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Station 3 ( Neurology Station):

Mr Lee complained of inability to hold his coffee cup in the morning, would you like to examine his hands neurologically.

( Source: www.meded.ucsd.edu)

Discussion:

An all-time favourite question in MRCP PACES neurology station. What is the obvious abnormality you can see in this picture?? I think you shouldn't miss the obvious left thenar muscles wasting in this picture.A few possible causes of thenar muscles wasting in MRCP PACES, the causes are outilned as below,

1) Carpal tunnel syndrome- you shouldn't miss this diagnosis because if you examine the hands properly, there shouldn't be other muscles wasting except the thenar muscles ( remember median nerve supplies LOAF muscles and ulnar nerve supplies other small muscles of the hand). However making the diagnosis of carpal tunnel syndrome only gives you 3 marks out of 4. You have to look further to find out the underlying cause. The common causes include pregnancy, rheumatoid arthritis, acromegaly,amyloidosis,hypothyroidism and never forget about chronic hemodialysis! ( due to deposition of beta 2 mircoglobulin).

Therefore, open your eyes and look beyond. If you want to get just an extra mark then you need to spend extra 10 seconds to look at the patient as a whole to find out the underlying cause!

2)Motor neuron disease- Remember the thenar muscles wasting may be just a part of generalised muscles wasting of the hand. You pick up thenar muscles wasting on inspection but you have to examine properly to see whether other muscles are involved or not!! However, presence of fasculation will confirm the diagnosis of motor neuron disease!There are a few clinical patterns of motor neuron disease, subtype progressive muscular atrophy ( 25% of cases) will give this picture!

3)Cervical lesion- remember your medical text book, small muscles of the hand are mainly supplied by ulnar nerve which mainly branches out from C8 and T1, therefore any lesion causing injury to C8 and T1 can lead to generalised muscles wasting of the hand. The common causes are syringomyelia ( cervical), bilateral cervical ribs and cervical spondylosis.

4)Peripheral nerve problems- causes include Guillain Barre syndrome, Charcot Marie Tooth disease.

Just spend a bit of time thinking how will differentiate all the above possible diagnosis and soon you will find that how easy you can pass this station!

Lesson to be learned in neurology station- know all your differential diagnosis whenever you are facing a clinical problem, find the clinical signs patient has and work towards your final diagnosis!

Popular questions examiners might ask you during your MRCP PACES,

1) How do you differentiate cervical spondylosis from syringomyelia?

2) How do you manage this gentleman if he has motor neuron disease?

Extra points:

Interesting Images in Clinical Medicine.

Case History:

    Mr L is a 35-year old HIV patient with CD4 count of 23 came in with cheif complaint of severe headache for 2 weeks.CT brain is done. What is the abnormality you see and what can you comment about the CT??

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