MRCP is well establised as an entry exam for advanced specialist training in many countries including Malaysia. It consists of 3 paper i.e. Part1, Part2(written tests) and PACES. PACES in full means Practical Assessment of Clinical Examination Skills. It is the third part and the candidate is assessed by fellows of RCP. I passed my PACES in 2005. I am glad that many seniors had guided me throughout my preparation for PACES and I wish to share my experiences with PACES candidates via this blog.
The responses for quiz series so far are great! Hence, I decided to post a video demonstrating a gait disorder.
Here, it goes.
This is the neurology station. Please observe the gait.
What type of gait is this man demonstrating?
How would you proceed with the necessary neurological examination?
Video contributed by Wuchereria
Labels: Gait, Neurology, Quiz series
posted by Dr. David Teoh @ 6/16/2007 11:44:00 PM
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14 Comments:
? ataxic gait
check rhombergs, vibration and proprioception
?SACD or tabes
Broad based steppage gait with high knee-rising. Also appears to have a large protuberant abdomen and awkward arm swing with the upper limbs mainly in extension.
Suspicious of severe peripheral neuropathy.
Common causes:
Diabetes
Alcohol
Look for trophic changes, ulcers, joint destruction and wasting of muscles particularly the small muscles of the foot.
Assess power. Peripheral neuropathy tends to have symetrical weakness.
Test reflexes (ankle and deep). These will be reduced or absent.
Check sensation. Look for glove-sock distribution. Test proprioception and vibration sense. Large myelinated fibers are affected more.
Test coordination and Romberg.
Check for postural hypo, cerebellar signs and do fundoscopy.
Will also be tempted to feel the abdomen and elicit abdo reflexes considering the buldging abdo. Not sure how useful they are though.
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No.
HINT: Look at the pelvic and hip region.
cute doc: This is waddling gait
Causes:
1-Duchenne muscular dystrophy
2-Polymyositis
3-Osteomalacia
err... trendelenburg gait? the patient can't maintain his pelvis level.
appears to be waddling and also tries to compesate by raising his legs slightly higher.. so trick me into thinking of steppage gait.
To add further from anonymous..
Look for muscle tenderness (polymyositis)
Heliotrope rash,facial erythema and gottron papules (dermatomyositis)
pseudohypertrophy of calf muscle, not that pronounced in the video but perhaps worth a closer look (Becker/Duchenne)
Limb girle muscle dystrophy could be likely as well..
Hmm....my first impression was ataxic gait too.
Now that you mention bout the hip and pelvic,more notable when viewed from the back of the patient towards the end of the video.
There is lumbar hyperlodosis with a protuberant abdomen.
Patient's shoulder is maintained backward with decreased forward arm swing.
There is a bilateral sagging of the pelvic, indicating pevlvic girdle weakness.
Bingo, it is waddling gait. Well done.
Perfect waddling Gait
a clue to assessment. 1 - the patient has a broad based gait 2 - due to proximal muscle weakness the hip tilts down on the side being lifted. To compensate the leg is raised higher at knee level than would be expected. therefore your differentials of proximal myopathy would be # CT tissue dse Dermatomyo, Polymyo #metabolic disorders , hyper, hypo kalemia, osteomalacia,hyper, hypo thyroid, drug induced inc Alcohol,diamorphine, lithium,corticosteroids, and not forgetting muscular dystrophies ( DMD ,Limb girdle MD)
With regards to proximal myopathy;
what groups of muscles exactly are affected in the ULs or LLs?
The patient is bending backwards while walking, has exaggerated lordosis,his abdomen appears protuberant as he is bending backwards to maintain balance. there is some hypertrophy of the calf muscles. there is no prominent waddling gait, but still i would think of myopathy in this case.Most likely it is beckers muscular dystrophy as the pateint is in middle age. Duchennes muscular dystrophy also has same features but it is more severe , starts in 1st decade and pt is wheelchair bound by second decade. both conditions are x linked recessive.
When walking, there's excessive tilting of his pelvis to left and right. This suggestive of proximal muscle weakness. He has a waddling gait.
Moreover, there is also protuberant abdomen with excessive lordosis of the back suggestive of weak anterior abdomen muscle.
Like to proceed with proximal muscle examination and to exhibit Gower's sign. Inspection of his calf to look for any hypertrophy. If his relative is there, i would also like to look at the calves of his relatives.
My impression is Duchenne Muscular Dystrophy/ Becker Muscular Dystrophy.
cerebellar gait
proceed to check coordination tests,
dysartheria, MRI for cerebellar lesion
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