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#NeuroPostItPearls #8 (early!): Practice thinking like a Neurologist.
To help you, a #Tweetorial Case adapted from my colleague and dear friend @emeltzermd's new book
“How to Think like a Neurologist.” amazon.com/How-Think-Like…
✨The Case✨
The Man Who Began To Drool.
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A 41 yo M w/ history of testicular cancer presents with a vague headache & several days of fatigue. A few days after these vague symptoms began, he developed burning over with left abdomen and right retroauricular pain. A day later his wife points out that he’s drooling.
🤤
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🛑Pause Here! (the book instructs you to do so!) 🛑
Just as suggested by this awesome chart shared by @LyellJ & @mayoneurores, all neurologic diagnosis starts with determining the tempo and focal/diffuse
So what do you think
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This sounds diffuse and subacute to me!
Now to localization📍:
You suspect he has facial weakness.
But how will you localize it?
[Admit it, you (like me) all just thought, “upper face involvement means LMN facial weakness.” Done.]
From: emdocs.net/wp-content/upl…
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Fair.
But there is so much more you can OBJECTIVELY test!
🛎️Bell’s phenomenon
👁️Corneal reflex
🦻Hearing acuity
👅Taste on the anterior 2/3s of the tongue
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Bell’s phenomenon (the palpebral oculogyric reflex) – omg don’t you love neurology speak?!
I have almost certainly never said oculogyric reflex, def not since critical care training… but 100% am going now.
What *is* the Bell’s phenomenon?
⏱️here: tinyurl.com/yc7jw5wu
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Understanding the other exam findings relies on understanding the anatomy of the facial nerve.
Ethan has you covered with a nice diagram of it in the book:
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👁️The corneal reflex is mediated by V (sens) & VII (motor). CN VII injury = no corneal reflex.
🦻Paralysis of the stapedius, innervated by VII results in the inability to appropriately dampen sound = hyperacusis
👅Taste to the anterior 2/3 of the tongue is also VII mediated!
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The point here is that by understanding the neuroanatomy, you can confirm a bedside diagnosis with greater accuracy by picking the right exam maneuvers.
With the cost of a Q-tip and some sugar we’ve confirmed a LMN pattern of CN VII injury!
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But what about this pain over the thorax?
On exam there were sensory changes in the T10 and T11 dermatome distribution.
📍Localization here is either a radiculopathy or neuropathy of the thoracic roots/intercostal nerves.
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So, our patient has an acute onset VII-nerve palsy and a thoracic neuropathy or possible radiculopathy.
Ok, great! MRI Brain + C + T spine!?!
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Gonna drop this knowledge bomb from the book instead:
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So the “Syndromic Diagnosis” (provided for every case!):
✨“acute onset VII-nerve palsy and thoracic radiculopathy or neuropathy due to a leptomeningeal process"✨
But what’s the etiologic diagnosis?
Back to @LyellJ chart. Looking for something inflammatory, but...
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We'll need to confirm that the patient does in fact have an "-itis." One of the best ways to do this?
C🧪S🧪F (hopefully not green tho!)
Lumbar puncture reveals:
➡️WBC 21 (high!!!)
➡️Protein 41 (nl)
➡️Glucose 57 (nl)
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This confirms that we have an “-itis”!!
You could now google “meningitis, facial palsy, and radiculopathy”:
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And...
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“So, patient... by the way, did you go camping in New England anytime recently?”
“Why, yes, actually! How did you know!? We went to Vermont a few weeks ago! Check out this rash I came back with!”
(multifocal erythema migrans)
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And there you have It, folks, neuroborreliosis!
Treated and fully recovered. No wasteful tests, no unnecessary imaging. An elegant syndromic and etiologic diagnosis just by Thinking Like a Neurologist! 🕵️🧠
amazon.com/How-Think-Like…
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Best part! Ethan has agreed to give away two copies of the book!
Retweet the thread and of those people I'll select two people at random to get a copy.
Look at this awesome artwork on the cover. I'm obsessed!
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@zach_london @harvardneuromds @NMatch2023 @gabifpucci @FTeixeiraMD @EmoryNeurology @EricLawson90 @sigman_md @AANmember @ContinuumAAN @syaddana_neuro @WNGtweets @ShadiYaghi2 @PulmCrit @drdangayach @MoiseyWoisey @JimSiegler @JimmySuhMD @AvrahamCooperMD @RebeccaFasanoMD @DxRxEdu
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