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INTERNAL MEDICINE SECRETS PDF

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Always start by looking at the animal across the room. Look for abnormal body postures i. If any of these things are observed, then the problem must involve the brain lesion above the foramen magnum. How will changes in gait help localize lesions?

After observing the animal across the room, next watch the animal walk, preferably on a nonslippery surface. Look again for abnormal head postures or movements, but then concentrate on gait. Is there one side that appears weaker than the other? Is there a similar amount of coordination in the front and rear limbs? If the front limbs are abnormal, are they more or less abnormal than the rear limbs? Because the brachial intumescence in most dogs is located between C6 to T2 spinal cord segments, normal to near normal gait in the front limbs with poor coordination in the rear limbs suggests a lesion caudal to the second thoracic spinal cord segment T2.

If the front limbs are as weak or weaker than the pelvic limbs, then the problem likely resides within the cervical intumescence. If the front limbs are abnormal, but appear stronger than the pelvic limbs, this usually indicates a lesion rostral to C6. If one side thoracic and pelvic limbs appears weaker than the other hemiparesis , the same rules apply as previously described, but one side of the spinal cord or brain is more severely affected than the other. How can you be sure that an abnormal gait is caused by neurologic disease rather than an orthopedic condition?

Sometimes it can be difficult to differentiate between neurologic and orthopedic diseases. The best way to do this is with a series of tests referred to as postural reactions. The animal must first recognize that the foot is in an abnormal position sensory systems and then have the strength to replace the foot in a more normal position motor systems. Animals with orthopedic disease can accomplish most postural reactions.

Occasionally animals with orthopedic disease will resist the postural reactions that require a lot of movement on the weight-bearing limb e. However, it is extremely rare that all postural reactions are abnormal in an animal with only orthopedic disease. The following are the more common postural reactions. I place a hand under the pelvis when evaluating the pelvic limbs, and under the chest when examining the thoracic limbs.

All four limbs should be examined. A normal 1 Neurologic Examination and Lesion Localization response is to immediately flip the paw over onto the normal weight-bearing surface. Abnormal responses include leaving the foot in the abnormal position, repositioning it slowly or repositioning it incompletely i. Push the animal forward so it must take several steps with the thoracic limbs to maintain balance. This is often accomplished first with the head and neck in a normal position, then repeated with the head and neck elevated.

Abnormal responses include delayed positioning of one or both thoracic limbs or exaggerated placement. Exaggerated placement may suggest an abnormality in the cerebellum or caudal brain stem.

A normal animal will often extend the limbs in anticipation of contact and then take several steps backwards to position the limbs correctly. An alternative technique for dogs that are too big to be picked up is to lift the front legs and push them backwards. I have rarely found this alternative helpful. Most normal animals can then accomplish lateral hopping movements with the supporting limbs.

Again, normal animals can make lateral hopping movements in the one supporting limb. A normal response is for the animal to see the table and reach for it with the closest limb. Again, a normal animal will attempt to place the limb in a position to bear weight. When do you test spinal reflexes? After completing the postural reactions, I have a good idea if the gait abnormality is orthopedic or neurologic in origin.

If it is neurologic, I use the same information regarding localization of gait abnormalities that I described previously. As previously mentioned, the cervical intumescence resides within spinal cord segments C6-T2, whereas the pelvic intumescence resides within spinal cord segments L4-S3. The intumescences contain the cell bodies for the lower motor neurons that innervate the thoracic or pelvic limbs, respectively.

Injury to the lower motor neurons will cause spinal reflexes to be decreased or absent. Because the predominate clinical feature is caused by injury to the lower motor neuron, paresis or paralysis with decreased or absent spinal reflexes is frequently referred to as lower motor neuron clinical signs. Alternatively, if the lower motor neuron is intact but the problem resides in one or more neurons upstream or closer to the motor center in the brain, then spinal reflexes will still be intact and may be exaggerated even though the animal has lost some or all voluntary motor ability in that limb.

Paresis or paralysis with normal to increased spinal reflexes if often referred to as upper motor neuron clinical signs that reflect that the injury is upstream from the lower motor neurons. Do spinal reflexes help distinguish between neurologic and nonneurologic diseases? Postural reactions do a better job of answering the question, Is the problem neurologic or nonneurologic in origin?

Spinal reflexes are strongly influenced by the temperament and anxiety level of the animal. If the animal is anxious, then the muscles are tense, and spinal reflexes often will appear exaggerated in an otherwise normal animal. If reflexes are abnormal, I will repeat postural reactions. It would be most unusual for neuronal injury severe enough to cause abnormal spinal reflexes to not also affect postural reactions.

Is it correct that spinal reflexes primarily distinguish between upper motor neuron and lower motor neuron injury? Yes, this is the primary value of spinal reflexes in a neurologic examination. How do you perform spinal reflexes and what should they look like? The afferent branch varies with the area pinched; the efferent nerves are those that mediate flexion of the limb axillary, musculocutaneous, median, and ulnar.

The appropriate response is flexion of the elbow. However, this is often hard to see when holding the limb, so often you only see a visible contraction of the biceps muscle.

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Both afferent and efferent axons are carried in the radial nerve spinal cord segments C7-T2 and the appropriate response is extension of the elbow. This is the most difficult reflex to see in the front leg.

Whereas they are both direct effects on the skeletal muscle and stimulation of stretch receptors and associated myotatic reflex , a normal response requires an intact radial nerve. The appropriate response is extension of the carpus. Afferents are carried in either the femoral nerve if the medial surface of the limb is stimulated or sciatic nerve.

The efferent axons are carried in the sciatic nerve L6-S1. The appropriate response is flexion of the limb. The peripheral nerve controlling this reflex is the femoral nerve spinal cord segments L4-L6. It requires an intact tibial branch of the sciatic nerve spinal cord segments L6-L7, S1.

Again this response is mediated by a combination of direct muscle contraction and a myotatic stretch reflex. A normal response requires an intact peroneal branch of the sciatic nerve spinal cord segments L6-L7, S1.

What would a lesion between L4 and S3 spinal cord segments look like? The animal would have gait abnormalities in the pelvic limbs. Postural reactions should be decreased in the pelvic limbs and normal in the thoracic limbs. Spinal reflexes should be decreased to absent in the pelvic limbs. In addition, the limb would feel flaccid and muscle atrophy would occur quickly. What would a lesion between T2 and L4 spinal cord segments look like?

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Show details. download the selected items together This item: Critical Care Secrets by Polly E. Customers who bought this item also bought. Page 1 of 1 Start over Page 1 of 1. Salvatore Mangione. Pediatric Secrets. Pocket Medicine: Marc S Sabatine. Critical Care Secrets. Emergency Medicine Secrets. Vincent J. Theodore X. Review This is a collection of internal medicine pearls residents would focus on during their training, organized in a question-and-answer format with key points.

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