DrMKZ

MRCP neuro station

Please examine patient lower limb

Question: This patient is underlying RVD positive presenting to you with bilateral lower limb weakness.

This RVD patient has walking problems.

Elicit

1. IV injection marks
2. Is there loss of muscle bulk to show chronic of the disease?
3. Gait- Bilateral foot drop
4. Thickening of the peroneal nerve
5. Heel to shin test
6. Diminished reflexes- diminished ankle reflex
7. Sensory loss- pin prick – callouses
8. Loss to vibration sense
9. Loss to propioception ( I wonder which one would be better elicited if the pathology is posterior dorsal column)
10. In articles it mention – temporal progression of peripheral sensory loss, loss of vibration sense then loss of temperature then loss of pain.
11. Calosities ? signs of thickend or hardened skin

I would to offer my differential diagnosis

1. Syphillis – neurosyphillis
2. Non ARV associated neuopathy, – Isoniazide
3. DM –
4. CIDP
5. Caudate equina syndrome- just to make it official the emergency diagnosis are excluded
6. Diffuse infiltrative lymphocytosis
7. Cryoglobilinimiea underlyng Hep C
8. ? Leprosy – thickened peroneal nerve, with sensory hypoaesthisia and foot drop.

Inv

1. TRO central causes – CT myelogram, MRI spine better define lesion, CT brain look for parasagital meningioma
2. NCS, EMG, Biopsy nerve and muscle

Ref

http://www.hiv.va.gov/provider/manual-primary-care/peripheral-neuropathy.asp