FFFF has been on a 3 month holiday. Now it’s back. You may note an emphasis on the arcana of the physical examination in the next few editions…
Start revving your cerebral engines folks, here we go!
Q1. What is dressing apraxia? Where is the lesion?
- Apraxia is the loss of the ability to execute learned purposeful movements.
- Patients with a lesion of the non-dominant parietal lobe may exhibit dressing apraxia.
- This can be tested by giving a patient a cardigan, coat or jacket that is folded inside out and asking him or her to put it on… As shown in this video clip, affected patients find this task impossible:
Q2. How can you check for plantar reflexes without causing a withdrawal response?
- The plantar reflex involves the L5, S1 and S2 nerve roots and (according to Talley & O’Connor) is elicited by using the ‘key to an expensive motor car’ to stroke distally along the lateral aspect of the sole of the foot then curving inwards towards the middle metatarsophalangeal joint before reaching the toes.
- Upgoing plantars are abnormal in people older than 1 year of age, and are characterised by extension of the hallux (big toe) at the first metatarsophalangeal joint in conjunction with with fanning of the other toes. This abnormal extensor response is also known as the Babinski response and suggests an upper motor neuron lesion.
- Assessing the plantars can be confounded by a withdrawal response to the noxious stimulus of the car key. This can be avoided by using the technique shown in this video:
- A test for abdominal wall pain attributed to American surgeon John Carnett.
- First, identify the localised area of tenderness by palpation with the patient supine.
- Ask the patient to cross his or her arms and sit halfway up, then palpate again.
- If the tenderness disappears the pain is likely to be from within the abdominal cavity. The contracted abdominal muscles protects the abdominal contents from compression by the palpating hand.
- If the tenderness persists or is greater, the pain probably orginates from the abdominal wall (e.g. muscle strain, myositis).
- False positives may arise from inflammation of the parietal peritoneum underlying the abdominal wall (e.g. appendicitis).
Q4. What does ‘milkmaid’s grip’ suggest?
- Chorea refers to non-repetitive abrupt involuntary jerky movements (more distal than proximal) classically resulting from lesions in the corpus striatum. Choreiform movements may be disguised by the patient by completing the involuntary movement with a voluntary one.
- Chorea may be detected on shaking the patient’s hand if they are unable to maintain a sustained grip. This known as the ‘milkmaid grip‘.
- Causes of chorea include:
- Huntington’s disease
- Sydenham’s chorea
- Wilson’s disease
- Drugs — e.g phenothiazines, oral contraceptive pill, phenytoin, L-dopa
- Vasculitis or connective tissue diseases, e.g. systemic lupus erythematosus
- Polycythemia or other causes of hyperviscosity
- Viral encephalitis
Q5. How is Weiss’ sign elicited and what condition does it suggest?
- Weiss‘ sign is better known as Chvostek‘s sign and is seen in hypocalcemia, as well as some other hyperexcitable states such as anxiety and even in some ‘normal’ individuals.
- The sign is elicited by tapping over the facial nerve anterior to the tragus of the ear. The sign is present if there is a brisk muscular twitch on the same side of the face (often involving the lips).
- The following video shows carpal spasm and Weiss’ (aka Chovstek’s) sign: