neuro case histories

Question 1

where are upper motor neurons *

Answer 1

brain and spinal chord

Question 2

where are lower motor neurons *

Answer 2

anterior horn cell, roots and plexuses to muscles

Question 3

symptoms of upper motor neuron lesions *

Answer 3

REFLEXES - increased
TONE - increased, spastic
SENSATION 
POWER - reduced
BABINSKI - extensor - when stroke foot toes curl upwards (should go down)
WASTING - no 
FASCICULATION - no

Question 4

symptoms of lower motor neuron lesions *

Answer 4

REFLEXES - reduced
TONE - flacid 
SENSATION 
POWER - reduced
BABINSKI - flexors or mute 
WASTING - yes 
FASCICULATION - yes

Question 5

what can be inferred if neuro symptoms started occurring a year ago *

Answer 5

that the disease is slowly progressive

Question 6

what can be inferred by the following symptoms 
- leg stiff
drag feet 
cant carry things 
have appetite but losing weight 
slurred speech (dysarthria)
sphincter function fine 
bilateral foot drop 
words grammatically correct
tongue wastage
swallow twice
palate elevated poorly, gag reflex brisk, jaw jerk increased
deep tendon reflexes brisk
planter extensor 
superficial reflexes absent *

Answer 6

leg stiff - tone increased - upper motor neuron (umn)
drag feet - impaired gait - cerebellar or weak so cant lift leg properly
cant carry things - weak
have appetite but losing weight - problem is dysphagia - bulbar muscles not working correctly
slurred speech - bulbar muscles not working correctly
sphincter func - bowel and urinary func fine
bilateral foot drop - weakness of dorsiflexion = tripping
grammatically correct - doesn’t have dysphasia
tongue wastage - lower motor neuron (lmn)
swallow twice - weakness of muscles, wastage, exaggerated reflex
fasciculations - lmn
palate, gag and jaw jerk - umn
tendon reflexes - umn
planters - umn
superficial reflex - umn

anatomical part of nervous system effected - umn and lmn
what pathway is affected - corticospinal tract because no sensory involvement
why abdo reflex absent - that is seen in umn
significance of fasciculation - lmn

diagnosis - motor neuron disease

Question 7

what is dysphasia *

Answer 7

substitute the wrong words

Question 8

explain the 2 types of dysphasia *

Answer 8

receptive - pt cant understand what people are saying to them
expressive - understand what people are saying but you cant get words out

Question 9

what are the deep tendon reflexes *

Answer 9

supinator 
biceps 
triceps 
knee 
ankle

Question 10

what are superficial reflexes *

Answer 10

upper and lower abdominal reflexes

cremasteric reflex - in men

Question 11

effect of umn on superficial reflexes *

Answer 11

they become absent

Question 12

what are fasciculations *

Answer 12

involuntary abnormal contraction of all muscle fibres in a single motor unit and is random in time and place

Question 13

how do fasciculations occur *

Answer 13

denervation leads to renervation by other neurons
effect is bigger than it should be
causes twitching and random firing

Question 14

what is suggested by the following symptoms
- leg stiff
trips
leg jerk
r bicep and supinator reflex absent
tricep and finger jerk reflex exaggerated

which segment supplies the bicep, tricep and finger jerks
what is the expected ankle reflex
what is the expected plantar reflex

what is the diagnosis *

Answer 14

leg stiff - umn, spasticity
trip - weakness/spasticity in leg - umn 
leg jerk - this is clonus - marker of spasticity - umn 
bicep and supinator reflex - lmn 
tricep and finger - umn 

bicep - c5-6 
tricep - c7 
finger - c8-t1 
ankle reflex - brisque 
plantar - extensor 

diagnosis - disk prolapse that pushes on spinal cord at c5-6 and on root so have lmn effects at c5. below c5 all upper neurons are affected so have umn defects below

Question 15

how can pain be interpreted *

Answer 15

it is localising

Question 16

what is paraesthesiae *

Answer 16

unusual sensation

Question 17

what is clonus *

Answer 17

rhythmic beating

Question 18

what is rigidity *

Answer 18

as you bend the same amount of force is required thoughout and it applies the same amount of force back

Question 19

what is spasticity *

Answer 19

more force you apply the more force is exerted back until it just gives
as move limb tone increases then suddenly gives

Question 20

what can be interpreted from the following symptoms 
R arm is stiff even when arm is displaced slowly with both flexors and extensors involved
R hand not working very well 
expressionless
reflexes symettrical 
no weakness
movements of r hand are slower than l 
increased tone in r leg

what symptoms are missing *

Answer 20

R arm stiff - rigidity

not weak and reflexes ok = not corticospinal tract

diagnosis - parkinsons

missing symptoms - tremor - because of problems with basal ganglia this is extrapyramidal
don’t blink
gait initiation failure - tilt forward to move their centre of gravity so that the fall triggers their walk, then they shuffle
micrographic handwriting

Question 21

what is bradykinesia *

Answer 21

slow movement

Question 22

how would you diagnose Parkinson’s *

Answer 22

DAT scan

Question 23

variants of Parkinson’s disease *

Answer 23

idiopathic - lesions in nigro-striatal tract (strokes in same area have the same effect)
lewy body disease 
MSAC
MSA
PSP

Question 24

summarise the function of the first 10 cranial nerves *

Answer 24

cn1 smell
cn2 see - colour, field of vision, acuity,
cn3 eye movement, eyelid, pupil constriction
cn 4 superior oblique muscle of eye
cn5 jaw jerk, corneal sensation (reflex) and sensation to face
cn 6 - lateral rectus muscle
cn 7 - facial expression
cn 8 - hearing and balance
cn 9 and 10 - swallowing

Question 25

where are the vertical and horizontal eye movement centres, what does this mean clinically *

Answer 25

centre of horizontal gaze - 6th nerve nuclei, in pons vertical gaze - higher up - rostral interstitial nucleus of cajal in different locations so can have damage to 1 without it affecting the other parts

Question 26

where do the cranial nerves come off *

Answer 26

1 2 3 4 midbrain 5 6 7 8 pons 9 10 11 12 medulla

Question 27

what can be interpreted from the following symptoms - sudden double vision ptosis of r eyelid previous TIAs conscious and not confused R pupil deviated to r and down R eye did not respond to caloric testing or in attempted convergance pupillary responses intact mild weakness in r arm and leg deep tendon reflexes physiologic and symettrical in upper extremities, and increased in L lower extremity compared to R L Babinski response sensation normal could articulate speech meaningfully visual field full to confrontation minor weakness in left corner of mouth when tried to grimace palate elevated symettrically, corneal jaw jerk and gag reflexes are intact tongue protruded on midline shoulder shrug symettrical and of physiologic strength mild weakness in l arm and leg, brisque reflex in l leg, plantor extensor, abdo reflex absent *

Answer 27

sudden - suggestive of vascular ptosis - drooping of eyelid - could be horners, 3rd nerve palsy or myasthenia gravis no dysarthria or dysphasia pupil deviated to r and down - cn 6 and 4 working this movement is from superior oblique and lateral rectus visual fields - cn 2 fine pupillary reflex fine - this is surprising because this si part of the 3rd nerve function - happens because pupillomotor fibres to 3rd nerve run in discrete bundle along 3rd nerve not in nerve itself. stroke (medical 3rd nerve palsy) affect 3rd nerve = pupil dilation because no 3rd nerve controlled constriction. aneurism (surgical 3rd nerve palsy) damage motor fibres surrounding 3rd nerve but 3rd nerve is fine so still get pupil reflex L mouth weakness - L facial nerve palate, corneal, jaw jerk and gag - 5 8 9 10 11 12 ok mild weakness in l arm and leg, brisque reflex in l leg, plantor extensor, abdo reflex absent - UMN in L diagnosis - medical 3rd nerve palsy, l hemiparesis with umn symptoms, L facial nerve palsy lesion is in the midbrain - oculomotor nerve here (cn3) affecting the ipsilateral side, and affecting contralateral corticospinal tract - fibres decussate further down eitiology - stroke - because pupillary reflex

Question 28

what is diplopia *

Answer 28

double vision

Question 29

describe horners *

Answer 29

failure of sympathetic ns | have pupil constriction and enophthalmos

Question 30

describe myasthenia gravis *

Answer 30

muscle disease with ach receptor causes fatigable weakness

Question 31

what is a caloric test *

Answer 31

water injected into ear to stimulate the vestibular system

Question 32

what can be determined from the following symptoms weak R leg, R arm and L mouth and stiff R leg high bp and ex smoker dysarthria cant move eye to L increased tendon reflexes *

Answer 32

weak R leg, R arm and L mouth and stiff R leg - umn bp and smoker - vascular problem dysarthria - cerebellar problem, hypoglossal problem with tongue, facial - half mouth not moving cant move eye to l - problem with lateral rectus = 6th nerve palsy - 6th nerve nuclei is the centre for horizontal gaze tone increased in R arm - umn r tendon reflexes increased on r, normal on l - umn r plantar extensor on r and plantar flexor on l - umn r r upper extremity flexed, lower was extended - both resisted opposite movement - this is because of increased tone and means hemiparesis been around a long time because flexors stronger in upper limb, increased tone stronger in flexors in upper limbs and extensors in lower limbs. wrist bend down, elbow in and shoulder down. leg extension and plantar flexion stronger than leg flexion and dorsiflexion so leg straight 6 and 7 cn palsy on L hand side upper motor neuron problem - spasiticity and weakness in R lesion is in the pons affects the pyramidal tract - contralateral hemiparesis 6th nuclei affected and facial nerve

Question 33

what can be determined from the following symptoms - present with fall and imbalance imbalance headache no neck trauma father had vascular death young poorly controlled dm bruises on 1 foot dysarthric left beating nystagmus L pupil smaller than R diminished sensation to l side face and corneal reflex L arm and leg ataxia, dysmetria, mild intention tremor pinprick sensation was diminished in upper extremities on R*

Answer 33

imbalance - vestibulocochlear problem, brainstem or cerebellum (coordination) headache - suggest haemorrhage no neck trauma - if have neck trauma the layers of the arteries in neck could split and blood pools between the layers making lumen irregular = turbulent flow, if lumen blocked = stroke - but there is no trauma in this case father death - family history of vascular problems dm - retinopathy/neuropathy bruises - maybe cant feel foot so it is weaker dysarthric - problem with cerebellum, facial palsy, or tongue problem L beating nystagmus - cerebellum not working properly L pupil smaller than R - horner's syndrome - no sympathetic stimulation diminished sensation to l side face and corneal reflex- L trigeminal problem L arm and leg ataxia, dysmetria, mild intention tremor - these are cerebellar signs pinprick sensation - loss of pain reception on R - damage to spinothalamic tract is causing loss of pain reception on contralateral side summary - balance - cerebellum problem, dysarthric - cerebellum, L beating nystagmus - cerebellum, horner's - sns, loss of sensation to face and cornea - cn5, cerebellum signs, loss of pain sensation contralaterally - spinothalamic tract diagnosis - lateral medullary syndrome - involve sns, trigeminal nerve, cerebellum and spinothalamic tract

Question 34

describe ataxia *

Answer 34

clumsy arms and legs | cant control position and movement of limbs

Question 35

describe dysmetria *

Answer 35

arm cant find place in space | it overshoots when you ask someone to lift arms up in front of them

Question 36

describe intention tremor *

Answer 36

do finger-nose test | affected hand cant find nose without tremoring

Question 37

what can be seen by asking a patient to rise their arms in front of them *

Answer 37

ataxia - affected arm drifts to 1 side sensory athetosis - fingers look for place in space so drift to each other - happens when lost dorsal columns weakness - arm drifts down