Neurology

Question 1

How does mononeuritis multiplex present?

Answer 1

Acute onset, peripheral neuropathy. Asymmetric and asychronous. Pain, weakness. LMN symptoms only. Associated w diabetes.

Question 2

What are the symptoms of restless leg syndrome?

Answer 2

Urge to move legs/arms assoc w unpleasant senstion; resting induces symptoms; gets better w activity; evening and night time worse. Rarely painful, some movements but no sustained contractions.

Question 3

What are the associations with restless leg syndrome? What are the differentials?

Answer 3

Iron deficiency, CKD, peripheral neuropathy, pregnancy, MS, parkinsons, dopamine antagonists can exarcerbate. DDx: akathisia, nocturnal leg cramps (pain + tight, need stretch), arterial disease/claudication, periodic limb movements - involuntary jerks.

Question 4

What are the non-pharm management options for restless legs syndrome?

Answer 4

Walk/exercise before bed, avoid coffee/alcohol/smoking, gentle stretching hamstrings before bed, doing mental activities when resting. Aim ferritin > 50

Question 5

What drugs are used for restless legs? What are the risks?

Answer 5

Levodopa + bensazeride or carbidopa. SE: nausea, postrual drop, gambling, hypersexuality. Symptom may augment come earlier or get worse + rebound when stopping. Alt: gabapentins, pramipexole.

Question 6

What are the symptoms of trigeminal neuralgia? Investigation and mx.

Answer 6

Unilateral shock like pain, can be triggered by wind, touch, eating, shave. Seconds to minutes. Recommend MRI for structural cause. Mx: carbamazepine 100mg BD (2nd line: oxcarbazepine)

Question 7

How is a TIA defined? What tests are indicated and when is emergency recommended?

Answer 7

Symptoms resolving < 24h and no MRI evidence of stroke. Do CT angio,ECG, echo + carotid doppler within 2 days. Consider Age >60, BP >140, unilateral weakness, duration > 60 min or diabetes as high risk for 2nd event.

Question 8

When is endarterectomy recommended?

Answer 8

Stenosis >70% + symptoms, within 2 weeks. If < 50%, meds only.

Question 9

How is a TIA managed?

Answer 9

Aim BP 120-130, high potency statin, long term antiplatelet - combo if high risk, or 1. Avoid driving 2 weeks, risk further TIA 3 mo. Anticoagulate if AF.

Question 10

What are the signs of an UMN and LMN lesion?

Answer 10

UMN: Increased tone, stiff, spasticity, hyperreflexia, full weakness, upgoing plantar, no fasciculation, wasting late. LMN: Weakness, wasting, fasciculation, hyporeflexia, distal weakness first.

Question 11

How does amyotrophic lateral sclerosis present? Signs, prognosis, followup.

Answer 11

Combined upper/lower motor neuron symptoms, asymmetric and focal onset. Weakness, then dysarthria and dysphagia. Atrophy, hyperreflexia, splint hand - lose thumb muscles. No bowel/bladder or eye involvement. 3-5y incurable death. Genes hard to find, 1-3% FDR risk, use tests for prenatal counselling.

Question 12

What are the features of a complex partial and simple partial seizures?

Answer 12

CP: unaware, disturbance of perception eg. hallucination, illusion, deja vu, may have lip smacking or pacing. SP: Jacksonian, jerking near hand or mouth that marches to rest of body.

Question 13

Abscence seizure - age, features, tests, treatment.

Answer 13

From 4yo to puberty, brief LOC up to 30sec. 3Hz wave and spike on EEG. Responsive to treamtnet and often resolve by puberty. 1st line: ethosuxamide.

Question 14

How is epilepsy managed - drugs, monitoring, driving.

Answer 14

If partial: carbamazepine (affects OCP). General: valproate (not in preg). Monitor effect not levels. No driving for 1st 6mo, then conditional licence until 2 years no seizure and 1 year no med change.

Question 15

Narcolepsy - symptoms, treatment.

Answer 15

Brief spells of irresistible sleep. Sleep attacks, cataplexy (loss muscle tone), sleep paralysis, terrifying hallucinations. Tx: modafinil.

Question 16

What are 6 causes of peripheral vertigo? What are 4 causes of central vertigo?

Answer 16

P: BPPV, menieres disease, vestibular neuritis/labyrinthitis, ramsay hunt syndrome, cholesteatoma, acoustic neuroma. C: Cerebellar infarct/haemorrhage, vertebrobasilar insufficiency, MS, migraine.

Question 17

What are 3 features of nystagmus concerning for a central cause of vertigo? Why is otoscopy used in exam?

Answer 17

Purely vertical or torsional; can’t suppress with fixation; bidirectional. Herpes zoster, retraction pocket in cholesteatoma.

Question 18

Features and treatment of meniere’s disease

Answer 18

Episodes lasting hours, with hearing loss, fullness and tinnitus. Reduce salt < 2g/day, reduce coffee/alcohol, vestibular rehab. ?Betahistine, ?HCT. Surgery or injections if required.

Question 19

Features of vestibular neuritis and labyrinthitis. Management.

Answer 19

VN: balance only. L: hearing + tinnitus. Post viral, acute onset, may have N/V. Often improve over days, if severe, prednisolone high dose 5 days then taper.

Question 20

Essential tremor - cause, features, triggers, workup, mx.

Answer 20

Autosomal dominant w variable penetrance. Young w slight tremor to hands or head. Anxiety worsens, alcohol helps. Exclude thyroid or drugs. 1st line propranolol 10mg BD, or primidone.

Question 21

What are the main signs of parkinsons disease? How is it treated?

Answer 21

Bradykinesia, muscle rigidity (cogwheel), assymetric rest tremor. Early dementia, falls and autonomic dysfunction are rare. Treat w levodopa w benserazide or carbidopa to see if effective.

Question 22

Myasthenia gravis - symptoms, diagnosis, tests, workup.

Answer 22

Fluctuating weakness + fatigue. No sensory or reflex loss. Ach-R antibodies 85% OR MuSK antibodies, neurophysiological tests, edrophonium if needed by specialists. Check thyroid, b12 +CT chest for thymoma.

Question 23

What are the differentials for unilateral facial weakness?

Answer 23

Bell’s palsy, MS, Ramsay hunt syndrome, stroke, tumour, acoustic neuroma or cholesteatoma can compress, parotid tumour can compress.

Question 24

What are the symptoms and management of bell’s palsy?

Answer 24

Whole side affected, taste of anterior tongue. May get sound sensitivity + dry eye from not closing. If < 72 hr, give pred 1mgkg 5 days. If shingles, add antiviral. If eye symptoms, patch + eye drops. Should recover, MRI at 4mo. Risk of regeneration - eyes water w chewing.

Question 25

How does idiopathic intracranial hypertension present? Symptoms, exam, test, mx.

Answer 25

Overweight young women, headache worse lying down +/- tinnitus, blurred vision. Papilodema + peripheral field defects. Normal MRI, elevated LP pressure. Weight loss + acetazolamide.

Question 26

What is brudzinki’s sign? Treatment of meningitis and C/I to LP and CT.

Answer 26

Passive neck flexion causes hip flexion. Ceftriaxone 2g IVor 2.4g benpen IV/IM. CT first if focal neurology, papilloedema, deteriorating consciousness, new seizures. No LP if bleeding disorder, infection over skin, unstable BP.

Question 27

What are the signs/symptoms of MS? Diagnosis

Answer 27

Can be UMN or LMN. Symptoms for hours/days, remit over weeks. Sensory loss, weakness, unilateral visual sx. Optic neuritis, INO, shocks down back/limbs w neck flexion, heat sensitivity. D: separate in time and space, evidence of CNS involvement (MRI or LP).

1st episode is clinically isolated syndrome.

Question 28

Guillain-Barre Syndrome: symptoms/presentation, cause, management.

Answer 28

Autoimmune progressive weakness and sensory disturbance - peripheral impaired reflexes with lower motor neuron pattern. Can be triggered by campylobacter, CMV/EBV. Confirm on LP. Hosptial to treat w IVIg, plasma exchange, may need ventilator.

Question 29

How are tension headaches and medication overuse headaches managed?

Answer 29

TTH: panadol/NSAID, 2ndline: amitriptyline. Overuse from opioid/triptan or panadol/nsaid. Switch to a preventer, use bridging naproxen or prednisolone.

Question 30

What are the features of a cluster headache? How are they managed acutely and long term?

Answer 30

Unilateral, severe w autonomic fx: tearing, ptosis, sweat, rhinorrhoea. Last 15min to hours, few per day. MRI pituitary recommended. Acute: high flow oxygen + subcut sumatriptant. Long term: verapamil (monitor ECG), home oxygen, valproate, nerve blocks/stimulator.

Question 31

What are the non-pharm management options for acute migraines? Prevention?

Answer 31

Rest in quiet, dark room; neck stretch/mobilisation; heat pack neck/shoulder; counter stimulation w icepack to head or strong mint/sour candy. SMART: sleep regular, meals + hydration, activity and avoid screens, relaxation techniques, trigger diary and avoid.

Question 32

How are acute migraines managed with meds in adults and kids?

Answer 32

Aspirin 900mg or ibuprofen 400-600, rpt 6hr; add maxalon if nausea. Triptan once per attack - riza 10mg. In kids, avoid aspirin due to reyes and maxalon due to dystonia. Can use sumatriptan.

Question 33

What are 5 options for migraine prophylaxis?

Answer 33

Amitriptyline, propranolol (avoid asthma), pregabalin, candesartan, topiramate (avoid if kidney stones, depression).

Question 34

What are the canadian head CT rules?

Answer 34

GCS < 15 2hr post injury, age > 65, vomiting 2+, suspected fracture/base of skull, amnesia >30min pre injury, high risk mechanism (MVA, fall >1m)

Question 35

How can concussion be assessed? What is the management? When to refer?

Answer 35

SCAT5 on and off field. Physical and cognitive rest. Return to sport when symptom free , graded return and stop if symptoms worsen. Symptoms > 2 weeks in adult or 4 in child needs referral.

Question 36

What is neurogenic claudication? Risk?

Answer 36

Pain to back/legs w walking and standing, relieved by leaning forward/sitting. If cauda equina, ED.