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Case ID: 1
Created: 5 May 2007

Examine this gentleman's cranial nerves.

Motor Neuron Disease- MRCP


     During your MRCP PACES examination, your examiners may give you clues and tell you that this gentleman has problems with his speech. If they give you clues that patient has problems with speech, I will examine the patient's lower cranial nerves first. Anyway, even though you have the habit for examining cranial nerves from the every first to the last, you would notice that this gentleman has very obvious wasting of the tongue.

    If you remember from your old medical school time, muscles of the tongue are supplied by hypoglossal nerve ( XII cranial nerve). You must look for other cranial nerves involvment in this gentleman. Further examination in this gentleman reveals that,

Motor Neuron Disease for MRCP

arrow He has fasciculations of the tongue,

arrow Vagus nerve(X) involvement as evidenced by weakness of soft palate

arrow Nasal speech.

    At this point, there are two important differential diagnosis, patients with Motor Neuron Disease can present with either bulbar or pseudobulbar palsy. Another important differential is Syringomyelia because it can involve lower cranial nerves. Therefore, you must suggest to examiners that you would like to examine your patient hands for any fasciculations or dissociated sensory loss in order to differentiate these two conditions. Although patients with Guillain-Barre syndrome may give rise to similar picture ( weakness of tongue with nasal speech), you must remember that wasting is not obvious ( due to short duration of weakness in Guillain Barre syndrome) and you may find ocular muscles involvement (Ophtalmoplegia) especially in Miller-Fisher variant.

Common questions examiners would ask you,

1) How do you differentiate bulbar from pseudobulbar palsy?

( You can find the answers in any medical text book, however, I think the tongue gives you good clues in differentiating these two conditions!)

2) What investigations you would like to order in this gentleman?

( Electromyography- shows widespread anterior horn cell damage. You may want to do MRCI to exclude other spinal cord or root compression!)

3) What are the clinical patterns of motor neuron disease?

( Bulbar, Progressive muscular atrophy and Amyotrophic lateral sclerosis?)

4) Who is the famous scientist in UK having motor neuron disease?

( Of course, the most famous motor neuron disease patient is Professor Stephen Hawking)


This gentleman has bulbar palsy due to motor neuron disease!

Extra points:

1) Get more information about Motor Neuron Disease here

arrow Scottish Motor Neuron Disease Association

Case ID:2
Created: 5 May 2007

Look at this diabetic lady skin . ( Station 5)

diabetic dermatopathy for MRCP


    OK, examiners give you two clues here, patient is diabetic and female. Yes, Necrobiosis Lipoidica Diabeticorum is sommoner among female diabetic patients. Classically it is decribed as well-circumscribed papules or nodules that expand with an active border to become waxy, atrophic, round plaques centrally. Initially, these plaques are red-brown in color but progressively become more yellow and atrophic in appearance.

Necrobiosis Lipoidica Diabeticorum is a disorder of collagen degeneration with a granulomatous response, thickening of blood vessel walls, and fat deposition. You must always suggest to examiners that you would like to look for similar lesions over pre-tibial area ( a classical location), scalp, trunk and upper extremities. Suggest to exaimers as well that you would like to check urine for glucose.

Common questions examiners would ask you,

1) What is the histology of this lesion?

(Histopathologically, it presents with interstitial and palisaded granulomas that involve the subcutaneous tissue and dermis.)

2) What is your differential diagnosis?

( Sarcoidosis of the skin!)


This lady has Nercobiosis Lipoidica Diabeticorum


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