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Time to make you think

Discussion in 'MSK and EMG Case Discussions' started by PMR 4 MSK, Jun 3, 2008.

  1. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor 5+ Year Member

    Oct 1, 2007
    Ok, Ludicolo and I can't be the only ones writing on this forum. 982 reads, but only 17 replies on the last 3 topics? C'mon people! Stir up some debate here! Post your cases! Reply to ours!

    My latest intersting case, just seen today:

    21 yo male, referred for EMG RUE to R/O Long thoracic nerve palsy for "scapular dyskineses" No winging, but scapular "popping" after W/C injury 3 months ago, not getting better with PT and subacromial steriod injection.

    NCV from right Erb's point to Serratus Ant, Supraspinatus, Deltoid, Triceps and Biceps all normal. LAC and MAC sensories normal. Median and ulnar motor and sensories normal.

    So I start the needle exam. Deltoid Normal. Triceps shows continuous "Dive bombers" (DBs). Normal MUAPs. Hmmm, unexpected this is.

    Biceps normal. Pronator Teres shows DBs, as do the EDC, EIP, FDIM and APB. They also have some PSW's and Fibs. Again, MUAP's normal. Recruitment normal, except FDIM doesn't get full recuitment.

    Up to the neck, Supraspinatus, Rhomboid, trapezius and cervical paraspinals all normal. Now this is Work Comp, and they hate when you do additional studies unrelated to the referred R/O, but I figure inquiring minds want to know, so I just won't bill for other limbs. So I go over to the left arm. I already tested the Long Thoracic on the left, for comparison.

    Left Tricep, EDC and FDIM all the same as the right side. I go to his left foot and the EDB also shows DBs and some Fibs. Peroneus longus showed some occasional DBs and a few fibs also. At this point I knew enough.

    What do you think his physical exam showed? I did a little more PE after the EMG to confirm my Dx. FHx unremarkable. No symptoms of the Dx noticed by the pt.
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  3. Ludicolo

    Ludicolo Fib Hunter Physician 7+ Year Member

    Mar 26, 2008
    Conjunction Junction
    I'm trying so hard not to post a response...
  4. SSdoc33

    SSdoc33 10+ Year Member

    Apr 23, 2007
    how big were his balls?
  5. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor 5+ Year Member

    Oct 1, 2007
    I didn't look, but they should be small...
  6. SSdoc33

    SSdoc33 10+ Year Member

    Apr 23, 2007
    if you shake his hand, does he let go?

    does his hairline resemble george costanza?
  7. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor 5+ Year Member

    Oct 1, 2007
    Actually, he had no grip myotonia. I had him grip my hand twice and then extend each time. The second time he could extend his fingers, but could not extend his wrist for about 15 seconds - "Wow, that's wierd" he said.

    Thumped his thenar eminences with a reflex hammer - yep, thumbs moved medially and stayed there a few seconds.

    His hairline was not too high, but wow, textbook "hatchet" face.

    Hopefully, this serves as a good case for residents (even if they are too chicken to answer...:D) - even potentially life-altering and disabling conditions can be picked up serendipitously while pre-symptomatic.

    So let's take this to the next level - any guesses on how many triplicate repeats his DNA will show?

    Let's say this guy is getting married in a few months. What would you advise him as far as having children?
  8. topwise

    topwise 5+ Year Member

    Sep 6, 2007
    Wow, that's a great learning case. It scares me a little bit though because it makes me realize that I've never heard the dive bomber before on a patient (only a simulation CD) and I don't know if I will before finishing residency. So I'm afraid that if a patient like that were sent to me, maybe I'd miss that diagnosis.

    Possibly stupid question but I have to ask: is there a particular reason why the triceps was positive and the biceps was negative?
  9. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor 5+ Year Member

    Oct 1, 2007
    Actually that's a very good question, but I'm not sure I have a good answer for you, other than the upper arms are just starting to destabilize (distal problems initially and mostly, in myotonic muscular dystrophy).

    We had an MDA clinic we attending a few times in our residency, you might try looking for one, our was run by the neurology dept.

    Actually, the first time you unexpectedly hear a dive-bomber on a patient, your first reaction is (or at least mine was, years ago) "WTF?!" Remember that they can occur in a lot of different conditions, and it's the pattern of involvement that points you to the direction of the Dx, when coupled with the physical exam. I didn't start seriously considering MMD until I tested the other arm. Then it was the excitement of finding something rare, coupled with the immediate knowledge of what this wass going to mean for the patient.

    Obviously, if this guy had been sent for "hand cramping" or "foot weakness/drop" you'd have a different plan of attack for the EMG. But when something like this comes about seredipidously, you go on "the hunt." Honestly, it's one of the things I live for - the academic hunt for the location/etiology of the disorder. It's what makes EMG so rewarding (besides the financial ;))
  10. drusso

    drusso Physician Moderator Emeritus Lifetime Donor Classifieds Approved 10+ Year Member

    Nov 21, 1998
    Over the rainbow
    That was a great case! It also highlights how just about anything can walk through the door.
  11. cbest

    cbest 10+ Year Member

    Dec 9, 2006
    As a soon-to-be 2nd year DO student and someone who is VERY interested in PM&R, I love scrolling through these cases mostly just to get a feel for the diagnostic process. Would you be able to post the Dx for this case? Thanks and keep the cool cases coming!
  12. PMR 4 MSK

    PMR 4 MSK Large Member SDN Advisor 5+ Year Member

    Oct 1, 2007
    Myotonic (Muscular) Dystrophy, very early presentation, mainly a serendipidous finding.
  13. neglect

    neglect 1K Member 10+ Year Member

    Sep 2, 2003
    Hearing true myotonic discharges is like nothing else. But I'd just like to point out a potential pitfall: CRDs. When CRDs are plentiful, they can be part of insertional activity, and they were initially called "pseudomyotonic discharges" because they can have the same sound.

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