Neurology

Question 1

What are the 5 most common causes of childhood headaches?

Answer 1

1) Migraine
2) Episodic tension headache
3) Chronic daily headache
4) Idiopathic stabbing headache
5) Post-traumatic headache
6) Other secondary headache
- sinusitis
- post-infective
- Arnold-Chiari Type 1 Malformation
- Cerebellar astrocytoma

Question 2

What are are 5 causes of raised ICP?

Answer 2

1) Posterior fossa tumours
2) Obstructive hydrocephalus
3) Meningitis, encephalitis, cerebral abscess
4) Subdural hematoma
5) Idiopathic intracranial hypertension

Question 3

What are 3 symptoms that are suggestive of a secondary cause of headaches?

Answer 3

1) OSA
2) Visual acuity issues
3) Allergic rhinitis/ sinusitis

Question 4

What are 3 symptoms that are suggestive of a primary cause of headaches?

Answer 4

1) Irregular meals
2) Insufficient sleep
3) Stress

Question 5

What are the migraine preventers and when are they indicated?

Answer 5

When:
- >2 headaches a month/ multiple missed school days/month
- affecting overall functioning
- to decrease severity/ frequency until behavioural treatment alone can sustain this response

1) ↓BP drugs (eg. propanolol, flunarizine)

2) TCAs (eg. amitriptyline

3) Anti-seizures (eg. topiramate, sodium valproate)

Question 6

What are acute/ impatient treatments for migraine?

Answer 6

1) Ibuprofen > acetaminophen
2) Triptans
3) Status migrainosus:
- opiates
- IV hydration
- anti-emetics
- sodium valproate

Question 7

What are the non-pharmacological treatments for migraines?

Answer 7

1) Removal of stressors
2) Exercise program
3) Dietary adjustment
4) Sleep hygiene

Question 8

What are the steps of a gait examination?

Answer 8

1) Normal walking
2) Running
3) Tiptoe
4) Walk on heels
5) Tandem gait
6) Gower’s sign/scapular winging
7) ±Walking on outer border of feet (peroneal weakness)

Question 9

What are the signs of facial weakness?

Answer 9

1) Inability to bury eyelashes
2) Inability to whistle

Question 10

What are the signs of ocular weakness?

Answer 10

1) Double vision
2) Ptosis

Question 11

What is the tool for headache disability scoring?

Answer 11

PedMIDAS
- based on school days and activities affected

Question 12

What are the signs of bulbar weakness?

Answer 12

1) Nasal speech
2) Poor sucking/swallowing

Question 13

What are the signs of neck weakness?

Answer 13

Poor head control

Question 14

Why do patients with waddling gait often show hyperlordosis?

Answer 14

To compensate for pelvic weakness

Question 15

What are the signs of trunk weakness?

Answer 15

1) Lordosis
2) Scoliosis
3) Difficulty sitting up

Question 16

What are the signs of shoulder girdle weakness?

Answer 16

1) Scapular winging
2) Difficulty lifting

Question 17

What are the signs of forearm/hand weakness?

Answer 17

Inability to clench fist

Question 18

What are the signs of pelvic girdle weakness?

Answer 18

1) Waddling gait
2) Gower’s sign

Question 19

What are the signs of leg/foot weakness?

Answer 19

1) Foot drop
2) Difficulty heel/toe walk

Question 20

What are the signs of respiratory weakness?

Answer 20

Use of accessory muscles

Question 21

What are 2 central causes of weakness?

Answer 21

1) Chromosome abnormalities
- down syndrome
- prader willi

2) Genetic defects

3) Chronic non-progressive encephalopathy (evolving CP)

Question 22

What are 4 peripheral causes of weakness?

Answer 22

1) Anterior horn cell
- Cong: SMA
- Acq: polio, west nile

2) Peripheral nerve
- Cong: HSMN/CMT
- Acq: Toxins, GBS, leprosy

3) N-M junction
- Cong: Myasthenia Gravis
- Acq: botulism, OP poisoning

4) Muscle
- Cong: myopathy, dystrophy
- Acq: endocrine/toxic myopathies, myositis

Question 23

What is the pattern of weakness and reflexes in central causes of weakness?

Answer 23

Mostly arms and legs
- proximal MIGHT be > distal

Normal/↑ reflexes

± seizures, delayed development

Question 24

What is the pattern of weakness and reflexes in anterior horn cell pathologies causing weakness?

Answer 24

Very weak legs and arms
- face only late stage
- MIGHT be proximal
- areflexia

±Tongue fasciculation

Question 25

What is the pattern of weakness and reflexes in peripheral nerve weakness?

Answer 25

Arm and leg weakness - no facial weakness Distal>proximal - ±sensory deficit, ↑ICP, ↓NCV, abnormal nerve biopsy

Question 26

What is the pattern of weakness and reflexes in neuromuscular junction weakness?

Answer 26

Face, arm and leg weakness - proximal=distal - normal reflexes Response to edrophonium: MG Fixed pupils: botulism

Question 27

What is the pattern of weakness and reflexes in myopathic weakness?

Answer 27

Arms, legs maybe face - Proximal > Distal ↓Reflexes - ↑CK

Question 28

What are 4 Ix for muscle weakness?

Answer 28

1) CK - ↓sens if IM injections, EMG 2) Aldolase, AST/ALT 3) EMG/NCS - Myopathy: brief small amplitude polyphasic potentials - Neuropathy: denervation potentials at rest (fibrillations, fasciculations, sharp waves); motor unit potentials that are large, prolonged, and polyphasic - Repetitive nerve stimulation for neuromuscular junction disorders 4) Genetic testing 5) Muscle biopsy 6) Nerve biopsy 7) Tensilon test 8) MRI brain

Question 29

What is the normal range of serum CK?

Answer 29

200-300

Question 30

What is the first line treatment for DMD?

Answer 30

Steroids

Question 31

What is the inheritance pattern of DMD?

Answer 31

XLR

Question 32

What are the preventative and surveillance measures for DMD?

Answer 32

1) Cardiac (cardiomyopathy) - ACEi for LV function 2) Respi (nocturnal hypoventilation) - non-invasive respi support 3) Orthopedic (contractures, scoliosis) - external support, internal fixation (scoliosis surgery)

Question 33

What is a tic?

Answer 33

Abnormal extra movement/vocalisation - fast, sudden, repetitive - stereotypical, partly involunary - able to exert some control - experience premonitory urge - can occur during sleep

Question 34

How are tics managed?

Answer 34

1) Educate parents/school - neurological disorder, cannot help it - do not damage brain - 1/3 resolve, 1/3 improve but remain, 1/3 worsen - peak 10-12, most outgrow by adult 2) Pharmacological - eg. clonazepam, risperidone, clonidine - screen for OCD, ADHD

Question 35

Tremor i) Rhythmicity ii) Speed iii) Stereotypical/variable iv) Suppressibility v) Other features

Answer 35

i) Yes ii) Fast iii) Stereotypical iv) No v) Sinus

Question 36

Chorea: i) Rhythmicity ii) Speed iii) Stereotypical/variable iv) Suppressibility v) Other features

Answer 36

i) No ii) Fast iii) Variable iv) No v) "dance-like", jerky

Question 37

Athetosis: i) Rhythmicity ii) Speed iii) Stereotypical/variable iv) Suppressibility v) Other features

Answer 37

i) No ii) Continuous writhing iii) Variable iv) No v) Usually occurs with chorea

Question 38

Dystonia: i) Rhythmicity ii) Speed iii) Stereotypical/variable iv) Suppressibility v) Other features

Answer 38

i) No ii) Slow and sustained iii) Stereotypical iv) No v) Twisting

Question 39

Myoclonus: i) Rhythmicity ii) Speed iii) Stereotypical/variable iv) Suppressibility v) Other features

Answer 39

i) Not usually ii) Fast iii) Stereotypical iv) No v) "shock-like", regional

Question 40

Stereotypies i) Rhythmicity ii) Speed iii) Stereotypical/variable iv) Suppressibility v) Other features

Answer 40

i) Sometimes ii) Variable iii) Stereotypical iv) Sometimes v) Flapping, excitement and stimulation

Question 41

Tics: i) Rhythmicity ii) Speed iii) Stereotypical/variable iv) Suppressibility v) Other features

Answer 41

i) No ii) Fast iii) Stereotypical iv) Yes v) Preceded by an urge/ sensation

Question 42

What are the types of febrile seizures?

Answer 42

1) Simple 2) Complex - seizure lasting > 15mins - seizures which is focal - >1 seizures in 24hr

Question 43

What is the clinical significance of complex febrile fits?

Answer 43

1) Higher risk of epilepsy later on in life 2) Risk of complex partial epilepsy from medial temporal sclerosis 3) Highest risk in those with focal seizures

Question 44

What is the rate or recurrence of febrile fits and associated risk of epilepsy in children?

Answer 44

Recurrence risk: after 1st: 25-50% after 2nd: 50% - most recur within 6-12mths (20% within same febrile illness) Epilepsy risk: - 2-3% (baseline 1%) - ↑ if FHx, abnormal development, complex febrile seizures

Question 45

What are the clinical features of meningitis?

Answer 45

Non-specific 1) Fever 2) Lethargy 3) Irritability 4) Vomiting Specific: 1) Headaches 2) Photophobia 3) Seizures 4) Bulging fontanelle 5) Neck stiffness 6) Kernig's sign

Question 46

How does the clinical presentation of meningitis differ in neonates and young infants?

Answer 46

Minimal and subtle - fever, lethargy, irritability - respi distress - jaundice - poor feeding, vomiting, diarrhea - convulsion, bulging fontanelle

Question 47

What should you do in the event on a seizure?

Answer 47

Lie patient on flat surface → roll to size to clear airway → lift jaw up to extend head - remove nearby objects, loosen tight clothing - cushion head - note time, duration and nature (can film) DO NOT - put anything in mouth - restrain him - inflict pain/apply pressure on neck

Question 48

What are 3 medications for acute seizure control in children?

Answer 48

1) Rectal diazepam 2) IV lorazepam 3) Buccal midazolam

Question 49

When is rectal diazepam indicated?

Answer 49

Seizure/cluster >5mins - may take 5-10 min to work (keep on side and hold butt together to prevent leak) - can be repeated