Conversational decision support from our CBBLE PaJR below:
[8/27, 2:59 PM] Rakesh Biswas: https://chat.whatsapp.com/
Other than falling with eyes open and mild disturbances in the heel shin test video what other signs suggest involvement of the cerebellum in this man who has this gradually progressive ataxia since 5 years?
What is his joint position and vibration sense?
Areflexia and reduced nerve conduction velocity suggests associated axonal demyelinating neuropathy but what does the conduction blocks in addition suggest?
@Chandana Kims Med PG @Aditya Samitinjay Medicine SR @Raveen 2020 Pg Med KIMs @Metapsychist Medical Student 2 @Akhil Kims SR Medicine
[8/27, 3:13 PM] Aditya Samitinjay Medicine SR: Blog link please?
[8/27, 6:51 PM] Rakesh Biswas: π@~Sampath Kasarabadha
[8/27, 8:18 PM] Aditya Samitinjay Medicine SR: Looking forward to this. Thank you.
[8/27, 8:20 PM] Rakesh Biswas: While it materializes can we see how to answer the question of confirming if the man's inability to stand with eyes open is specific to cerebellar or could it even be just due to his neuropathy?
[8/27, 8:32 PM] Aditya Samitinjay Medicine SR: From whatever information I have
Problem Representation - 72/M with? Chronic Progressive Gait instability, areflexia and axonal neuropathy on NCS
Guided exam - would do a full cerebellar exam (Dysdiadochokinesis, intention tremor, past pointing, nystagmus with HINTS exam, heel shin, finger nose and finger finger)
We have data that he is falling with eyes open and also has impaired heel shin on both sides, suggesting a midline cerebellar involvement? Checking for nystagmus and delayed corrective saccades can weigh it in favor of a cerebellar lesion.
As alluded to, vibration and proprioception can weigh it in favor of a sensory neuropathy.
Really big data gaps which need some filling here. Looking forward to more info.
[8/27, 8:53 PM] Rakesh Biswas: @Metapsychist Medical Student 2 Can you fill these information gaps by asking the duty interns to check these findings that haven't been shared yet?
@Aditya Samitinjay Medicine SR I'm expecting his joint position sense and vibration sense to be impaired and his other cerebellar signs to be negative and there's no doubt that he could be labeled sensory ataxia alone if not for that Rhomberg's fall with eyes open (can we even call it rhomberg's negative) but I guess I'm hinting at either a limitation of the specificity of rhomberg's test here and need to know if it has been publicized before in this manner by others (from a review of literature)
I also need to know more about the significance of his conduction block along with the neuropathy
@Metapsychist Number 1 Kims 2015 @Rahul healthcare 2.0 Can an ΔΉΔΉM help here?
[8/27, 8:55 PM] Metapsychist Number 1 Kims 2015: No,LLM can't help here.
There are few things which LLM can't replace yet..
Like,affective/hands on domain,clinical sense and emotional intelligence
[8/27, 8:56 PM] Metapsychist Number 1 Kims 2015: We need a skillful intern at point of care.
No replacements for this
[8/27, 8:59 PM] Rakesh Biswas: Why don't we have them when we need them? Answer this from your own experiences as an intern here in 2021-22!
Feel free to destroy our own high and mighty assumptions! π
[8/27, 9:01 PM] Metapsychist Number 1 Kims 2015: In technical terms,we define them as hidden nodes.
Hidden nodes maybe
1.Lack of understanding of purpose of medical education.
2.High of trying to get a PG seat by few months of roting
Many more..
[8/27, 9:30 PM] Rakesh Biswas: Those hidden nodes appear to be part of a hidden curriculum? Would be nice to identify these nodes further and list them for better effective optimizing strategies
[8/28, 10:45 AM] Rakesh Biswas: Here's the case report prepared by @~Sampath Kasarabadha π
Please guide him how to develop it further @Chandana Kims Med PG @Aditya Samitinjay Medicine SR
[8/28, 12:00 PM] Chandana Kims Med PG:
Firstly , we’ll done @~Sampath Kasarabadha
Can improve the blog by adding individual muscle testing of lower limbs.
Heel knee test can be misleading ,may be he is unable to do it because of the neuropathy.
His gait appears to be a little high stepping kind of gait ,but it is not as clear as in a patient of peroneal palsy because is this patient the muscles supplied by tibial nerve are also affected,so I suggest you to check dorsi flexion and plantar flexors power separately if not already done .
…………..
Coming to the NCS report:
In Upper limbs :
NCS shows reduced _*motor conduction velocity *_in Right median nerve with *conduction Block * and
*reduced motor conduction velocity * in left mediam Newe. There is *conduction block * across right ulnar nerve.
This is suggesting demyelination (along with absent reflexes)
…………..
In Lower limbs:
*Absent MUAPS * in Bilateral peroneal nerve and *reduced CMAP* in B/L TibialNerves .
Reduced CMAP ,MUAPS is not always axonal,This can also be due to demyelination when there is a conduction block.For this we need to know the conduction velocity and presence of any conduction block in tibial and peroneal nerves which is not given in this report.
If there is conduction block and conduction velocity is slow with reduced CMAP it is demyelination and not necessarily axonal.
…………
sensory conductions show *absent SNAP* in Right median nerve with absent SNAP in Bilateral sural nerves.
The same applies for sensory nerves ,reduced /absent SNAP can be there in demyelination,we need to know the conduction velocity in these nerves.
If conduction velocity is also decreased it is sensory motor demyelination (CIDP)
[8/28, 12:04 PM] Chandana Kims Med PG: Any drop in CMAP amplitude or area of more than 20% implies conduction block and any increase in the CMAP duration of more than 15% signifies temporal dispersion; both are hallmarks of demyelination
[8/28, 12:07 PM] Chandana Kims Med PG: And what about upper limb muscles? All muscles 5/5? @~Sampath Kasarabadha
[8/28, 12:10 PM] Vivek Kurma 2022 KIMs Pg Med: Ma'am will do all the individual muscle testing and upload it by today evening
[8/28, 12:23 PM] Rakesh Biswas: Very well done inputs ππ
Can we explain away his inability to stand with his eyes closed as not cerebellar but simply part of his chronic upper and lower limb demyelination?
[8/28, 12:28 PM] +91 95024 79628: Thank you mam
I will do individual muscle testing with help of Vivek sir mam
[8/28, 11:04 PM] Rahul healthcare 2.0: As @Metapsychist Number 1 Kims 2015 said, LLMs can't compensate for domain knowledge and reasoning skills, at least not yet. I tried to ask it relevant questions and here is what Google Bard gave me.
----
Q1. What are conclusive tests to determine -
1. Cerebellar Ataxia
2. Sensory Neutopathy
3. Guillain Barre Syndrome
A1. There is no single conclusive test for any of these conditions, but a combination of tests can be used to make a diagnosis.
Cerebellar ataxia: The following tests may be used to diagnose cerebellar ataxia:
Cerebellar exam: This exam is performed by a doctor to assess the patient's coordination, balance, and reflexes.
Magnetic resonance imaging (MRI): This imaging test can be used to visualize the cerebellum and look for any structural abnormalities.
Electroencephalogram (EEG): This test records the electrical activity of the brain and can be used to look for abnormalities that may be associated with cerebellar ataxia.
Sensory neuropathy: The following tests may be used to diagnose sensory neuropathy:
Nerve conduction studies (NCS): This test measures the electrical activity of the nerves and can be used to assess the severity of nerve damage.
Electromyography (EMG): This test measures the electrical activity of the muscles and can be used to assess the health of the nerves that innervate the muscles.
Skin biopsy: This test may be performed to look for changes in the skin that may be associated with sensory neuropathy.
Guillain-BarrΓ© syndrome: The following tests may be used to diagnose Guillain-BarrΓ© syndrome:
Cerebrospinal fluid (CSF) analysis: This test can be used to look for proteins and cells that are characteristic of Guillain-BarrΓ© syndrome.
Nerve conduction studies (NCS): This test can be used to assess the severity of nerve damage.
Electromyography (EMG): This test can be used to assess the health of the nerves that innervate the muscles.
In addition to these tests, the doctor may also ask the patient about their medical history, symptoms, and family history. This information can also be helpful in making a diagnosis.
If you are concerned that you or someone you know may have one of these conditions, it is important to see a doctor for evaluation. Early diagnosis and treatment can help to improve the outcome of these conditions.
=================
Q2. What is Rhomberg's test? Are there places where it gives false negatives?
A2. Romberg's test is a simple neurological test that is used to assess balance and proprioception. It is performed by asking the patient to stand with their feet together and their eyes closed. If the patient sways or falls, the test is considered positive.
Romberg's test is a sensitive test for detecting proprioceptive deficits, which are problems with the body's ability to sense its own position in space. However, it can also give false negatives, meaning that the test is negative even though the patient has a proprioceptive deficit.
There are a few reasons why Romberg's test can give false negatives. One reason is that the test relies on the patient's ability to see. If the patient has their eyes open, they can use visual cues to help them maintain their balance. This can mask any proprioceptive deficits that they may have.
Another reason why Romberg's test can give false negatives is that the patient may be compensating for their proprioceptive deficit. For example, they may press their feet down harder on the ground or take a wider stance to help them stay upright. This can also mask any proprioceptive deficits that they may have.
Finally, Romberg's test is not always performed correctly. If the patient is not standing still or if they are not asked to close their eyes for long enough, the test may be inaccurate.
If Romberg's test is negative, it does not mean that the patient does not have a proprioceptive deficit. Other tests, such as the Unterberger's test or the tandem gait test, may be more sensitive in detecting proprioceptive deficits.
Here are some of the places where Romberg's test can give false negatives:
* **In patients with visual impairment:** Patients with visual impairment may rely on proprioception more than patients with normal vision. This means that they may be more likely to sway or fall even if they have no proprioceptive deficits.
* **In patients with fatigue:** Fatigue can also affect balance. Patients who are fatigued may be more likely to sway or fall, even if they have no proprioceptive deficits.
* **In patients with anxiety or stress:** Anxiety and stress can also affect balance. Patients who are anxious or stressed may be more likely to sway or fall, even if they have no proprioceptive deficits.
* **In patients with musculoskeletal disorders:** Musculoskeletal disorders, such as arthritis or muscle weakness, can also affect balance. Patients with musculoskeletal disorders may be more likely to sway or fall, even if they have no proprioceptive deficits.
If you are concerned that you or someone you know may have a proprioceptive deficit, it is important to see a doctor for evaluation. Early diagnosis and treatment can help to improve balance and prevent falls.
[8/29, 8:53 AM] Rakesh Biswas: Well done google bard ππ
So the bard feels that the only other test we can do to look for structural cerebellar involvement is an mri that may show cerebellar involvement and there may be nothing else other than a clinical examination (showing more points than falling with eyes open, which could even be due to just his peripheral neuropathy)!
The other things picked up by the bard can be discounted by epidemiologic reasoning hinting at likelihood or probability estimates.
Was asking our intern yesterday to do this kind of a literature search and I guess the bard beat him to it ππ
AI driven LLMs are already into our workflow now with a little bit of enthusiastic promoting by AI engineers. ππ
[8/29, 9:21 AM] Rakesh Biswas: We "healthcare only people" would need to fasten our seat belts for the roller coaster ride ahead ππ@Rahul healthcare 2.0
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