Multiple Sclerosis - Summary Multiple Sclerosis (MS) is an autoimmune-mediated neurodegenerative disease of the central nervous system • Inflammatory demyelination with axonal transection. • Results in physical disability, cognitive impairment, decreased quality of life Multiple Sclerosis Epidemiology: • Female to male sex distribution of nearly 3:1 • MS typically presents in young adults (mean age of onset, 20-30 years) Presentation - Young adults aged 20 to 30 years with: • Unilateral optic neuritis • Partial myelitis • Sensory disturbances • Or brainstem syndromes such as internuclear ophthalmoplegia Atypical Fulminant Forms of MS: • Tumor-like large multifocal demyelinating lesions: • Tumefactive demyelination • Balo’s concentric Sclerosis • Marburg Variant Examination: • UMN signs (Hyperreflexia, Clonus, Babinski’s sign) • Uhthoff’s phenomena • Lhermitte’s sign • Internuclear ophthalmoplegia • Afferent pupillary defect SIGNS/SYMPTOMS: • CENTRAL: Fatigue, Depression, Cognitive impairment, Mood disorder • MUSCULOSKELETAL:, Spasm, Cramping, Weakness, Ataxia • GU: Frequent urination, Incontinence • VISUAL: Nystagmus, Optic neuritis, Diplopia • MOUTH: Slurring/Stuttering speech, Dysphagia • GI: Constipation, Diarrhea, incontinence • SENSES: Tingling, Burning, Paresthesias, Sensitivity to pain, Trigeminal neuralgia Multiple Sclerosis Diagnosis - Based on a combination of: 1. Signs and symptoms 2. Radiographic findings (eg, magnetic resonance imaging [MRI] T2 lesions) McDonald diagnostic criteria for MS 3. Laboratory findings (eg, cerebrospinal fluid-specific oligoclonal bands) - Oligoclonal bands are found in up to 95% of patients with clinically definite MS 4. VEP’s: EEG of visual stimulation Clinical Course of Multiple Sclerosis: • Relapsing-remitting MS (FLARE) (85% of pts) → Enter a period of progressive decline → Secondary Progressive MS • Primary Progressive MS (Spinal cord predominant) (15% of pts) → Steady decline without flares Multiple Sclerosis Treatment: • Functionally disabling symptoms with objective evidence of neurologic impairment (Loss of vision, Diplopia, Weakness, and/or cerebellar symptoms) • Acute: - IV methylprednisolone 500 to 1000 mg daily 3-5 days - Oral prednisone (1000 mg to 1250 mg) without an oral taper 3-7 days - Short course of intramuscular adrenocorticotropin hormone gel • Refractory Relapse: Plasma exchange (PLEX) or IVIg #Multiple #sclerosis #diagnosis #management #neurology #treatment #MS

In a patient in the supine position, raising the leg with the knee extended stretches the nerve root over the protruded disk and results in a response of muscle contraction. A positive test consists of reproduction or marked Worsening of the patient’s initial pain and firm resistance to further elevation of the leg. A diagnosis of disk compression is likely if pain radiates from the buttock to below the knee when the angle of the leg is between 30 and 70 degrees. Many persons without spinal abnormalities have hamstring and gluteal tightness With discomfort elicited by straight leg raising, but the pain is more diffuse than in sciatica and the leg can be lifted higher if the maneuver is performed slowly. Increased pain on dorsiflexion of the foot or large toe increases sensitivity. The crossed straight-leg-raising test (Fajersztajn’s test) involves raising the unaffected leg; in a positive test, sciatic pain is elicited in the opposite (affected) leg. This test is 90% specific for disk herniation on the contralateral side but is insensitive. #Diagnosis #PhysicalExam #StraightLeg #Lasegues #Test #Sciatica

Diabetic Foot Guidelines: Test patients w diabetes for peripheral neuropathy using the Semmes-Weinstein test JAMA. 2017;318(14):1387-1388. doi:10.1001/jama.2017.11700 #Diagnosis #PrimaryCare #Diabetic #Neuropathy #Monofilament #Testing #Locations

Shoulder Exam - Provocative Testing Supraspinatus muscle injury: - Jobe’s Test - Hawkin’s Test - Drop Arm Test Infraspinatus muscle injury: - Infraspinatus Scapular Rotation Test Subscapularis muscle injury: - Lift-Off Test Rotator cuff subacromial impingement: - Neer Test Labral tear: - Crank Test - O’Brien Test Biceps muscle: - Yergason Test #Diagnosis #PhysicalExam #Shoulder #Testing #Maneuvers #RotatorCuff #Injury #Tendinopathy #Impingement #ALiEM

Dix-Hallpike Maneuver for BPPV Procedure: 1. Make the patient sit on examination table, such that the shoulders would level on the edge of table when lying down 2. Always start the examination with the ear that is least suspected 3. Turn the patient’s head to 45° towards the test ear, by holding the both sides of the patient’s head with your hands 4. Instruct the patient to fix his/her eyes on a point directly in front of him/her and keep the eyes open throughout the test 5. Supports the patient’s head as the patient lies back quickly from a sitting to supine position, ending with the head hanging 30 degrees off the end of the examination table 6. Observe the patient in this position for 30 seconds 7. Then the patient returns to the upright position and is observed for 30 seconds. 8. Repeat the entire maneuver with the head turned 45 degrees toward the opposite side. Observe* 1. Nystagmus 2. Vertiginous symptoms Interpretation: When the head is turned to the affected right ear, the nystagmus occurs as follows: 1. When the head is lowered 30 degree below the bed, the fast phase of the nystagmus is upward , rotating toward the affected ear 2. When the patient is brought back to the sitting position, the fast phase of the nystagmus is downward , rotating toward the affected ear #Dix #Hallpike #DixHallpike #Maneuver #BPPV #Instructions #Diagnosis #neurology