons elicits a normal response.

Back 5

NO weakness (cerebellum, basal ganglia, cortex)

hypokinetic (suggests basal ganglia)

soft voice, slower tapping forefinger to thumb (hypokinetic)

NO atrophy, NO fasciculations, cogwheel tone (suggests Parkinson's), normal reflexes

Suggests basal ganglia issue

Parkinson's

Front 6

A 45-year-old female presents with a six-month history of increasing generalized weakness. She finds it difficult to grasp a jar and unscrew the lid. She has difficulty placing objects on the shelf above her head. She finds that she has to pull herself up by her arms to arise from a chair. Her speech becomes "slurred" and she finds that occasionally she will choke while drinking a class of water. On examination there is marked weakness in all her extremities. There is significant wasting of muscles in her upper and lower extremities and fasciculations are noted. Tapping the muscle tendons fails to elicit muscle contraction. Muscle tone is normal. There are no involuntary movements except for the fasciculations.

Back 6

Weakness (UMN, LMN, peripheral n., muscle, NMJ)

slurred speech, throat/swallowing issues

Atrophy + (not UMN), NO reflexes (NOT UMN, NMJ, suggests LMN, peripheral n.)

Fasiculations + with decreased reflexes (LMN lesion)

LMN lesion

Front 7

A 35-year-old male presents with the sudden onset of weakness in his right upper extremity following a fall in which he landed on his right shoulder. These symptoms began about one month prior to his visit. On examination there is weakness and atrophy (wasting) of the deltoid and biceps muscle. No atrophy is noted elsewhere. No fasciculations are noted. Muscle tone at the elbow with extension at the elbow (stretching the biceps muscle) is reduced although normal elsewhere. Tapping the biceps muscle tendon fails to produce contraction of the biceps muscle of the right arm. Tapping of muscle tendons elsewhere produces a normal response.

Back 7

Weakness (UMN, LMN, peripheral n, NMJ, muscle)

Atrophy + (muscle maybe, not UMN), No tendon response at elbow (LMN, peripheral n.), No fasciculations

NO reflexes and NO fasiculations suggests peripheral n. (probably severed in fall)

Front 8

A 57-year-old woman was brought to the emergency room because of the sudden onset of unusual behavior. The patient appeared to have normal strength but to have difficulty properly using objects such as using a knife, fork or spoon (i.e. if given glasses or spoon upside down, she will try to use them upside down). She appeared to grasp the objects and manipulate and move objects in a coordinated fashion. It appeared that she just forgot how to use these objects. For example, she would hold the spoon upside-down while attempting to eat. On examination, the patient has normal strength and tone. No involuntary movements are noted. Her movements appear purposeful and normal, specifically there is no tremor or shaking and they are not slow. No fasciculations are noted. Tapping muscle tendons elicits a normal response.

Back 8

NO weakness (cerebellum, basal ganglia, association cortex)

Inappropriate use of spoon, glass etc., Looks coordinated (not cerebellum), NO involuntary movements (not hyperkinetic), purposeful and normal, no shaking, no tremor, not slow (NOT basal ganglia)

Looks like an association cortex (premotor frontal and parietal cortex) issue