For each case of disordered movement A–E, select the most appropriate option from the following list of areas of neurological damage.
1. One cerebral hemisphere.
2. Extrapyramidal system.
3. Cerebellum.
4. Patchy areas throughout the central
5. Motor neurones.
4. nervous system.
6. Sensory neurones
- The patient initially notices some weakness and clumsiness in one hand, with wasting of the thenar eminence. Twitching is noticed on the affected side. The weakness spreads over some months to both arms and legs so that walking is only possible with suppo
- The patient walks with a very unsteady, staggering gait. Speech is rather indistinct. When the patient fixes the gaze to one side, jerking movements of the eyes can be seen. When asked to touch the examiner’s finger, the patient’s finger moves irregularly
- When the patient is sitting at rest, a tremor of the hand and slow ‘vibration’ of the foot is noticed. The patient has started to walk leaning forward and with small shuffling steps. On passive bending of the arm, increased resistance is noted.
- The patient reports a variety of temporary disturbances, double vision and visual difficulties on both sides at different times, weakness and clumsiness in an arm or leg now and again. With time there has developed more constant difficulty and unsteadines
- The patient walks a little unsteadily, dragging one foot. Testing shows loss of power and impaired sensation in the arm and leg on that side.
Medicine
A. Option 5 Motor neurones. The symptoms are due to gradual destruction of motor neurones, with no suggestion of any sensory loss. Wasting and twitching suggest involvement of the lower motor neurones. The history is typical of motor neurone disease.
B. Option 3 Cerebellum. The cerebellum smooths movements and makes them precise. The patient shows the opposite in the legs causing unsteadiness, in the muscles of speech causing slurring and in the eyes, causing nystagmus. ‘Intention’ tremors, i.e. shakiness during movements, are typical of cerebellar disease.
C. Option 2 Extrapyramidal system. In contrast to the above, this patient has tremors at rest. The extrapyramidal system provides appropriate muscle tone and associated movements and these are impaired in the patient whose features are typical of Parkinsonism (an extrapyramidal disorder).
D. Option 4 Patchy areas throughout the central nervous system. This patient has had a variety of temporary disturbances involving various scattered regions: optic nerves, nerves to the eye muscles, regions controlling arm and leg movements. The condition is intermittent but tends to lead gradually to permanent difficulties. This is typical of multiple sclerosis (MS).
E. Option 1 One cerebral hemisphere. This patient has motor and sensory loss in one side of the body due to damage in the cerebral hemisphere on the other side. The features are typical of a patient with moderate recovery from one or more strokes affecting motor and sensory pathways in one cerebral hemisphere.
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