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the familial (hypokalemic) type of periodic paralysis, may affect only the pelvic and thigh muscles In a number of the congenital polymyopathies (central core, nemaline, myotubular, etc), a relatively nonprogressive weakness affects girdle muscles more than distal ones These are discussed in Chap 52 Proximal muscles are occasionally implicated in progressive spinal muscular atrophy, as in the syndrome rst described by Wohlfart and coworkers and by Kugelberg and Welander, which unfortunately adds to confusion in diagnosis 8 Bicrural palsy presenting as lower leg weakness with inability to walk on the heels and toes, or as paralysis of all leg muscles With the exception of rare but distinctive distal types of muscular dystrophy, this pattern is not due to myopathy Symmetrical weakness of the lower legs is usually due to polyneuropathy, although peroneal, anterior tibial, and thigh muscles are often weakened in muscular dystrophy Diabetic polyneuropathy or carcinomatous or lymphomatous radiculopathy may cause asymmetrical weakness of thigh and pelvic muscles, often with pain and little sensory change Chronic in ammatory demyelinating polyneuropathy (CIDP) may do the same In total leg and thigh weakness, one, of course, considers a spinal cord disease, in which case there is usually impaired sphincteric function of the bladder and bowel as well as loss of sensory perception below a certain level on the trunk Motor system disease may begin in the legs, asymmetrically and distally as a rule, and affect them out of proportion to other parts Thus the differential diagnosis of distal or generalized leg weakness involves more diseases than are involved in the restricted paralyses of other parts of the body A pure quadriceps femoris weakness may be the expression of several diseases If bilateral, it usually indicates a polymyositis, an early stage of inclusion body myositis (where it may also be unilateral or asymmetrical), or a restricted dystrophy In thyrotoxic and steroid myopathies, the major effects are on the quadriceps muscles If unilateral or bilateral with loss of patellar re ex and sensation over the inner leg, this condition is due most often to a femoral neuropathy, as occurs from diabetes, or to an upper lumbosacral plexus lesion Injuries to the hip and knee cause rapid disuse atrophy of the quadriceps muscles A painful condition of infarction of this muscle is seen in diabetic patients 9 Distal bilateral limb palsies presenting usually as foot drop with steppage gait (with or without pes cavus), weakness of all lower leg muscles, and later wrist drop and weakness of hands The principal cause of this syndrome is a familial polyneuropathy, mainly the group of peroneal muscular atrophies of Charcot-Marie-Tooth type or the hypertrophic polyneuropathy of Dejerine and Sottas (see Chap 46) Chronic nonfamilial polyneuropathies, particularly paraproteinemic and in ammatory ones with motor conduction block and exceptionally some forms of familial progressive muscular atrophy and distal types of progressive muscular dystrophy (Gowers, Milhorat, Welander, and Miyoshi types) may also present in this way In myotonic dystrophy, there may be weakness of the leg muscles as well as the forearms, sternocleidomastoids, face, and eyes With these exceptions, the generalization that girdle weakness without sensory changes is indicative of myopathy and that distal weakness is indicative of neuropathy is clinically useful. excel barcode add in font tool Barcode Add-In for Word & Excel Download and Installation
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It is extremely easy to create and print barcodes in Excel . Please make sure that ... Tutorial in using the Barcode Fonts in Microsoft Excel 2003 . Set the Security ... Generalized or universal paralysis: limb (but usually not cranial) muscles, involved either in attacks or as part of a chronic persistent, progressive deterioration When acute in onset and episodic, this syndrome is usually a manifestation of familial hypokalemic or hyperkalemic periodic paralysis One variety of the hypokalemic type is associated with hyperthyroidism, another with hyperaldosteronism (Chap 54) Attacks of porphyric neuropathy and of Refsum disease have an episodic nature Generalized paresis (rather than paralysis) that has an acute onset and lasts many weeks is at times a feature of a severe form of idiopathic or parasitic (trichinosis) polymyositis and rarely of the toxic effects of certain pharmaceutical agents, particularly those used to treat hypercholesterolemia Idiopathic polymyositis and rarely inclusion body myositis may involve all limb and trunk muscles but usually spare the facial and ocular muscles, whereas the weakness in trichinosis is mainly in the ocular and lingual muscles In infants and young children, a chronic and persistent generalized weakness of all muscles except those of the eyes always raises the question of Werdnig-Hoffman spinal muscular atrophy or, if mild in degree and relatively nonprogressive, of congenital myopathy or polyneuropathy In these diseases of infancy, paucity of movement, hypotonia, and retardation of motor development may be more obvious than weakness Arthrogryposts may be present at birth As a rule, universal weakness of muscle does not occur in the muscular dystrophies Widespread ascending paralysis (progressing from the arms to the legs), developing over a few days, with involvement of cranial (including ocular) muscles, is usually due to an in ammatory demyelinating or axonal polyneuritis (Guillain-Barre syndrome) and occasionally to porphyric or diphtheric polyneuropathy, tick paralysis, or severe hypophosphatemia In a setting of a critical illness with multiple organ failure or sepsis, generalized weakness of variable degree may occur from either a neuropathy ( critical illness neuropathy) or a severe and widespread myopathy that is thought to be caused by the use of high doses of corticosteroids, especially if there has been concomitant use of neuromuscular blocking agents Certain generalized neuropathies evolve subacutely, and this may also be true in patients undergoing peritoneal dialysis for end-stage renal failure or with toxic exposure to certain heavy metals An even more insidious onset and slow (months to years) progression of paralysis, atrophy, and fasciculation of limb and trunk muscles without sensory loss characterize motor system disease Here the eye muscles are always spared The LambertEaton syndrome may cause a similar picture 11 Paralysis of single muscles or a group of muscles This is usually neuropathic, less often spinal or myopathic Muscle disease does not need to be considered except possibly in certain instances of pressure-ischemic necrosis of muscle due to local pressure or infarction, as in so-called monoplegic alcoholic myopathy or in diabetic muscle infarction Also, the weakness of inclusion body myositis has a preference for certain sites, speci cally parts of the quadriceps, or of the forearm muscles, particularly the long nger exors ( exor digitorum profundus) From this exposition of the topographic aspects of weakness, one can appreciate that each neuromuscular disease exhibits a pred-. | 231 ilection for particular groups of muscles Apart from these topographic patterns that suggest certain possibilities of disease and exclude others, diagnosis depends on additional features the age of the patient at the time of onset and tempo of progression, the coexistence of medical disorders, and certain laboratory ndings (serum concentrations of muscle enzymes, EMG, and biopsy ndings) and genetic determinants also gure prominently in the delineation of muscle diseases barcode for excel 2007 free 2D Excel Native Barcode Generator - Free download and software ...
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