Amir Sam: Neurology Flashcards Preview

Year 3 Medicine > Amir Sam: Neurology > Flashcards

Flashcards in Amir Sam: Neurology Deck (90):
1

Causes of collapse (groups)

1. Low glucose (hypoglycaemia)

2. Heart:
-Vasovagal
-Arrythmia
-Outflow obstruction
-Postural hypotension

3. CNS: seizure

2

Cardiac causes of collapse

Vasovagal
Arryhtmia (fast/slow)
Outflow obstruction (left: aortic stenosis; right: PE)
Postural hypotension

3

59 yr old man
Long-standing HTN
Exertional chest pain
Normal ECG

What is the most likely diagnosis?


A. Coronary artery stenosis
B. Musculoskeletal
C. Pericarditis
D. Relapsing polychondritis
E. Vasculitis

A. Coronary artery stenosis


HTN
Exertional chest pain
Normal ECG

4

Crease on ear lobe

Frank's sign: diagonal crease along the tragus
Thought to be associated with coronary artery disease

5

Neurology problem: Anatomy

Brain
Spinal cord
Nerve roots
Peripheral nerve(s)
Neuromuscular junction

6

Neurological problem: Pathology

VIITT
Vascular
Infection
Inflammation/Autoimmune
Toxic/Metabolic
Tumours/Malignancy

Hereditary/congenital
Degenerative

7

Neurology problem: Where? Anatomy

(level of the lesion/problem)
Brain
Spinal cord
Nerve roots
Peripheral nerve(s)
Neuromuscular junction

8

Neurological problem: What? Pathology

VIITT
Vascular (bleed/infarction)
Infection (meningitis/ encephalitis/ abscess)
Inflammation/Autoimmune (demyelination central: MS, peripheral: Guillain Barre. Also vasculitides (CTDS: SLE)
Toxic/Metabolic (DM, B12 deficiency)
Tumours/Malignancy (tumour directly causing symptoms or paraneoplastic manifestation- Pancoast's)

Hereditary/congenital
Degenerative

9

Signs of UMN lesion

Tone: increased (spasticity)
Power: decreased
Reflexes: increased (upgoing plantars)

10

Signs of LMN lesion

Tone: reduced (flaccid)
Power: reduced
Reflexes: reduced

11

Cerebellar symtpoms

DANISH
Dysdiadokineses/Dysmetria (past pointing)
Ataxia (coordiantion/balance)
Nystagmus
Intention tremor (finger-nose test)
Slurred speech/ scanning (staccato speech)
Hypereflexia/hypotonia

12

Causes of cerebellar disease:

PASTRIES

Do a CT scan

Posterior fossa tumour
Alcohol
Stroke
Trauma
Rare
Inherited (Friedrich's ataxia)
Epilepsy drugs (carbamazepine, phenytoin)
Sclerosis (MS)

OR
Vascular (bleed/clot- Stroke)
Infection (varicella (chicken pox), toxoplasmosis)
Inflammation (demyelination- MS)
Malignancy/Tumour (primary (posterior fossa tumour) or metastasis)
Metabolic/Toxic (B12 deficiency, Alcohol)

13

Spastic paraparesis
Increased tone in legs, but weakness
Peripheral neuropathy

Subacute combined degeneration

Vitamin B12 deficiency (but can also present in other ways)

14

Hemisensory loss

Cerebral cortex (contralateral)

15

Sensory loss below a level (eg- umbilicus)- eg- with pin prick test

Spinal cord

16

Sensory loss in a dermatome(s)

Nerve roots (eg- radiculopathy)

17

Sensory loss in a specific area

Mononeuropathy

18

Glove and stocking distribution of sensory loss

Polyneuropathy (diabetic peripheral neuropathy)

19

Glove and stocking distribution of sensory loss

Polyneuropathy (diabetic peripheral neuropathy)

20

Reduced pin prick sensation in there left arm and left leg

Right cerebral cortex

21

Glove and stocking distribution of sensory loss. Causes:

Polyneuropathy:
The most common is diabetes

Infection: HIV
Inflammation: chronic inflammatory demyelinating polyneuropathy (CIDP)
Malignancy: Paraneoplastic; Paraproteinaemia
Metabolic: Diabetes, Alcohol, B12 deficiency

22

Glove and stocking distribution of sensory loss. Causes:

Polyneuropathy:
The most common is diabetes

Infection: HIV
Inflammation: chronic inflammatory polyneuropathy disorder (CIPD)
Malignancy: Paraneoplastic; Paraproteinaemia
Metabolic: Diabetes, Alcohol, B12 deficiency

23

Wasted, shortened lower limb
Reduced T,R,P unilaterally
Scars on leg
Sensation normal

Polio myelitis (favourite for OSCE)

Pure motor neuropathy (LMN- reduced TRP)
Wasted shortened limb (chronic)
Normal sensation
Lots of scars- corrective surgery as person grows

24

Toxic/metabolic causes of peripheral neuopathy:

Drugs: (amiodarone; psychotoxic drugs- phenytoin)
Alcohol (high MCV, high GGT)
B12 deficiency (high MCV)
Diabetes: (HbA1C)
Hypothyroidism
Uraemia (high urea/creatinine)

Amyloidosis (chronic infection/inflammation or Myeloma)

25

Toxic/metabolic causes of peripheral neuopathy:

Drugs: (amiodarone; psychotoxic drugs- phenytoin)
Alcohol (high MCV, high GGT)
B12 deficiency (high MCV)
Diabetes: (HbA1C)
Hypothyroidism
Uraemia (high urea/creatinine)

Amyloidosis (chronic infection/inflammation or Myeloma)

26

Toxic/metabolic causes of peripheral neuopathy:

Drugs: (amiodarone; psychotoxic drugs- phenytoin)
Alcohol (high MCV, high GGT)
B12 deficiency (high MCV)
Diabetes: (HbA1C)
Hypothyroidism
Uraemia (high urea/creatinine)

Amyloidosis (chronic infection/inflammation or Myeloma)

27

55 year old man
Numbness and tingling in hands and feet
PMH: T1DM
On basal/bolus insulin
HbA1C: 50mmol/L
B12: 500pg/ml (200-900)
eGFR: 90

Reduced sensation to PP (glove and stocking distribution)

1. Codeine
2.Duloxetine
3.Hydroxocobalamin
4.Paracetemol
5.Pregabalin

2. Duloxetine (first linbe- NICE)
(also used for premature ejaculation)

Codeine/Paracetemol won't work
Hydroxocobalamin- used in B12 deficiency

Pregabalin- used but not first line (considered if duloxetine is not effective)

28

55 year old man
Numbness and tingling in hands and feet
PMH: T1DM
On basal/bolus insulin
HbA1C: 50mmol/L
B12: 500pg/ml (200-900)
eGFR: 90

Reduced sensation to PP (glove and stocking distribution)

1. Codeine
2.Duloxetine
3.Hydroxocobalamin
4.Paracetemol
5.Pregabalin

2. Duloxetine (first linbe- NICE)
(also used for premature ejaculation)

Codeine/Paracetemol won't work
Hydroxocobalamin- used in B12 deficiency

Pregabalin- used but not first line (considered if duloxetine is not effective)

29

55 year old man
Numbness and tingling in hands and feet
PMH: T1DM
On basal/bolus insulin
HbA1C: 50mmol/L
B12: 500pg/ml (200-900)
eGFR: 90

Reduced sensation to PP (glove and stocking distribution)

Diabetic peripheral neuropathy

30

Toxic/metabolic causes of peripheral neuopathy:

Drugs: (amiodarone; psychotoxic drugs- phenytoin)
Alcohol (high MCV, high GGT)
B12 deficiency (high MCV, anaemia)
Diabetes: (HbA1C)
Hypothyroidism (TFTs)
Uraemia (high urea/creatinine)

Amyloidosis (chronic infection/inflammation or Myeloma)

31

55 year old man
Numbness and tingling in hands and feet
PMH: T1DM
On basal/bolus insulin
HbA1C: 50mmol/L
B12: 500pg/ml (200-900)
eGFR: 90

Reduced sensation to PP (glove and stocking distribution)

Diabetic peripheral neuropathy

32

55 year old man
Numbness and tingling in hands and feet
PMH: T1DM
On basal/bolus insulin
HbA1C: 50mmol/L
B12: 500pg/ml (200-900)
eGFR: 90

Reduced sensation to PP (glove and stocking distribution)

Diabetic peripheral neuropathy

33

Non metabolic causes of peripheral neuropathy:

Infection: HIV
Inflammation/Autoimmune: vasculitis, CTD (SLE), inflammatory demyelinating neuropathy (GBS acute, CIDP)

34

Non metabolic causes of peripheral neuropathy:

Infection: HIV

Inflammation/Autoimmune: vasculitis, CTD (SLE), inflammatory demyelinating neuropathy (GBS acute, CIDP)

Tumour/malignancy: paraneoplastic, paraproteinaemia

Hereditary: hereditary sensory, motor neuropathy (eg- if have pers cavus- arch in foot- so peripheral neuropathy has been there a long time)

35

Non metabolic causes of peripheral neuropathy:

Infection: HIV

Inflammation/Autoimmune: vasculitis, CTD (SLE), inflammatory demyelinating neuropathy (GBS acute, CIDP)

Tumour/malignancy: paraneoplastic, paraproteinaemia

Hereditary: hereditary sensory, motor neuropathy (eg- if have pers cavus- arch in foot- so peripheral neuropathy has been there a long time)

36

34 year old man
Weakness in legs
Blurred vision
Legs: T: Increased; P: decreased; R: brisk, decreased pin prick sensation
Fundoscopy: shows blurred optic disc

Most likely causes of blurred vision?
A. Amaurosis fugax
B. Anterior uveitis
C. Papillodoema
D. Pailiitis
E. Vitreous haemorrhage

Weakness in both legs, increased tone- spastic paraparesis (not LMN)

There is a level of sensory loss (legs)

Lesion is in the spinal cord- inflammation in CNS so MS

D. Pappilitis- inflammation at the head of the optic nerve

DDx of blurred optic disc is papilloedema or papillitis

37

Blurred optic disk of fundoscopy:

1. Papilloedema
2. Papillitis

Both may have blurred vision (more likely in papillitis) and optic disc won't be clear. However- papillitis will have pain when moving the eye (inflammation)

38

34 year old man
Weakness in legs
Blurred vision
Legs: T: Increased; P: decreased; R: brisk, decreased pin prick sensation
Fundoscopy: shows blurred optic disc

Most likely causes of blurred vision?
A. Amaurosis fugax
B. Anterior uveitis
C. Papillodoema
D. Pailiitis
E. Vitreous haemorrhage

Weakness in both legs, increased tone- spastic paraparesis (not LMN)

There is a level of sensory loss (legs)

Lesion is in the spinal cord- inflammation in CNS so MS

D. Pappilitis- inflammation at the head of the optic nerve

DDx of blurred optic disc is papilloedema or papillitis

39

Blurred optic disk of fundoscopy:

1. Papilloedema
2. Papillitis

Both may have blurred vision (more likely in papillitis) and optic disc won't be clear. However- papillitis will have pain when moving the eye (inflammation)

40

34 year old man
Weakness in legs
Blurred vision
Legs: T: Increased; P: decreased; R: brisk, decreased pin prick sensation
Fundoscopy: shows blurred optic disc

Multiple sclerosis

In CNS (spastic pareisis)
In spinal cord (sensory loss in both legs- a level- otherwise would be one side and in arm as well).

Blurred vision

Therefore inflammation in spinal cord and in optic nerve: 2 lesions separated in space/time- MS

41

Blurred optic disc margins (fundoscopy)
Blurred vision
Pain on eye movement

Where and what?

Optic nerve
Optic neuritis (papillitis)

Inflammation of optic nerve (eg- in MS)

42

Blurred optic disc margins (fundoscopy)
Blurred vision
Pain on eye movement

Where and what?

Optic nerve
Optic neuritis (papillitis)

Inflammation of optic nerve (eg- in MS)

43

Weak legs
Upgoing planatars, hypereflexia
Fevers, night sweats

Pott's Disease: TB of the spine- abscess compressing spinal cord

MRI: diagnosis
Neurosurgeons and and TB treatment

44

Causes of spastic paraparesis:
(weak legs, hypertonia, upgoing plantars)

Vascular: infarction in anterior spinal artery

Infection: Abscess (Pott's disease TB)

Inflammation: MS, transverse myelitis (associated with Mycoplasma pneumoniae)

Toxic/metabolic: B12 deficiency

Tumour/Malignancy: Tumour of spinal cord

45

Multiple Sclerosis:

Two lesions
Separated in time/space

46

Multiple Sclerosis:

Two lesions
Separated in time/space

47

60 year old
pain and paraesthesia in right anterolateral thigh
PMH: T2 diabetes
Metformin
HbA1C: 60 mmo

BMI: 30
Reduced pin prick sensation in anteriolateral thigh

Next step?
A.Lose weight
B. Insulin
C.Statin
D.Aspirin
E.MRI brain

A. Lose weight

Where? What?
Anterolateral thigh, pain and paraesthesia (prickling)- one area- so mononeuropathy

He has meralgia parasthetica: compression of the lateral femoral cutaneous nerve (as it passes inguinal ligament)

Reassure, avoid tight garments, LOSE WEIGHT

If persistent: carbamazepine, gabapentin

48

Sensory innervation of hand: lateral 3 1/2 digits (index and middle finger)

Median nerve

49

Sensory innervation of the hand: Medial 1 1/2 digits (little finger)

Ulnar nerve

50

Sensory innervation of the hand: Medial 1 1/2 digits (little finger)

Ulnar nerve

51

Sensory innervation of the hand: base of thumb (dorsal)

Radial nerve

52

Sensory innervation of the hand: base of thumb (dorsal)

Radial nerve
(check to see if sensation at base of the thumb- anatomical snuffbox)

53

Radial nerve palsy:

wrist drop, sensation lost at base of hand and back and proximal of first 3 fingers

54

Pain in buttock, radiating down the leg below the knee

Sciatica- compression of lumbosacral nerve roots (radiculopathy)
Compression by disc herniation, spinal canal setnosis

Radiculopathy (disease of nerve roots)

55

wrist drop, loss of sensation at base of thumb

Radial nerve palsy

56

wrist drop, loss of sensation at base of thumb

Radial nerve palsy

57

60 year old man
Recurrent falls
Tremor at rest
Rigidity
More forgetful
Dysphagia
Microphagia (small handwriting)
Limited upgaze

Most likely diagnosis?

A. Progressive supranuclear palsy
B. Lewy body dementia
C. Stroke
D. Epilepsy
E. Alzheimer's disease

Parkinsonian features

PLUS limited upgaze

A. Progressive supranuclear palsy

Parkinson's (tremor, rigidity, bradykinesia)

PSP (Steele-Richardson syndrome): parkisnonian features, upgaze abnormality

58

Triad of tremor, rigidity, bradykinesia

Parkinson's disease

59

Alzheimer's and Parkinsonian features
PLUS hallucinations

Lewy Body dementia

60

55 yr-old man
confusion and chest pain
no headache or neck stiffness
recently moved to new house
Temp: 37
PR: 100, BP: 120/60
Normal CVS/Resp/GI/Neuro exam
ECG: sinus tachycardia, widespread ST depression
Blood glucos: 7 mmol/L
WCC/CRP normal
CT head normal

New house: CO poisoning

Rule out other things (normal)

61

55 yr-old man
confusion and chest pain
no headache or neck stiffness
recently moved to new house
Temp: 37
PR: 100, BP: 120/60
Normal CVS/Resp/GI/Neuro exam
ECG: sinus tachycardia, widespread ST depression
Blood glucos: 7 mmol/L
WCC/CRP normal
CT head normal

New house: CO poisoning

Rule out other things (normal)

62

Causes of confusion (reduced AMTS):

VIITT/VIMM and others

Hypoglycaemia!!!

Vascular: bleed
Infection: meningitis, encephalitis
Inflammation: cerebral vasculitis
Metabolic/Toxic: CO poisoning
Malignancy/Tumour

Other causes:
post-ictal (history of seizure)
Dysphagia (receptive/expressive)- not confused but can't communicate- stroke/TIA
Dementia: Alzheimer's, Vacular (multi-infarct- history of IHD/PVD), alcoholic (signs of excess alcohol), Inherited eg- Huntington's (other features- chorea)
Depressive pseudodementia (depression): elderly, withdrawn, poor eye contact. Often a precipitating factor

63

Causes of confusion (reduced AMTS)

VIITT/VIMM and others

Hypoglycaemia!!!

Vascular: bleed: headaches, collapse.
Subdural haematoma (fall, fluctuating conciousness)


Infection: meningitis, encephalitis (?temp, ?intracranial (meningitis/enceph), ?extra-cranial (chest/UTI in elderly)

Inflammation: cerebral vasculitis, autoimmune encephalitis

Metabolic/Toxic: CO poisoning, drugs, U&Es, LFTs, Vit deficiency, Endocrinopathies

Malignancy/Tumour


Other causes:
post-ictal (history of seizure)
Dysphagia (receptive/expressive)- not confused but can't communicate- stroke/TIA
Dementia: Alzheimer's, Vacular (multi-infarct- history of IHD/PVD), alcoholic (signs of excess alcohol), Inherited eg- Huntington's (other features- chorea)
Depressive pseudodementia (depression): elderly, withdrawn, poor eye contact. Often a precipitating factor

64

Causes of confusion (reduced AMTS)

VIITT/VIMM and others

Hypoglycaemia!!!

Vascular: bleed: headaches, collapse.
Subdural haematoma (fall, fluctuating conciousness)


Infection: meningitis, encephalitis (?temp, ?intracranial (meningitis/enceph), ?extra-cranial (chest/UTI in elderly)

Inflammation: cerebral vasculitis, autoimmune encephalitis

Metabolic/Toxic: CO poisoning, drugs, U&Es, LFTs, Vit deficiency, Endocrinopathies

Malignancy/Tumour


Other causes:
post-ictal (history of seizure)
Dysphagia (receptive/expressive)- not confused but can't communicate- stroke/TIA
Dementia: Alzheimer's, Vacular (multi-infarct- history of IHD/PVD), alcoholic (signs of excess alcohol), Inherited eg- Huntington's (other features- chorea)
Depressive pseudodementia (depression): elderly, withdrawn, poor eye contact. Often a precipitating factor

65

GCS:

Eyes (4)
Verbal response (5)
Motor response (6)

66

GCS Eyes:

1: no response
2: open to pain
3: open to speech
4: spontaneous opening

67

GCS Motor:

Motor (6)
1: no response to pain
4: withdraws to pain
5: localising response to pain
6: obeying commands

68

GCS Verbal:

Verbal (5)
1: none
2: sounds
3: words
4: confused conversation
5: orientated

69

GCS Verbal:

Verbal (5)
1: none
2: sounds
3: words
4: confused conversation
5: orientated

70

Abbreviated Mental Test:

DOB
Age
Time
Year
Place
Recall (3 words)
Recognise doctor/nurse
Prime minister
Second WW
Count backwards from 20

71

Abbreviated Mental Test:

DOB
Age
Time
Year
Place
Recall (3 words)
Recognise doctor/nurse
Prime minister
WWII
Count backwards from 20

72

Abbreviated Mental Test:

DOB
Age
Time
Year
Place
Recall (3 words)
Recognise doctor/nurse
Prime minister
WWII
Count backwards from 20

73

Abbreviated Mental Test:

DOB
Age
Time
Year
Place
Recall (3 words)
Recognise doctor/nurse
Prime minister
WWII
Count backwards from 20

74

Headache in the Emergency Department (serious causes):

Meningitis (fever, neck stiffness, meningism, Kernig's sign)- treat with ceftriaxone

Subarachnoid haemorrhage: (sudden onset, thunderclap. CT, LP (xanthochromia- yellow CSF- breakdown products of RBCs))

Giant cell arteritis: polymyalgia rheumatic, (shoulder girdle pain, stiffness, jaw claudication, malaise, fever).
>50years. Give high dose steroids


Also:
Migraine: throbbing, vomiting, photo/phonophobia, FHx, Aura

75

Headache in the Emergency Department (serious causes):

Meningitis (fever, neck stiffness, meningism, Kernig's sign)- treat with ceftriaxone

Subarachnoid haemorrhage: (sudden onset, thunderclap. CT, LP (xanthochromia- yellow CSF- breakdown products of RBCs))

Giant cell arteritis: polymyalgia rheumatica(shoulder girdle pain, stiffness malaise, fever) or alone.
>50years. Give high dose steroids


Also:
Migraine: throbbing, vomiting, photo/phonophobia, FHx, Aura

76

Headache in the Emergency Department (serious causes):

Meningitis (fever, neck stiffness, meningism, Kernig's sign)- treat with ceftriaxone

Subarachnoid haemorrhage: (sudden onset, thunderclap. CT, LP (xanthochromia- yellow CSF- breakdown products of RBCs))

Giant cell arteritis: polymyalgia rheumatica(shoulder girdle pain, stiffness malaise, fever) or alone.
>50years. Give high dose steroids


Also:
Migraine: throbbing, vomiting, photo/phonophobia, FHx, Aura

77

Throbbing headache, vomiting, photo/phonophobia, FHx, Aura

Migraine

High dose aspirin (900mg)/ naproxen (NSAIDs)

78

Determining what management of stroke:

Time of onset
4.5 hours

79

Management of stroke

80

Management of stroke >4.5 hours

>4.5 hours
- CT head (exclude haemorrhage)
- Aspirin (300mg), assess swallow
- Maintain hydration, oxygenations, monitor blood glucose

(Don't treat BP acutely unless >220/120- dangerous to bring it down to quickly)

81

TIA

- Aspirin
- Don't treat BP actuely (unless >220/120 or other indication)
- ECG, Echocardiogram
- Carotid Doppler
- Risk factor modification

82

Management of stroke

83

Management of stroke >4.5 hours

>4.5 hours
- CT head (exclude haemorrhage)
- Aspirin (300mg), assess swallow
- Maintain hydration, oxygenations, monitor blood glucose

(Don't treat BP acutely unless >220/120- dangerous to bring it down to quickly)

84

TIA

- Aspirin
- Don't treat BP actuely (unless >220/120 or other indication)
Find underlying cause- to see if the patient is a candidate for carotid end arterectomy:
- ECG, Carotid Doppler, Echocardiography (thrombus in the heart causing emboli)
- Risk factor modification (stop smoking, DM, HTN)

85

TIA

- Aspirin
- Don't treat BP actuely (unless >220/120 or other indication)
Find underlying cause- to see if the patient is a candidate for carotid end arterectomy:
- ECG, Carotid Doppler, Echocardiography (thrombus in the heart causing emboli)
- Risk factor modification (stop smoking, DM, HTN)

86

40 year old
Back ache
LMN weakness (weak legs and depressed reflexes)

Admitted to HDU
Regular FVC
Cardiac monitor
IVIG

Most likely diagnosis?

A. Guillain-Barre
B. Stroke
C. Cord compression
D. Cauda equina syndrome
E. Myaesthenia Gravis

A. Guillain-Barre

LMN, young person
Back ache- radiculopathy (nerve roots)


Stroke and Cord compression would cause UMN signs (brisk reflexes)

Cauda equina- LMN legs, but saddle (perianal) anaesthesia, problems with bowel (is still a DDx- MRI to see any compression)

87

Management of Guillain-Barre

- Admit to HDU
- Regular FVC (forced vital capacity- respiratory depression)
- Cardiac monitor (autoimmune disturbances)
- IVIG (IV immunoglobulins treatment)

If FVC drops below 20ml/kg- send to ITU- intubation

88

Management of Guillain-Barre

- Admit to HDU
- Regular FVC (forced vital capacity- respiratory depression)
- Cardiac monitor (autoimmune disturbances)
- IVIG (IV immunoglobulins treatment)

If FVC drops below 20ml/kg- send to ITU- intubation

89

Management of Guillain-Barre

- Admit to HDU
- Regular FVC (forced vital capacity- respiratory depression)
- Cardiac monitor (autoimmune disturbances)
- IVIG (IV immunoglobulins treatment)

If FVC drops below 20ml/kg- send to ITU- intubation

90

Management of Giant Cell Arteritis:

Giant cell arteritis/Temporal arteritis:

If suspected: Start on high dose prednisolone 60mg/d immediately to prevent visual loss
Blood: ESR (will be increased) and so will CRP
Get a temporal artery biopsy within 7 days of starting treatment (10% will be negative as skip lesions occur)