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Case ID: 1
Created: 20 January 2007

This gentleman is unable to walk,examine his lower limbs neurologically.



     Although it is a rare case in MRCP PACES, I still think that it is an important question. You notice that this gentleman has deformity of both lower limbs and one leg ( left leg) is slightly bigger than the other ( the right leg is more wasted). Therefore, you know that there is asymmetrical involvement. If you proceed to examine the tone, both legs have normal tone and there might be presence of fasciculations. Knee reflex is normal and ankle reflex might be reduced.

    A lot of candidates become panic at this moment, always remember that there are two common conditions in MRCP PACES that give asymmmtrical involvement in lower limbs in your neurology station. These conditions are poliomyelitis and spina bifida.If you proceed to examine the sensory of lower limbs involvement in this gentleman, you will find that L5 and/or S1 dermatomes are involved.In a complete neurological examination of lower limbs, always remember that you must examine the spine. If you look at the spine of this young gentlman, you will know the diagnosis immediately!



You notice that there is a big dimple with scarring above his sacrum. I hope you know the diagnosis by now!

You must suggest to examiners that you would like to know the following,

arrow bladder and bowel symptoms. You anticipate this gentleman has neurogenic bladder and needs intermittent catheterization to empty his bladder,
arrow any risk factors to predispose him to have spina bifida such as usage of sodium valproate in pregnancy and maternal diabetes.

Common questions examiners would ask you,

1) How do you manage this condition?

( Mainly supportive, however remember that patients tend to have renal impairment if the neurogenic bladder is not properly managed. This is a case where you need involvement of mutiple teams such as urology, physiotherapy,neurology, and orthopaedics)

2) Is there any way to minimize this condition?

( Remember the answer is Folic Acid Supplement!)


This young gentleman has spina bifida .

Extra points:

1) Get more information about Spina Bifida here

arrow Spina Bifida Association Web Site

Created: 20 January 2007

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