Examinations

Question 1

Internuclear opthalmoplegia

Answer 1

Demyelination of the medial longitudinal fasciculus which normally connects CN III and CN VI. This results in a loss of coordination of lateral gaze.

Question 2

MS focussed exm

Answer 2

Walking aids
Gait - spastic, ataxic
Limbs - inc tone, dec power, poor coordination/proprioception, dec sensation, inc reflexes (UMN picture)
CN II - red desaturaiton, RAPD, pale optic disc
CN III & VI - Internuclear opthalmoplegia
CN X - staccato speech

Finish: offer full neuro exam UL, LL and cranial nerves, full history exploring onset and development of symptoms.

Ix: MRI, LP for oligoclonal bands, visual evoked potentials

Question 3

Cerebellar gait

Answer 3

Wide stance, ataxic, unsteady on their feet, fall towards the side with the lesion, swaying, unable to tandem walk

Question 4

Scissoring gait

Answer 4

Spastic paraparesis, tiptoe walk, arms flexed, seen in cerebral palsy

Question 5

High stepping gait

Answer 5

Peripheral neuropathy, equine, weakness in dorsiflexors so have to step high to prevent tripping over

Question 6

Hemiplegic gait

Answer 6

Circumductive gait, pyramidal lesions with arms flexed & legs extended

Question 7

Sensory ataxia gait

Answer 7

Stomping so vibration from this helps sense where feet are in space

Question 8

Waddling gait

Answer 8

Trendelenberg positive, due to myopathy of hip abductors

Question 9

Parkinsonian gait

Answer 9

Shuffling, marche a petis pas, festination

Question 10

Ankle reflex

Answer 10

S1

Question 11

Knee reflex

Answer 11

L3/L4

Question 12

Brachioradialis

Answer 12

C5/C6

Question 13

Biceps reflex

Answer 13

C5/C6

Question 14

Triceps reflex

Answer 14

C6/C7/C8

Question 15

Pyramidal pattern of weakness

Answer 15

Arms flexors stronger

Legs extensors stronger

Question 16

Pronator drift

Answer 16

UMN lesion

Stroke

Question 17

Upwards drift arms out

Answer 17

Cerebellar lesion

Question 18

Glove and stocking distribution

Answer 18

Spinal cord lesion

Peripheral neuropathy

Question 19

Median nerve muscles innervated

Answer 19

Lumbricals
Opponens pollicis
Abducor pollicis brevis
Flexor pollicis brevis

Question 20

Cerebellar exam

Answer 20

Inspection
Sitting upright - truncal ataxia
H test - Nystagmus
Scanning speech
Hypotonia
Finger to nose - past pointing with intentional tremor
Hand clapping - dysdiadokinesia
Pronator drift 
Gait - unsteady, fall towards side with lesion, unable to heel to toe walk
Rombergs +ve

Dysdiadokinesis
Ataxia
Nystagmus
Intentional tremor
Scanning speech
Hypotonia

DDx: brainstem stroke, hypothyroidism, alcoholic, SOL, multiple sclerosis

Question 21

Parkinson’s disease exam

Answer 21

Inspection - stooped posture, masked facial expressions
Gait - reduced arm swing, small, shuffling steps, festenation,
Shoulder pull test - postural stability
Count to 20
Lead pipe rigidity - tap knee with other hand
Play piano, finger to thumb movement
H test - difficulty with vertical gaze (PSP), nystagmus (MSA)
Cerebellar - past pointing, dysdiadokinesia
Changes with sense of smell?
Speech - slow
Dystonia - torticollis (MSA)

Extras: BP (postural hypotension), MMSE, write (micrographia), mood

DDx: idiopathic parkinsons, iatrogenic (antipsychotics), lewy body dementia (dementia symptoms before PD Sx)

Question 22

Causes of unilateral LMN facial palsy

Answer 22

Bell’s palsy
Parotid tumour, surgery or trauma
Fracture of base of skull affecting temporal bone

Question 23

Ptosis & small pupil

Answer 23

Horners

Question 24

Ptosis & large pupil

Answer 24

Complete 3rd nerve palsy

Question 25

Ptosis & normal pupil

Answer 25

Partial 3rd nerve palsy / Myasthenia

Question 26

Complete third nerve palsy

Answer 26

Eye turned down and out
Pupil dilated
Ptosis

Question 27

Third nerve palsy causes

Answer 27

DM
Posterior cerebral artery aneurysm
Raised ICP

Question 28

Sparing forehead UMN lesion

Answer 28

There is bilateral input to the upper part of the facial nerve nucleus

Question 29

Optic neuropathy signs

Answer 29

Loss of visual acuity
Pale optic disc
Optic atrophy
Red desaturisation
Central scotoma
Relative afferent pupillary defect

Question 30

Causes papiloedema

Answer 30

Optic neuritis
Raised ICP
Essential intracranial hypertension

Question 31

Causes optic neuritis

Answer 31

Secondary to papiloedema
Demyelinating disease
Trauma

Question 32

Papiloedema fundoscopy

Answer 32

Polo mint

Question 33

T1 nerve root lesion

Answer 33

Pancoast syndrome
Horners
Sensory loss in axilla (dermatome affected)
Claw hand
Wasting of thenar eminence (median nerve myotome affected)

Question 34

Ulnar nerve palsy

Answer 34

Froment’s sign - loss of pincer grip

Flexors act when adductor is weak through median nerve

Question 35

Charcot marie tooth examination

Answer 35

Walking aids, orthotics, padded shoes
Inspection: symmetrical wasting of distal leg muscles, Small arched feet, Claw toes, calluses, varus deformity
Gait: high stepping gait, rombergs +ve
Exam: normal tone & power, weakness on dorsiflexion, patchy sensation loss, reduced proprioception, co-ordination intact, absent knee/ankle reflexes.

Question 36

Charcot marie tooth disease

Answer 36

Autosomal dominant condition, there are several variants and tends to run in families.
Hereditary peripheral motor and sensory neuropathy.
Present with ankle sprain, painful feet. It is a progressive condition in which the deformity will develop over time.
No cure but the condition can be managed well with an MDT approach.
Pt - take care of calluses, non-weight bearing exercise,
Occ health, chiropody, physio, specialist nurse -> foot care, shoe advice, orthoptics
Med - pain relief, surgical to release tendons/shave off bone

Question 37

Guillan-Barré

Answer 37

Ascending, symmetrical weakness, arreflexia and paralysis. Starts in legs and ascends upwards.
Sx: numbness, pain, tingling.
Cause: campylobacter jejuni diarrhoea about 3/7 previously
Dx:
LP - CSF high protein, normal WCC
Bloods - LFTs, CRP
Lung function tests
ECG
Stool culture - camp jejuni
Mx: IVIG, pain relief, frequent monitoring, MDT approach (physio, SALT), ICU if deteriorating rapidly