The story
A 28 year old woman presented to the neurology clinic with a 3 month history of progressive problems with her walking.
She was struggling to get up and down the stairs, get out of a low chair and do her normal job.
On closer questioning, he also reported some sensory disturbance in the left foot and a sense of urinary urgency.
Past medical history was of Grave’s disease and she has recently had a relapse. She was awaiting further treatment for this.
Medication was propranolol and carbimazole.
On examination
- Speech & higher mental function – normal
- Gait – abnormal; legs clearly weak; unable to rise from standing with the arms crossed
- Visual assessment – normal
- Motor cranial nerves – normal
- Sensory cranial nerves – normal
- Upper limbs – inspection, tone, power, coordination and sensation all normal; reflexes a little brisk
- Lower limbs – inspection normal; tone increased with bilateral ankle clonus; power reduced bilaterally (hip flexors weaker than hip extensors); reflexes brisk and spreading; plantars extensor; sensory exam (rarely helpful) showed a reduction in pin and temperature sensation in the left foot.
Questions?
- Is this a “central” or “peripheral” problem?
- What helps you decide?
- Where is the problem most likely to be?
- What are the top 3 potential causes?
- If you had only one test you could do, what would it be?