موقع العيادة السورية

موقع العيادة السورية هو موقع طبي ثقافي يهتم باغناء المحتوى الطبي العربي على الانترنت.
يتألف الموقع من مجموعة غنية من الأقسام كالمكتبة الطبية, الموسوعات الطبية, المنتديات الطبية, وغيرها.

حالات سريرية في الأمراض العصبية Neurology Cases

HTML clipboard

INSTRUCTION

This patient is suspected to have difficulty in micturition accompanying paraparesis. Would you like to ask him a few questions'?

SALIENT FEATURES

Proceed as follows:Ask the patient the following questions:· Do you get a sensation when the bladder is full'?· Do you feel the urine passing'?· Are you able to stop urine passing in midstream at your own will'?· Does the bladder leak continually'?· Do you suddenly pass large volumes'?· Is there any difficulty in defaecation?· ls there any numbness in the perineal region'?Tell the examiner that in a male patient you would like to take a history of impo-tence and examine the neurological system andspine.

DIAGNOSIS

This patient has a spastic bladder (lesion) accompanying his paraparesis which occurred as a result of trauma (aetiology) andrequires an indwelling urinary catheter (functional status).

ADVANCED-LEVEL QUESTIONS

What are the types of neurogenic bladder?

Spinal or spastic bladderThe bladder is small and spastic and holds less than 250 ml. It is seen in lesions of the spinal cord secondary to trauma, multiplesclerosis, and spinal cord tumour (upper motor neuron lesion). Bladder fullness is not appreciated and the bladder tends to emptyreflexly and suddenly - the automatic bladder. Evacuation may be incomplete unless the bladder is massaged by pressure in thesuprapubic region.The autonomous bladderThis resultsfrom damage to the cauda equine, i.e. lower motor neuron lesion. The patient is incontinent with continualdribbling and there is no sensation of bladder fullness. Despite the dribbling there is considerable residual urine. There is loss ofperineal sensation and sexual dysfunction. (ln conus medullaris-cauda equine lesions, it is possible to have a flaccid lower motorneuron detrusor with a spastic sphincter. The reverse may also occur.)The sensory bladderThis is similar to autonomous bladder and is seen in tabes dorsalis, subacute combined degeneration of the cord and multiplesclerosis. There is loss of aware-ness of bladder fullness with a loss of spinal reflex. This results in retention of large quantities ofurine, incontinence with dribbling, and a high volume of residual urine which can be voided by considerable straining.The uninhibited bladderThis occurs with lesions affecting the second gyrus of the frontal lobe, e.g. frontal lobe tumours, parasagittal meningiomas,aneurysms of the anterior communicating arteries and dementia. Patients have urgency despite low bladder volumes and havesudden uncontrolled evacuation. There is no residual urine. When there is deterior-ation of the intellect, the patient may pass urineat any time without concern.

What do you know about the neurological control of the bladder?

* Micturition follows activation of the parasympathetic pathways to the detrusor muscle and inhibition of the somatic input to theexternal urethral sphincter. The parasympathetic reflex is based in the S3 roots and S3 segments of the cord.· The sympathetic system promotes urinary storage by increasing urethral resistance and depressing detrusor contractions. Thesympathetic supply descends into the pelvis from the hypogastric reflex.· A cortical representation of the bladder is present in the paracentral lobule, stimulation of which may evoke bladdercontractions. It may play a part in initiating voluntary contractions and in stopping micturition by initiating contrac-tion of theexternal sphincter.

What investigations are performed to evaluate bladder function?

Cystometry, sphincter electromyography, urofowmetry with measurement and recording of urinary flow, urethral pressure profiles,and electrophysiological tests of bladder wall innervation.

What are the different types of urinary incontinence?

Urinary continence is dependent on a compliant reservoir (the bladder) and sphinc-teric efficiency which relies on its twocomponents: the involuntary smooth muscle of the bladder neck and the voluntary skeletal muscle of the external sphincter. Urinaryincontinence occurs when urine leaks involuntarily and is of five types:· Total incontinence: the patient loses urine at all times and in all positions. It occurs when the sphincter is damaged (by surgery,cancerous infiltration and nerve damage) or when there is a fistula between the urinary tract and the skin, or ectopic ureters.· Stress incontinence: occurs when there is an increase in intra-abdominal pressure (on coughing, sneezing, lifting, exercising). Itis seen in patients with a lax pelvic floor (e.g. multiparous women, patients who have undergone pelvic surgery). Patients donot lose urine in the supine position.· Urge incontinence: loss of urine preceded by a strong, unexpected urge to void urine. It occurs with inflammation or neurogenicdisorders.· Overflow incontinence occurs in chronic urinary retention from a chronically distended bladder.· Enuresis: a form of involuntary nocturnal incontinence. It is usually seen in children.

INSTRUCTION

Perform a neurological examination on this patient.

SALIENT FEATURES

History

· Dizziness when standing up (due to postural hypotension).· Dysphagia.· Ataxia.· Symptoms of Parkinson's disease .· hnpotence, bladder disturbances .· Anhidrosis.

Examination

· Mask-like facies and other features of bradykinesia.· Increased tone (rigidity).· Cerebellar signs.

Proceed as follows:

Tell the examiner that you would like to look for:· Postural hypotension, the hallmark of this condition (due to autonomic failure).· Signs of autonomic dysfunction (pupillary asymmetry, Homer's syndrome).

DIAGNOSIS

This patient has cerebellar and Parkinson's signs (lesion) due to multiple system atrophy, a degenerative disorder (aetiology), andhas marked disability including incontinence (functional status).

ADVANCED-LEVEL QUESTIONS

What are the types of multisystem atrophy?

· Striatonigral degeneration: clinical picture resembles Parkinson's disease but without tremor. These patients do not respond toanti-Parkinson medications and often develop adverse reactions to these agents.· Shy-Drager syndrome: clinical picture consists of Parkinson's disease combined with severe autonomic neuropathy (particularlypostural hypotension). Other important clinical features are impotence and bladder disturbances.· Olivopontocerebellar atrophy: combination of extrapyramidal manifestations and cerebellar ataxia. Patients may also haveautonomic neuropathy and anterior horn cell degeneration.· Parkinsonism and motor neuron disease: rare.

What is the pathology in Shy-Orager syndrome?

In 1960, Shy and Drager described changes in the brainstem and ganglia; sub-sequently, loss of neurons has been shown in theautonomic nervous system and in the cells of the intermediolateral column of the spinal cord. Positron emission tomo-graphy showsdecreased uptake of dopamine in the putamen and caudate lobe.

What factors can lower blood pressure in these patients?

Standing up (orthostatic hypotension, a hallmark of this condition), food and exercise.Food and exercise can produce hypotensioneven in the supine position (JNeurol1990; 237(suppl 1): S24; JAm Coil Cardiol 1993; 21: 97A).

What is the morbidity of this condition?

It tends to disable most patients severely by the end of 5-7 years.

How would you treat these patients?

Treatment is symptomatic and supportive for hypotension and neurological deficits. Symptoms of postural hypotension may beameliorated by antigravity stockings and fluorohydrocortisone.G.M. Shy (1919-1967), a US neurologist who obtained his MRCP in London in 1947.G.A. Drager (1917-1967), a US neurologist.Bradbury and Eggleston in 1925 first described the combination of postural hypotension, incontinence, impotence and abnormality ofsweating (anhidrosis). Neurological manifestations develop later.Christopher J. Mathias, FRCP, DSc, contemporary Professor of Medicine, St Mary's Hospital Medical School and National Hospital,Queen Square, London, whose chief interest is the autonomic control of the cardiovascular system.

 

HTML clipboard

INSTRUCTION

Examine this patient's lower limbs, in which weakness began distally.

SALIENT FEATURES

History

· Weakness: difficulty in rising up from sitting position or climbing stairs; legs usually affected before upper limbs.· Dyspnoea late in the course, suggesting diaphragmatic and intercostal muscle weakness.· Cranial nerve involvement: diplopia, drooling of saliva, regurgitation of food.· Paraesthesias.· Urinary symptoms.· Systemic symptoms: fatigue.· Ascertain whether the (inset was preceded by a trivial viral illness.

Examination

· Weakness of distal limb muscles.· Distal numbness.· Arefiexia.

Proceed as follows:

Tell the examiner that you would like to:· Assess respiratory function (forced vital capacity).· Check blood pressure (for labile blood pressure).

DIAGNOSIS

This patient has Guillain-Barrd syndrome (lesion) and is currently experiencing weakness of the distal limb muscles (functionalstatus).

QUESTIONS

What is the pathology?

It is a demyelinating neuropathy.

ADVANCED-LEVEL QUESTIONS

How is the diagnosis confirmed?

· Nerve conduction studies demonstrate slowing of conduction or conduction block.· CSF shows albumino-cytological dissociation, i.e. cell count is normal but the protein concentration is frequently raised.

What is Miller-Fisher syndrome?

A rare proximal variant of Guillain-Barre syndrome which initially affects the ocular muscles and in which ataxia is prominent.

What is the differential diagnosis?

Poliomyelitis, botulis ,primary muscle disease or other neuropathy (porphyric, diphtheric, heavy metal or organophosphoruspoisoning).

How would you treat such patients?

· High-dose intravenous y-globulin during the acute phase to reduce the severity and duration of symptoms (N Eng! J Med 1992;326:1123-9). This is equivalent to plasma exchange in reducing disability, but the combination of intravenous immunoglobulinand plasma exchange offers no significant additional advantage (Dmcet 1997; 349: 225-30).· Ventilatory support if respiratory muscles are affected.· Physiotherapy and occupational therapy for muscle weakness..

الصفحة 1 من 20

دورة الإسعافات الأولية

دورة الإسعافات الأولية

كورس تعليمي هام جداً في الاسعافات الاولية ينبغي على جميع الناس تعلمه سواء أخصائيين أو لا و يتضمن: مبادئ الاسعاف, اسعافات الحروق , اسعافات الكسور, الوظائف الحيوية و الصدمة, تدبير التنفس...

أمراض الجسم البشري

موجز أمراض الجسم البشري

شلل الأطفال, أمراض الجهاز البولي, الحمل و الولادة مع الصور و الفيديو (ضمن الوسائط الطبية), التهاب الكبد, الانفلونزا, الروماتيزم, متلازمة العوز المناعي الايدز, الداء السكري, فقر الدم.

حالات سريرية

موسوعه الحالات السريرية

حالات سريرية طبية مميزة و منتقاة مع صور توضيحية و جداول توضح الحالة مع حل و مناقشة الحالة بتوسع و تتضمن حالات: هضمية, عصبية, جلدية, رثوية مفصلية, غدد, عينية, قلبية, رئوية صدرية.

النشرة البريدية

اشترك بالنشرة البريدية ليصلك جديد الموقع
نحن في موقع العيادة السورية نهتم كثيراً بخصوصية الزوار الكرام.

جميع المعلومات التي نجمعها عن زوارنا الكرام تخضع لسياسة الموقع.

الرجاء مراجعة سياسة الموقع.

العيادة السورية