Neurology (4) Flashcards by E E

What is Frank’s sign? What is it a sign of?

Diagonal earlobe crease from tragus to rear auricle – it is a sign of diabetes mellitus and cardiovascular disease (IHD)

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What are the two main questions you must consider with any neurological condition?

What is the problem?
Where is the problem?
- Brain (BS, cerebellum), SC, nerve roots, peripheral nerves, NMJ, muscle

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List a surgical sieve that you can use to consider different types of causes of neurological symptoms.

Vascular 
Infection (subacute Hx)
Inflammation/Autoimmune
Toxic/Metabolic
Tumour/Malignancy

Hereditary/Congenital (Pes Cavus)

NOTE: INVITED MD can also be used (infection, neoplasia, vascular, inflammatory/autoimmune, trauma, endocrine, degenerative - Parkinson’s, metabolic, drugs)

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List the order in which different optic nerve functions are tested in a neurological examination.

Visual acuity (count fingers, hand movements, light perception)
Visual fields
Pupillary reflexes
Fundoscopy

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Main features of upper motor neurone lesions

Hyperreflexia
Hypertonia (spasticity)
Upgoing plantars
Reduced power

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Main features of lower motor neurone lesions

Hyporeflexia
Hypotonia (flaccid)
Wasting 
Reduced power 
Fasciculations

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Where is the lesion likely to be in a patient with widespread bilateral derangement of motor function?

Neuromuscular junction

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Name an important condition that causes loss of motor function in which the lesion is at the level of the neuromuscular junction.

Myasthenia gravis – autoantibodies against nicotinic acetylcholine receptors

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What is Lambert-Eaton syndrome caused by?

Defect in the calcium channel on the presynaptic membrane involved in vesicular exocytosis
Similar symptoms to myasthenia gravis

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What is a major risk factor for botulism?

IV drug use (expecially under the skin - skin popping –> skin abscess)
Botox inhibits ACh release so affects a wider range

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Describe the test used to confirm a diagnosis of botulism.

Bioassay – two mice are injected with a serum sample from the patient, and one of the mice is given the botulinum antitoxin. If the mouse without the antitoxin dies, it is botulism

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Describe the neurological signs seen in the examination of a patient with botulism.

LMN lesion signs:
Hyporeflexia
Hypotonia
Reduced power

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What are the six main features of cerebellar disease?

DANISH

Dysdiadochokinesia
Ataxia
Nystagmus
Intention tremor (Dysmetria, pass-pointing)
Scanning speech (+ slurred)
Hypotonia

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Using the surgical sieve mentioned previously, list some causes of cerebellar disease.

Vascular – bleed in the cerebellar fossa
Infection – TB, varicella zoster, cerebellitis
Inflammation – MS
Tumour – primary or metastases
Toxic/Metabolic – alcohol, phenytoin

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Describe how the anatomical level of a sensory lesion affects the area of which the abnormal sensation experienced.

Brain – hemisensory
Spinal cord – at spinal cord level (e.g. T10 = umbilicus)
Nerve root (radiculopathy) – dermatomal 
Mononeuropathy – specific area of skin 
Polyneuropathy – gloves and stockings

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What is the most common cause of polyneuropathy?

Diabetes mellitus

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What is duloxetine and what can it be used to treat?

Anti-depressant (SNRI)

It can be used to treat peripheral neuropathy and premature ejaculation

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Which other drug may be used to treat neuropathic pain?

Pregabalin

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List the main toxic/metabolic causes of peripheral neuropathy.

Drugs
Alcohol 
B12 deficiency 
Hypothyroidism
Uraemia 
Amyloidosis 
Diabetes mellitus

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Suggest investigations that may reveal clues about each of the causes listed above.

Drugs – history
Alcohol – history + high GGT + high MCV
B12 deficiency – low Hb + high MCV
Hypothyroidism – TFTs
Uraemia – U&Es
Amyloidosis – history of multiple myeloma or chronic infection/inflammation
Diabetes mellitus – history + blood glucose + HbA1c

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Explain why myeloma is associated with amyloidosis.

Myeloma causes increased production of immunoglobulins, which have light chains
The light chains are a precursor to amyloid fibrils
Deposition of abnormal protein in various organs

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Explain why chronic inflammation/infection is associated with amyloidosis.

Inflammation leads to high levels of serum amyloid protein A (an acute phase protein)

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List some associated symptoms to ask patients presenting with neurological symptoms.

Impaired vision 
Impaired hearing 
Headache 
Speech disturbance
Weakness 
Sensory disturbance 
Bowel continence 
Urinary continence

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List some inflammatory/autoimmune causes of peripheral neuropathy.

Vasculitis
Connective tissue diseases
Demyelinating polyneuropathy (e.g. Guillain-Barre syndrome)

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Define ‘paraprotein’.

Monoclonal immunoglobulin or light chain present in the blood or urine

Describe the appearance of the feet in patients with long-term peripheral neuropathy.

High-arched foot (pes cavus) | Clawed toes

What is amaurosis fugax?

Painless temporary loss of vision in one or both eyes; descending curtain

List two causes of blurring of the optic disc margin and explain how you would differentiate between them.

Papilloedema – NO pain and NO blurring of vision | Papillitis – pain and blurring of vision

What is papillitis? What is it associated with?

Inflammation of the head of the optic nerve, associated with dymyelination (MS)

In which part of the spinal cord do you find the descending inhibitory tracts? What happens if there is a lesion?

Corticospinal tract - results in brisk reflexes and upgoing plantars. In Descending motor pathway: weakness

What happens if the spinothalamic tract is compressed at a particular level?

Impaired/loss of sensation up until the level of the lesion

Define paraparesis.

Partial paralysis of the lower limbs | Spastic paraparesis - increased tone, weak legs

State a vascular cause of spastic paraparesis.

Obstruction of the anterior or posterior spinal arteries

State an infective cause of spastic paraparesis.

TB of the spine (Pott’s disease)

State an inflammatory (demyelinating) cause of spastic paraparesis.

Transver myelitis (may be associated with infections e.g. chest infections caused by Mycoplasma pneumonia)

What features of the history are necessary for a diagnosis of multiple sclerosis?

Two lesions separated in time and space

Which condition causes pain and paraesthesia on the anterolateral thigh? (Reduced pinprick sensation)

Meralgia paraesthetica

What is this meralgia paraesthetica caused by?

Compression of the lateral femoral cutaneous nerve

Outline the treatment of this condition.

Reassure the patient that it isn’t something serious Avoid tight garments Lose weight

Which pharmaceutical options might you consider if the treatments persist despite these measures?

Carbamazepine | Gabapentin

Describe the sensory innervation of the hand, and signs if the nerves are affected

Front: Ulnar – medial 1.5 fingers Median – lateral 3.5 fingers Back: Ulnar – medial 1.5 fingers Radial – rest of the back of the hand Median – finger tips of 1st, 2nd and 3rd digits Ulnar claw Radial - wrist drop; check base of hand Median: Opposition affected, thumb abduction - point to the ceiling affected

What is a radiculopathy?

Disease of the nerve roots

What is sciatica?

Pain in the buttock, radiating down the leg below the knee | It is caused by compression of the lumbosacral nerve roots

What can cause compression of nerve roots?

Disc herniation | Spinal canal stenosis (degen)

Describe the main features of Parkinson’s disease.

``` Rigidity Bradykinesia Resting tremor (Pill Rolling, unilateral) Gait instability (Dysphagia, amnesia, micrographia) ```

List some other diseases that cause symptoms that are similar to Parkinson’s disease.

Progressive supranuclear palsy (Parkinsons + limited upgaze) | Lewy body dementia

What is the key feature of progressive supranuclear palsy that helps distinguish it from Parkinson’s disease?

Limited up-gaze

What is the underlying pathological process that causes Parkinson’s disease?

Depletion of dopaminergic neurons in the subtantia nigra

What is cogwheel rigidity caused by?

A tremor superimposed on increased tone

What is another name for progressive supranuclear palsy?

Steele-Richardson syndrome

What are the key features of Lewy body dementia?

Vivid Hallucinations Alzheimer's Parkinsonism

If there are no abnormalities seen on examination and imaging of a patient presenting with confusion, what is the likely cause?

Toxic/metabolic

What dangerous state can cause confusion and chest pain?

Carbon monoxide poisoning

List four causes of confusion with reduced AMTS.

Post-ictal Dysphasia - not true confusion Dementia Depressive pseudodementia - withdrawn, poor eye contact, precipitating factor (death)

List 5 causes of dementia.

``` Alzheimer’s disease Vascular dementia Lewy body dementia Alcoholism Inherited (e.g. Huntingdon’s disease) ```

Given the causes of dementia listed above, what are some important features of the history that you should check?

History of ischaemic heart disease/peripheral vascular disease History/signs of alcohol abuse Other symptoms (e.g. Huntingdon’s chorea)

List a differential diagnosis for confusion and reduced consciousness.

``` Hypoglycaemia Vascular (i.e. bleed) Infection Inflammation - cerebral vasculitis (rash) Malignancy Toxic/metabolic ```

What are some distinguishing features of a subdural haematoma?

Falls and fluctuating consciousness

What are the main symptoms of intracranial infection?

Headache Neck stiffness Changed behaviour Fever

State an inflammatory cause of confusion with reduced consciousness.

Cerebral vasculitis

List some investigations you would perform to look for a toxic/metabolic cause of confusion with reduced AMTS.

``` Drug history U&Es LFTs Vitamin deficiencies Endocrinopathies (Cushing's psychosis) ```

Which endocrine disease may present with confusion?

Cushing’s disease

What is the motor criteria of the GCS?

6 (obeys commands > localises pain > withdrawal from pain > flexion to pain (decorticate) > extension to pain (decerebate) > no motor response)

What is the verbal criteria of the GCS?

5 (oriented > confused > inappropriate words > incomprehensible sounds > no verbal response)

What is the eye criteria of the GCS?

4 (spontaneous eye opening > eye opening in response to speech > eye opening in response to pain > no eye opening)

In the AMTS, patients are asked to count backwards from 20 to 1. Why is this done?

To check for any deficits in attention/concentration

What are the four main diseases that you need to think about when a patient presents in the emergency department with a headache?

Meningitis Giant cell arteritis Subarachnoid haemorrhage Migraine

List the main symptoms of meningitis.

``` Headache Neck stiffness Fever Photophobia Kernig’s sign ```

What is Kernig’s sign?

When the hip is flexed and the knee is at 90 degree, extension of the knee causes pain

Describe the presentation of subarachnoid haemorrhage.

Sudden-onset worst headache ever

What is the first investigation that is performed in suspected SAH?

CT Head

What would you look for when doing a lumbar puncture of a patient with SAH?

Xanthochromia (yellow discolouration of the CSF due to the break down of haemoglobin)

List the main symptoms of giant cell arteritis.

Headache Loss of vision Jaw claudication Scalp tenderness

Which disease is giant cell arteritis associated with?

Polymyalgia rheumatica (Shoulder girdle pain, systemic upset)

How do you treat giant cell arteritis?

High-dose prednisolone - blindness risk

List two investigations that you would perform in a patient with giant cell arteritis.

ESR | Temporal artery biopsy

Describe the features of migraine.

Unilateral, throbbing pain around the eye, vomiting, photo/phono phobia, FHx

List examples of negative and positive auras.

Negative – dark, black holes | Positive – flashing lights

What is the window for thrombolysis in a patient with stroke?

Within 4.5 hours of onset of symptoms

Which investigation must you perform in stroke patients before giving any treatment?

CT Head – exclude haemorrhage

Describe the management of a stroke patient who presents > 4.5 hours after the onset of symptoms.

CT head to exclude haemorrhage Aspirin (300 mg) Swallow assessment Maintain hydration, oxygenation and monitor glucose

At what point do you worry about the blood pressure of a patient with a TIA?

If the blood pressure rises > 220/120 mm Hg | Otherwise don't treat acutely

Describe the management of a patient with TIA.

Aspirin | Risk factor modification

List some investigations that you would perform in a patient with a TIA.

ECG (AF) Echocardiogram Carotid artery Doppler (CA Stenosis)

Why is it important to monitor FVC in a patient with Guillain-Barre syndrome?

It can cause respiratory muscle weakness and reduce ventilation

How is FVC monitored?

Spirometry

What must you do if the FVC begins to drop?

Ventilate

Why is it important to set up a cardiac monitor for patients with Guillain-Barre syndrome?

Guillain-Barre syndrome is associated with autonomic neuropathy

How is Guillain-Barre syndrome treated?

IVIg

Construct a simple list of causes of collapse.

Hypoglycaemia Cardiac – vasovagal, arrhythmia, outflow obstruction, postural hypotension Neurological – seizure

Give another 2 causes of blurred vision

Anterior uveitis, vitreous haemorrhage

Other causes of spastic parasthesia

Toxic/metabolic: subacute combined demyelination of the spinal cord; tumour malig/mets

How do you test bradykinesia?

Fingers 2-5 to touch thumb

Proximal Myopathy - name 4 causes

Cushings Thyrotoxicosis Osteomalacia Vit D deficiency

Name infections and inflammatory causes of peripheral neuropathy

Infection – HIV Inflammation – Guillain-Barre syndrome, ConTis Disease, Vasculitis, CIDP (Chronia inflammatory demyelinating polyneuropathy)

Name toxic causes of peripheral neuropathy

Alcohol, cisplatin, amiodarone, metronidazole, phenytoin, isoniazid, nitrofurantoin, gold

Name Metabolic causes of peripheral neuropathy

Diabetes, amyloidosis, CKD, B12 Deficiency

Name Hereditary causes of peripheral neuropathy

Hereditary - CMT disease, Dejerine-Sottas Disease, Refsum disease

Name malignant causes of peripheral neuropathy

Paraneoplastic syndromes | Paraproteinaemia

Neurology (4) Flashcards

(99 cards)