Electrodiagnostic Medicine in Practice : 50Challenging Cases

Key features include:

- The logical thinking process in every step of the diagnosis,

enabling readers to refine their own rationale in electrodiagnosis

- Challenging cases raising difficult yet interesting issues to electromyographers

- Three tables of contents to easily find interesting cases again







Edited by
Tai Ryoon Han, MD, PhD
Professor, Department of Rehabilitation Medicine
Seoul National University College of Medicine
Seoul National University Hospital







Preface



The value of experience is not in seeing much, but in seeing wisely.

(William Osler, 1894)


The start of this book, Electrodiagnostic Medicine in Practice: 50 Challenging Cases, can be traced back 25 years ago,
when we embarked on a weekly electromyography case conference.

During the discussion on challenging cases of the previous week, it was the difficult and intriguing questions in the
conference that made all our colleagues logic-based and technically refined. In recent decades, the diagnostic
armamentarium available to physicians who treat patients with neuromuscular diseases has increased exponentially.
Accordingly, our case conference has become more colorful with laboratory results, imaging studies and various genetic
tests. However, we found that without a well-trained logical process, even a lot of information can lead to nowhere and
sometimes to the wrong place.

Although there are excellent books of case studies, there is a paucity of literature on the purpose of a refinement of
logic in electrodiagnostic medicine. For this purpose, we intentionally added a logical thinking process in every step
of the diagnosis. Readers can follow the thought patterns of the contributors. Another unique feature of this book is
its comprehensive coverage on the presented cases. It covers the initial presentation to the clinical course after
adequate treatment or during regular visits. In addition, each case presents the results of the laboratory tests and
imaging studies as well as the history and physical examination.

As noted in the title, the cases presented herein are challenging not simply because they are uncommon or unusual, but
because they raised difficult issues to electromyographers. Although typical textbook cases are good educational
materials for beginners, they are not intellectually interesting enough for experienced clinicians. This book poses
challenging questions for physicians, fellows and residents who have practical experience in the diagnosis and
treatment of patients with neuromuscular diseases. I hope this book will help readers refine and fine-tune both their
understanding and practice.

The 50 cases are organized according to the presenting symptoms. Cases that manifested as focal problems of the upper
and lower extremities are presented initially, followed by cases with generalized symptoms. Pediatric cases are placed
in the end. The following three tables of contents are provided for the convenience of identifying the cases of
concern: 1) table of content with the primary symptoms (in numerical order of case number), 2) with the final diagnosis
and interesting aspects (in numerical order), and 3) with the final diagnosis (according to the disease categories).

Each case consists of pairs of unfolding information about the case and the subsequent development of a differential
diagnosis. A list of differential diagnoses is made and revised after a description of the history, physical
examination and laboratory results, electrophysiological data, and additional studies. The discussion and references
were kept succinct.

I am very grateful to the contributors for their devotion to this book. In particular, I want to acknowledge the
following colleagues for their reviews and comments: Byung-Mo Oh (one of the contributors), So-Ra Baek, Joon-Beom Hong,
Jong-Yub Lim, and all the residents in our department. Special thanks go to the staff of Koonja publishing company.



Tai Ryoon Han, MD, PhD

Seoul, Korea


FOCAL-UPPER EXTREMITIES

CASE 1 A Man Unable to Flex the Thumb and Index Finger of His Left Hand / 1

CASE 2 A Woman with Acute Postpartum Hand Weakness and Tingling Sensation / 9

CASE 3 A Man with Left Arm Weakness / 17

CASE 4 A Man Who Has Difficulty in Releasing the Right Hand After Grasping / 23

CASE 5 A Woman with Left Ring and Little Finger Tingling Sensation / 29

CASE 6 A Man with Right Hand Weakness and Deformity / 35

CASE 7 A Woman Reporting Pins and Needles on the Fingertips of Both Hands / 41

CASE 8 A Man with Bilateral Upper Extremity Weakness / 49

CASE 9 A Man with Right Hand and Forearm Tingling Sensation / 55

CASE 10 A Man with Tingling Sensation in the Left Little Finger / 62

CASE 11 A Man with Bilateral Upper Extremity Weakness / 69

CASE 12 A Woman with Weakness of the Right Hand and Wrist After Childbirth / 77

CASE 13 A Man with Right Arm Weakness / 81

CASE 14 A Woman with Pain in the Posterior Neck and the Lateral Aspect of the Left Arm / 87

CASE 15 A Man with Weakness of the Right Hand / 93

CASE 16 A Man with Tingling Sensation in the Right Hand / 99

CASE 17 A Man with Arm Weakness After a Motorcycle Accident / 105

CASE 18 A Man with Tingling Sensation of His Left Ring and Little Fingers/ 111




FOCAL-LOWER EXTREMITIES

CASE 19 A Woman with Weakness and Sensory Loss in Both Lower Extremities / 117

CASE 20 A Young Man with Bilateral Foot Drop / 123

CASE 21 A Man with Right Lower Extremity Weakness/ 131

CASE 22 A Woman with Pain and Paresthesia on the Left Big Toe and Sole / 137

CASE 23 A Woman with Tip-toe Gait / 143

CASE 24 A Man with Recurrent Ulcerations on Both Feet / 149

CASE 25 A Man with Progressive Leg Weakness and Low Back Pain / 153

CASE 26 A Woman with Bilateral Lower Extremitrs Weakness / 161

CASE 27 A Woman with Unilateral Foot Drop After Childbirth / 167

CASE 28 A Man with Slowly Progressive Weakness of the Right Lower Extremity / 175

CASE 29 A Man with Low Back Pain and Right Lower Extremity Pain / 181

CASE 30 A Woman with Weakness in Her Right Lower Leg / 187

CASE 31 A Woman with Weakness of the Legs and Pain in the Right Heel / 193

CASE 32 A Young Man with Foot Deformities / 201

CASE 33 A Man with Weakness of the Left Leg / 209




GENERALIZED PRESENTATION

CASE 34 A Man with Four Extremity Weakness / 217

CASE 35 A Man with Persistently Elevated Levels of Muscle Enzymes / 223

CASE 36 A Man with Tingling in All Extremities of 3-month Duration / 229

CASE 37 A Woman with Progressive Right Side Weakness / 233

CASE 38 A Man with Paresthesias on Bilateral Fingers and Toes / 239

CASE 39 A Man with Tingling of the Four Extremities / 247

CASE 40 A Man with Facial Weakness and Swallowing Difficulty / 255

CASE 41 Three Patients with Hoarseness / 261




PEDIATRIC CASES

CASE 42 A Boy with Newly Developed Gait Disturbance / 269

CASE 43 A Girl with Right Foot Drop / 275

CASE 44 A Child with Sudden Weakness of Both Lower Extremities / 281

CASE 45 A Girl with Gait Disturbance and Lower Extremity Weakness / 287

CASE 46 A Girl with Generalized Muscle Cramp / 291

CASE 47 A Boy with an Elevated Serum Creatine Kinase / 295

CASE 48 Two Children with Developmental Delay / 301

CASE 49 A Boy with Limping Gait / 311

CASE 50 Two Boys with Weakness of the Lower Extremities / 317