Neurology

Question 1

What is Glia?

Answer 1

Supportive cells throughout the CNS and PNS supporting Neurones, each with different functions.

Question 2

What are astrocytes?

Answer 2

Glia cells that connect neurones and blood capillaries to form the BBB

Question 3

What are Satellite cells?

Answer 3

Located in the PNS provide neuronal support

Question 4

What are microglia?

Answer 4

Immune and Phagocytic functions

Question 5

What are Ependymal Cells?

Answer 5

They line the CSF filled ventricles and the central canal of the spinal cord

Question 6

What are oligodendrocytes?

Answer 6

Oligodendrocytes in the CNS provide the Myelin sheath

Question 7

What are Schwann Cells?

Answer 7

Schwann Cells in the PNS provide the Myelin Sheath

Question 8

Describe the clinical findings of Relative Afferent Pupillary Defect.

Answer 8

Pupiliary defect:
Light shone on unaffected eye causes full and symmetrical constriction of both eyes, when light swings to AFFECTED eye, the constriction is still symmetrical but REDUCED.

Caused by:
Damage between the Retinal Ganglion and Lateral Geniculate Body.

Question 9

What is the Lateral Geniculate body?

Answer 9

Located in the Thalamus, it provides a relay station for all the axons of the retinal ganglion cells where the neurons from the lateral geniculate body project, by way of the optic radiations, the occipital lobe, which is the primary cortical area for vision.

Question 10

What can Relative Afferent Pupillary Defect indicate?

Answer 10

-optic neuropathy
-optic neuritis
-optic nerve compression (orbital tumours or dysthyroid eye disease) –trauma
-asymmetric glaucoma.

Question 11

What is Miosis?

Answer 11

Pupiliary Defect:
Excessive Constriction of pupil

Causes:Commonly associated with HORNER’s SYNDROME due to a LESION of the sympathetic chain between the hypothalamus and eye.

Question 12

What can Miosis indicate?

Answer 12

HORNER’s SYNDROME due to …
-Pancoast tumour (lung cancer)
-Trauma
-Thoracic Aortic Aneurysm

Question 13

How would you confirm Horner’s Syndrome?

Answer 13

4% cocaine eye drops will dilate the unaffected eye BUT NOT the AFFECTED eye.

Question 14

What is Fixed Dilated Pupil?

Answer 14

Pupiliary defect:
Permanent dilation of pupil that does not constrict on light impulse.

Causes:
Due to sphincter pupillae damage

Question 15

A patient has Fixed Dilated Pupil. What needs to be excluded?

Answer 15

Third Nerve Palsy

Question 16

What are the causes of Fixed Dilated Pupil?

Answer 16

-THIRD NERVE PALSY!
-Surgical mistake
-Physical trauma
-Tumour
-Posterior Artery Aneurysm
-Uncal Herniation

Question 17

A patient has unilateral enlarged pupil / fixed dilated pupil. What could this be due to and how is this medical complaint considered?

Answer 17

Uncal Herniation
=Neurosurgery Emergency

Question 18

What is Uncal Herniation?

Answer 18

Uncal herniation occurs when rising intracranial pressure causes portions of the brain to move from one intracranial compartment to another. This is usually caused by something increasing the pressure e.g Bleeding in the brain or Tumour

Question 19

What is Horner’s Syndrome?

Answer 19

Due to a disruption in the sympathetic nerve supply presenting with these triad symptoms :

1.Partial ptosis (drooping or falling of upper eyelid)
2.Miosis (constricted pupil)
3.Facial anhidrosis (loss of sweating)

Question 20

What are the causes of Horner’s Syndrome?

Answer 20

Most common: Carotid Artery Dissection

(Disruption to the Sympathetic Chain)
Blockage or damage to the sympathetic nerves that lead to your eyes.
The underlying causes of nerve damage CAN VARY WIDELY, from a middle ear infection to a carotid artery dissection or apical chest tumor.

Question 21

What is Papilloedema?

Answer 21

An INCREASE OF INTRACRANIAL PRESSURE caused by an accumulation of CSF expanding the ventricles (DUE TO HYPERTENSION USUALLY DUE TO MALIGNANCY) and increasing the overall pressure which affects the optic nerves : and causes the SWELLING of THE OPTIC DISC.

Question 22

A patient presents with headaches and nausea. Upon Fundoscopy, you see that the Optic disc is swollen. What would you do next and why?

Answer 22

Sounds like PAPILLOEDEMA
=1.CT scan of brain
2.If imaging normal, do Lumbar Puncture as Intracranial Hypertension is suspected

Question 23

What is Mydriasis?

Answer 23

Excessive dilation of the pupil

Question 24

What are the clinical signs of Third Nerve Palsy?
(See imaging power point)

Answer 24

1.Myadriasis
2.Ptosis
3.Cycloplegia of affected eye
-Exotropia (eye looking outward)
-Hypotropia (one eye always looking upward)
=Issues with accomodation

Additional associated symptoms:
-Fixed dilated pupil and Horizontal Diplopia

Question 25

A patient presents with Myadriasis, Ptosis and Cycloplegia of her right eye. What artery could have been responsible for 'this' and why?

Answer 25

Presentation = Third Nerve Palsy =Posterior Communicating Artery (runs close to third nerve so an aneurysm of this artery can cause Third Nerve Palsy.

Question 26

What is Cycloplegia?

Answer 26

Paralysis of accomodation (because of paralysis in the ciliary muscles which are responsible for accomodation).

Question 27

What is accomodation of the eye?

Answer 27

The eyes ability to focus on images far away AND up close =Pupil should constrict when something is close (tip of pen) and dilate when far away. If this doesn't happen : CYCLOPLEGIA

Question 28

A patient presents with symptoms indicating Third Nerve Palsy however the MR angiography is normal. What is the next step?

Answer 28

Repeat the MR angiography =Vasospasms of an aneurysm (constriction of the blood vessel) can give a falsely normal MR so repeat it again.

Question 29

What nerve does Third Nerve Palsy affect?

Answer 29

Oculomotor

Question 30

What muscle does the Trochlear Nerve innervate and what are the actions of that muscle?

Answer 30

Superior Oblique Muscle of the eye =Abducting, Depressing and Internally Rotating the eye

Question 31

What is the most common cause of 4th Nerve Palsy?

Answer 31

Trauma -due to its long and slender coarse it is very vulnerable to damage

Question 32

How does 4th Nerve Palsy present? (See Imaging Power Point)

Answer 32

-Vertical Diplopia -Excyclotorsion Can also have : torsional diplopia, head tilt, and ipsilateral hypertropia.

Question 33

What is Vertical Diplopia?

Answer 33

Double Vision =Vertical meaning that the overlapping image will be on top of the other

Question 34

What is Horizontal Diplopia?

Answer 34

Double Vision =Horizontal meaning that the overlapping image will be side by side

Question 35

What is Excyclotorsion?

Answer 35

Affected eye deviates upward and rotates outward when looking in the opposite direction e.g affected right eye looking left will look upward and rotate outwards

Question 36

What is the Bielschowsky test and what result would you expect for a patient with 4th Nerve Palsy?

Answer 36

Check head tilting =Hyperdeviation head tilt

Question 37

What are the clinical signs of Sixth Nerve Palsy?

Answer 37

-Esotropia ( either one or both of your eyes pointing inward) -Horizontal Diplopia (double vision with images side by side)

Question 38

What are the common causes of 6th Nerve Palsy?

Answer 38

-Microvascular Disease (from Diabetes Mellitus and Hypertension) -External Compression (from acoustic neuroma and raised intracranial pressure)

Question 39

What is an Acoustic Neuroma?

Answer 39

Acoustic neuromas, also known as vestibular schwannomas, are noncancerous tumours that grow in the ear, and that can affect hearing and balance. -Cause is largely unknown but regarded to be due to environmental factors such as radiation

Question 40

What muscle is innervated by the Abducens Nerve?

Answer 40

The 6th cranial nerve innervates the ABDUCTOR MUSCLE OF THE EYE

Question 41

A patient has Arcuate Scotoma. What Nerve is affected and what are the 4 potential causes of it?

Answer 41

Optic Nerve (1) 1.Glaucomatous Cupping 2.Vitamin B12 deficiency 3.Trauma 4.Optic Neuritis

Question 42

A patient has Centrocecal scotoma. What Nerve is affected and what are the 4 potential causes of it?

Answer 42

Optic Nerve (1) 1.Glaucomatous Cupping 2.Vitamin B12 deficiency 3.Trauma 4.Optic Neuritis (due to Multiple Sclerosis)

Question 43

A patient has complete unilateral loss of visual field. What Nerve is affected and what are the 4 potential causes of it?

Answer 43

Optic Nerve (1) 1.Glaucomatous Cupping 2.Vitamin B12 deficiency 3.Trauma 4.Optic Neuritis

Question 44

What is a scotoma?

Answer 44

Visual blind spot

Question 45

What is a Centrocecal scotoma?

Answer 45

Blind spot in the centre of the visual field

Question 46

A patient has Bilateral Hemianopia. What Nerve is affected and what are the potential causes of it?

Answer 46

BRAIN TUMOURS: -Pituitary tumour -Craniopharyngioma (tumour between pit. gland and hypothalamus) -Meningioma (benign tumour arising from the meningeal layers of brain) =due to issue where the OPTIC NERVES cross at the Optic Chiasm.

Question 47

A patient has Contralateral Homonymous Hemianopia. What are the potential causes of it?

Answer 47

Tumour, Multiple Sclerosis (MS)

Question 48

What does Homonymous eye defect mean?

Answer 48

Same visual field in both eyes

Question 49

A patient has Contralateral Superior Quadrantanopia.What are the potential causes of it?

Answer 49

-Mass lesion in the temoral lobe -Stroke

Question 50

A patient has Homonymous Hemianopia. What is the most likely cause of it?

Answer 50

Stroke

Question 51

What does Hemianopia mean?

Answer 51

A hemianopia is where there is a loss of one half of your visual field

Question 52

What characterises Parinaud Syndrome?

Answer 52

-Vertical Gaze palsy (cannot look up or down!) -Convergence Nystagmus OR -Diplopia

Question 53

What is meant by Convergence Nystagmus?

Answer 53

Quick jerking movements of eyes looking inwards

Question 54

What causes Parinaud Syndrome?

Answer 54

Pineal Gland tumour compressing the vertical gaze centre.

Question 55

What are the 3 main reasons for patients presenting with Vertigo?

Answer 55

Benign Paroxysmal Positional Vertigo Meniere's Disease Vestibular Neuronitis

Question 56

A patient presents with hearing loss and vertigo. What could be the most likely cause?

Answer 56

-Meniere's Disease OR -Labyrinthitis

Question 57

A patient presents with persistent vertigo. What is the most likely cause?

Answer 57

-Vestibular Neuronitis -Labyrinthitis

Question 58

What is an Otolith?

Answer 58

Calcium carbonate stone of the ear

Question 59

What is the pathophysiology of Benign Paroxysmal Positional Vertigo (BPPV)?

Answer 59

Otoliths (stones) get dislodged in the semi-circular canals which produces the sensation of vertigo.

Question 60

What is the cause of Benign Paroxysmal Positional Vertigo (BPPV)?

Answer 60

Idiopathic HOWEVER -Most likely to be due to trauma / head injury when it presents in younger people

Question 61

Who is most likely to present with Benign Paroxysmal Positional Vertigo (BPPV)?

Answer 61

-Over age 50 years -WOMEN more affected than men

Question 62

What other disorders is Benign Paroxysmal Positional Vertigo (BPPV) associated with (i.e can present with)?

Answer 62

-Meniere Disease -Vestibular Neuronitis

Question 63

A patient has Benign Paroxysmal Positional Vertigo (BPPV). What would you believe to make their symptoms better or worse?

Answer 63

-Provoked by head movement -WORSEN: Head tilted / on one side/ when waking in the morning -RESOLVES: When head is kept straight and still

Question 64

What 2 symptoms if present with vertigo would rule out Benign Paroxysmal Positional Vertigo (BPPV)?

Answer 64

-Hearing loss -Tinitus

Question 65

Describe the onset of symptoms of Benign Paroxysmal Positional Vertigo (BPPV)?

Answer 65

Episodic lasting under a mintue and often resolve temporarily when head is kept still.

Question 66

What investigation(s) are done for a suspected Benign Paroxysmal Positional Vertigo (BPPV)?

Answer 66

Dix-Hallpike test =A positive test diagnoses BPPV and no more investigations are required. HOWEVER - if severe neck issues such as Rheumatoid Arthritis or Cervical Spondylosis etc ...Cannot do this test and will need to be referred for ENT specialist.

Question 67

What is the Dix-Hallpike test?

Answer 67

Manoeuvre : 1.Patient lies on side (ear on bed and other facing ceiling) and looks up 2.Look for Nystagmus (jerking of eye) =If Nystagmus present this is a POSITIVE test and diagnosed BPPV.

Question 68

What is the management for Benign Paroxysmal Positional Vertigo (BPPV)?

Answer 68

-Epley Manoeuvre (moving head both sides 45 degrees) -Brandt-Daroff exercises (lying down and looking to one side with eyes closed and doing it on the other side) =These should be done until 2 consecutive days without symptoms

Question 69

What lifestyle advice should be given to a patient with a new diagnosis of Benign Paroxysmal Positional Vertigo (BPPV)?

Answer 69

-Avoid driving -Avoid any tasks that can be adversely affected by vertigo (e.g painting of ladder - you could fall!!)

Question 70

What is the pathophysiology of Meniere's Disease?

Answer 70

Somewhat unknown (interplay between genes and enviroment) cause of the EXTENSIVE EXPANSION of the membranous labyrinth which causes the sensation of vertigo.

Question 71

What is the classical triad of symptoms for Meniere's Disease?

Answer 71

-Vertigo -Tinnitus -Fluctuating Hearing Loss (sensorineural in nature)

Question 72

What is meant by Aural Fullness?

Answer 72

The feeling of ear pressure or a clogging sensation of the ear

Question 73

Who is usually affected by Meniere's Disease?

Answer 73

40-50years

Question 74

Other than the classical triad of symptoms what other symptoms are associated with Meniere's Disease?

Answer 74

Aural fullness Anxiety and Depression

Question 75

Describe the onset of symptoms in patients with Meniere's Disease?

Answer 75

ACUTE attack lasting minutes - hours (MOST COMMONLY BEING 2-3HRS) -These attacks can occur in clusters but often there is a remission period of months before the next one

Question 76

What investigations are required for a patient with suspected Meniere's Disease?

Answer 76

NO investigations -The triad of symptoms ALL being present is enough for diagnosis after REFERAL TO AN ENT SPECIALIST

Question 77

A patient has been diagnosed with Meniere's Disease? What advice and legal action is required from you as a doctor?

Answer 77

-Advise not to drive =Inform the DVLA -Advise not to perform work that could be adversely affected

Question 78

What is the management of Meniere's Disease?

Answer 78

1.Betahistine (to reduce frequency of attacks) to be tried 2.If SEVERE: Admission for IV Labyrinthine Sedatives 3.Prochlorperazine = for use during ACUTE ATTACKS

Question 79

What are the contraindications for Betahistine?

Answer 79

-Phaeochromocytoma (adrenaline secreting tumour) -TRY to avoid during Pregnancy and Breastfeeding

Question 80

A patient is being considered to be put on Betahistine. What should be considered and therefore increase monitoring of the patient's tolerance of the medication?

Answer 80

Asthma History of peptic ulcer Allergic dermatitis Vomiting

Question 81

List 3 common side effects of Betahistine.

Answer 81

Gastrointestinal discomfort headache nausea

Question 82

What is Labyrinthitis?

Answer 82

Inflammation of the inner ear (can also be referred to as Vestibular Neuronitis)

Question 83

What causes Labyrinthitis?

Answer 83

Inflammation due to a viral (usually being an upper respiratory infection) or bacterial infection.

Question 84

What are the viral pathogens that can cause Labyrinthitis?

Answer 84

-Varicella-Zoster Virus -Cytomegalovirus -Measles -Mumpes -Rubella

Question 85

What are the bacterial pathogens that can cause Labyrinthitis?

Answer 85

Otitis Media Cholesteatomas Complication of late-stage syphillis

Question 86

What is the most common cause of Labyrinthitis in those 30-60years?

Answer 86

Viral

Question 87

What is the presentation of Labyrinthitis?

Answer 87

-Sudden onset of vertigo associated with nausea and vomiting (can persist up to 72hrs) -Ongoing Sensorineural hearing loss -Ongoing tinnitus

Question 88

What are the main presenting differentiators between Meniere's Disease and Labyrinthitis?

Answer 88

-Meniere's usually can be associated with AURUL FULLNESS while Labyrinthitis is not usually associated with it -Meniere's mostly presents with the MAIN SYMPTOM being the Vertigo while Labyrinthitis presents with Hearing loss / Tinnitus as the main symptom

Question 89

What investigations are required for Labyrinthitis?

Answer 89

-Physical exam (Weber and Rinne tests

Question 90

What type of medication is Prochlorperazine?

Answer 90

Antipsychotic that can also be used to treat severe nausea

Question 91

What is the management for Labyrinthitis?

Answer 91

For 3 days only (as correcting for too long can affect the body's compensatory mechanism and therefore disrupt recovery) -Antihistamines (e.g Cinnarizine) -Prochlorperazine (anti psychotic)

Question 92

What does the term palsy mean?

Answer 92

Paralysis accompanied with involuntary tremors

Question 93

Who is more likely to present with Bell's Palsy?

Answer 93

Pregnant Women

Question 94

Describe the presentation of the facial palsy of Bell's Palsy.

Answer 94

UNILATERAL Palsy (one side of face) SUDDEN onset

Question 95

What are the contraindications of Prochlorperazine?

Answer 95

-Avoid oral route in child under 10 kg --CNS depression (substance overdoses, poisoning) -Comatose states -Phaeochromocytoma (adrenaline secreting tumour)

Question 96

A patient is being considered for being put on Prochlorperazine. What underlying health condition should make you monitor them to ensure it is being tolerated?

Answer 96

HyPOthyroidism

Question 97

When prescribing Prochlorperazine for the elderly, what illness could it potentially worsen?

Answer 97

Parkinsonism or Lewy Body Disease

Question 98

A patient presents with a facial palsy that is recurrent and bilateral. What differential diagnoses would you consider?

Answer 98

-Sarcoidosis -Lyme Disease -Guillain Barre syndrome -HIV

Question 99

What is Bell sign?

Answer 99

When the eye rolls when the patient attempts to close it

Question 100

What is the presentation of a patient with Bell's Palsy?

Answer 100

-Sudden onset -Unilateral facial weakness -Ear ache / preauricular pain -Eye dryness -Inability to close eyes fully -Bell sign (eye rolls when patient tries to close it) -Hyperacusis (reduced tolerance to sound)

Question 101

What is Hyperacusis?

Answer 101

Reduced tolerance to sound -Normal level sounds sound VERY loud -Loud sounds cause discomfort or pain

Question 102

How would you differentiate between Bell's Palsy and stroke based on presentation?

Answer 102

Stroke is an Upper Motor Lesion (Upper spares upper) while Bell's is Lower. = Stoke : Can wiggle forehead =Bell's palsy : Frozen forehead

Question 103

What is the prognosis for Bell's Palsy?

Answer 103

Recovery in 6-9mnths (only a small number of people are left with permanent effects)

Question 104

What is the general management for Bell's Palsy?

Answer 104

-Prednisolone for 10 days -Eye drops

Question 105

What is the presentational difference between Ramsay Hunt Syndrome and Bell's Syndrome?

Answer 105

Ramsay Hunt as well as unilateral facial palsy would also cause PAIN of the face while Bell's doesn't

Question 106

What is the most common cause of Ramsay Hunt Syndrome?

Answer 106

Herpes Zoster Virus

Question 107

What is usually prescribed to treat Herpes Zoster Virus?

Answer 107

Aciclovir

Question 108

What is the treatment for Ramsay Hunt Syndrome?

Answer 108

Aciclovir (for the virus) and Steroids

Question 109

What is the prognosis for Ramsay Hunt?

Answer 109

Less likely (than Bell's Palsy) to fully recover

Question 110

How is Postural Hypotension diagnosed?

Answer 110

If there is a change greater than 20/10 on lying / standing BP after standing for 3minutes

Question 111

A patient on the ward has fainted. What should immediately be done?

Answer 111

Increase salt and water intake

Question 112

What is cardiac syncope?

Answer 112

A transient loss of consciousness as a result of inadequate cardiac output leading to cerebral hypoperfusion.

Question 113

What are the causes of cardiac syncope?

Answer 113

-Bradycardia / Tachycardia -Pacemaker ICD malfunctions -Structural abnormalities (check with Echo) -

Question 114

Who are at an increased risk of epilepsy?

Answer 114

-Family history -Learning disabilities -Previous neurological infections

Question 115

What are the 2 definitions for Status Epilepticus?

Answer 115

-Continuous seizure for 30minutes or longer -Recurrent seizures without regaining consciousness lasting 30 minutes or longer

Question 116

What are the 6 groups of seizures?

Answer 116

-Simple Focal (Partial) -Complex Focal (Partial) -Secondary Generalised (Focal (partial) progressing to generalised tonic-clonic seizures) -Absence seizures -Myoclonic seizures -Tonic Clonic (grand-mal) seizures

Question 117

What does simple and complex refer to in terms of seizures?

Answer 117

Simple : Maintaining consciousness Complex: Impaired consciousness

Question 118

A pregnant patient has been diagnosed with Epilepsy. What is the treatment?

Answer 118

Lamotrigine

Question 119

What is Todd Paresis?

Answer 119

Focal weakness of a body part (one side) after a seizure (usually upper or lower limbs). =This is most likely associated with Epilepsy Named after the dude who discovered it and also created Hot Toddy's!

Question 120

Describe the presentation of simple focal seizures.

Answer 120

-Consciousness retained -focal motor usual symptoms (muscle jerking) -can get sensory (tasting/smelling things not there during seizure)

Question 121

What part of the brain is most commonly affected in a Simple Focal Seizure?

Answer 121

Temporal lobe

Question 122

Describe the presentation of complex focal seizures.

Answer 122

-May have preceeding aura: (Unexpected tastes,smells, parasthesia (numbness / tingling) or rising abdominal sensation -Lip smacking and chewing -Unable to recall that they just had a seizure

Question 123

Describe the presentation of Secondary Generalised seizures.

Answer 123

-UNIlateral jerks -UNIlateral head turning -Todd Paresis

Question 124

Describe the presentation of Absence seizures.

Answer 124

-BEGINS IN CHILDHOOD -Sharp onset and offset - lasting no longer than 30seconds -Child just stares for a few seconds -Eyelid Twitching -May occur dozens - hundreds of times daily

Question 125

Describe the presentation of Myoclonic seizures.

Answer 125

-Brief shock-like contraction of the limbs -Conscious attained

Question 126

Describe the presentation of Tonic-Clonic seizures.

Answer 126

-Stiffening -Rhythmic limb jerking -Associated with TONGUE BITING, INCONTINENCE, LOSS OF CONSCIOUSNESS

Question 127

What investigations are to be done for a pateint after a seizure?

Answer 127

-Bloods (incl LFT) -U&Es EEG AFTER 2nd seizure -MRI (IF FOCAL ONSET)

Question 128

What characteristics of a seizure suggest a focal origin?

Answer 128

smacking your lips. rubbing your hands. making random noises. moving your arms around. picking at clothes or fiddling with objects. chewing or swallowing.

Question 129

What is considered first line for Focal Seizures?

Answer 129

Lamotrigine or Levetiracetam (=Broad-spectrum anti-epileptics)

Question 130

What is the drug of choice for Absence seizures?

Answer 130

Ethosuximide

Question 131

Carbamazepine is sometimes prescribed for focal seizures. What type of seizure can it worsen?

Answer 131

May worsen myoclonic seizures.

Question 132

When is Carbamazepine indicated?

Answer 132

Focal seizure, Diabetic Neuropathy

Question 133

What are common side effects of Levetiracetam?

Answer 133

Mood disorders, Anxiety, and Suicidal ideation

Question 134

Name 2 examples of Narrow Spectrum Epileptic medications.

Answer 134

Carbamazepine Phenytoin

Question 135

Name 4 Broad spectrum anti-epileptic medications.

Answer 135

Levetiracetam Lamotrigine Sodium Valporate Topiramate

Question 136

What is the main difference between Narrow and Broad spectrum anti-epileptics?

Answer 136

Narrow is mainly for focal while Broad can be used for a wider range (e.g incl Myoclonic)

Question 137

What is the difference between a primary and secondary headache?

Answer 137

Primary is not associated with anything else while secondary has an attributable cause.

Question 138

A patient has a headache after intercourse / exertion. What should be excluded first and what is it most likely to be?

Answer 138

RED FLAG: Subarachnoid Haemorrhage Most likely: Primary Post-Coital or Exertional Headache

Question 139

What are the 3 main types of Primary Headaches?

Answer 139

-Tension-type headaches -Cluster headaches -Migraine

Question 140

What are the 7 causes of Secondary Headaches?

Answer 140

-Trauma -Vascular event -Infection -Raised intracranial pressure -Space-occupying lesion -Disorders that can worsen primary headache -Medication overuse

Question 141

What drugs are common causers of Medication overuse headaches?

Answer 141

-Triptans (for cluster headaches) -Opioids -Ergots (for throbbing headaches) -Combination analgesic medication (e.g Co-codamol) -Paracetamol -NSAIDs -Aspirin

Question 142

What is the definition of a migraine?

Answer 142

Episodic primary headache that CAN present with aura or prove to be chronic.

Question 143

Who is most likely to suffer Migraines?

Answer 143

Women (3x more likely than men)

Question 144

What is the pathophysiology of migraines?

Answer 144

Inflammation of Trigeminal sensory neurones causing increased vascular permeability and platelet activation which increases their SENSITIVITY and interpret normal arterial blood flow through the meningeal arteries as PAINFUL

Question 145

What is the diagnostic criteria for a Migrain WITHOUT aura?

Answer 145

Presentation of 3 or more of these symptoms: POUND Pulsatile nature One day's duration Unilateral (mainly) Nausea or vomiting Disability

Question 146

What is the presentation for a Migraine WITH aura?

Answer 146

Headache with -TRANSIENT HEMIANOPIC DISTURBANCES (loss of vision field) -SPREADING SCINTILLATING SCOTOMA (blind spot) Aura may include: -Paraesthesisa -Numbness of hand, face, upper lips

Question 147

What mediation in particular would you want to ask a women is on if she presents with Migraine?

Answer 147

Combined Oral Contraceptive Pill. This contraception is CONTRAINDICATED in women with Migraines WITH Aura

Question 148

What is the management for a migraine (with/without aura).

Answer 148

-Oral Triptan and NSAIDs (/paracetamol) Note: Naming for Triptans ends in -triptan +IF attacks happen >2/month =Propanolol or Topiramate

Question 149

A pregnant women has migraines 3 times a month. What medication CANNOT be given to her and what can be given?

Answer 149

CANNOT: Topiramate (Teratogenic!) CAN: Propanolol

Question 150

A pregnant patient with Bradycardia has migraines more than twice a month. What would be prescribed as Prophylaxis to prevent migraines?

Answer 150

-Acupuncture

Question 151

What supplements may reduce the frequency of Migraines?

Answer 151

Riboflavin and Magnesium

Question 152

A patient describes a 'tight band' around head when stressed. What is this?

Answer 152

Tension headache

Question 153

A patient has chronic recurrent Tension headaches. What would you prescribe?

Answer 153

Tricyclic antidepressants: Amitriptyline (titrate down over time)

Question 154

Describe a cluster headache.

Answer 154

Intense pain coming from within / behind eye Presents with: -red watery eye -nasal congestion -headache

Question 155

Who is most likely to have a Cluster Headache?

Answer 155

Men

Question 156

What is the duration of onset and when do Cluster Headaches classically happen?

Answer 156

-Occur frequently at night -Can last up to 3hrs!!

Question 157

What 2 lifestyle factors are linked to Cluster headaches?

Answer 157

smoking and alcohol

Question 158

What is treatment for an acute attack of a cluster headache?

Answer 158

-100% Oxygen -Subcutaneous / Nasal Triptan (e.g Sumatriptan)

Question 159

What are the 2 differentials for Cluster headaches and how do you differentiate them?

Answer 159

1.Chronic Paroxysmal Hemicranias =Responsive to indomethacin (while Cluster headaches WONT) 2.Short Lasting Unilateral Neuralgiform =Occur up to HUNDREDS OF TIMES in 24hrs

Question 160

What is the prophylaxis treatment for cluster headaches?

Answer 160

Verapamil (Calcium Channel Blocker)

Question 161

What are the main contraindications for Verapamil (calcium channel blocker)?

Answer 161

-Acute Porphyrias (can exacerbate and cause Porphyrias Crisis) Think: Heart pumping -Atrial Fibrillation -Wolf-Parkinson's-White Syndrome -Impaired Left ventricular syndrome -AV block -Hypotension -Elderly with postural hypotension (increases risk of falls)

Question 162

Who is most likely to present with Trigeminal Neuralgia?

Answer 162

-Young patients with MS -Older patients

Question 163

Describe the typical presentation of Trigeminal Neuralgia.

Answer 163

Pain in Trigeminal area (jaw area) =DISABLING CONDITION -SUDDEN -Painful, sharp stabbing pain Note: COMMONLY BILATERAL

Question 164

What are the secondary causes of Trigeminal Neuralgia?

Answer 164

-Compression from vein or artery -Arteriovenous Malformation -Compression from tumour

Question 165

How is Trigeminal Neuralgia diagnosed?

Answer 165

MRI (to exclude secondary causes)

Question 166

What is the first line treatment for Trigeminal Neuralgia?

Answer 166

Carbamazepine

Question 167

What are the common side effects of Carbamazepine?

Answer 167

Dizziness Drowsiness Small risk of : Agranulocytosis

Question 168

What is the next management step for a patients with Trigeminal Neuralgia who is not responsive to Cabamazepine treatment?

Answer 168

-Percutaneous Radiofrequence Coagulation -Microvascular Decompression /Rhizotomy =dampen pain signals

Question 169

What are the common side effects of Calcium Channel blockers?

Answer 169

Abdominal pain; dizziness; drowsiness; flushing; headache; nausea; palpitations; peripheral oedema; skin reactions; tachycardia; vomiting

Question 170

Name 2 pathological reflexes and would it be upper or lower motor neurone damage?

Answer 170

Upper motor: Hoffman reflex (upper limbs) Babinski reflex (lower limbs)

Question 171

What are the 3 regions of the brain stem?

Answer 171

-Midbrain -Pons -Medulla Oblongata

Question 172

What are gyri and sulci?

Answer 172

Gyri = ridges Sulci = Depression

Question 173

What is the Corpus Callosum?

Answer 173

White matter connecting the 2 cerebral hemispheres

Question 174

What is meant by the cortex in the brain?

Answer 174

The surface of each cerebral hemisphere

Question 175

What is the Longitudinal Fissue?

Answer 175

=Runs in between the 2 hemispheres

Question 176

What is the central sulcus?

Answer 176

Located between the frontal and parietal lobes

Question 177

What is the Pre-Central Gyrus and where is it located?

Answer 177

This is the PRIMARY MOTOR CORTEX -Located in the frontal lobe towards the parietal lobe

Question 178

What is the Post-Central Gyrus and where is it located?

Answer 178

This is the PRIMARY SENSORY CORTEX -Located at the front of the parietal lobe towards the frontal lobe

Question 179

Name the 3 meningeal layers (from the outer layer to the inner layer)

Answer 179

1.Dura Mater 2.Arachnoid Mater 3.Pia Mater

Question 180

What are the 2 layers of the Dura Mater?

Answer 180

-Outer Periosteal -Inner Meningeal

Question 181

What are Dural Partitions and what do they do?

Answer 181

The folds between the Outer Periosteal and Inner Meningeal layers (of the dura mater) = They restrict rotary displacement of the brain

Question 182

Name 4 of the Dural Partitions.

Answer 182

-Falx Cerebri -Tentorium Cerebelli -Falx Cerebelli -Diaphragma Sellae

Question 183

What is the Terpion?

Answer 183

Where all the bones meet and therefore is the most vulnerable part of the skull

Question 184

What Artery in the brain is most at risk of damage and why?

Answer 184

The Middle Meningeal Artery =It lies between the Terpion (at risk area) and the Dura Mater

Question 185

What are Fontanelles?

Answer 185

Soft spots of bone not fused in new borns

Question 186

When do the Fontanelles fuse?

Answer 186

Anterior = 7-8mnths Posterior = 2mnths

Question 187

Where is primary motor control located and what is it responsible for?

Answer 187

Pre-central gyrus of frontal lobe =voluntary movements (sends signals to muscles)

Question 188

Where is primary sensory control located and what is it responsible for?

Answer 188

Post-central gyrus of parietal lobe =processing sensory information from skin to produce sensations related to temperature, pressure and pain

Question 189

Where is Primary Auditory control located and what is it responsible for?

Answer 189

Temporal lobe =analysis of auditory information

Question 190

Where is primary visual area control located and what is it responsible for?

Answer 190

Occipital lobe =receives and processes visual information

Question 191

What is Brocca's Area and where is it located?

Answer 191

Production of speech =Frontal lobe of left cerebral hemisphere

Question 192

What is Wernicke's Area and where is it located?

Answer 192

Language development =Temporal lobe of left cerebral hemisphere

Question 193

What does the Forebrain contain?

Answer 193

-Cerebral Hemispheres -Thalamus -Hypothalamus

Question 194

What does the Hindbrain contain?

Answer 194

-Pons -Medulla Oblongata -Cerebellum

Question 195

What communicates with the Thalamus to coordinate movement?

Answer 195

Basal Ganglia

Question 196

What is the dorsal horn?

Answer 196

The dorsal horn is found at all spinal cord levels and is comprised of sensory nuclei that receive and process incoming somatosensory information. From there, ascending projections emerge to transmit the sensory information to the midbrain and diencephalon.

Question 197

What is another name for the Dorsal Horn?

Answer 197

Substantia Gelatinosa

Question 198

What does Ipsilateral mean?

Answer 198

Same side (i.e opposite of Contralateral)

Question 199

Where is a lesion of the Dorsal Column Lemniscal Pathway usually located?

Answer 199

Spinal cord

Question 200

What are 2 common causes of a lesion of the Dorsal Column Lemniscal Pathway?

Answer 200

-B12 Deficiency -Tabes Dorsalis (complication of syphilis)

Question 201

How does a lesion of the Dorsal Column Lemniscal Pathway present?

Answer 201

=Ipsilateral loss of : -Touch -Vibration -Proprioception !Can still perform tasks requiring tactile information due to the few fibres in the Anterolateral system still functioning

Question 202

At what level do the 1st order neurones of the Dorsal Column Lemniscal Pathway start?

Answer 202

T6

Question 203

Where in the spinal cord do the 1st order neurones of the Dorsal Column Lemniscal Pathway travel?

Answer 203

Dorsal Columns

Question 204

Where in the brainstem would neurones from the Dorsal Column Lemniscal Pathway travel?

Answer 204

Medial Lemniscus

Question 205

Summarise the Dorsal Column Lemniscal Pathway.

Answer 205

=carries FINE TOUCH SIGNALS FROM PNS TO CNS 1.1st order neurons enter spinal cord at T6 and synapse in the Medulla Oblongata 2.2nd order neurones start in MO and synapse in Thalamus 3.3rd order neurons start in the Thalamus and synapse in the Ipsilateral Primary Cortex of the brain

Question 206

How does injury to the Anterolateral System present?

Answer 206

=Contralateral loss of pain and temperature sensation

Question 207

Summarise the Anterolateral system pathway.

Answer 207

=carries Touch & Pressure (anterior) and Pain & Temperature (lateral) 1.1st order neurones enter spinal cord and ascend 2 vertebral levels before synapsing at the Dorsal Horn 2.2nd order neurons split into 2 concurrent tracts (anterior and lateral) that travel to the Thalamus 3.3rd order neurones start in the Thalamus and synapse in the Ipsilateral Primary Sensory Cortex

Question 208

When are the Spinocerebellar tracts most likely to be damaged?

Answer 208

WITH a Descending Motor injury (not usually occurring in isolation)

Question 209

Where in the primary sensory centre in the cortex of the brain is the information processed?

Answer 209

Sensory homunculus

Question 210

What is another name for pain?

Answer 210

Nociception

Question 211

When pain presents as fast and sharp, what kind of pain could it be?

Answer 211

Mechanical and Thermal

Question 212

When pain presents as slow and dull what type of pain could it be?

Answer 212

All types- Chemical, Mechanical and Thermal

Question 213

Describe the Nociceptor stimulus pathway when due to tissue damage.

Answer 213

Tissue damage causes Calcium to enter which activates TRPV1 Chloride channels = negative ions leaving the cell causes depolarisation which opens enough sodium channels to cause Action Potential.

Question 214

Describe the Nociceptor stimulus pathway when due to inflammatory signals e.g prostaglandin and bradykinin.

Answer 214

Gprotein coupled receptor causes Calcium release from ER causing activation of Cl- ion channels so Cl- leaves the cell causing depolarisation and therefore Na+ channels on the axons open and cause an Action Potential.

Question 215

What are the 2 nerves carrying nociceptor signals and speed of conduction as well as the type of pain felt?

Answer 215

Myelinated (rapid signal= fast and sharp) and Unmyelinated neurones (slow signal=slow and dull)

Question 216

What is another name for Unmyelinated neurones?

Answer 216

C fibres

Question 217

What is another name for Myelinated neurones?

Answer 217

Alpha delta neurons

Question 218

Where do the signals usually come from for Myelinated vs Unmyelinated nociceptor neurons?

Answer 218

Myelinated: Skin (superficial) Unmyelinated : Deep tissue (joints and organs)

Question 219

Why does pain from Kidney stones present on the same side as the organ and what pain pathway is it?

Answer 219

Gracile Fasciculus pathway (part of the ascending tract) : Alpha delta fibres (myelinated) carry signals from deep in the body and the information is processed in the thalamus. The fibres DO NOT CROSS OVER and therefore the pain is ipsilateral. Therefore is it hard to pinpoint where the pain is.

Question 220

A patient has tooth ache. How the pain signalled?

Answer 220

C fibres (unmyelinated) from the trigeminal nerve cross over in the spinal cord into thalamus and into somatosensory cortex to detect exactly where it is e.g tooth pain

Question 221

What are the autonomic responses to pain controlled by parasympathetic and sympathetic?

Answer 221

Parasympathetic: -Bradycardia -Syncope -Hypotension -Urination -Nausea Sympathetic: -Fear -Pupillary dilation -Pallor -Sweating

Question 222

What is Neuropathic pain?

Answer 222

Pain that is chronic in nature persisting for >3 months and often unresponsive to analgesia. =Damage to nerves NOT the tissues

Question 223

How does Neuropathic pain present?

Answer 223

Burning, tickling, dull aches that can be associated with Hyperalgesia or Allodynia.

Question 224

What is Hyperalgesia?

Answer 224

Increased intensity of pain sensation for a given nociceptive stimulus (that is quite small)

Question 225

What is Allodynia?

Answer 225

Sensation of pain to stimulus that should not give pain (e.g light touch)

Question 226

What is meant by sensitisation of peripheral nerves?

Answer 226

Sensitisation of peripheral nerves. =Increased Prostoglandin release, increases expression of sodium channels and therefore INCREASED NOCICEPTOR SENSITIVITY

Question 227

What is meant by central sensitisation?

Answer 227

Increased sensitivity of nerves of the spinal cord 1.increased glutamate release and glutamate release causing =Hyperalgesia 2.Rewiring of spinal cord causing =Allodynia

Question 228

Describe Descending Pain Pathway in response to pain.

Answer 228

1.Periventricular nuclei in the hypothalamus signals to the 2.Periaqueductal Gray (PAG) which signals via Enkephalin release to the 3.RMN which signals via Serotonin release to the 4.Dorsal Horn inhibitory neurones to inhibit the pain signal via GABA or Enkephalin release i)GABA ii)Enkephalin

Question 229

What does the Descending Pain Pathway do?

Answer 229

Reduces pain signals by decreasing the amount of action potentials and releasing natural opioids. i.e the body's natural mechanism to combat pain

Question 230

Describe the action of Enkephalin released by inhibitory neurons of the Dorsal Horn.

Answer 230

=2 pathways 1.opens Potassium channels to Hyperpolarise and reduce ability to reach Action Potential 2.Inhibits Calcium channels (as it increases neurotransmitters so by inhibiting will mean less signal firing)

Question 231

Describe the action of GABA released by inhibitory neurons of the Dorsal Horn.

Answer 231

Hyperpolarises by activation of Cl-channels and Cl- enter (so harder to depolarise so less likely to set up action potentials)

Question 232

How does rubbing a wound help reduce the pain?

Answer 232

Mechanoreceptors signal to brain which descending and deals with the pain (descending pain pathway)

Question 233

What are the 4 forms of analgesia?

Answer 233

1.Opioids 2.NSAIDs 3.Local Anaesthetics 4.Anti-depressants

Question 234

Why can Anti-depressants be used to treat pain?

Answer 234

Emotional response to pain makes pain worse.

Question 235

How do opiods work?

Answer 235

Same as Enkephalin acting on opioid receptors and hyperpolarising the neurons to decrease transmission of signal in the spinal cord

Question 236

When are opiods used?

Answer 236

For severe pain : -Surgical pain -Child birth -Unresponsive pain -End of life care (as it has a sedative effect)

Question 237

Side effects of opiods

Answer 237

Constipation: activates opioids in bowels which opposes gut motility Vomiting : stimulation of chemoreceptors in medulla Respiratory depression : Centre in medulla issue, CO2 buildup

Question 238

What are the withdrawl effects of opioids?

Answer 238

Nausea Muscle aches Diarrhoea Trouble sleeping Low mood

Question 239

How do NSAIDs work?

Answer 239

Inhibits COX receptors which inhibits Prostagandin release and therefore causes a decrease in sensitivity

Question 240

What is the main side effect of NSAIDs?

Answer 240

Blocking Cox receptors protect the stomach as well so NSAIDs can cause GI bleeding, ulcers

Question 241

When do you give a low vs high dose of aspirin?

Answer 241

High dose for preventing pain Low dose for issues such as heart attack and stroke

Question 242

How do Local Anaesthetics work?

Answer 242

Binds and Stops Sodium channels opening so no Action Potentials

Question 243

How would a Topical local anaesthetic work on an area with a bacterial infection and why?

Answer 243

No effect due to bacterial infection ionising the anaesthetic making it acidic and therefore it cannot reach the sodium channels.

Question 244

What should be given with a local anaesthetic and why?

Answer 244

Vasoconstrictor such as Adrenaline / Noradrenaline =keeps the effects of the anaesthetic LOCAL and not widespread

Question 245

How do Antidepressant work to treat pain?

Answer 245

Increases serotonin which is involved in the descending pain pathway which increasesinhibition of pain signals.

Question 246

Where does the spinal cord extend to and from?

Answer 246

From the : Foramen Magnum To the: L1-2 (adults), L3-4 (children)

Question 247

Where do the nerves leave the spinal cord from?

Answer 247

Vertebral foramens

Question 248

What is the Cauda Equina?

Answer 248

'the horse's tail' of nerves of the spinal cord after the vertebra

Question 249

What does the Midbrain contain and therefore is responsible for?

Answer 249

-Eye movement: Nuclei for CN III and IV -Eye pupil diameter and accomodation: Edinger-Westphal nucleus -Eye reflexes : Neurons responsible

Question 250

What is meant by Basal Ganglia?

Answer 250

Interconnecting nuclei within the forebrain, diencephalon and midbrain important for INITIATION AND CONTROL OF VOLUNTARY MOVEMENT including: -Caudate nucleus -Subthalamic nucleus -Substantia Nigra

Question 251

What is meant by the Limbic system?

Answer 251

Interconnected and interacting structures controlling EMOTIONAL BEHAVIOURS

Question 252

What is the hippocampus important for?

Answer 252

Memory

Question 253

What allows storage of new memories ?

Answer 253

Hippocampus has Neurogenesis occuring in the denate gyrus

Question 254

What is meant by Anterograde amnesia?

Answer 254

Lesion in hippocampus causing memory storage of new memories to not be turned into long memories. Note: memories from before the lesion are unaffected

Question 255

What is the Amygdala responsible for?

Answer 255

Emotional learning (fear memory and reward memory e.g addiction)

Question 256

What neurotransmitter is the most common excitatory in the CNS?

Answer 256

Glutamate

Question 257

What is the role of the middle ear?

Answer 257

1.Critical Damping = It stops the sound vibrating when the sound stops 2.Amplifies the signal to the oval window

Question 258

What are the common causative organisms of the meninges? Remember mnemonic

Answer 258

NHS -Neisseria meningitidis -Haemophilus Influenzae (type B) -Streptococcus pneumoniae

Question 259

What type of bacteria is Neisseria meningitidis?

Answer 259

Gram negative diplococcus (in pairs)

Question 260

How is Neisseria meningitidis spread?

Answer 260

Person-person with outbreaks commonly in families, semi-closed environments e.g prisons or university accomodation

Question 261

What is another name (s) for Neisseria meningitidis?

Answer 261

Meningococcus or Meningococci.

Question 262

What type of bacteria is Haemophilus Influenzae (type B)?

Answer 262

Gram negative cocco-bacillus

Question 263

What type of bacteria is the Streptococcus Pneumoniae?

Answer 263

Gram positive diplococcus

Question 264

What less common bacterial causative organism can cause meningitis and in what groups of people?

Answer 264

Listeria Monocytogenes =Elderly, Neonates and Immunocompromised persons

Question 265

What can Listeria Monocytogenes cause?

Answer 265

Meningitis and Sepsis

Question 266

What type of bacteria is Listeria Monocytogenes?

Answer 266

Gram positive rod shaped

Question 267

In developing countries what type of meningitis is more likely to occur?

Answer 267

Tuberculosis causing -associated with miliary TB

Question 268

How is Listeria transmitted?

Answer 268

Food-bourne

Question 269

What advice is given to pregnant women to avoid Listeria?

Answer 269

Don't eat unpasteurised soft cheeses (they could carry Listeria).

Question 270

What bacteria is tested for in the vagina of a pregnant woman to ensure that it doesn't cause Meningitis of the baby during child birth?

Answer 270

Streptococcus Agalactiae aka Group B Streptococcus (GBS)

Question 271

A pregnant patient's urine sample comes back positive with Group B Streptococcus. What does that mean and what should be done?

Answer 271

Can cause meningitis for baby which can be caught during child birth. =Prophylactic antibiotics at the time of delivery (Intravenous penicillin G)

Question 272

What is the most common fungal cause of meningitis?

Answer 272

Cryptococcus Neoformans

Question 273

Who is more likely to get Cryptococcus Neoformans causing meningitis?

Answer 273

Those immunocompromised: -HIV/AIDs -Chemotherapy

Question 274

How is Cryptococcus Neoformans causing meningitis diagnosed?

Answer 274

-Indian ink staining CSF showing the capsule surrounding the Cryptococcus. -Culture and antigen detection test of CSF

Question 275

Who is most likely to suffer from Toxoplasma?

Answer 275

Immunocompromised patients particularly those with HIV with a low CD4 count

Question 276

How is Toxoplasma transmitted?

Answer 276

Domestic cats in the UK

Question 277

What can a Ziehl Neelsen stain identify?

Answer 277

Mycobacteria such as TB

Question 278

What would you notice in a CSF sample with a patient with Bacterial infection of the CNS?

Answer 278

High neutrophils making the CSF look visibly cloudy

Question 279

What would you notice in a CSF sample with a patient with a Viral infection of the CNS?

Answer 279

High number of T-lymphocytes, and the fluid will look clear.

Question 280

What is the drug of choice for Meningitis?

Answer 280

Ceftriaxone

Question 281

A patient has suspect Meningitis but their lab results are pending. What should be done?

Answer 281

EMERGENCY ! Don't wait- give IV Ceftriaxone

Question 282

When can Ceftriaxone not be given and what is given instead?

Answer 282

Penicillin allergy =Chloramphenicol

Question 283

What is the drug of choice for Meningitis in Neonates?

Answer 283

Cefotaxime as Ceftriaxone can cause Bilirubin accumulation

Question 284

What is offered to those who were in close contact with a patient with Meningococcal Meningitis?

Answer 284

Prophylaxsis = Ciprofloxacin

Question 285

Give an example of an organism that can cause Meningitis accompanied with Encephalitis.

Answer 285

Toxoplasma Gondii

Question 286

Describe the presentation of a patient with Encephalitis.

Answer 286

-Altered consciousness -Can lead to coma -Unusual behaviour -Confusion -Seizures may be present -Fever may be present by not accompanied by a significant rise in CRP and WBC

Question 287

What viruses of the CNS also cause a characteristic vesicular rash?

Answer 287

Herpes Simplex Virus Varicella zoster virus (chickenpox)

Question 288

What is the most common cause of Viral Encephalitis in the UK and what is the pathophysiology?

Answer 288

Herpes Simplex latent virus that reactivates in the trigeminal ganglia and causes infection of the temporal lobes

Question 289

A patient is febrile and has altered consciousness. What is the most likely diagnosis?

Answer 289

Encephalitis

Question 290

What are the key investigations for Encephalitis?

Answer 290

CT scan or MRI =indicates raised intracranial pressure (due to inflammation of brain and meninges) ECG (sometimes used) Note: CSF lumbar puncture is contraindicated in patients with high Intracranial pressure

Question 291

Why is lumbar puncture contraindicated in patients with high intracranial pressure?

Answer 291

Coning =Life threatening due to Sudden drop in pressure when needle draws CSF can draw brainstem structures throughh the foramen magnum

Question 292

How does Encephalitis appear on an ECG?

Answer 292

Sharp wave potentials

Question 293

What is the management for Viral Encephalitis?

Answer 293

-IV ACICLOVIR (Antiviral to target Herpes Simplex and Varicella zoster virus) for 3 weeks Supportive: -Ventilation -Fluid management -Management of seizures if present -Steroids for reducing swelling

Question 294

What are the 3 forms of Aciclovir and what are they generally used to treat?

Answer 294

-Oral : Mild infections -Topical : Herpetic rashes (cold sores) -IV: Encephalitis

Question 295

Summarise the mechanism of action of Aciclovir.

Answer 295

It is a viral analogue of Deoxyguanosine that competes to be incorporated into viral DNA and therefore stops the DNA from replicating. It is much more attracted to viral Herpes Simplex DNA polymerase than human DNA polymerase :)

Question 296

What herpes virus is common in organ transplant patients?

Answer 296

Cytomegalovirus (CMV)

Question 297

What prophylaxis is given to organ transplant patients to protect against Cytomegalovirus?

Answer 297

Valaciclovir

Question 298

What are causes of headaches that present with a fever?

Answer 298

-System illness (flu / vaccine) -Paranasal Sinusitis (upper resp. tract infection / dental pain) -Meningitis (viral and bacterial) -Encephalitis

Question 299

Where are aneurysms most likely to occur?

Answer 299

Where arteries branch

Question 300

What is the presentation of Meningitis?

Answer 300

PROGRESSIVE headache with fever Non blanching rash Neck stiffness Photophobia +Lethargy later on

Question 301

Give 3 examples of Primary headaches.

Answer 301

Tension, Migraines, Cluster headaches

Question 302

Describe the presentation of Idiopathic Intracranial Pressure.

Answer 302

-Headache: -->Non-pulsitile, bilateral headache worsening in the morning or after bending forwards and can be associated with morning vomitting -Visual disturbances (transient visual darkening) -Bilateral papilloedema (on fundoscopy)

Question 303

Who is most likely to have Temporal Arteritis?

Answer 303

Older population over 50

Question 304

What is an Idiopathic stabbing headache?

Answer 304

Most usually benign headache characterised with stabbing like pain

Question 305

What 2 signs are tested for upon clinical exam of a suspect meningitis?

Answer 305

Kernig's and Brudzinski's sign =lying patient flat and do leg exercises

Question 306

A patient has been diagnosed with Meningitis. Other than a doctor's duty of care to the patient what else should be done?

Answer 306

Meningitis long term prophylaxis for close contacts and notify Public Health agency for contact tracing

Question 307

What serious issue could a Postural headache indicate?

Answer 307

CSF fluid leak

Question 308

What are Dural Venous Sinuses?

Answer 308

They are spaces / pathways in the brain located between the periosteal and meningeal layers of the dural mater.

Question 309

Where does the blood flow come from to the Dural Sinuses?

Answer 309

Diploie of the skull, the inner ear and from the CNS.

Question 310

Where is the Confluence of Sinuses located?

Answer 310

Back of the occipital lobe

Question 311

Describe the flow of blood starting from the Superior Sagittal Sinuses.

Answer 311

1.Superior Sagittal Sinus to 2.Confluence of Sinuses to 3.Right Transverse Sinus to 4.Right Sigmoid sinus (merging with left SS to become) 5.Internal Jugular Vein

Question 312

Describe the flow of blood starting from the Inferior Sagittal Sinuses.

Answer 312

1.Inferior Sagittal Sinus to 2.Straight Sinus to 3.Left Transverse Sinus to 4.Left sigmoid sinus (merging with left SS to become) 5.Internal vein

Question 313

Where are the Right and Left Transverse Sinuses located?

Answer 313

Posterior cranial fossa

Question 314

Describe the flow of blood from the Cavernous Sinus.

Answer 314

1.Cavernous Sinus to 2.Superior sagittal Sinus 3.Junction between Left transverse and Left Sigmoid sinus 4.Petrosal Sinuses to 5.Internal Jugular vein

Question 315

Where are the Cavernous Sinuses located?

Answer 315

Just lateral to the sphenoid bone

Question 316

Where do Cavernous Sinuses receive their tributaries from?

Answer 316

Opthalamic veins Sphenoparietal sinuses (along the lesser wing of sphenoid bone)

Question 317

Where is CSF secreted?

Answer 317

By Choroidal Epithelial cells of the choroid plexus in the lateral, 3rd and 4th ventricles

Question 318

What is meant by the Ventricular System?

Answer 318

The pathway by which CSF flows in the brain

Question 319

Where is CSF reabsorbed?

Answer 319

Arachnoid Granulations which protrude through the meningeal layer of the Dura Mater to access the Sinuses

Question 320

Describe the flow of CSF.

Answer 320

1.Lateral Ventricle to 2.Interventricular Foramana to 3.3rd Ventricle to 4.Cerebral Aqueduct to 5.Lateral Apertures to 6.Subarachnoid space to (some reabsorbed) 7.Median Apertures to 8.Spinal cord (Central Canal)

Question 321

What would an obstruction of the Cerebral Aqueduct mean?

Answer 321

Blockage of CSF meaning that it can't leave the Subarachnoid space =Hydrocephalus

Question 322

What procedure should be considered for a patient with Hydrocephalus?

Answer 322

Peritoneal Shunt =drains the CSF into the Peritoneal cavity (abdomen)

Question 323

Define the Central canal.

Answer 323

Carries the CSF along the spinal cord

Question 324

What are the key risk factors of a brain haemorrhage due to an aneurysm?

Answer 324

-Smoking -Hypertension -Polycystic kidney disease -Connective tissue disorders (since they affect the integrity of the blood vessels)

Question 325

What is the investigation for Subarachnoid Haemorrhage (starting with first line)?

Answer 325

1.CT brain AS SOON AS POSSIBLE (as the bleed will disperse and you'll miss the diagnosis) 2.Lumbar puncture =look for bilirubin (Xanthochromia - yellow CSF) 3.CT Angiogram (if CT brain is positive to find what artery is responsible)

Question 326

What blood vessel is most likely to have had an aneurysm to cause a brain haemorrhage?

Answer 326

Right middle cerebral artery

Question 327

Where do you do a lumbar puncture?

Answer 327

Iliac crest at L4

Question 328

List the contraindications of doing a lumbar puncture.

Answer 328

-Coagulopathy -Local infection at puncture site -Focal neurology and abnormal conscious level

Question 329

When can you do a lumbar puncture and when is it too late?

Answer 329

Can: Within 2 weeks of a headache Cannot: After 2 weeks because you won't be able to detect the bleeding anymore

Question 330

A patient had a haemorrhage due to an aneurysm. What is the main treatment?

Answer 330

Coiling

Question 331

When is Vasopasm most likely to happen and why?

Answer 331

During Subarachnoid haemorrhage due to oxygen present since its due to arterial bleeds while a head injury is due to venous bleeds

Question 332

What is the Vasospasm treatment?

Answer 332

Bolus IV Saline / Colloid

Question 333

What are complications of a Subarachnoid Haemorrhage?

Answer 333

-Hydrocephalus -Seizures -Low sodium -Pulmonary oedema / pneumonia

Question 334

What is the prognosis for a Subarchnoid haemorrhage?

Answer 334

Poor- most survivors are dependant with only 20% of survivors regaining full quality of life. Note that 30% don't even make it to hospital!

Question 335

What are the causes of Intracerebral Haemorrhage?

Answer 335

-Hypertension -Vascular Lesions -Neoplastic -Coagulation disorders -Cerebral venous thrombosis -Haemorrhagic transformation of ischaemic stroke -Vasculitis -Substance abuse -Amyloid

Question 336

What veins are most likely to be a cause of a haemorrhage in a Hypertensive emergency?

Answer 336

Small vessels deep in the brain (that supply the motor pathways)

Question 337

What investigations are to be done for a suspect Idiopathic Intracranial Hypertension and what results would you expect?

Answer 337

-Fundoscopy (bilateral papilloedema) -CT and MRI of brain (increased intracranial pressure) -Lumbar puncture (will reveal opening pressure above 20cmH20 but no differences in the CSF profile)

Question 338

What is the management for Idiopathic Intracranial Hypertension?

Answer 338

1.Encourage weight loss 2.Acetozolamide (Carbonic Anhydrase inhibitor) 3.Topiaramate (anti-seizure med) and Candesartan (ARB)

Question 339

Who is most likely to present with an Idiopathic Intracranial Hypertension?

Answer 339

Young, obese women

Question 340

What is Temporal Arteritis?

Answer 340

Inflammatory disease of the arteries specifically the arteries at the temples.

Question 341

What is another name for Temporal Arteritis?

Answer 341

Giant Cell Arteritis

Question 342

What is the presentation of Temporal Arteritis?

Answer 342

-Temporal headache -Pain on temples -Jaw claudication (pain chewing food) -Transient monocular blindness -Systemic features (fever, fatigue, weight loss and malaise)

Question 343

Who is most likely to be affected by Temporal Arteritis?

Answer 343

Females over 60

Question 344

What will be found on presentation on a patient with Temporal Arteritis?

Answer 344

-Thickened, tender temporal artery on examination, which may be pulseless -Scalp tenderness -(Rarely) arterial bruits, asymmetrical blood pressure and absent pulses

Question 345

What are the key complications of Temporal Arteritis?

Answer 345

-Permanent monocular blindness -Stroke -Aortic aneurysms

Question 346

How do patients describe Monocular blindness?

Answer 346

Curtains closing on their vision

Question 347

What investigations are to be done for Temporal Arteritis and results?

Answer 347

1.Inflammatory markers (present) 2.Histology : Granulomatous inflammation with infiltration of inflammatory cells including giant cells 3.Doppler Ultrasonography (halo sign within vessel wall)

Question 348

What is the management of Temporal Arteritis?

Answer 348

-High dose steroids to prevent blindness and stroke (titrate down over time with methotrexate to lower the dose) -Low dose aspirin If on long term steroids: +Bisphosphonates (protect against Osteoporosis) +PPIs (protect against gastric ulcers)

Question 349

A patient has a new onset headache. What are the categories within this?

Answer 349

-Thunderclap -Fever -Focal -Persisting -Provoked

Question 350

What are the differentials of a thunderclap headache?

Answer 350

-Subarachnoid Haemorrhage -Pituitary Apoplexy -Spontaneous Intracranial Hypotension

Question 351

Summarise how you would differentiate between the 3 types of thunderclap headache simply based on symptoms?

Answer 351

Subarachnoid: MOST SEVERE Pituitary Apoplexy : With drowsiness often progressing to coma Spontaneous Intracranial Hypotension: Positional headache

Question 352

How is the diagnosis of a Subarachnoid haemorrhage confirmed?

Answer 352

CT without contrast -If CT negative Xanthochromia in CSF will confirm it

Question 353

A patient has a Subarachnoid Haemorrhage. What should be done?

Answer 353

-Angiography with catheter to localise bleed -Endovascular coiling -Post op: Nimodipine

Question 354

What is the management for Pituitary Apoplexy?

Answer 354

Hydrocortisone (GIVEN ASAP AS IT COULD BE FATAL) -do an mri

Question 355

What investigation should be done for Spontaneous Intracranial Hypotension?

Answer 355

MRI of whole spine

Question 356

What is the management of Spontaneous Intracranial Hypotension?

Answer 356

Bed rest fluids, caffeine and pain relief (if it doesn't improve - Epidural blood patch)

Question 357

What is the most likely diagnosis of a Fever new onset headache and what is the red flag diagnosis to rule out?

Answer 357

Most likely = Systemic Red flag: Meningitis

Question 358

What is meant by a new onset focal headache?

Answer 358

One part of brain being affected can present as MOVEMENT CHANGES, PARALYSIS, WEAKNESS, LOSS OF MUSCLE CONTROL, INCREASED MUSCLE TONE, LOSS OF MUSCLE TONE OR INVOLUNTARY MOVEMENTS (E.G TREMOR)

Question 359

What are the 2 main possibilities for a focal new onset headache?

Answer 359

-Migraine with aura -Stroke

Question 360

How do you differentiate between migraine with aura and stroke upon presentation?

Answer 360

Migraine aura resolves while stroke aura persists

Question 361

List the Persisting New onset headaches.

Answer 361

-CO poisoning -Giant Cell Arteritis -Cervicogenic -Paranasal sinus -Tumour -High CSF pressure

Question 362

List the provoked new onset headaches?

Answer 362

-Exertional / Coital headache -Cluster -Trigeminal neuralgia

Question 363

What are the possible differentials of recurrent headache?

Answer 363

-Tension -Ice pick -Cervicogenic -Migraine with or without aura

Question 364

What is the presentation of an Ice Pick Headache?

Answer 364

Sudden episodic sudden, sharp, stabbing head pain (or a quick series of pains)

Question 365

What is the treatment for Ice pick headaches?

Answer 365

If severe and frequently reoccuring: Indometacin

Question 366

What is the presentation of Idiopathic Intracranial Hypertension?

Answer 366

-Changes in vision -Peripheral vision loss -Neck stiffeness -Trouble waking -Vomiting and nausea

Question 367

What is the treatment for Idiopathic Intracranial Hypertension?

Answer 367

Diuretics

Question 368

What investigation is done for Idiopathic Intracranial Hypertension?

Answer 368

MRI

Question 369

What is the first line management for Migraine with or without aura?

Answer 369

-Oral triptan + paracetamol / NSAID (nasal for ages 12-17) Prophylaxsis: -Propranolol or Topiramate

Question 370

What is the management for Tension-type headaches?

Answer 370

-Paracetamol / NSAIDs (Ibeprofen 400mg) -Prophylaxsis : Acupuncture

Question 371

What is the management for Cluster Headaches?

Answer 371

-100% Oxygen -Subcutaneous / Nasal Triptans -Prophylaxsis: Verapamil (calcium channel blocker)

Question 372

A patient with migraines after first line treatment has found no improvement. What is the next management step?

Answer 372

Addition of an Anti-emetic e.g Metoclopramide or Chlorpromazine

Question 373

What supplements can be suggested for patients with migraines?

Answer 373

-Riboflavin (B2) -Magnesium

Question 374

A patient with Tension headaches has found no improvement despite first line treatment. What is the next management step?

Answer 374

Addition of a Tricyclic antidepressant (Amitriptyline)

Question 375

How do Triptans work?

Answer 375

Serotonin Receptor agonist Remember: Serotonin release activates inhibitory interneurons in the spinal cord

Question 376

How do Anti-emetics work?

Answer 376

Block specific receptors that respond to neurotransmitter molecules, such as serotonin, dopamine and histamine.

Question 377

How do Tricyclic Antidepressants work?

Answer 377

Inhibit reuptake of Serotonin and Norepinephrine to elevate concentration within synaptic cleft which therefore increases blocking of pain

Question 378

What is meant by the spinal cord level of neural integration?

Answer 378

-Stereotypical behaviours -Reflexes

Question 379

What is meant by the subcortical level of neural integration?

Answer 379

Medulla and Pons supervising spinal reflexes

Question 380

What is meant by the cortical level of neural integration?

Answer 380

Highest level of neural activity

Question 381

What level of neural integration is affected in Stroke?

Answer 381

Cortical gone, but not subcortical and spinal cord level which is why you would still have spasticity

Question 382

What neural fibres in the muscles are important for sensing lengthening and stretching of a muscle? For example : Elongating your arm

Answer 382

Extrafusal fibres made up of muscle spindles called Intrafusal (membrane and nerve to detect stretch and length of a muscle)

Question 383

What is meant by a muscle spindle?

Answer 383

Collection of nerves (lower motor nerves) in the muscles for detecting movement of muscle (stretch and forceful movement)

Question 384

What are the 2 types of Intrafusal fibres within the muscle spindle?

Answer 384

Nuclear bag Nuclear chain

Question 385

Within the muscle spindle, what are the 3 main sections and what are they composed of and what are they responsible for?

Answer 385

Nuclear Bag =VELOCITY (of moving muscle) -Type 1Alpha fibres : Fast conducting so stop conducting immediately once the signal has stopped Nuclear Chain=Stretch / Length (of the muscle being moved) -Type 2Alpha fibres : Slow conducting so still conducting even when signal has stopped. Gamma Efferent Fibres = Stop the muscle from become floppy as it sets the baseline tone of muscle

Question 386

What is the difference of function between Alpha and Gamma muscle spindle neurons?

Answer 386

alpha = voluntary control gamma = subconscious control setting baseline tone

Question 387

What are the function of muscle spindles?

Answer 387

=Have alpha and gamma fibres for voluntary and subconscious moving, smoothing and dampaning of muscle contractions (e.g elongating arm) : E.g of subconscious muscle control: -deactivate antagonist muscle -signals length and velocity of muscle stretch to cerebellum (for conscious and unconscious awareness of length of muscle i.e arm elongated) -i.e proprioceptive understanding of where your arm is

Question 388

Where is the Golgi tendon organ and when is it activated?

Answer 388

Nerve ending interdigitating with TENDON via Alpha neurons =do not activate unless there is A LOT of muscle contraction force not passive STRETCH

Question 389

Compare passive stretch and muscle contraction force

Answer 389

Passive stretch is the conscious (basic movement e.g walking) and subconscious (proprioceptive understanding of where your body parts are), this is controlled by muscle spindles. While Contraction force is for tasks such as lifting which is controlled by the Golgi Tendon Organ.

Question 390

What is the function of the Golgi tendon body?

Answer 390

Forcfully control force and length so that you can carry something (e.g a dumbell) -sensitive to how heavy it is and is therefore responsible for telling you if it is slipping out of your hands as it is too heavy

Question 391

What do Facial muscle reflexes indicate?

Answer 391

Hypocalcaemia

Question 392

Describe the pathophysiology of a 8hz physiologic tremor?

Answer 392

The Brain supervises the stretch reflexes so in a stroke for instance , the reflexes are not supervised and therefore HYPER-REFLEXES =clonus

Question 393

When would you get pathologic clonus?

Answer 393

Stroke ALS MS UM Lesions Hepatic Encephalopathy

Question 394

What is meant by clasp knife rigidity in Upper Motor Lesions?

Answer 394

Initial resistance (passive strength fibres are over signalling position and therefore resistant to move) to elongate arm and then sudden, quick and forceful (golgi tendon overactive giving force) elongation LIKE A CLASP KNIFE

Question 395

What is meant by Spastic posture and what tract is responsible?

Answer 395

Upper: Flexed elbows and wrist, Clenched wrist Lower: Plantar flexed foot and toes =Pyramidal tracts

Question 396

Where is the Vestibular Nucleii and what does it do?

Answer 396

Between pons and medulla, position and posture sense that goes down the Vestibulospinal tract

Question 397

Where is the Vestibulospinal tract (Lateral or Medial)

Answer 397

Medial

Question 398

What is the Final Common Path?

Answer 398

Descending motor pathway whereby 1 motor neurone recieves input from multiple different descending motor pathways (e.g Rubrospinal and Corticospinal etc)

Question 399

Where is the location of 60% of intracerebral haemorrhages?

Answer 399

Internal capsule which is involved in the pyramidal descending motor pathway.

Question 400

What is Babinski sign and what does it mean?

Answer 400

Plantar reflex = Big toe points upwards rather than curl downwards = UML

Question 401

Describe the Putamen circuit and what is it's function?

Answer 401

Motor cortex to putamen in the basal ganglia to Substantia nigra to thalamus back to the motor cortex =Learning and motor control (e.g speech articulation, cognitive functioning and addiction)

Question 402

What does Athetosis mean?

Answer 402

Abnormal muscle contraction causing involuntary writhing movements e.g in Cerebral Palsy

Question 403

What does Ballismus mean?

Answer 403

Involuntary throwing/flinging movements of limbs caused by large muscle contractions

Question 404

What does Chorea mean?

Answer 404

Sudden, unintended and uncontrollable jerky movements of arms, legs and facial muscles e.g huntington's chorea

Question 405

Describe the Caudate circuit. What is it responsible for?

Answer 405

From brain, to putamen, globus palludis, thalamus to brain =Planning movements and cognitive control (desire to move - do i want to get out of bed?)

Question 406

What is the physical connection between the Substantia Nigra and Striatum?

Answer 406

Excitory connection releasing Dopamine

Question 407

What causes Parkinson's?

Answer 407

Degeneration of Dopamine neurones from the Substantia Nigra to the Striatum =Hyper and Hypokinesia (tremor)

Question 408

Compare the type of rigidity of Parkinson's vs of a Stroke.

Answer 408

Parkinson's: Lead pipe + Cogwheel Stroke: Clasp knife

Question 409

What is the function of the Spinocerebellum?

Answer 409

Responsible for matching intended movement (signals from motor cortex) with the actual movement that is done (proprioceptive muscle spindles).

Question 410

What is the function of Cerebrocerebellum?

Answer 410

Planning movements and ensuring accuracy e.g picking up a pencil Skills learnt (usually in an adult) are stored here e.g learning to drive, sports, even a new language learnt after age 8 while a first language would be stored in Broca's area)

Question 411

What are the presentation hallmarks of a Vestibulo and Spinocerebellar problem?

Answer 411

=wide stance =swaying while standing =inappropriate =nystagmus =ataxic gait

Question 412

What are the presentation hallmarks of cerebrocerebellar problems?

Answer 412

=movement accuracy =compromised decomposition of movements (e.g picking up a pencil will take ages as each mirco movement has a pause in between and won't be smooth) =intention tremor

Question 413

Intention tremor vs parkinson's tremor

Answer 413

Intention: moving from different places when trying to pick up a pencil for instance Parkinson's : Pill rolling

Question 414

What are the 3 parts of the Cerebellum?

Answer 414

Vestibulocerebellum, Spinocerebellum and Cerebrocerebellum

Question 415

4 lesion locations

Answer 415

UMN LMN Extrapyramidal Cerebellar

Question 416

What is meant by Anticipatory maintenance of posture?

Answer 416

Other muscles will contract in anticipation of the planned movement to support balance

Question 417

Define what a Upper and Lower Motor Neuron is?

Answer 417

UMN: Brain or Spinal Cord LMN: Anterior horn cell, motor nerve roots, peripheral motor nerve

Question 418

What happens to the stretch reflex in issues with UMN and how does it present?

Answer 418

Exaggerated stretch reflex (due to lack of control and inhibition) =Spasticity e.g clonus

Question 419

Spascitisty vs Rigidity

Answer 419

Spasticity = damage to Pyramidal tract: Increased tone in only part of the movement Rigidity = damage to Extrapyramidal tract : Increased tone throughout range of movement

Question 420

What does Hemiplegia mean vs Hemiparesis?

Answer 420

Hemi: One sided Plegia: Paralysed Paresis: Weakness

Question 421

A patient has a Cervical lesion (up to C5), what is the hallmark presentation?

Answer 421

-Spastic quadraparaesis =All 4 limb weakness and spastic posture

Question 422

A patient has Thoraci and lumbar spinal lesion, what is the hallmark presentation?

Answer 422

Spastic paraparesis (impaired not completely lost in lower limbs)

Question 423

List UMN issues.

Answer 423

-stroke -brain tumour -ALS -intracranial haemorrhage -post head injury / trauma -MS -Spinal cord stenosis -Prolapsed disc

Question 424

Upon beside and gait inspection, what would you expect for a LMN?

Answer 424

Fasciculations Waddling Gait

Question 425

Describe the hallmark presentation of Guilliene-Barre

Answer 425

flaccid Paraplegia losing reflexes

Question 426

Proximal vs Distal weakness (LMN)

Answer 426

Distal - Focal or Widespread (e.g Peripheral neuropathy - diabetes) =difficulty with fine tasks e.g writing Proximal = Difficult with rising, walking stairs =Muscular Dystrophy, Rediculopathy

Question 427

Fatiguable weakness

Answer 427

Ocular and Bulbar e.g Myasthenia Gravis

Question 428

What is meant by the LMN Foot drop?

Answer 428

Cannot dorsiflex foot, wasting of Tibialis anterior muscle in nerve = weakness and numbness

Question 429

What is meant by LMN wrist drop and what are the causes?

Answer 429

wasting of triceps, unable to extend wrist =radial nerve lesion of the axilla causes: -trauma -humeral fracture -motor neurone disease

Question 430

Give examples of LMN.

Answer 430

GP: -Radiculopathy -Bells palsy -Peripheral neuropathy -Occular Myasthenia Gravis -Muscular Dystrophy Hospital: -Motor neurone disease -Cauda Equina -Guillain-Barre -Myasthenia Gravis -Inflammatory myopathies

Question 431

Where is there Dual pathology and give an example.

Answer 431

Anterior horn cells of the spinal cord = where the nerve tracts overlap =Motor Neuron Disease

Question 432

What are the hall mark features of Extrapyramidal disease (Basal Ganglia)?

Answer 432

-no weakness -disorder of movement: =sequencing and smooth fluid control -jerking -rigid tone -bradykinesia -resting tremor -shuffling gait =Parkinson's

Question 433

What is meant by Sensory Ataxia and what are the causes?

Answer 433

=loss of movement proprioception e.g when you are drunk with alcohol -Cerebellar lesion -Stroke -MS -tumour

Question 434

Do Cerebellar lesions present as contra or ipsilateral?

Answer 434

Ipsilateral

Question 435

What common drug can cause a tremor?

Answer 435

Salbutamol

Question 436

Where is the Substantia Nigra?

Answer 436

Midbrain

Question 437

What is the Striatum?

Answer 437

Largest structure of the Basal Ganglia

Question 438

How would you differentiate between a UMN lesion in the brain vs in the spinal cord?

Answer 438

Brain: -Contralateral Hemiplegia -Flexed Upper limbs -Extended Lower limbs Spinal cord: Quadriplegia (cervical) and Paraplegia (thoracic / lumbar)

Question 439

What does Paraplegia mean?

Answer 439

Complete paralysis of legs

Question 440

What does Quadraplegia mean?

Answer 440

Complete paralysis of all 4 limbs

Question 441

A patient has a Cervical Lesion- how does that affect the limbs?

Answer 441

Quadriplegia

Question 442

A patient has a Thoracic / Lumbar Lesion- how does that affect the limbs?

Answer 442

Paraplegia

Question 443

What are the 2 most common causes of UMN issues?

Answer 443

Multiple sclerosis, road traffic accident

Question 444

Describe the Anterolateral pathway.

Answer 444

This is an Ascending (Somatosensory) Pathway 1.Starting from the Sensory receptors of the Periphery 2.Enters the spinal cord and ascends 1-2 levels 3.Synapse at the Dorsal Horn (Substantia Gelatinosa) 4.Splits into 2 tracts - Anterior and Lateral 5.Travel together and ends in the Thalamus

Question 445

What is the Anterior Anterolateral tract responsible for?

Answer 445

Touch and Pressure

Question 446

What is the Lateral Anterolateral Tract responsible for?

Answer 446

Pain and temperature

Question 447

What syndrome is the most common cause of damage to the Anterolateral System and what would therefore be presented?

Answer 447

Brown-Sequard Syndrome =Contralateral loss of pain and temperature sensation

Question 448

What are the Pyramidal pathways?

Answer 448

Descending motor pathway responsible for voluntary motor control of musculature of body and face

Question 449

What are the Extrapyramidal pathways?

Answer 449

Descending motor pathway responsible for involuntary automatic control of all musculature such as muscle tone, balance, posture and locomotion.

Question 450

What 2 pathways are part of the Pyramidal pathway system?

Answer 450

Corticospinal and Corticobulbar tracts

Question 451

What pathways are part of the Extrapyramidal pathway system?

Answer 451

-Vestibulospinal -Reticulospinal -Rubrospinal -Tectospinal tracts

Question 452

What is the Vestibulospinal tract responsible for?

Answer 452

Ipsilateral Balance and Posture

Question 453

What is the Reticulospinal tract responsible for?

Answer 453

-Ipsilateral Muscle tone (medial increases and lateral decreases) and Voluntary movements (medial facilitates and lateral inhibits) (ipsilateral)

Question 454

What is the Rubrospinal tract responsible for?

Answer 454

Contralateral Fine control of hand movements

Question 455

What is the Tectospinal tract responsible for?

Answer 455

Contralateral Coordination of head in relation to vision stimuli

Question 456

What is the Cortiocospinal tract responsible for?

Answer 456

Voluntary motor control of musculature of body

Question 457

What is the Corticobulbar tract responsible for?

Answer 457

Voluntary motor control of musculature of face and neck

Question 458

Describe the Corticospinal Pathway.

Answer 458

Descending motor pathway 1.Recieves information from the Primary motor cortex, Premotor cortex, Supplementary motor area and Somatosensory area 2.From the Thalamus 3.To the Medulla 4..Motor neuron splits into anterior and lateral 5.Lateral crosses over and the Anterior remains Ipsilateral 6.Ends at the Ventral horn

Question 459

What is a Capsular Stroke?

Answer 459

The internal capsule (between the thalamus and basal ganglia) is extremely susceptible to compression from HAEMORRHAGIC BLEEDS =causes a lesion of the descending tract

Question 460

Describe the Corticobulbar tract.

Answer 460

1.From the Lateral aspect of the primary motor cortex 2.Through Internal capsul to midbrain, pons and medulla oblongata 3.Lower motor neurones innervate the face and neck 4.Innervates cranial nerves

Question 461

What are somatic senses?

Answer 461

Temperature Touch pressure vibration proprioception pain

Question 462

What are nociceptors?

Answer 462

Mechano-thermo and chemothermoreceptors resulting in PAIN

Question 463

What makes the finger tips increased sensitivity compared with your back?

Answer 463

The receptive fields (the areas that sense stimulus) overlap while the receptive fields on the back are further apart and therefore not as sensitive.

Question 464

What is meant by a Phasic response?

Answer 464

Transient response with a quick Action potential that resolves quickly e.g pain

Question 465

What is meant by Tonic response?

Answer 465

The excitability of the neuron is maintained giving constant sensation e.g Proprioception.

Question 466

List the types of Mechanoreceptors.

Answer 466

-Tactile receptors (majority on skin and some in deep tissue) -Proprioceptors (e.g Muscle spindles, Golgi tendon etc) -Baroreceptors (Cardiovascular) -Inner ear receptors (cochlear and vestibular)

Question 467

What are TRP channels?

Answer 467

Protein channel recptors situated in the skin, hypothalamus, skeletal muscle, spine and liver that open for different temperature ranges. e.g -Menthol (mint) is an agonist for TRPA1 which activates this protein channel creating a cool sensation -Chilli is an agonist for TRVP1 which activates the protein channel receptor and creates a hot sensation

Question 468

What is meant by the Spinal Lamina?

Answer 468

In the ascending tract, the C fibres (pain + temperature) do not infiltrate very far into the grey matter while Alpha fibres (proprioception) infiltrate a lot deeper into the ventral horn meaning that there are LAYERS IN THE BRAIN THAT PROCESS DIFFERENT TYPES OF INFORMATION FROM THE DIFFERENT TYPES OF NEURONAL FIBRES.

Question 469

Give an example of a dermatomal illness and its basic pathophysiology.

Answer 469

The infection (e.g Shingles) lies dormant in the Dorsal root ganglion of the sensory nerves and (if immunocompromised) will travel down nerve and express at the dermatome.

Question 470

Where do the cell bodies of sensory neurons lie?

Answer 470

Dorsal Root Ganglia (DRG)

Question 471

What is the most common cause of Meningitis?

Answer 471

Viral (Coxsackie virus) Note: Bacterial incidences have significantly decreased with the vaccine.

Question 472

What is Mollaret Meningitis?

Answer 472

A form of aseptic meningitis characterised by recurrent episodes of meningism interspersed with symptom free weeks (associated with Herpes Simplex 2)

Question 473

What are the key investigations for a suspect case of Meningitis and would you expect the results to be?

Answer 473

!Provide empirical antibiotics IMMEDIATELY rather than wait for investigation results to come back 1.Lumbar puncture (Raised Intracranial pressure, fluid clear with elevated glucose, protein) 2.Bloods (Viral PCR, ABG, CRP, U&E etc)

Question 474

What is the management for Meningitis?

Answer 474

1.IV Ceftriaxone / Cefotaxime for 10 days

Question 475

If a patient is <3months or >50 years, what should be added to their management plan for Meningitis?

Answer 475

-Add Amoxicillin IV for 14 days (Or Chloramphenicol if allergic to Penicillin)

Question 476

A neonate / infant has meningitis. What can't be given as part of their management and why?

Answer 476

Ceftriaxone causes worsening of jaundice and acidosis -Give Cefotaxime instead

Question 477

If Viral Meningitis or Encephalitis is suspected, what should be given?

Answer 477

IV Acyclovir

Question 478

What is the presentation of Encephalitis?

Answer 478

Classic triad of rapidly progressing symptoms: -Fever -Headache -Altered mental status

Question 479

What is the pathophysiology of Encephalitis?

Answer 479

Inflammation of the parenchyma due to viruses most frequently: -Herpes Simplex 1 = Herpes Simplex Encephalitis affecting the temporal lobes

Question 480

What other viral infection can Encephalitis occur with?

Answer 480

Meningitis

Question 481

Who is most likely to suffer from Encephalitis?

Answer 481

Neonates, elderly and immunocompromised

Question 482

What investigations are to be done for a suspect Encephalitis patient?

Answer 482

-Lumbar puncture -Blood tests -Neuroimaging (CT/MRI)

Question 483

What would a ring enhancing lesion on a CT/MRI indicate and what should be initially done?

Answer 483

-Cerebral Abscess -Tumour -Metastasis -Demyelination =Neurosurgical referral

Question 484

A patient has a cerebral abscess. What should be administered?

Answer 484

IV Ceftriaxone

Question 485

What is the management for Encephalitis?

Answer 485

-Prompt IV Acyclovir -Empirical antibiotics -Monitoring for seizures

Question 486

What should NOT be done with a patient with Encephalitis?

Answer 486

-Corticosteroid administration -Excessive fluid therapy (can exacerbate cerebral oedema)

Question 487

List the risk factors for developing a stroke.

Answer 487

-Hypertension -Smoking -Diabetes Mellitus -Hypercoagulability -Hyperlipidaemia -Combined Oral Contraceptive Pill -Trauma -Atrial Fibrillation! -Anticoagulation (due to increased risk of bleeds)

Question 488

What are the 4 classifications of a stroke that would be assessed in A&E?

Answer 488

1.Total Anterior Circulation Infarct 2.Partial Anterior Circulation Infarct 3.Lacunar Infarct 4.Posterior circulation Infarct

Question 489

What are the 2 types of stroke?

Answer 489

Ischaemic and Haemorrhagic

Question 490

What is meant by a Total Anterior Circulation Infarct?

Answer 490

Large infarct of the main stem of the Middle Cerebral Artery or Anterior cerebral artery !WORST PROGNOSIS- LIFE THREATENING!

Question 491

What is meant by Partial Anterior circulation infarct?

Answer 491

Branch of Middle Cerebral artery / anterior cerebral artery infarct

Question 492

What is meant by a Lacunar stroke?

Answer 492

Occlusion of the small arteries around the thalamus, pons, basal ganglia and internal capsule

Question 493

What is meant by a Posterior Circulation Stroke?

Answer 493

Vertebasilar stroke affecting the cerebellum / brainstem

Question 494

What is the presentation of a stroke due to the Anterior Cerebral Artery occlusion?

Answer 494

-CONTRAlateral sensory and motor weakness -LOWER LIMBS symptoms are more dominant

Question 495

What is the presentation of a stroke due to the Middle Cerebral Artery occlusion?

Answer 495

-CONTRAlateral sensory and motor weakness -UPPER LIMBS symptoms are more dominant -CONTRAlateral homonymous hemianopia -Aphasia

Question 496

What is the presentation of a stroke due to the Posterior Cerebral Artery occlusion?

Answer 496

-CONTRAlateral homonymous hemianopia -Macular sparing

Question 497

What does Macular sparing mean?

Answer 497

Visual defect where only the central visual field can be see

Question 498

What is the presentation of a stroke due to the Anterior Cerebral Vertebasilar Artery occlusion?

Answer 498

-Loss of Consciousness -Homonymous Hemianopia occuring in ISOLATION

Question 499

A patient has a suspect stroke. What are the investigations to be done?

Answer 499

URGENT: CT/MRI (CT usually preferred) =Exclude Haemorrhagic stroke -Assess for hypertension -Bloods and U&E -Speech and language assessment -ECG (AF?) -Echo (Embolism or Vascular disease?) -Carotid Artery duplex ultrasound

Question 500

What is the initial management for an Ischaemic stroke?

Answer 500

1.Alteplase (thrombolysis) -If swallow impaired 2.=NG tube 3.Aspirin (300mg) orally or rectally if swallowing impaired

Question 501

A patient has a stroke due to their hypertension - what procedure should therefore be considered?

Answer 501

Carotid Endarterectomy (for treating stenosis)

Question 502

What is Aspiration pneumonia, and what type of patients are most at risk of it?

Answer 502

Serious complication associated with stroke presenting as chest pain with coughing up of green sputum with pus or blood as well as wheezing. Therefore swallowing should always be assessed.

Question 503

Describe the post-stroke treatment plan?

Answer 503

1.Aspirin for 2 weeks 2.Switch to oral Clopidogrel 75mg once daily IF ATRIAL FIBRILLATION +Anticoagulation IF HYPERTENSIVE +Statin

Question 504

What is the definition of a Transient Ischaemia Attack?

Answer 504

Acute cerebrovascular pathology that resolves within 24hrs

Question 505

How may a haemorrhagic stroke present differently than a ischaemic stroke?

Answer 505

Similar focal symptoms BUT -Pronounced headaches -Neck pain -Photophobia -Nausea and Vomiting

Question 506

What is the ABCD2 score for a patient that has had a TIA?

Answer 506

A score of more than or equal to 4 suggests a high likelihood of a stroke in the future: Age : >60yrs = 1 point Blood pressure >140/90 = 1 point Clinical features -Unilateral weakness = 2 points -Slurred speech, absence of motor weakness = 1 point Duration of symptoms >1hr = 2 points 10-59mins = 1 point Diabetes Mellitus = 1 point

Question 507

If a TIA patient has an ABCD2 score of >/= to 4, what is the management?

Answer 507

300mg Aspirin daily Specialist assessment and investigation within 24hrs

Question 508

If a TIA patient has an ABCD2 score of <4, what is the management?

Answer 508

300mg aspirin daily Specialist investigation and assessment no later than 1 week

Question 509

What is meant by Crescendo TIA?

Answer 509

A patient presenting with 2 or more TIAs within a week (puts them at high risk of stroke despite their ABCD2 score).

Question 510

What is Amaurosis Fugax?

Answer 510

Means fleeting darkness and is a visual field defect described as "a curtain coming down on their vision". =Caused by emboli from the ipsilateral carotid artery representing a nonhemispheric TIA (could be cerebellar / brain stem).

Question 511

A patient had Amaurosis Fugax, what investigative step should be done?

Answer 511

=Curtains coming down on vision -->Carotid artery imaging

Question 512

Compare Focal vs Diffuse brain injury.

Answer 512

Damage to one part of the brain (e.g impact to the head) vs injury across the whole brain (e. road traffic incident whereby the brain is bashed within the skull and therefore the damage is widespread).

Question 513

What is meant by Diffuse axonal injury?

Answer 513

Tearing of the nerves throughout the brain - type of traumatic head injury

Question 514

What is meant by Diffuse vascular injury?

Answer 514

Tearing of the blood vessels of the brain = Type of traumatic head injury

Question 515

After a blunt trauma to the back of the head, a patient has a black eye. Why is that?

Answer 515

=Basilar scalp fracture Blood moves with gravity to eye orbits

Question 516

What is meant by a Stellate laceration?

Answer 516

=splitting of the skin (common with falling backwards), and the fracture is NOT linear (in relation to head injuries)

Question 517

What is the most common type of skull fracture?

Answer 517

Linear

Question 518

What is a Depressed skull fracture?

Answer 518

=skull being pushed in aswell as fracturing

Question 519

Define a Hinge skull fracture.

Answer 519

From the midline of the brain to the temporal bones =usually presents with blood in the ear ~MOST COMMON IN: Road traffic incidents

Question 520

Define a Pond / Ripple skull fracture.

Answer 520

Depressed type fracture in a child

Question 521

What causes an Extradural haemorrhages and when would it present?

Answer 521

Usually due to impact to the side of the skull =accumulate over time - will take minutes to hours before the raised intracranial pressure rises and gives rise to symptoms -before symptoms arise = Lucid interval pressure of blood pushes up against the brain and compresses it

Question 522

What is the Lucid interval?

Answer 522

Is the period of no symptoms of a Extradural Haemorrhage (/Haematoma) before symptoms present (this is because it takes a while for the blood to accumulate) =can present as if they are drunk

Question 523

What is a key sign of a basal skull fracture?

Answer 523

Leaking of csf and blood in ear

Question 524

Describe the pathophysiology of a Subdural haemorrhage.

Answer 524

Impact causes the brain floating in the CSF to cause tearing of bridging veins which empty into the superior saggital sinus

Question 525

Who is most at risk of Subdural Haemorrhage / Haematoma and why?

Answer 525

-Elderly -Alcoholics =Their brains have shrunk which causes strain on the bridging veins so that very minor falls, the movement of the brain in the CSF can cause a subdural haemorrhage starting with confusion and leading to unconsciousness -Huntington's, Alzheimer's, Amyloidosis =Amyloid deposition makes a minor fall result in a major haemorrhagic event

Question 526

What is meant by a Contrecoup fracture?

Answer 526

Bruising of the brain is opposite to the point of impact (e.g impact at the back causing the brain in the csf to whack the front of the skull so bruising will be at front) =cerebral oedema =pinching onto the pons which controls your breathing --> death

Question 527

What are the consequences of a child falling down stairs vs adults falling

Answer 527

Bounce and won't have significant injuries (e.g head trauma) compared with an adult, so if head trauma is present -->ABUSE

Question 528

Where are the common sites for Cerebral contusions (contra-coup)?

Answer 528

Frontal lobes and Temporal poles

Question 529

Where is contra-coup head injury less likely to happen?

Answer 529

Occipital lobe

Question 529

What is the most common cause of Subarachnoid haemorrhage?

Answer 529

Berry Aneurysms

Question 530

When would you most likely see a Traumatic diffuse axonal injury?

Answer 530

-road traffic collision -fall from height =usually present unconscious =EXTREMELY LIFE THREATENING

Question 531

What is meant by a Basilar Skull fracture?

Answer 531

Fracture to the base of the skull =Usually caused by substantial blunt force trauma, involves at least one of the bones that compose the base of the skull, most commonly involving the TEMPORAL BONES but may involve the occipital, sphenoid, ethmoid, and the orbital plate of the frontal bone as well.

Question 532

What is a contusion?

Answer 532

Bruise

Question 533

What is laceration?

Answer 533

Cuts or tears of the skin

Question 534

What is an incision?

Answer 534

Slash injury

Question 535

What is a penetrating wound?

Answer 535

Stab wound

Question 536

What is meant by a Sentinel Bleed?

Answer 536

Symptoms of headaches, dizziness and visual disturbances may precede a Subarachnoid Haemorrhage 2-3 weeks before due to an expansion of the aneurysm.

Question 537

List the risk factors for a Subarachnoid Haemorrhage.

Answer 537

Smoking Hypertension Alcohol Cocaine Connective tissue diseases Family History

Question 538

What other illnesses is Berry Aneurysms associated with?

Answer 538

-Polycystic Kidney Disease -Connective Tissue disorders -Coarctation of the aorta

Question 539

What investigations are required for a suspect Subarachnoid Haemorrhage?

Answer 539

1.CT without contrast 2.Angiography with a catheter = to localise bleed 3.IF CT NEGATIVE =Lumbar Puncture (Detection of Xanthochromia confirms diagnosis i.e Yellow CSF)

Question 540

What is a Subdural Haematoma?

Answer 540

Pooling of blood in the subdural space most commonly due to the rupture of bridging veins.

Question 541

What type of head injury are Subdural Haemorrhages associated with?

Answer 541

Vigorous Coup and Counter-coup forces in NON ACCIDENTAL INJURIES IN CHILDREN

Question 542

Compare a Subdural Haematoma with a Extradural Haematoma in terms of presentation?

Answer 542

Subdural: Consciousness doesn't fully recover and it gradually decreases with increasing confusion. Other symptoms: Drowsiness, Incontinence ~Usually seen in the elderly Extradural: -LUCID INTERVAL =Regain full consciousness but have an ongoing and severe HEADACHE Other symptoms: Raised intracranial pressure symptoms (nausea, vomiting and visual problems) -->Gradually lose consciousness

Question 543

What type of haematoma / haemorrhage are you most likely to see a lucid interval in?

Answer 543

Extradural

Question 544

When do you usually see an Extradural Haemorrhage?

Answer 544

The typical presentation is of a young patient involved in a head strike (either during sport or a result of a motor vehicle accident) who may or may not lose consciousness transiently

Question 545

When do you usually see a Subdural Haemorrhage?

Answer 545

Typically due to falls or Non-accidental injuries in children

Question 546

Compare the CT findings between a Extradural haematoma and a subdural haematoma.

Answer 546

Extradural: Lens-like appearance Subdural: Crescent shaped haematoma

Question 547

What is the management for a Subdural Haematoma?

Answer 547

Burr hole craniotomy haematoma evacuation

Question 548

Where in the brain is usually affected by an Extradural Haematoma?

Answer 548

Middle Meningeal Artery in parietal or temporal bone fractures

Question 549

What are the main causes of Raised intracranial pressure?

Answer 549

-Space occupying lesion in brain -Infections -Intracranial thrombosis e.g Extradural Haematoma -CSF excess e.g Hydrocephalus

Question 550

How does raised intracranial pressure present?

Answer 550

-Headache : Nocturnal or morning (upon waking) and WORSE ON COUGHING OR STRAINING -Nausea and vomiting -Visual issues -Ptosis -Cranial nerve 3 and 6 palsies -Blurring optic disc -Hyperaemia (increased blood flow to head) -Papilloedema

Question 551

What is Hydrocephalus?

Answer 551

Increase in the volume of circulating CSF within the cerebral ventricles

Question 552

What are the 4 forms of Hydrocephalus?

Answer 552

1.Communicating 2.Non-communicating 3.Normal pressure 4.Hydrocephalus ex vacuo

Question 553

What is meant by Communicating Hydrocephalus?

Answer 553

-Impaired absorption of CSF -NO OBSTRUCTION to CSF flow within ventricles

Question 554

What are the causes of Communicating Hydrocephalus?

Answer 554

-Subarachnoid Haemorrhage -Meningitis

Question 555

What is meant by Non-communicating Hydrocephalus?

Answer 555

Obstruction of CSF flow, due to congenital deformities (e.g Arnold-Chiari / Spinal Bifida/ Aqueduct stenosis) or acquired from bleeding, infections and tumours.

Question 556

What is Normal pressure hydrocephalus?

Answer 556

When the Cerebral Ventricles are dilated.

Question 557

How does Normal Pressure Hydrocephalus present?

Answer 557

-Urinary Incontinence -Dementia -Gait Disturbances =Magnetic (Feet seemingly stuck to the floor with small strides)

Question 558

What investigations are required for Normal Pressure Hydrocephalus?

Answer 558

-MRI/CT

Question 559

What is the management for Normal Pressure Hydrocephalus?

Answer 559

-Lumbar puncture =remove large volume to provide short term improvement -CSF shunting =DEFINITIVE treatment

Question 560

What is Hydrocephalus Ex Vacuo?

Answer 560

Brain atrophy (e.g Dementia) causes compensatory dilatation of the ventricles causing Hydrocephalus

Question 561

What is the management for Hydrocephalus Ex Vacuo?

Answer 561

Drain / Shunt procedure (definitive treatment)

Question 562

What is the treatment for hydrocephalus while waiting for definitive treatment?

Answer 562

-Mannitol / Hypertonic Saline as bolus = to cause osmotic diuresis and decrease CSF -Treat Pyrexia and Seizures if present

Question 563

What is the presentation of Idiopathic Intracranial hypertension and who is most likely to present with it?

Answer 563

1.Raised Intracranial pressure -Morning/Nocturnal headaches -Vomiting -Pulsatile Tinnitus -Papilloedema 2.Young, Obese, Pregnant

Question 564

What is Cerebral Vein Thrombosis?

Answer 564

Aka CVT, when there is a blood clot in the brain =Presents like a stroke / Intracranial Hypertension

Question 565

List the risk factors for Cerebral Vein Thrombosis (CVT).

Answer 565

-oral contraceptives -recent pregnancy -infection. -most common in females ages 30–41.

Question 566

Describe the presentation of Cerebral Vein Thrombosis.

Answer 566

~50% of patients have SEIZURES -Nausea and vomiting -Loss of consciousness -Focal neurology may develop depending on the area of the brain affected

Question 567

What investigations are required to diagnose Cerebral Vein Thrombosis?

Answer 567

CT scan of head or MRI D dimer levels Antiphospholipid antibodies

Question 568

What is the treatment for Cerebral Vein Thrombosis?

Answer 568

Anticoagulation ONLY ONCE HAEMORRHAGE HAS BEEN EXCLUDED

Question 569

What does D dimer indicate and what is a worrying result?

Answer 569

The amount of clotting >0.5 ~ thrombosis

Question 570

What does Anosmia mean?

Answer 570

Partial or full loss of smell

Question 571

A patient presents with seizures. What is the first diagnosis to exclude?

Answer 571

Space occupying lesion

Question 572

What could be a Space occupying lesion in the brain?

Answer 572

-Tumour (or from metastasis) -Haematoma -Infiltration (infection) -Abscess

Question 573

A patient presents with anosmia. What lobe of the brain is most likely affected?

Answer 573

Frontal

Question 574

A patient presents with behavioural changes. What lobe of the brain is most likely affected?

Answer 574

Frontal

Question 575

A patient presents with dysphasia. What lobe of the brain is most likely affected?

Answer 575

Temporal lobe

Question 576

Are brain tumours in adults usually Supratentorial or Infratentorial?

Answer 576

Supra

Question 577

Are brain tumours in children usually Supratentorial or Infratentorial?

Answer 577

Infra

Question 578

What is the treatment for Increased Cranial Pressure?

Answer 578

-Mannitol / Hypertonic saline

Question 578

What is the most common brain tumour in adults?

Answer 578

Metastatic from lung and breast cancer

Question 579

A patient has a suspected brain space occupying lesion. What are the next steps (investigations / management)?

Answer 579

-CT or MRI (MRI preferred) -Treat underlying intracranial pressure (mannitol) -Neurosurgical excision

Question 579

What are the 2 most common forms of brain tumours?

Answer 579

-Glial (e.g Ependymomas, Astrocytomas) -Meningiomas

Question 580

What are risk factors for Multiple Sclerosis?

Answer 580

-Viral infections e.g Epstein Barre -Lack of sunlight -Vit D Deficiency -HLA-DRB1

Question 581

What is the pathophysiology of Multiple Sclerosis?

Answer 581

Inflammation, demyelination and axonal degeneration caused by CD4 cell mediated destruction of the oligodendrocytes (supporting neuronal cells) resulting in NEURONAL DEATH

Question 582

Name a common type of brain tumour and its most aggressive form as well as its prognosis.

Answer 582

-Glial =Glioblastoma Multiforme 1 year to live:(

Question 583

What gene is linked to Multiple Sclerosis?

Answer 583

HLA-DRB1

Question 584

What histological results would you expect from a patient with Multiple Sclerosis?

Answer 584

-Inflammatory cells : -T cells -B cells -Macrophages

Question 584

What is the most common form of Multiple Sclerosis?

Answer 584

Relapsing-remitting subtype (80-85% of cases)

Question 585

What is meant by Relapsing-remitting Multiple Sclerosis?

Answer 585

Episodes of new or worsening symptoms, known as relapses that WORSEN OVER A FEW DAYS and last for days to weeks and then SLOWLY IMPROVE.

Question 586

Describe a typical INITIAL presentation of someone with Multiple Sclerosis.

Answer 586

Visual: -Optic Neuritis (Scotoma, Colour Desaturation and pain on eye movement) Sensory: -Loss of pain and temperature (Spinothalamic tract) -Loss of vibration, light touch and proprioception (Spinocerebellar tract) -Radicular pain -Trigeminal neuralgia -Tingling/Tightness/ Twisting/Burning/Tearing sensation

Question 587

What does Radicular pain mean?

Answer 587

Pinching of the nerves at the root causes pain in back and hips, radiating down the LEGS. Character of pain: BURNING, or STINGING pain, Decreased sensation of the legs, Numbness and Tingling Muscle weakness (in severe cases)

Question 588

List the potential presentations of Multiple Sclerosis?

Answer 588

-Visual defects (most common) -Sensory defects (most common) -Motor defects -Cerebellar defects -Autonomic defects -Fatigue -Depression

Question 589

List the potential visual defects of Multiple Sclerosis.

Answer 589

-Optic Neuritis -Opthalmoplegia -Bilateral Internuclear Opthalmoplegia

Question 590

What is Opthalmoplegia?

Answer 590

Paralysis or weakness of any of the 6 muscles controlling the EYE MOVEMENTS Presenting -Inability to move eyes -Ptosis -Diploplia -Blurry vision -Strabismus (misalignment of eye(s))

Question 591

What is Bilateral Internuclear Opthalmoplegia?

Answer 591

Movement disorder of the eye due to a lesion of the Medial Longitudinal Fasciculus affecting the ability of LATERAL GAZE: Eye that abducts = NYSTAGMUS Contralateral eye = NO MOVEMENT

Question 592

What is Strabismus?

Answer 592

Misalignment of one or both eyes

Question 593

What are the potential sensory defects of Multiple Sclerosis?

Answer 593

-Loss of pain and temperature (Spinothalamic tract) -Loss of vibration, light touch and proprioception (Spinocerebellar tract) -Radicular pain -Trigeminal neuralgia -Tingling/Tightness/ Twisting/Burning/Tearing sensation

Question 594

What are the potential motor defects of Multiple Sclerosis?

Answer 594

-Upper motor neuron features (Spascisity in the legs more than arms, Hypertonia, Hyper-reflexia and Babinski -Transverse Myelitis

Question 595

What are the potential Cerebellar symptoms of Multiple Sclerosis?

Answer 595

-Ataxia -Slurred speech -Nystagmus -Vertigo

Question 595

What is Transverse Myelitis (incl presentation)?

Answer 595

=Idiopathic Inflammation of part of the spinal cord that is associated with infections and autoimmune diseases. =Common symptoms are back or neck pain, weakness or sensation changes in the arms or legs, or loss of bladder or bowel control.

Question 596

What are the autonomic potential symptoms of Multiple Sclerosis?

Answer 596

-Loss of bladder and bowel continence -Erectile dysfunction -Impotence -Increased sweating -Constipation

Question 597

What are the investigations to be done for a suspect Multiple Sclerosis and what results would you expect?

Answer 597

1.MRI - taken 3 months apart =Gandolinium-Enhanced Lesions (multiple little white plaques across the brain) 2.Lumbar Puncture =IgG Oligoclonal bands in CSF 3.Evoked Potentials =demonstrates neuronal delayed response

Question 598

What is the treatment for acute exacerbation / worsening of symptoms of Multiple Sclerosis?

Answer 598

-Oral Prednisolone / IV Methyl Prednisolone

Question 599

What is the treatment for preventing relapses of Multiple Sclerosis?

Answer 599

Disease Modifying Therapies: (specifically for relapsing-remitting) -Dimethyl Fumarate -Teriflunomide -Alemtuzumab

Question 600

What is the treatment for symptomatic relief of fatigue for patients with Multiple Sclerosis?

Answer 600

Amantadine, CBT

Question 601

What does Dyskinesia mean?

Answer 601

Involuntary movements (usually due to Parkinsons)

Question 602

What is the treatment for symptomatic relief of depression for patients with Multiple Sclerosis?

Answer 602

Amitriptyline

Question 603

What is the treatment for symptomatic relief of Neuropathic pain for patients with Multiple Sclerosis?

Answer 603

Choice of : -Amitriptyline -Duloxetine -Gabapentin -Pregabalin

Question 604

What is meant by Lumbar spinal stenosis?

Answer 604

Narrowing of the central spinal cord causing back pain etc

Question 605

What are the causes of Lumbar spinal stenosis?

Answer 605

-Tumours -Prolapsed Discs -Degenerative changes: -Facet Joint Osteoarthritis -Osteophytes formation -Articular cartilage erosion (e.g sports injury) =Causes mechanical compression and narrowing of the spinal canal

Question 606

What are Osteophytes?

Answer 606

Bone spurs / bony lumps that grow on the bones in the spine or around joints usually due to arthritis.

Question 607

What is the presentation of Lumbar Spinal Stenosis?

Answer 607

-Progressive back pain / lower limb pain (buttock pain is also possible), WORSE WHEN WALKING, BETTER WITH SITTING, LEANING FORWARD -Numbness -Paraesthesia

Question 608

What does Paraesthesia mean?

Answer 608

Sudden burning or prickling sensation that is usually felt in the hands, arms, legs, or feet, but can also occur in other parts of the body.

Question 609

Compare Neurogenic and Arterial Claudication.

Answer 609

Claudication is pain when walking causing a LIMP =can be due to Peripheral Arterial disease or Neuronal compression Can differentiate by: -Neurogenic : Pain is positional (pain eased by leaning forward) -Arterial : Peripheral pulses are diminished / absent

Question 610

What investigations should be done for suspect Lumbar Spinal Stenosis?

Answer 610

MRI

Question 611

What is the management of Lumbar Spinal Stenosis?

Answer 611

-Body weight reduction (lifestyle changes) -NSAIDs and Physiotherapy IF UNRESPONSIVE: =Decompressive Laminectomy

Question 612

What is Syringomyelia?

Answer 612

Development of a fluid-filled tubular cavitation within the spinal cord (usually the CERVICAL) portions. Note: Think 'Syringe'- as in a tube filled with liquid

Question 613

What is the most common cause of Syringomyelia?

Answer 613

Obstruction of CSF flow

Question 614

What congenital disorder predisposes someone to Syringomyelia?

Answer 614

Arnold Chiari

Question 615

What is Arnold Chiari?

Answer 615

Congenital malformation causing the brain to push down on the spinal cord - life expectancy means unlikely to make it to childhood

Question 616

What is the onset of Syringomyelia?

Answer 616

INSIDIOUS onset between 20-30years, rapid progression

Question 617

What is the presentation of Syringomyelia?

Answer 617

Classical 'cape-like' loss f sensation of: -Chest -Shoulders -Upper limbs -Muscle weakness

Question 618

What investigations are to be done for suspect Syringomyelia?

Answer 618

-MRI

Question 619

What is the management of Syingomyelia?

Answer 619

Neurosurgical intervention: -Shunt insertion -Syringotomy and drainage -Laminectomy -IF ARNOLD CHIARI : Decompression of the malformation

Question 620

What is Anterior Spinal Artery Syndrome?

Answer 620

Ischaemic event that causes a decrease in blood supply to the anterior 2/3rds of the spinal cord.

Question 621

what is another name for Spinal Artery Syndrome?

Answer 621

Vertebrobasilar occlusion or Beck Syndrome

Question 622

What is the presentation of Beck Syndrome?

Answer 622

-Loss of sensory input from anterior cord (Pain and Temperature)

Question 623

What is the most common cause of Beck Syndrome?

Answer 623

Aortic pathology e.g Dissection / Aneurysm

Question 624

What column is usually spared i.e unaffected by Syringomyelia?

Answer 624

Dorsal column (therefore will retain proprioception and vibration)

Question 625

What column is usually spared i.e unaffected by Beck Syndrome?

Answer 625

Dorsal column (therefore will retain proprioception and vibration)

Question 626

What is the prognosis of Beck Syndrome?

Answer 626

Permanently Paraplegic or Quadraplegic

Question 627

What is Spondylosis?

Answer 627

Age-related degeneration of the spinal cord commonly caused by Osetoarthritis causing pain or sensinorimotor disturbances due to compression of the nerve

Question 628

What is the management for Spondylosis?

Answer 628

Conservative - NSAIDs and Physiotherapy

Question 629

What is Spondylolisthesis?

Answer 629

Anterior or Posterior displacement of vertebra due to usual wear and tear, arthritis

Question 630

What is the management for Spondylolisthesis?

Answer 630

Conservative - NSAIDs

Question 631

What is Brown-Sequard Syndrome?

Answer 631

Insult / Injury to the lateral half of the spinal cord affects the Corticospinal (movement of body) and Spinothalamic (vibration and proprioception, temperature and pain). Very RARE ~ trauma

Question 632

What is the presentation of Brown-Sequard Syndrome?

Answer 632

IPSILATERAL loss of -Proprioception, vibration sense CONTRALATERAL loss of: -Pain and temperature

Question 633

List the red flag symptoms in relation to back pain?

Answer 633

-Saddle Anaesthesia -Bowel / Bladder dysfunction - incontinence -Trauma -Point tenderness / sudden onset -Pain at night - waking from sleep -History of malignancy -History of IV drug missuse -

Question 634

What is Subacute Combined Degeneration of the cord?

Answer 634

Due to a deficiency in B12 / Folate : Degeneration the dorsal columns of the spinal cord (impairment of proprioception and vibration)

Question 635

What illnesses cause Subacute Combined Degeneration of the cord?

Answer 635

-B12 deficiency -Vit E deficiency -Pernicious anaemia -Malabsorption disorders (e.g IBS)

Question 636

What does a flapping tremor indicate?

Answer 636

-Carbon dioxide retention -Liver impairment (late-stage)

Question 637

What is an essential tremor?

Answer 637

Most common type of tremor due to genetic link affecting mainly the upper limbs and can affect speech and tremor of the head (Titubation) IMPROVES : With alcohol WORSENS: When goal orientated, arms outstetched NOTE: VERY RARE to tremor at rest

Question 638

What does Titubation mean?

Answer 638

Tremor of the head

Question 638

What is the treatment for an essential tremor?

Answer 638

-Propranolol or Primidone

Question 639

List the causes of Parkinsonism.

Answer 639

-Multisystem Atrophy /Shy-Drager Syndrome -Progressive Supranuclear Palsy -Lewy Body Dementia -Corticobasilar degeneration -Vascular Parkinsonism -Antipsychotic medication (e.g Metoclopramide, Prochlorperazine) -Wilson Disease -Chronic traumatic Encephalopathy

Question 639

What does Parkinsonism mean?

Answer 639

Broadly encompasses several disorders (incl Parkinsons) that cause these HyPOkinetic symptoms : -Resting tremor -Bradykinesia -Rigidity

Question 640

What are the clinical presentations of Shy Drager Syndrome?

Answer 640

-Parkinsonism -Speech disturbances -Autonomic dysfunction (e.g bladder atony, postural hypotension)

Question 641

What does Atony mean?

Answer 641

Loss of tone

Question 642

What are the clinical presentations of Progressive Supranuclear Palsy?

Answer 642

-Parkinsonism -Speech disturbances -Personality changes -Dementia -Vertical Gaze Palsy

Question 643

What are the clinical presentations of Lewy Body Dementia?

Answer 643

-Parkinsonism -Deteriorating cognitive ability -Visual Hallucinations

Question 644

What are the clinical presentations of Corticobasilar degeneration?

Answer 644

-Parkinsonism -Alien limb syndrome (limb movement without cognitive awareness) -Apraxia -Aphasia

Question 645

What does Apraxia mean?

Answer 645

Disorder of planned motor performance e.g understands words but has difficulty articulating words

Question 646

How does the cerebellum attach to the brainstem?

Answer 646

Cerebrum Peduncles

Question 647

Where do the cranial nerves originate?

Answer 647

The brainstem

Question 648

What are the deep structures of the Diencephalon?

Answer 648

-Thalamus -Hypothalamus -Third ventricle (CSF)

Question 649

Name the 3 types of nerve fibres (between the hemispheres going to brain stem).

Answer 649

(Depending on where the axons are going) 1.Association fibres (intrahemispheric-stay in the same hemisphere) 2.Commisural (cross over the corpus callosum connecting the hemispheres) 3.Projection (leave and exit hemispheres and out of the brain stem and into the spinal cord)

Question 650

What is the most important cell type in cerebral cortex?

Answer 650

Pyramidal cells (output neurons)

Question 651

Stellate cells

Answer 651

Star shaped interneurones (single axons with lots of dendrites connecting neurons to one another within cerebral cortex)

Question 652

What are the Cells of Martinotti?

Answer 652

long axon projecting to top of cerebral cortex

Question 653

Pyramidal cells

Answer 653

Lots of dendrites varying in size - one of the biggest cells in the entire body

Question 654

What are the 6 Layers of the cerebral cortex?

Answer 654

1.Molecular Plexiform layer (Afferent / Sensory : Synaptic layer) 2.External/ Outer granular layer(Afferent / Sensory : Predominance of Stellate interneurons) 3.External Pyramidal layer (Afferent / Sensory : Less densely populated but mainly has Pyramidal cells ) 4.Internal / Inner Granular layer (stellate cells and nerve plexus to act as a barrier between the afferent (1-3) and efferent (5-6) 5.Internal Pyramidal / Ganglionic layer (efferent/ motor : Betz (type of pyramidal- very big) 6.Multiform cell layer (efferent / motor) Note: That the thickness and dominance of the different layers will vary depending on where it is e.g Sensory cortex of brain : Layers 1-3 will be thicker and in Motor cortex of the brain : Layers 5-6

Question 655

Give examples of supporting neuronal cells giving rise to cancer.

Answer 655

Astrocytoma and Glioblastomas

Question 656

What is the white matter in the Cerebellum?

Answer 656

Arbor vitae (tree like structure to increase surface area)

Question 657

What is the grey matter in the Cerebellum?

Answer 657

Folia and Central Nuclei

Question 658

What are the 3 layers of the Cerebellum

Answer 658

1.Molecular (axons and fibres here - lots of synaptic communication) 2.Central layer (Purkinje cell bodies here) 3.Inner granule layer (smaller nuclei present here)

Question 659

What is the predominant cell type in the cerebellum?

Answer 659

Purkinje cells (large and expanding dendrites)

Question 660

Spinal cord grey matter H shape structure- 3 main columns

Answer 660

1.Dorsal Horn / Posterior (afferent /sensory) 2.Lateral (Autonomic senses) 3.Ventral Horn / Anterior (Efferent / motor)

Question 660

Anterior horn

Answer 660

in cervical, lumbar and sacral enlargement =controls upper and lower limbs

Question 661

anterior and posterior horn slim where?

Answer 661

thoracic level

Question 662

Ascending (afferent) and Descending (efferent) tracts where are they present?

Answer 662

White matter (and then goes to grey)

Question 663

Most common cause of Hydrocephalus in children / babies?

Answer 663

Intraventricular Haemorrhage (usually in premature babies as brain isn't full developed)

Question 664

Most common causes of hydrocephalus in adults?

Answer 664

Stroke of the cerebellar hemispheres, Tumours

Question 665

Colloid cyst

Answer 665

benign lesions causing obstruction of CSF flow

Question 666

Presentation of hydrocephalus in infants

Answer 666

Early signs are not obvious: -Macrocrania (enlarged head) -Vomiting / Poor feeding -Abnormal cry -Sunsetting eyes If they go unchecked the pressure on the brain stem causes: -Bradycardia -Recurrent apnoea / pneumonia

Question 667

Main first presenting symptom in children/ adults

Answer 667

early morning headaches, positional

Question 668

Acute presentation of hydrocephalus

Answer 668

-headaches, vomiting -Diplopia -Cranial nerve palsies (3rd, 4th and 6th) -Ataxia -Incontinence -Dementia -Bradycardia -Hypertension

Question 669

Patient presents with headache and has a shunt, what are you most suspicious of?

Answer 669

Hydrocephalus

Question 670

What is meant by Sunsetting eyes?

Answer 670

Sign of raised intracranial pressure where by the pupils are pointing downwards (can't look up)

Question 671

What is meant by shock?

Answer 671

Life threatening condition where there is impairment of oxygenation of numerous organs

Question 672

Give examples of Ischaemic conditions.

Answer 672

-TIA -Stable angina -Intestinal angina / Mesenteric Ischaemia Intermittent claudication

Question 673

What is an Endarterectomy?

Answer 673

Removal of atheroma in the endothelium -might be offered to a patient with an atheroma causing a TIA

Question 674

What is meant by Vasculitis?

Answer 674

Group of diseases where there is inflammation of blood vessels due to idiopathic or autoimmune (don't know cause) Examples: -Cutaneous vasculitis (vasculitis rash) -systemic (multiple organs) -Kidneys : Heilim F Purpura -Vasculitis of brain = strokes (cause for younger people)

Question 675

What is the most common cause of Haemorrhagic strokes?

Answer 675

Hypertension

Question 676

What is meant by an Arteriovenous malformation?

Answer 676

A congenital abnormal tangle of arteries and veins within the brain or on the surface, INCREASING risk of bleeding

Question 677

What genetic condition is known for increasing the risk Berry Aneurysms?

Answer 677

Autosomal dominant polycystic kidney disease

Question 678

What does Congo Red positive deposition mean?

Answer 678

Amyloid deposition

Question 679

What is the definition of Parkinson's disease?

Answer 679

Neurodegenerative disorder characterised by resting tremor, rigidity and bradykinesia.

Question 680

What is the pathophysiology of Parkinson's?

Answer 680

Degeneration and loss of DOPAMINERGIC NEURONS in the SUSTANTIA NIGRA which is associated with accumulation of protein.

Question 681

What protein accumulates in the Substantia Nigra in Parkinson's disease?

Answer 681

Alpha-Synuclein protein

Question 682

What is the difference between Bradykinesia and Hypokinesia?

Answer 682

Brady = slowness of movements Hypo- absence of movements

Question 683

What is the presentation of Parkinson's?

Answer 683

1.Bradykinesia 2.Hypokinesia 3.Stiffness / Rigidity (lead pipe and cogwheel) 4.Pill rolling tremor resting tremor (improves on moving)

Question 684

Give examples of signs of hypokinesia?

Answer 684

-Reduced facial expression -Arm swing -Blinking -Slow, shuffling gait -Difficulty to turn in bed -Difficulty with fine movements e.g handwriting, buttoning clothes

Question 685

What does micrographia mean?

Answer 685

-Difficulty with fine movements e.g handwriting, buttoning clothes

Question 686

What are 3 specifically LATE signs of Parkinson's Disease?

Answer 686

-Postural hypotension -Tendency to fall backwards -Dementia and psychosis

Question 687

What is the criteria for diagnosing Parkinson's?

Answer 687

Bradykinesia + one of the following: -Muscular rigidity -Fine rest tremor -Postural instability

Question 688

What is the first line management for a patient with Parkinson's disease and what is the main consideration before prescribing?

Answer 688

Levodopa -Whether their symptoms affect their daily life (don't prescribe otherwise)

Question 689

What is the management for patients with Parkinson's when their symptoms aren't severe?

Answer 689

Dopamine agonist (Pramipexole / Ropinirole)

Question 690

A patient has been using Levodopa after their diagnosis of Parkinson's yet they have developed motor fluctuations, what is the next management step?

Answer 690

Adjuvant therapy e.g Entacapone or Tolcapone (Dopamine agonists)

Question 691

What medication should be given with Levodopa to Parkinson patients to reduce peripheral side effects?

Answer 691

Dopa-decarboxylase inhibitors e.g Carbidopa

Question 692

What is the cause of Amyotrophic lateral sclerosis (ALS)?

Answer 692

Neurodegenerative disorder that is mainly idiopathic but 10% of cases are linked to familial causes (genes).

Question 693

Describe a classical presentation of ALS.

Answer 693

-Lower motor signs in the upper limbs -Upper motor signs in the lower limbs -Progression of symptoms to other parts of the body e.g face (bulbar).

Question 694

What is the least common type of onset of ALS?

Answer 694

Bulbar onset whereby the symptoms start in the face before the limbs

Question 695

What is the management for ALS?

Answer 695

Riluzole (glutamate antagonist to slow progression of disease and lengthen lifespan) -NOTE: NOT a cure

Question 696

What is the leading cause of death in ALS patients?

Answer 696

Respiratory failure due to progressive muscle weakness and atrophy

Question 697

List the cranial nerves. Remember Mneumonic.

Answer 697

Oh Oh Oh To Touch And Feel Very Giant Volcanos Ahhh Hot! 1. Olfactory (I) 2. Optic (II) 3. Oculomotor (III) 4. Trochlear (IV) 5. Trigeminal (V) 6. Abducens (VI) 7. Facial (VII) 8. Vestibulocochlear (VIII) 9. Glossopharyngeal (IX) 10. Vagus (X) 11. Accessory (XI) 12. Hypoglossal (XII)

Question 698

Which cranial nerves are motor, sensory or both? Remember mneumonic.

Answer 698

Some Say Marry Money But My Brother Says Big Brains Matter More I Sensory II Sensory III Motor IV Motor V Both VI Motor VII Both VIII Sensory IX Both X Both XI Motor XII Motor

Question 699

What is Progressive bulbar palsy?

Answer 699

Neurodegeneration of the nerves supplying the face presenting as facial weakness in swallowing, talking or chewing.

Question 700

Is Progressive bulbar palsy lower or upper motor neurone issue and cranial nerves are affected?

Answer 700

Lower : IX Glossopharyngeal X Vagus XII Hypoglossal

Question 701

What are the key clinical signs of Progressive bulbar palsy?

Answer 701

-Absent jaw jerk / Gag reflex -Tongue wasting

Question 702

What is the management for progressive bulbar palsy?

Answer 702

No cure, just supportive

Question 703

What is Pseudobulbar palsy and how is it different from progressive bulbar palsy?

Answer 703

Neurodegenerative UPPER motor (not lower as in Progressive bulbar palsy) affecting the face.

Question 704

What cranial nerves are affected by Pseudobulbar palsy?

Answer 704

IX, X, XII

Question 705

What are the clinical signs of Pseudobulbar palsy?

Answer 705

-Tongue muscles and speech are SPASTIC -HYPER-reflexic of jaw jerk and gag reflex

Question 706

What is Hereditary Spastic Paraplegia?

Answer 706

Group of genetic disorders causing progressive muscle SPASTICITY and disordered gait in LOWER limbs due to AXONAL DEGENERATION with varying levels of disability but NORMAL LIFE EXPECTANCY

Question 707

What is meant by Hemisballismus?

Answer 707

Rare disorder causing LARGE INVOLUNTARY FLINGING MOVEMENTS of one half of the bodyWhat are t

Question 708

he causes of Hemisballismus?

Answer 708

-Contralateral stroke -Traumatic injury -ALS

Question 709

What is Benign Essential Myoclonus and what is the possible treatment?

Answer 709

Sudden involuntary twitching / jerks which is not present as a feature of other illnesses such as epilepsy usually presenting in childhood or adolescence =Clonasepam or Sodium Valproate

Question 710

What is the genetic cause of Huntington's disease?

Answer 710

CAG triplet repetition found on the HTT (Huntington) Gene located on chromosome 4.

Question 711

When is the usual onset of Huntingtons?

Answer 711

30-50s

Question 712

What is the presentation of Huntington's Disease?

Answer 712

-Depression (may be first sign) -Chorea -Poor coordination -Dysarthria -Dysphagia -Jerky eye movements

Question 713

What is meant by Chorea?

Answer 713

Abnormal involuntary movements (such as fidgeting, involuntary vocalisation etc)

Question 714

What is the prognosis of Huntington's?

Answer 714

20 years from onset of symptoms :(

Question 715

What is the management of Huntington's?

Answer 715

Benzodiazepines (for Chorea and depression)

Question 716

What is the inheritance of Friedreich ataxia?

Answer 716

Autosomal recessive

Question 717

What is the genetics of Friedreich ataxia?

Answer 717

Autosomal recessive mutation in the Frataxin gene on chromosome 9.

Question 718

When is the onset of Friedreich ataxia?

Answer 718

Teens and twenties

Question 719

Describe the typical presentation of Friedreich ataxia.

Answer 719

-Progressive ataxia -Weakness -Loss of proprioception and joint position

Question 720

What disorders is Friedreich ataxia associated to?

Answer 720

-Pes Cavus -Hypertrophic Cardiomyopathy -Arrythmias -Scoliosis -Visual disturbances -Diabetes Mellitus

Question 721

What is meant by mononeuropathy?

Answer 721

Neuropathy affecting one particular nerve

Question 722

What is meant by polyneuropathy?

Answer 722

Multiple nerves affected within a region

Question 723

What is meant by mononeuritis multiplex?

Answer 723

Multiple nerves affected in different locations in the body

Question 724

What medication is associated with the development of Peripheral Neuropathy?

Answer 724

Isoniazid (for TB) Vincristine /Vinblastine (Chemotherapy)

Question 725

List the disorders causing sensory peripheral neuropathy.

Answer 725

-Diabetes Neuropathy -VitB12 deficiency -Alcohol -Leprosy -Vasculitis

Question 726

List the disorders causing motor peripheral neuropathy.

Answer 726

-Guillain-Barre syndrome -Hereditary Sensorimotor neuropathies -Lead poisoning

Question 727

Give symptomatic examples of autonomic neuropathy.

Answer 727

-Urinary retention -Impotence -Sweating -Sweating -Tachy or bradycardia -GI disturbances

Question 728

What is the cause of Guillain-Barre syndrome?

Answer 728

Prior infection with Campyykibacter Jejuni.

Question 729

What is the most common subtype of Guillain Barre in Asia?

Answer 729

Miller-Fisher syndrome

Question 730

What antibodies are present in Miller Fisher syndrome?

Answer 730

Anti-GQ1b

Question 731

What is the most common subtype of Guillain Barre syndrome (worldwide)?

Answer 731

Acute Immune Demyelinating Polyneuropathy

Question 732

Who is most likely to be affected by Guillian Barre syndrome?

Answer 732

Men at the age of 40

Question 733

List the clinical features of Guillain Barre Syndrome.

Answer 733

1.Weakness =Symmetrical, Bilateral and Ascending (sensory) paralysis 2.Sensory disturbances =Paraesthesia in distal extremities =Absent or reduced motor reflexes (lower motor signs) 3.Pain =Back, limb or neuropathic pain 4.Autonomic dysfunction =Sweating, urinary retention etc 5.Respiratory muscle paralysis

Question 734

Describe the weakness symptoms of Guillian Barre Syndrome.

Answer 734

-Symmetrical and Bilateral -Ascending weakness

Question 735

Where are the sensory disturbances felt in Guillian-Barre Syndrome?

Answer 735

Distal extremities (Hands and Feet)

Question 736

How is Guillain-Barre Syndrome diagnosed?

Answer 736

Based on clinical observations But if unclear: +Pulmonary function tests +Anti-ganglioside antibodies or GQ1B antibodies for Miller-Fisher

Question 737

What is the management of Guillain-Barre?

Answer 737

-IV Immunoglobulin exchange +Symptom control

Question 738

A patient has Guillian-Barre. What is the criteria for admitting the patient to the Intensive Care Unit?

Answer 738

Flow Volume <1.5L

Question 739

What type of drug can cause a delay in recovery from Guillian-Barre?

Answer 739

Corticosteroids

Question 740

What is the prognosis for Guillian-Barre?

Answer 740

Great- most recover fully but 10% DIE from respiratory complications

Question 741

What drugs are contraindicated in patients with Charcout-Marie-Tooth Disease?

Answer 741

-Isoniazid (TB) -Vincristine (Chemotherapy)

Question 742

What is Charcot-Marie-Tooth Disease?

Answer 742

Group of hereditary sensory AND motor neuropathies

Question 743

What is the inheritance of Charcot-Marie-Tooth Disease?

Answer 743

Autosomal Dominant

Question 744

What is the classical presentation of Charcot-Marie-Tooth Disease?

Answer 744

-Lower limb muscle weakness and wasting -Champagne bottle legs (redness and compression above ankle to below knee looking like an inverted champagne bottle) -Foot drop -Small muscle wasting of the hand causing 'claw hand' (small fingers curled in) -Pes Cavus -Neuropathic pain

Question 745

What is meant by Pes Cavus?

Answer 745

Abnormally high plantar longitudinal arch (i.e the arch of the foot between heel and toe is pronounced)

Question 746

How is the diagnosis of Charcot-Marie-Tooth Disease confirmed?

Answer 746

Nerve conduction studies or genetic testing

Question 747

What is the genetic pathology of Charcot-Marie-Tooth Disease?

Answer 747

Duplication mutation of the short arm of chromosome 17 effecting mitochondrial proteins which are required for axons and schwann cells for optimal nerve functioning

Question 748

What is the pathophysiology of Myasthenia Gravis?

Answer 748

Autoimmune condition affecting the Acetylcholine receptors at the neuromuscular junctions due to attack by autoantibodies therby decreasing the regularity of action potenital generation causing progressive muscle weakness .

Question 749

Who is most likely to suffer from Myasthenia gravis?

Answer 749

Women in their 30-40s

Question 750

If men are affected by Myasthenia Gravis, what age is the usual onset?

Answer 750

60s (different from women)

Question 751

What other disorders is Myasthenia Gravis associated with?

Answer 751

-Thymomas -Thymic Hyperplasia

Question 752

What is the classical presentation of Myasthenia Gravis ?

Answer 752

-Bilateral Ptosis or Diplopia -Limb weakness or general weakness -Myasthenic 'snarl' upon smiling -Voice becomes softer counting to 50 =Better in mornings, worse in evenings and with exercise / activity

Question 753

How is muscle tone, wasting and reflexes affected in Myasthenia Gravis ?

Answer 753

Not affected! :) (because this isn't an upper or lower, but a neuromuscular junction issue)

Question 754

What can worsen symptoms of Myasthenic Gravis?

Answer 754

-Emotional distress -Pregnancy -Certain Medications -Intercurrent disease (other disease at same time)

Question 755

What symptoms are seen upon worsening and progression of Myasthenia Gravis ?

Answer 755

-Dysphagia -Respiratory Compromise

Question 756

What is Lambert Eaton Myasthenic Syndrome and how is different to Myasthenia Gravis ?

Answer 756

Another neuromuscular junction issue - Calcium channels affected in LE while Acetylcholine channels affected in MG Remember mneumonic: Early Learning Centre (Eaton Lambert - Calcium) Make America Great Again (MyAsthenia Gravis - Acetylcholine)

Question 757

What is strongly associated with Lambert-Eaton Myasthenic Syndrome?

Answer 757

Small Cell Lung Cancer

Question 758

What test is done to differentiate between Myasthenia Gravis and Lambert Eaton Myasthenic Syndrome?

Answer 758

3,4 Diaminopyrodine treatment to detect antibodies to voltage gated calcium channels.

Question 759

A patient comes into the emergency department with symptoms typical of Myasthenia Gravis. What is a simple test to detect your suspicions?

Answer 759

Ice test: Ice held against patient's eye should reduce ptosis has the cold reduces the breakdown of acetylcholine by acetylcholinesterase at the neuromuscular junction.

Question 760

What is the diagnostic process for Myasthenia Gravis ?

Answer 760

-Autoantibody detection (85% of patients will have this) -Pulmonary function tests -CT scan of thorax (to exclude thymomas)

Question 761

What is the management of Myasthenia Gravis ?

Answer 761

1.Pyridostigmine (anticholinesterase inhibitor) =Improves muscle weakness 2.Immunosupression -->Short term: Steroids -->Relapses: Cyclosporin, Methotrexate, Azathioprine, 3.Conisder Thymectomy

Question 762

What is meant by muscular dystrophies?

Answer 762

Genetic conditions causing progressive muscular weakness, degeneration and wasting.

Question 763

What is the inheritance for Duchenne Muscular Dystrophy and where is the mutation?

Answer 763

X linked recessive =mutation in the dystrophin gene (which is a protein required in muscles)

Question 764

What is the difference in pathophysiology between Duchenne Muscular Dystrophy and Becker's Muscular Dystrophy?

Answer 764

Duchenne is a complete ABSENCE of the Dystrophin protein while Becker's is disordered production of the protein and therefore less severe.

Question 765

When is the onset of Duchenne Muscular Dystrophy?

Answer 765

Before the age of 4

Question 766

What is the presentation of Duchenne Muscular Dystrophy?

Answer 766

-Delayed milestones (e.g speech and language) -Gait abnormalities -Proximal myopathy and wasting -Calf pseudohypertrophy

Question 767

What is the Gower's sign and what does it indicate?

Answer 767

When a child has to use their hands and arms to arrive at the standing position indicates Duchenne Muscular Dystrophy.

Question 768

What is the diagnostic procedure for Duchenne Muscular Dystrophy?

Answer 768

Based on clinical observations Note: Elevated Creatinine Kinase will be seen in bloods

Question 769

What is the prognosis of Duchenne Muscular Dystrophy?

Answer 769

Poor, few patients survive past young adulthood :(

Question 770

What is the mode of inheritance of Becker Muscular Dystrophy?

Answer 770

X linked recessive

Question 771

What is the presentation of Becker Muscular Dystrophy and when is it usually diagnosed?

Answer 771

Similar presentation to Duchenne Muscular Dystrophy but LESS SEVERE. =usually diagnosed in adolescence

Question 772

What is the advice given to a patient with Becker Muscular Dystrophy?

Answer 772

Exercise regularly and optimise nutrition

Question 773

What is a common complication of Becker Muscular Dystrophy?

Answer 773

Dilated Cardiomyopathy (enlarged heart chambers than can't contract)

Question 774

What is Myotonic Dystrophy?

Answer 774

Autosomal dominant disorder causing progressive muscle weakness and muscle wasting.

Question 774

What additional tests should be done after a diagnosis of Becker Muscular Dystrophy?

Answer 774

Cardiovascular function test to check for Dilated Cardiomyopathy

Question 775

What is the difference between type 1 and type 2 Myotonic Dystrophy?

Answer 775

Type 1 is congenital and SEVERE while type 2 is much milder

Question 775

What is the presentation of Myotonic Dystrophy?

Answer 775

-Prolonged muscle contractions (impairment of muscle relaxation) -Muscle wasting and weakness particularly head (TEMPORAL) and NECK -Endocrine abnormalities (insulin resistance and fronto-temporal male pattern baldness) -Heart block or Cardiomyopathy

Question 776

What is Tuberous Sclerosis?

Answer 776

Autosomal Dominant causing both systemic and neurocutaneous abnormalities .

Question 777

Describe the neuropathic pain in Multiple Sclerosis.

Answer 777

-Stabbing, tingling pain -Feelings of being 'hugged' around trunk

Question 778

What is the most common type of Multiple Sclerosis?

Answer 778

Relapsing-Remitting MS (rather than Secondary Progressive)

Question 779

Describe the pattern of Secondary Progressive Multiple Sclerosis.

Answer 779

-Follows initial course of Relapsing Remitting -Constant symptoms that worsen Note: This is the least occurent form

Question 780

Name examples of Demyelinating disease.

Answer 780

-Multiple Sclerosis -Neuromyelitis Optica -Acute Disseminated Encephalomyelitis

Question 781

Name 2 metabolic disorder differentials for Multiple Sclerosis.

Answer 781

-Vit B12 deficiency -Adult-onset leukodystrophies

Question 782

Name 2 infections that are differentials for Multiple Sclerosis.

Answer 782

-Lyme Disease -Tropical Spastic Paraparesis

Question 783

Name 2 systemic disorders that are differentials for Multiple Sclerosis.

Answer 783

Lupus Sarcoidosis

Question 784

What 2 malignant conditions are differentials for Multiple Sclerosis?

Answer 784

-Neostatic Brain Lesions -Paraneoplastic syndromes

Question 785

List the causes of folate acid deficiency.

Answer 785

-Medications -Phenytoin (anti-convulsant) -Methotrexate (Rheumatoid arthiritis) -Pregnancy -Alcohol excess

Question 786

Describe the presentation of folate / B12 deficiency.

Answer 786

-Cognitive impairment -Dementia -Peripheral neuropathy -Degeneration of the spinal cord

Question 787

What is important to note when deciding on the treatment for a patient with both a folate and B12 deficiency?

Answer 787

Giving folate before B12 supplementation can cause a SUBACUTE DEGENERATION of the spinal cord (demyelination of the spinal cord worsening and causing severe neurological problems)

Question 788

When are pregnant women considered high risk for their babies getting a neural tube defect?

Answer 788

-Phenytoin medication -Methotrexate (Rheumatoid arthiritis and Chron's disease) -Coeliac disease -Diabetes -Thalassaemia -Obese (BMI >30)

Question 789

A pregnant woman is on Methotrexate for her Chron's disease. What needs to be considered?

Answer 789

Methotrexate can increase risk of neural tube defect as it interferes with folate metabolism. =5mg of folic acid prescribed to be taken on days when she doesn't take her methotrexate.

Question 790

What is the importance of Folate?

Answer 790

Involved in synthesis of neurotransmitters

Question 791

What is the role of B12?

Answer 791

Involved in the production of myelin

Question 792

Is Motor Neuron Disease upper or motor neuron disorder?

Answer 792

Mixture of both!

Question 793

What is the most recognised side effect of Sodium Valproate?

Answer 793

Ataxia

Question 794

What factors would indicate a poorer prognosis of Multiple Sclerosis?

Answer 794

-Age (older) -Male -motor signs at onset -early relapses -many MRI lesions and axonal loss

Question 795

What is the only way to measure respiratory function in a patient with Guillian Barre?

Answer 795

Forced Vital Capacity at bedside

Question 796

What are the signs of a cerebellar stroke? Remember mneumonic.

Answer 796

DANISH Dysdiachokinesia Ataxia Nystagmus Intention tremor Slurred speech Hypotonia

Question 797

What is the first line treatment Myoclonic seizures?

Answer 797

Sodium Valproate

Question 798

What is the Macula of the eye?

Answer 798

Important for Central vision =Temporal to the optic disc where the blood vessels of the eye do not run

Question 799

What is the clinical sign of Central Artery Occulsion seen on Fundoscopy?

Answer 799

Cherry red pot

Question 800

Central artery occlusion, what happens and why?

Answer 800

As it is an end vessel, if there is a clot, it causes a Central Artery Occlusion (stroke of the eye)

Question 801

What is the definition of Papilloedema?

Answer 801

A swollen optic nerve specifically due to raised intracranial pressure

Question 802

What are the 2 layers of the retina (Retinal Pigmented Epithelium RPE) ?

Answer 802

Inner neural layer and outer pigmented layer

Question 803

What treatment is regularly used for these common conditions-Macula degeneration, Diabetic Retinopathy ?

Answer 803

Intravitreol injection (through the vitreos of the eye specifically the Ora Serota)

Question 804

Why is the Subretinal space (of the RPE) clinically important?

Answer 804

This is where water accumulates in Macula degeneration

Question 805

What do the tight junctions of the RPE transport into the retina of the eye?

Answer 805

Glucose, Retinal, Phospholipids (for making photoreceptors)

Question 806

How is light absorbed?

Answer 806

-A photon of light is absorbed by 11-cis retinal in the photoreceptors of the retina -11-cis retinal changes to all-trans and free opsin -All-trans is re-isomerised in the RPE

Question 807

What does Opsin (of the eye) do?

Answer 807

Closes sodium channels to hyperpolarise and cause an action potential to produce vision

Question 808

What does the RPE secrete?

Answer 808

VEGF promotes vascular leakiness

Question 809

What is Optical Coherence Tomography used for?

Answer 809

Bio marker for retinal disease =gives a histological like view of the retina without using a biopsy =Offered to all Macula degeneration patients

Question 810

What is the visual clinical sign of a Pituitary adenoma?

Answer 810

Bitemporal Hemianopia =Temporal vision fields affected (outer vision fields)

Question 811

Where do the optic nerves synapse?

Answer 811

Lateral Geniculate body

Question 812

What is the clinical sign of an occlusion of the Optic nerve?

Answer 812

ONE eye complete loss of vision

Question 813

What is the clinical sign of an occlusion from behind the optic chiasm?

Answer 813

Right Homonymous hemianopia (same side of each eye)

Question 814

When are Anti-VEGF injections commonly given?

Answer 814

Macula degeneration / diabetic eye disease (as it is due to an excess of VEGF) so treatment = anti-VEGFs required to save vision

Question 815

An MRI shows bilateral temporal hyperintensity. What does this indicate?

Answer 815

Herpes Simplex Virus causing Encephalitis

Question 816

Causes of conductive deafness ?

Answer 816

-Wax -Ruptured tympanic membrane -Otitis Media (e.g with Labyrinthitis) -Otosclerosis (sclerotic process which fuse the malleus and incus together so that they can no longer vibrate)

Question 817

Causes of sensorineural deafness?

Answer 817

-Cochlea degeneration from ageing -Sound pollution -Meniere's disease -Acoustic Neuroma -Tumours (VERY RARE)

Question 818

Rinnes and Weber's test: Sensorineural vs Conductive

Answer 818

Normal : Air better than bone conduction Conductive: Rinnes -ve = Bone>Air Weber=hearing better in one ear Sensorineural: Rinnes +Ve = Air>Bone Weber=

Question 819

What frequencies are lost in Sensorineural vs Conductive hearing loss?

Answer 819

Sensorineural: high frequencies Conductive: generalised frequencies

Question 820

Is dilation and constriction due to Para, or Sympathetic innervation?

Answer 820

Sympathetic - dilates Parasympathetic - constricts

Question 821

Is Horner's Syndrome ipsilateral or contralateral?

Answer 821

Ipsilateral

Question 826

Define mania

Question 827

Causes of mania

Answer 827

-Prednisolone -Cocaine -Ecstasy -HIV -Huntingotons -MS MND -Hyperthyroidism

Question 828

Typical presentation of bipolar disorder

Question 829

psychiatric symptoms of tumours

Answer 829

-older (can indicate and diff from bipolar) -any general psych pres

Question 830

Responding to hallucinations

Answer 830

acute psychosis

Question 831

Intoxication (Amphetamine/Cocaine/Meth)

Answer 831

abrupt severe psychological presentation =Benzodiazepines and supportive environment

Question 832

What neurotransmitter is behind psychosis usually?

Answer 832

Dopamine

Question 833

catatonic symptoms

Answer 833

-Mutism- not talking for hours on end -Catalepsy - bizarre postures that they will hold for hours -Stupour (inmobility) AND/OR Motor excitement -Echolalia =repeat what you say -Echopraxia = copy your movements

Question 834

Autoimmune Encephalitis antibodies

Answer 834

1.Look for antibodies (anti-NMDAR) 2.Sometimes won't show up so do a lumbar puncture for DEFINITIVE DIAGNOSIS

Question 835

Treatment

Answer 836

acute confused state

Question 837

Withdrawl states

Answer 837

Pregabalin Benzodiazepines Alcohol

Question 838

Withdrawal states symptoms

Question 839

Causes of catatonia

Answer 839

1Neurological causes -Autoimmune encephalitis -CNS infection -Metabolic disturbance -Withdrawl state 2.Schitzoprenia

Question 840

First line investigations for psychiatric-like presentation.

Answer 840

Rule out neurological causes -Bloods (anti-NMDAR -MRI -EEG -Lumbar puncture

Question 841

Treatment for Catatonia

Answer 841

-Lorazepam challenge (high dose: 8-16mg) -If it doesn't work: ECT

Question 842

Neurotic personality

Answer 842

Always anxious and particular

Question 843

Medication Causes of anxiety

Answer 843

-Dominergic agents (parkinsons) -Phenytoin -B2 agonists (salbutamol) -Stimulants (Phenylephrine for adhd) -Thyroxine

Question 844

Conditions causing anxiety

Answer 844

-Complex partial seizures -Dementia -Migraine Arrhythmias Mitral valve prolapse Pulmonary Emboli Phaeochromocytoma Hypoglycaemia Hyperthyroidism

Question 845

Reversible causes of dementia

Answer 845

B12 and folate Hypothyroidism Wilson's disease (serum copper) HIV Syphilis serology Chronic alcoholism (Korsokoff syndrome)

Question 846

Delirium vs Dementia vs Psychosis

Answer 846

Delerium is abrupt and consciousness fluctuates with prominent VISUAL HALLUCINATIONS which is not like Dementia (no visual and it is constant throughout the day)

Question 847

Visual hallucinations

Answer 847

Not common feature so points to organic cause (underlying condition)

Question 848

Multiple Sclerosis

Answer 848

dperession and anxiety

Question 849

Post ictal

Answer 849

~Temporal epilepsy =suicidal and high risk of violence

Question 850

Parkinsons

Answer 850

visual and auditory hallucinations psychosis

Question 851

Vast majority are auditory hallucinations so otherwise points to neurological

Question 852

Confusion / disorientation points to neurological as this is not present in psychiatric illnesses

Question 853

Age of onset

Answer 853

younger (older points to neurological)

Question 855

First presentation of psychosis investigations

Answer 855

MRI/CT head and EEG

Question 856

Dissociative neurological symptoms / Conversion disorder

Answer 856

Any psychiatric symptom which is related to physical injury or childhood abuse /neglect

Question 857

Fugue

Answer 857

Amnesia - no memory and turns up somewhere else

Question 858

Semantic memory

Answer 858

Facts

Question 859

Dissociative Amnesia

Answer 859

Acute onset of memory loss after traumatic events

Question 860

Hydochondriacal disorder

Answer 860

-overriding preoccupation of health worry

Question 861

Management for Hypochondriacal disorder

Answer 861

CBT

Question 862

Chronic Fatigue

Answer 862

Not really known ~ Viruses (EBV, Herpes) ~Psychological trauma ~IBS ~Fibromyalgia

Question 868

What is a Functional Neurological disorder?

Answer 868

Neurological symptoms that can't be explained and are reversible e.g seizures

Question 869

What is meant by functional seizure?

Answer 869

Seizures do to psychological cause that can go on for a long time and not cause any damage

Question 870

Triggers for Functional Neurological disorder?

Answer 870

-Illness -Traumatic event

Question 871

What is meant by a Functional tremor ?

Answer 871

High amplitude tremor that can stop with distractions I.e caused by psychological issues rather than a condition such as Parkinson's

Question 872

What drugs can cause Drug induced Parkinson's?

Answer 872

Causes: Schitzophrenia - antipsychotics (Haloperidol) Prochlorperazine - long term vertigo

Question 873

When is parkinson's referred as genetic and not sporadic/idiopathic?

Answer 873

First-degree relative or early onset

Question 874

How to tell between drug induced and idiopathic parkinsons?

Answer 874

DAT scan in idiopathic will have neurodegeneration while drug induced will be normal (as all that is affected is dopmine blockade rather than neurodegeneration)

Question 875

What is meant by Lewy Body Dementia?

Answer 875

triad of dementia, parkinsonism and visual hallucinations

Question 876

Atypical Parkinsonism

Answer 876

Doesn't respond to levodopa and therefore has a high mortality rate and lower prognosis

Question 877

Deep brain stimulation for Parkinsons (also look into what the NICE guidelines / indications are in the uk)

Answer 877

Subthalamic Nucleus targeted

Question 878

Delusion definition

Answer 878

Fixed false belief without reason

Question 879

Delerium

Answer 879

Acute fluctuating disturbance of attention and awareness with impairment in cognition

Question 880

Hallucinations

Answer 880

PEricieved without stimuli

Question 881

Psychosis

Answer 881

All of the above (delusion, delerium and hallucinations)

Question 882

Meaning of extracampine

Answer 882

presence always with them (not always negative could be positive like a dead parent so wouldn't be treated)