Q25 - Reflexes Quiz

Reflex Quiz Theme & Discussion : 

Reflex Quiz Theme & Discussion Dr. Aswini Kumar. MD Professor of Medicine Medical College Hospital Thiruvananthapuram

1. Normal reflex pattern: 

1. Normal reflex pattern Additional Points: Asymptomatic Patient is conscious Higher functions - normal Cranial nerves – normal Muscle bulk - normal Muscle tone - normal No motor d eficits No abnormal movts No sensory deficits No cerebellar signs No meningeal signs Knee +++ Knee +++ Conjval + Corneal + Jaw - Triceps ++ Triceps ++ Biceps ++ Biceps ++ Supinator ++ Supinator ++ Ankle + Ankle + Plantar  Plantar  Abdominal + + + + Cremasteric + + 01

2. Rt Hemiplegia Neuronal Shock: 

2. Rt Hemiplegia Neuronal Shock Additional Points: Middle aged man Weakness right UL LL Inability to speak Patient Conscious Motor Aphasia + UMN Facial [Right] Hypotonia [Right] Grade 0 power [Right] No Sensory Deficits No Cerebellar signs No Meningeal Signs Knee ++++ Knee - Conjval + Corneal + Jaw ++ Triceps +++ Triceps - Biceps - Biceps +++ Supinator - Supinator ++ Ankle - Ankle ++ Plantar  Plantar  Abdominal - + - + Cremasteric - + 02

3. Left Hemiplegia Post shock : 

3. Left Hemiplegia Post shock Additional Points: Middle aged woman Weakness left UL LL No speech defect Patient Conscious Higher Functions N Left UMN Facial Clasp Knife [Left] Grade 2 [Left] No Sensory Deficits No Cerebellar signs No Meningeal Signs Knee ++++ Knee +++ Conjval + Corneal + Jaw ++ Triceps +++ Triceps +++ Biceps +++ Biceps +++ Supinator ++ Supinator ++ Ankle + Ankle ++ Plantar  Plantar   Abdominal + - + - Cremasteric + - 03

4. Old Right Hemiplegia: 

4. Old Right Hemiplegia Additional Points: Old man Sudden onset 1year back Weakness right Ul+LL Patient Conscious UMN Facial [Right] Tone  [Right] Contractures [Right] Power Grade 3 [Right] Patellar Clonus [Right] Ankle Clonus [Right] RHD MS Atrial Fibrillation Knee +++ Knee ++++ Conjval + Corneal + Jaw ++ Triceps ++ Triceps ++++ Biceps ++++ Biceps ++ Supinator +++ Supinator ++ Ankle +++ Ankle + Plantar   Plantar Abdominal - + - + Cremasteric - + 04

5. Pseudo-bulbar Palsy: 

5. Pseudo-bulbar Palsy Additional Points: 75 year-old woman Right stroke 1y back Left stroke 1m back Patient - conscious Emotional incontinence Exaggerated gag reflex Hypertonia bilaterally Variable weakness UL LL Primitive reflexes ++ No Cerebellar signs No Meningeal Signs Knee ++++ Knee ++++ Conjval + Corneal + Jaw ++ Triceps ++ Triceps ++ Biceps ++ Biceps ++ Supinator ++ Supinator ++ Ankle +++ Ankle +++ Plantar   Plantar   Abdominal + + + + Cremasteric + + 05

6. Parkinson’s Disease: 

6. Parkinson’s Disease Additional Points: 85 year-old man Slow in walking Patient Conscious Expressionless face Cranial Nerves Normal Cog wheel rigidity Generalized h ypokinesia Glabellar Tap + Resting tremor ++ No cerebellar signs No Meningeal Signs Knee +++ Knee +++ Conjval + Corneal + Jaw - Triceps ++ Triceps ++ Biceps ++ Biceps ++ Supinator ++ Supinator ++ Ankle + Ankle + Plantar  Plantar  Abdominal + + + + Cremasteric + + 06

7. Lateral Medullary Syndrome [L]: 

7. Lateral Medullary Syndrome [L] Additional Points: Acute onset vertigo Acute onset ataxia Acute onset vomiting Acute onset hiccups Patient Conscious Horner’s Syndrome[left ] IX palsy [left] X palsy [left ] Pain & Temp lost Lt face Pain & Temp lost Rt body Cerebellar signs [left ] Knee +++ Knee +++ Conjval + Corneal + Jaw - Triceps ++ Triceps ++ Biceps ++ Biceps ++ Supinator ++ Supinator ++ Ankle + Ankle + Plantar   Plantar   Abdominal + + + + Cremasteric + + 07

8. Quadriplegia C3 Level: 

8. Quadriplegia C3 Level Additional Points: Young man Road traffic accident Sudden weakness all 4 limbs Patient fully conscious Respiratory distress Hypertonia Bilateral Grade 2-3 power all limbs Distal > proximal weakness Total sensory loss below C3 Pectoral/Trapezius Reflex + UMN Bladder Knee ++++ Knee ++++ Conjval + Corneal + Jaw - Triceps +++ Triceps +++ Biceps +++ Biceps +++ Supinator +++ Supinator +++ Ankle +++ Ankle +++ Plantar   Plantar   Abdominal - - - - Cremasteric - - 08

9. Right C5 Radiculomyelopathy: 

9. Right C5 Radiculomyelopathy Additional Points: Middle aged woman Pain radiating from neck Stiff gait with stumbling falls Patient Conscious Higher Functions N Normal tone in UL Hypertonia Lower limbs Shoulder abduction  Elbow flexion  Sensory loss along C5 C6 UMN Bladder Knee ++++ Knee ++++ Conjval + Corneal + Jaw - Triceps +++ Triceps +++ Biceps - Biceps ++ Supinator Inverted Supinator ++ Ankle +++ Ankle +++ Plantar   Plantar   Abdominal - - - - Cremasteric - - 09

10. Syringomyelia C-8 T-1 Level: 

10 . Syringomyelia C-8 T-1 Level Additional Points: Young man Burns of finger tips Patient Conscious Higher mental function Normal Cranial nerves Normal Hypotonia distally both ULs Small muscle wasting ULs Handgrip weakness B/L Motor weakness both LL Suspended sensory loss C8T1 Sensory Dissociation Knee ++++ Knee ++++ Conjval + Corneal + Jaw - Triceps ++ Triceps +++ Biceps +++ Biceps ++ Supinator +++ Supinator ++ Ankle +++ Ankle +++ Plantar   Plantar   Abdominal - - - - Cremasteric - - 10

11. Paraplegia T-10 Level : 

11. Paraplegia T-10 Level Additional Points: Young girl Sudden onset Weakness both lower limbs Patient Conscious Higher Functions N Cranial Nerves Normal Hypertonia both LLs Grade 0 both LLs Beevor’s sign + Sensory level at Umbilicus UMN Bladder Knee ++++ Knee ++++ Conjval + Corneal + Jaw - Triceps ++ Triceps +++ Biceps +++ Biceps ++ Supinator +++ Supinator ++ Ankle +++ Ankle +++ Plantar   Plantar   Abdominal + + - - Cremasteric - - 11

12. Right T11 Brown- Sequard : 

12. Right T11 Brown- Sequard Additional Points: Young man Stab injury to back Weakness of right LL Patient is conscious Higher Functions N Right lower limb grade 2 Tone reduced right LL Pain and temp lost left LL Vibration lost right LL Joint position sense llost RLL Right T11 hyperaesthesia Knee +++ Knee - Conjval + Corneal + Jaw - Triceps ++ Triceps +++ Biceps +++ Biceps ++ Supinator +++ Supinator ++ Ankle - Ankle + Plantar  Plantar  Abdominal + + - + Cremasteric - - 12

13. Paraplegia L1 Level - Shock: 

13. Paraplegia L1 Level - Shock Additional Points: Middle aged lady Sudden onset back pain Weakness of both LL Patient is conscious Higher functions N Cranial nerves Normal Hypotonia both LL Power grade 0 both LL Total sensory loss below L1 No Cerebellar signs UMN Bladder Knee - Knee - Conjval + Corneal + Jaw - Triceps ++ Triceps +++ Biceps +++ Biceps ++ Supinator +++ Supinator ++ Ankle - Ankle - Plantar   Plantar   Abdominal + + - + Cremasteric - - 13

14. Cauda Equina Syndrome: 

14. Cauda Equina Syndrome Additional Points: Middle aged man Sub-acute onset Pain radiating to lower limbs Weakness below knee Patient is conscious Higher Functions N Asymmetric Wasting of LL Hypotonia both LL Weakness below L3 Patchy sensory loss below L3 No Cerebellar signs Late Bladder involvement Knee +++ Knee - Conjval + Corneal + Jaw - Triceps ++ Triceps +++ Biceps +++ Biceps ++ Supinator +++ Supinator ++ Ankle - Ankle + Plantar  Plantar  Abdominal + + - + Cremasteric - + 14

15. Amyotrophic Lateral Sclerosis: 

15 . Amyotrophic Lateral Sclerosis Additional Points: Old age lady Gradually progressive Weakness of UL and LL Patient is conscious Higher functions Normal Wasting hands & calf Tone Increased B/L Variable muscle power No Sensory Deficits Fasciculation present No bladder involvement Knee ++++ Knee ++++ Conjval + Corneal + Jaw - Triceps +++ Triceps +++ Biceps +++ Biceps +++ Supinator +++ Supinator +++ Ankle +++ Ankle +++ Plantar  Plantar  Abdominal + + + + Cremasteric + + 15

16. Gullian Barre Syndrome : 

16. Gullian Barre Syndrome Additional Points: Young giral Onset over 2 days Numbness of legs Ascending paralysis Patient Conscious Higher Functions N Markedly reduced tone No Sensory Deficits Single Breath Count < 20 Bilateral LMN Facial No Bladder involvement Knee - Knee - Conjval + Corneal + Jaw - Triceps - Triceps - Biceps - Biceps - Supinator - Supinator - Ankle - Ankle Plantar -- Plantar -- Abdominal + + + + Cremasteric + + 16

17. Peripheral Neuropathy : 

17. Peripheral Neuropathy Additional Points: Middle aged man Uncontrolled diabetic Numbness of extremities Patient is conscious Higher functions Normal Cranial Nerves Normal Tone reduced bilaterally Distal weakness UL & LL Glove & Stocking sensory No Cerebellar signs No Meningeal Signs Knee + Knee + Conjval + Corneal + Jaw - Triceps ++ Triceps ++ Biceps ++ Biceps ++ Supinator - Supinator - Ankle - Ankle Plantar /- Plantar /- Abdominal + + + + Cremasteric + + 17

18. Myasthenia Gravis : 

18. Myasthenia Gravis Additional Points: Middle aged lady Subacute in onset Proximal muscle weakness Fatigability present Patient is conscious Higher functions N Bilateral partial p tosis Tone is normal No Sensory Deficits No Cerebellar signs No Meningeal Signs Knee +++ Knee +++ Conjval + Corneal + Jaw - Triceps ++ Triceps ++ Biceps ++ Biceps ++ Supinator ++ Supinator ++ Ankle + Ankle + Plantar  Plantar  Abdominal + + + + Cremasteric + + 18

19. Friedrichs ataxia : 

19. Friedrichs ataxia Additional Points: Symptomatic before 20 years Gradually progressive UMN weakness of lower limbs H/o ataxia in family Higher f unctions Normal Pes cavus deformity Kyphoscoliosis present Power grade 4 all limbs Ataxia both lower limbs Vibration impaired distally J oint position impaired distally Knee ++ Knee ++ Conjval + Corneal + Jaw - Triceps + Triceps + Biceps + Biceps + Supinator - Supinator - Ankle - Ankle - Plantar  Plantar  Abdominal + + + + Cremasteric + + 20

20. Subacute combined degeneration of spinal cord : 

20. Subacute combined degeneration of spinal cord Additional Points: Young man Sub-acute onset Weakness and stiffness Both LL followed by UL Patient is conscious Higher functions - irritable Bilateral optic atrophy Grade 4 power all 4 limbs Loss of vibration Loss of joint position sense Megaloblastic anemia Knee +++ Knee +++ Conjval + Corneal + Jaw + Triceps ++ Triceps ++ Biceps ++ Biceps ++ Supinator - Supinator - Ankle - Ankle - Plantar  Plantar  Abdominal + + + + Cremasteric + + 20

21.Facioscapulo humeral dystrophy : 

21.Facioscapulo humeral dystrophy Additional Points: Young man Facial weakness Shoulder girdle weakness W inging of scapula D eltoid preserved Pseudo-hypertrophy Tone of muscles reduced Wrist extensors grade 2 Flexors grade 3 No Sensory Deficits No Cerebellar signs No Meningeal Signs Knee + Knee + Conjval + Corneal + Jaw + Triceps - Triceps - Biceps - Biceps - Supinator + Supinator + Ankle + Ankle + Plantar  Plantar  Abdominal + + + + Cremasteric + + 21

22. Cerebral palsy : 

22. Cerebral palsy Additional Points: Adolescent child Progressive weakness Affecting all 4 limbs Hypoxia at birth Onset in infancy Non progressive Weakness of LL More than UL weakness Tone Increased Scissoring gait No Sensory Deficits Knee ++++ Knee ++++ Conjval + Corneal + Jaw + Triceps +++ Triceps +++ Biceps +++ Biceps +++ Supinator +++ Supinator +++ Ankle +++ Ankle +++ Plantar  Plantar  Abdominal - - - - Cremasteric - - 22

23. CIDP : 

23. CIDP Additional Points: Middle aged man Chronic history Weakness of all 4 L Relapsing remitting Patient conscious Higher Functions N Proximal weakness ++ D istal weakness + Tone reduced Sensory loss distally No cerebellar signs Knee - Knee - Conjval + Corneal + Jaw - Triceps - Triceps - Biceps - Biceps - Supinator - Supinator - Ankle - Ankle - Plantar  Plantar  Abdominal - - - - Cremasteric - -

24. Anterior spinal artery occlusion : 

24. Anterior spinal artery occlusion Additional Points: Young woman Hyper acute onset Weakness both LL No fever/radicular pain Patient Conscious Higher Functions N Cranial nerves N Hypotonia both LL Grade 0 power LL Pain and temp lost both LL Vibration preserved J oint position preserved Knee - Knee - Conjval + Corneal + Jaw - Triceps ++ Triceps++ Biceps ++ Biceps ++ Supinator ++ Supinator ++ Ankle - Ankle - Plantar  Plantar  Abdominal + + + + Cremasteric - -

25. Myotonic dystrophy : 

25. Myotonic dystrophy Additional Points: Middle aged man Frontal balding Bilateral Partial Ptosis Patient Conscious Hatchet facies Testicular atrophy Grade 4 power proximally Grade 2 distally Myotonia (slow relaxation) No Sensory Deficits Knee + Knee + Conjval + Corneal + Jaw - Triceps + Triceps + Biceps + Biceps + Supinator + Supinator + Ankle + Ankle + Plantar  Plantar  Abdominal + + + + Cremasteric + +