Myopathy & Neuropathy Differences

 How to Differentiate Myopathy from Neuropathy Clinically?

1.Myopathy usually proximal, neuropathy has distal weakness

2.Neuropathy may have concomitant sensory symptoms and signs where Myopathy is purely motor.

3.In Myopathy all reflexes preserved till late of the disease course,but in neuropathy reflexes lost early

4.Fasciculations may be present in neuropathy and in Myopathy it is usually absent

5.In neuropathy atrophy is present where in Myopathy no atrophy until late

6.Contracture may be present in Myopathy whereas absent in neuropathy

7.In Myopathy there may be accompanying cardiac dysfunction with dystrophies,whereas it is not a typical feature of Neuropathy.

Stages of Problem-solving Psychotherapy

 Stages of Problem-solving Psychotherapy

1.List the problems such as a man has

a) headache

b) vague abdominal pain

c)Monetary problem

2.choose one from the list to work on

Such from the above list we choose to solve headache

3.Now we have list the possible solutions

Such as as we have chosen to alleviate headache then we can formulate some solution of his headache such as

a)He can use OTC drugs

b) Visit a specialist such as neurologist or expert in headache.

4.Evalution the possible solution and choosing the best.

Such as from the above solutions best is to visit neurologist for evaluation of headache.if any definite cause of headache found then it will be easily solved.

5.Evalutaion of the result

such as evaluation of treatment of headache it is improved or not

6. Repeat until problems are solved

such as if his headache not improved then further consultation,if improved then address another problem in the same way.

(In this example his monetary problem also be main factor causing the other problems.Then the approach will be following the same stages but in different way.

Pigmentation in Addison's disease

 

Scenario:

A male patient,55-year-old nonsmoker, nondiabetic, non-alcoholic presented with weakness, loss of appetite and weight loss, dizziness and generalized pigmentation for 1 year.

 

History:

Ask About pigmentation, distribution of it-focal or generalized, site of predilection (In our patient he has generalized pigmentation more marked in the tongue & palate)

 

Ask about weight loss, how much he has lost? what is present weight? if not measured then how does he ascertain weight loss? does his clothes become looser? Is the weight loss intentional or not? ask about food habit, induced vomiting, laxative, diuretic use.

(In our patient he lost about12 kg in last 1 year, which was unintentional)

 

Ask about dizziness-What does he mean by it? Is it lightheadedness, unsteadiness or spinning? in which position it is more, such as standing from sitting? does he know his blood pressure? if yes then what is during sitting or lying or during standing?

(In our patient he has dizziness during standing from sitting, he reported that his blood pressure is low but did not know the exact measurement)

 

Ask about loss of appetite such as its duration, in any specific food or to all foods? Is there any association with nausea vomiting etc. (In our patient he has loss of appetite to all foods)

 

Ask about associated gastrointestinal symptoms such as dysphagia, nausea/vomiting, abdominal pain, GI bleeding, bowel habit, steatorrhea etc. (None of the symptoms was present in our patient except nausea)

 

Ask about symptoms of TB such as prolong fever, cough, hemoptysis, anorexia etc. (No such history)

 

Search for vitiligo which may point to autoimmune disease. (Absent)

 

Ask about other disease such as CKD, CLD, Kala-azar, haemochromatosis where pigmentation may be seen. (Absent)

 

Take past medical history including DM, Thyrotoxicosis, Adrenalectomy or adrenal irradiation. See any features of depression. (No history of this type of illness)

 

Ask any member of the family suffering from this type of illness or other chronic condition. (In our patient All family members in good health)

 

Ask about past and present medication history specially steroids. (He is taking methylprednisolone 2mg tablet for his low blood pressure for last 6 month but his condition was not improving)

 

 

Physical Examination:

General examination

   In this patient we found that patient was emaciated, pigmentation in lip, tongue and palate. We have search other body parts such as palmar crease and knuckles, nipples, axilla, perineum or in surgical scar. Search for vitiligo, though it was absent in our patient.

 

His blood pressure was in sitting position 100/70mmHg but on standing it was 75/50mmHg (Postural Hypotension)

 

Other findings in GE was normal.

 

Systemic examination: Perform systemic examination including CVS, Respiratory system, Nervous system and MSK system. (Though in our patient all systemic examination were normal)

 

Provisional Diagnosis:

 

Considering the history and findings in clinical examination our Provisional Diagnosis is “Addison’s Disease”

 

 

Points in favor of our Diagnosis:

   1.Weakness, Weight loss, nausea

   2.Dizziness and postural hypotension

   3.Generalised pigmentation

 

 

 

 

 

 

Investigations:

 

 

FBC (for lymphocytosis, eosinophilia)

Electrolytes (for hyponatremia, hyperkaliemia, hyperchloremic acidosis,

hypercalcemia)

Blood glucose, looking for hypoglycemia

Short tetracosactrin (synacthen) test; if positive, follow-up with a prolonged

ACTH stimulation test

ACTH and cortisol levels: in Addison’s disease the 9 am ACTH is elevated

(>300 ng/l)

Adrenal autoantibodies: 21-hydroxylase autoantibodies are elevated in

80%

Chest radiography for TB

Plain radiograph of the abdomen for adrenal calcification

CT scan of the adrenals.

HIV Screening

We should screen for thyroid disease, pernicious anemia, type-1 diabetes if evidence of autoimmune adrenal failure.