Active Learning Discussion around a 55 year old patient with Left hemiparesis and Left UMN Facial palsy.

[2/27, 5:36 PM] MBBS UG Student 1: Good evening, sir. We were able to interact with and examine the 55 year old patient with Left hemiparesis and Left UMN Facial palsy today.

 

[2/27, 5:36 PM] MBBS UG Student 1: I have a few questions, sir. 

[2/27, 5:37 PM] MBBS UG Student 1: Since the UMN type of VII nerve palsy is to the same side of the hemiplegia, shouldn't the lesion be in the right internal capsule? 

[2/27, 5:38 PM] MBBS UG Student 1: If the lesion is in the pons, there should be an LMN facial palsy with contralateral hemiparesis.

[2/27, 5:40 PM] Post-residency PG 1 : Check out the pathophysiology around medial mid pontine syndrome

 

MRI - showing hyperintense lesion in right medial pons :

 

[2/27, 5:46 PM] MBBS UG Student 1: Another question I had was, while we performed a motor system examination, on examining the muscle tone we noticed left upper limb and left lower limb hypotonia and the muscle power of the left upper limb and left lower limb were 0/5 and 4/5 respectively. Whereas, the deep tendon reflexes such as the Biceps jerk, Triceps jerk, Supinator jerk, Knee jerk, Ankle jerk were brisk (+3) on the left side. Even the plantar response was upgoing (Babinski's reflex) on the left, whereas on the right all the corresponding findings including reflexes were normal (+2)

[2/27, 5:50 PM] MBBS UG Student 1: I also noticed muscle wasting of the left forearm muscles and left thigh muscles, when I measured with a tape. 

[2/27, 5:47 PM] MBBS UG Student 1: Why is it that one can find features of both LMN and UMN on the same side of hemiparesis?

[2/27, 11:09 PM] Post-residency PG 1 : It's due to neuronal shock 

[2/27, 11:24 PM] MBBS UG Student 1: Yes sir, I understand how there can be hypotonia and diminution of muscle power in the stage of neural shock but shouldn't the reflexes be affected too? Shouldn't they be diminished or absent? 

 [2/28, 12:45 PM]Post-residency PG 1: As the neuronal shock recovers the reflexes are the first to return from below upwards. In exam they are particularly fond of knowing which reflex returns first 

 [2/28, 1:16 PM] MBBS UG Student 1: The Bulbocavernosus reflex returns first

 [2/28, 1:18 PM] MBBS UG Student 1: Because it's root value is S3 - S4 

[2/28, 1:26 PM]Post-residency PG 1: 👍

 [2/28, 1:26 PM] MBBS UG Student 1: So, if I understand correctly, the reflexes return first, but they don't go back to normal directly. They go from Areflexia to Hyperreflexia to normal. But some reflexes such as the plantar response doesn't go back to normal, even after recovery. 

[2/27, 7:45 PM] MBBS UG Student 1: And sir, how much loss of muscle (in centimeters) is considered as muscle wasting? Or do we just compare it with the opposite, healthy side to call it muscle wasting? 

[2/27, 11:09 PM] Post-residency PG 1: Comparison 

 SPOTTERS : 

 1. Frank's sign ear lobe crease predicts 45% possibility of CAD :

2. Easy representative images of the motor and sensory tracts and the blood supply :

 At the top is Mickey mouse midbrain, in the middle is the merry pons and at the bottom is the medulla

 

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Contributions :

Image Courtesy : Vyshnavi Ma'am, Sai charan sir and Aditya sir. 

Video Courtesy : Y. Srinidhi.