Good cases

Today, I actually saw some great cases.

First, I saw a classic presentation of Bell's Palsy. I got to strut my stuff a little in front of the intern. You see, the intern had read in the chart that the patient had a suspected lower motor neuron lesion, as opposed to an upper motor neuron lesion. For the layperson, an upper motor neuron (UMN) lesion basically means something in the brain itself, and a lower motor neuron (LMN) means something in the nerves from the brain to the terminus. This is an oversimplified explanation, but sufficient for the story. Now, an UMN lesion is something like a stroke, cerebral mass or infection of the brain. An LMN is something outside of the brain along the course of the nerve, like trauma, inflammation, or loss of oxygen. Anyway, the intern saw that it was an LMN, as opposed to an UMN lesion, and I got to pull out a clinical pearl. You see, Bell's Palsy presents as the sudden onset of one-sided facial droop, slurred speach, and the inability to completely close the eye on the affected side. A stroke can present with very similar symptoms. So, as an EM doc, I may have some paniced patient come into my ED with one-sided facial droop, and slurred speach. Well, there is a fairly effective way of differentiating between Bell's Palsy, and a stroke. Ask the patient to raise their eyebrows. If they both go up, then the patient is having a stroke, and it is time to order a CT without contrast, and quickly. If only one goes up, then you can be reassured that it is unlikely that they are having a stroke (be advised, it is not impossible, but it is exceedingly rare fore a stroke to present with only one eyebrow raising). Anyway, I pointed this out to the intern, and got props for it.

The next case we saw was a case of Myasthenia Gravis. The attending was the only one who had seen this patient, and decided to test our diagnostic skills by having the patient track an object visually (which they failed to do for more than 1 second), and asking us some questions about what they had. The patient also has vitelligo. We were asked what that should point us towards (autoimmune). Then we were asked what the patient had. I asked for what the presenting ccomplaint was, and was told "weakness." I then asked about the course of it, and figured that it was most likely to be either Multiple Sclerosis, Myasthenia Gravis, or Lambert-Eaton. So, I asked about whether a tensilon test had been done, and what the results were. This, of course, solved the 'mystery.'

Anyway, it was a good day, even if it did run a little long.

Respectfully Submitted,
-doc Russia