2 History Taking of Common Pediatric Cases
2.26 Lower-Limb Weakness
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Table 2.8 (continued)
Short case scenarios Diagnosis and special point(s) in favor A 3-year-old male child presents, after an
intramuscular injection, with weakness of his left leg, starting gradually and evolving within 2 days to involve the left-upper hands and accompanied by a low-grade fever, malaise, muscle pain, and severe headache, as well as nuchal rigidity
Poliomyelitis
– Flaccid paralysis or paresis is usually asymmetric and commonly involves one leg, and then one upper limb is involved. The proximal areas of the limbs are more affected than the distal areas – Bulbar weakness may occur
– The paralysis may be preceded by a history of an intramuscular injection in half of the patients
– Bowel and bladder dysfunction may occur;
it often accompanies paralysis of the lower extremities
– Sensory symptoms are not present in a child with poliomyelitis; their presence should raise the concern for a disease other than poliomyelitis
A 9-year-old male child presents at the emergency room with acute symmetric weakness of the lower extremities, associated with anesthesia and reduced sensory perception below the level of the umbilicus. The weakness was preceded by thoracic back pain and bilateral lower-limb numbness. According to the mother, the child has no history of trauma
Transverse myelitis
– Rapid progression of weakness over a period lasting from a few hours to a few days
– The patient may present with thoracic back pain, lower-limb numbness, and then acute uniform symmetric (or asymmetric) weakness of the lower extremities, associated with anesthesia and reduced sensory perception below the level of the lesion
– Progressive bladder or bowel dysfunction – May be preceded by viral infection,
bacterial infection, or vaccination An adolescent male presents with
progressive lower-limb weakness associated with a high-grade fever, headache, vomiting, neck stiffness, limb pain, and severe localized back pain, which increased in severity with cough or flexion
Epidural abscess
– Limb pain starts 3–6 days after the onset of back pain, followed by a progressive limb weakness and bladder dysfunction
A school-aged child presents with acute right lower-limb weakness occurring within a few hours after trauma to the back and associated with an inability to pass urine
Traumatic paralysis
– Acute asymmetric limb weakness occurs from a few hours to a few days after the trauma
– This is typically associated with bowel and bladder dysfunction
An adolescent female presents with lower-limb weakness that evolved over 6 weeks and associated with headache, vomiting, and behavioral changes. She is a known case of a brain tumor
Brain tumor
– The patient usually has a history of known brain tumor or a history of a lower-limb weakness
– A severe headache may occur when there is a hemorrhage inside the tumor
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Short case scenarios Diagnosis and special point(s) in favor An adolescent male presents with gait
difficulty and lower-limb weakness that evolved over 3 months and associated with back pain and loss of sensation over the affected limb
Spinal cord tumor
– This usually presents with a slowly progressive lower-limb weakness, accompanied by sensory loss and back pain – It may be accompanied by bowel and
bladder dysfunction Table 2.8 (continued)
• Identity: Age, sex, address, nationality
• Chief complaint: Lower-limb weakness
• History of present illness:
1. Timing of weakness onset: Acute, subacute, or chronic 2. Duration/specific date of onset
3. Progression: Increasing, static, or improving
4. Site: Where did it start? Is it proximal or distal involvement? Is it sym-metrical or asymsym-metrical?
5. Evolution: Are both limbs affected simultaneously or one after the other?
6. Degree of weakness: Ability of the child to walk, to lift arm to comb hair, to lift an object, or to move leg in bed (if unable to walk)
7. Associated symptoms: Fever, headaches, neck or back pain, disturbed level of consciousness, seizure, involuntary movements, tremors, dys-phagia, mouth deviation, aphonia, hoarseness
8. Sensory loss, tingling, or any changes in sensation? If so, in what distribution?
9. Bowel and bladder dysfunction
10. Cranial nerve involvement: Visual problems, hearing and speech prob-lems, drooling of saliva
11. Precipitating factors: Fever, convulsion, exercise, trauma, intramuscular injections, or snake bite
12. Preceded by gastroenteritis, flu-like illness (especially in the last 10 days) 13. Recovery: Rapid recovery, slow regression over a period of time, or
per-sisting indefinitely
• Past history:
A—Birth history: Preterm, breech presentation, prolonged labor, delayed cry at birth, birth asphyxia
B—Past medical and surgical history: Previous limb weakness, numbness, or other neurologic symptoms, head trauma, epilepsy, tuberculosis,
dia-History Station 2.25: Lower-Limb Weakness
Continued on the next page 2.26 Lower-Limb Weakness
betes mellitus, hypertension, autoimmune disorders, or multiple sclerosis
• Medication history: Recent use of medications (e.g., steroids), drug allergies
• Immunization history: Recent vaccination, poliomyelitis vaccine (inject-able or oral), rabies vaccine, influenza vaccine, meningococcal conjugate vaccine, and tetanus toxoid
• Feeding/dietary history: Type of feeding, ingestion of home-canned foods, undercooked meat
• Family history: Family history of leg weakness, muscular dystrophies, neu-ropathies, myopathies, myasthenia gravis, hypertension, diabetes mellitus, epilepsy, or migraine
• Social history: Poor sanitation, crowding, water contamination, educational achievements, exposure to toxins (organophosphorus, inorganic lead, arsenic)
• Review of systems: Dark urine (rhabdomyolysis), dyspnea, diarrhea, vomit-ing, myalgia, recent weight loss (brain tumor, tuberculosis)
• Weakness that occurs and deteriorates suddenly without trauma may suggest subarachnoid hemorrhage, stroke, or brain neoplasm with hemorrhage [69].
• Weakness that occurs in conjunction with headache, particularly in children with focal neurological signs or progressive morning vomiting, should raise the concern for an intracranial mass lesion [69].
• Subacute, chronic, or indolent presentations of weakness should raise the pos-sibility of neuropathies (e.g., Guillain–Barré syndrome) or myopathies (e.g., muscular dystrophy).
• The occurrence of weakness in combination with a seizure may point to acute intracranial hemorrhage or stroke. It may also result from a self- limited Todd paralysis [69].
• Weakness that is preceded by a history of viral infection, bacterial infection (particularly Campylobacter jejuni infection), surgery, or vaccination is sug-gestive of Guillain–Barré syndrome, the most common cause of acute flac-cid paralysis in children [26].
Key Points 2.25
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