Neuro letter - clinical exam paragraph

Thank you for reading this Karen :slight_smile: On examination she looked well. She had some colour washout in the left eye. There was a little temporal pallor on the left disc although I did not think it was particularly striking. Her eye movements were normal. Facial movements were normal. There was no drift. Power in the upper limbs was symmetrical and normal. Reflexes I felt were 2+. There was, if anything, slight clumsiness of the right arm but I thought this was within the normal range given that she is left-handed. In the lower limbs I thought she had proximal weakness with several beats of clonus at the ankles. There was subtle weakness at the knee on the left side with extension and flexion both affected and dorsiflexion slightly at the left knee. There was no muscle wasting. Reflexes at the knees were brisk asymmetrically, more so on the left and pathologically so on the left. The right plantar was clearly down going. The left was somewhat mute. The ankle jerks were 2+ with the left brisker than the right. Tone I thought was increased in the left leg. She was able to squat. She could heel toe walk satisfactorily. She could hop on both legs with no real asymmetry but she was very tentative. Her abdominal reflexes were absent. She does have some signs in the lower limbs and there is history of recurrent neurological symptoms so it would be appropriate to arrange imaging, inflammatory markers in the blood and we will see her to discuss the results in the not too distant future. The rest of the letter was him relaying to my GP my symptom history etc. he didn’t give any indication at all as to what could be going on during the exam. I think all in all the above paragraph had a lot of positives in but towards the end I’m not sure if I should be a little concerned. The word normal comes out a few times so that is excellent news! Thank you Karen and anyone else who is kind enough to read and/ or comment :slight_smile: Sam xx

“She had some colour washout in the left eye. There was a little temporal pallor on the left disc although I did not think it was particularly striking.” Your colour perception is affected in your left eye (the neuro probably showed you something red?). Looking into your eyes, the right hand side of your left optic disc is slightly paler than expected. (These suggest an episode of optic neuritis.)

Your eye movements are smooth and the eyes work together. Your face muscles are working properly.

Your arms are fine. Drift refers to the test where you hold your arms out. Your reflexes are normal. A question mark about a clumsy right arm, but within normal limits.

“proximal weakness with several beats of clonus at the ankles” means your ankles are weak and the reflex test made your feet tap afterwards. This is a sign of upper motor neuron damage (basically a problem in the pathway between the brain and the muscles so that the brain is struggling to tell the muscle when to relax).

I’m not sure if he meant that both knees are weak on the left and don’t bend and straighten properly and your left knee also doesn’t bend when your toes are high or if it’s all to do with your left knee only. (I guess you’ll know though!) Your muscles have not shrunk at all.

Your knee reflexes were fast/large on both sides, but your left knee was abnormally so. (“Brisk” can be a normal finding.)

“The right plantar was clearly down going. The left was somewhat mute.” When he scraped the soles of your feet, your right foot’s response was normal, but your left foot didn’t respond as much as expected. (A slightly mute plantar response can be because of weak flexion (bend) in the knee, which you have.)

Your ankle reflexes were in the normal range, but again the left was more brisk than the right.

Increased “tone” means that he thought you had some spasticity in your left leg which means that your muscles are larger & tighter there. (This fits with the clonus.)

Your balance was OK, although you were careful about hopping. (A good heel to toe walk plus the normal eye movements suggests that your cerebellum is working fine. The cerebellum is the bit of the brain that coordinates and “smooths” movements.)

No abdominal reflexes means that your belly button didn’t move when he stroked your tummy. (This suggests a problem in the lower thoracic cord/nerves.)

“She does have some signs in the lower limbs and there is history of recurrent neurological symptoms so it would be appropriate to arrange imaging, inflammatory markers in the blood and we will see her to discuss the results in the not too distant future.” Your arms are fine, but your legs are not so he’s sending you for tests :slight_smile:

Hth!

Karen x

Thank you Karen. I have my MRI on 23rd November so I need to concentrate on lots of positive thinking until then. Struggling with that today though, never mind eh! Sam x