Cases for finals #1 – examination

Speech slurred – dysarthric
Higher mental function – normal
Cranial nerves – normal
Limbs
  • Tone – normal
  • Power – global weakness UL & LL (3/5)
  • Reflexes – brisk
  • Sensation – normal
  • Gait – unsteady

Not too much to go on here.

Dysarthria could be spastic (UMN), cerebellar or flaccid (LMN). You don’t have much to go on here. A tight, stuff tongue and a brisk jaw jerk would suggest a “spastic” UMN cause whereas a thinned, weak, fasciculating tongue would suggest a LMN cause. There is nothing here to suggest a cerebellar ataxia, so that is unlikely.

You really want some information on inspection. If I offer up the fact that there is wasting of the hands and quadriceps, with fasciculation evident, then alarm bells will really be ringing (hopefully). Add to this that, in a wasted, fasciculating limb (LMN signs), the reflexes are brisk (UMN signs) and you have a disorder that is damaging the entire motor system – and there is only one thing that does that.

Diagnosis – MND (ALS phenotype)

Investigations?

  • Bloods – not much to do here but I always check thyroid function, inflammatory markers and a CK (just in case it’s a funny myopathy)
  • You might do an MRI of the spine, to rule out degenerative disease – but this would not cause slurred speech and respiratory symptoms.
  • NCS/EMG – are the best option here
  • DON”T FORGET – respiratory assessment (FVC, oximetry) and SALT assessment are vital here too.

Want to know a bit more about MND? Follow this link

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