Neuroscience Flashcards
A 65-year-old woman presents with progressive slurred speech with nasal quality, and episodes of choking on liquids, for the last 4 to 5 months. Neurological examination reveals facial, palatal, and tongue weakness; tongue muscle wasting and fasciculations; dysarthria; hypophonic speech; and brisk reflexes throughout (including jaw jerk).
Motor neurone disease
A 37-year-old woman presents with a 12-year history of episodic headaches. She experiences these 4 times a week, typically beginning at the end of a working day. The pain is generalised and described as similar to wearing a tight band around her head. The headaches are bothersome, but not disabling, and she denies any nausea or vomiting. She is slightly sensitive to noise but has no photophobia. Pain during her attacks typically responds to ibuprofen. Examination reveals tenderness of her scalp and both trapezius muscles.
Tension-type headache
A 76-year-old man reports double vision for the past 2 months. Within the past 2 weeks he has developed bilateral ptosis (drooping eyelids). His ptosis is so severe at times that he holds his eyes open to read. He is unable to drive due to the ptosis and the diplopia (double vision). His symptoms are generally better in the morning and progress throughout the day.
Myasthenia gravis
A 67-year-old man with a prior history of hypertension, diabetes, hyperlipidaemia, and a 50 pack-year smoking history noted rapid onset of right-sided weakness and subjective feeling of decreased sensation on his right side. His family reported that he seemed to have difficulty forming sentences. Symptoms were maximal within a minute and began to spontaneously abate 5 minutes later. By arrival in the emergency department 30 minutes after onset, his clinical deficits had largely resolved with the exception of a subtle weakness of his right hand. Forty minutes after presentation, all of his symptoms were completely resolved.
Transient ischaemic attack (TIA)
A 26-year-old woman presents with multiple sessile fleshy skin lesions. She has been aware of multiple café au lait spots since early childhood, although she ignored them as they were deemed to be birthmarks. The truncal skin lumps that led to her presentation began to appear (or become prominent) during the early second trimester of her recent pregnancy, at the end of which she delivered a female infant with multiple light brown birthmarks. Physical examination of the woman shows café au lait spots, bilateral axillary freckling, and multiple cutaneous neurofibromas over the trunk and proximal limbs. She has no neurological abnormalities. A slit-lamp ophthalmological examination reveals multiple iris Lisch nodules bilaterally.
Neurofibromitosis (T1)
A 40-year-old woman awakens with left-sided facial fullness and a subjective feeling of facial and tongue ‘numbness’ without objective hypoaesthesia. She also notes left-sided dysgeusia. Later that day she develops left-sided otalgia, hyperacusis, post-auricular pain, and facial discomfort. associated oral incompetence, facial weakness, and asymmetry progressing to complete flaccid paralysis by the next morning. On physical examination, the resting appearance of the left face demonstrates brow ptosis, a widened palpebral fissure, effacement of the left nasolabial fold, and inferior malposition of the left oral commissure. There is complete absence of brow movement, incomplete eye closure with full effort, and loss of smile, snarl, and lip pucker on the affected side. The remainder of the history and physical examination are unremarkable.
Bell’s palsy
A 28-year-old white woman who has smoked 1 pack per day for the last 10 years presents with subacute onset of cloudy vision in 1 eye, with pain on movement of that eye. She also notes difficulty with colour discrimination, particularly of reds. She was treated for a sinus infection 2 weeks ago and on further history recalls that she had a 3-week history of unilateral hemibody paraesthesias during examination week in university 6 years ago. She occasionally has some tingling on that side if she is overly tired, stressed, or hot.
Multiple sclerosis
A 75-year-old man presents with problems walking that have developed over the previous 2 years, consisting of slow gait, imbalance (especially on turning), short stride length, and gait initiation failure. He reports urinary frequency, occasional urge incontinence, and some memory loss. On examination, his symptoms are symmetrical and much more prominent in the lower half of the body, with relative sparing of hand function, and normal facial expressiveness. He has previously been diagnosed with Parkinson’s disease; however, therapy with levodopa has not improved his symptoms.
Hydrocephalus
A 31-year-old woman with strong family history of autoimmune disease is 6 months postnatal and develops ascending numbness and weakness in both feet, slightly asymmetrically, over a period of 2 weeks. She gradually develops difficulty walking to the point where she presents to an emergency department and is also found to have a urinary tract infection.
Multiple sclerosis
A 53-year-old black woman complains of a sudden, excruciating headache while sitting at work. The headache is diffuse, intense, and accompanied by nausea and vomiting. She describes the headache as the worst headache of her life. She loses consciousness following onset of the headache and is on the floor for less than 1 minute. She is being treated for hypertension and is a smoker. On examination she has a normal mental state, meningismus, bilateral subhyaloid haemorrhages, and right third cranial nerve palsy. There are no sensory deficits or weakness. Brain computed tomography (CT) reveals diffuse subarachnoid blood in basal cisterns and sulci.
Subarachnoid haemorrhage
A 40-year-old woman presents with back pain and difficulty with her gait. She has a long history of smoking and has had some haemoptysis recently. Her examination reveals diminished pinprick sensation from the nipple line caudally, power in the lower extremities of 4/5, absent joint position sense in the lower extremities, and diminished vibratory sense. Anal sphincter tone is intact.
Spinal cord compression
A 72-year-old white woman presents with partial vision loss in the right eye. She reports bitemporal headache for several weeks, accompanied by pain and stiffness in the neck and shoulders. Review of systems is positive for low-grade fever, fatigue, and weight loss. On physical examination, there is tenderness of the scalp . Fundoscopic examination reveals pallor of the right optic disc. Bilateral shoulder range of motion is limited and painful. There is no synovitis or tenderness of the peripheral joints.
Temporal Arteritis
When present, symptoms of jaw claudication and diplopia are powerful predictors of a positive temporal artery biopsy result.[1] Neurological manifestations occur in about one third of patients and may include stroke, transient ischaemic attack, or neuropathy. Respiratory tract symptoms are uncommon but may include cough or sore throat. Rarely, dental pain, tongue pain, or infarction of the tongue may be present. An older person may present with a new headache. In addition, some patients who predominantly have polymyalgia rheumatica can have subtle evidence of GCA that could be missed.[2] GCA can rarely present as an unexplained systemic illness or fever of unknown origin with elevated levels of inflammatory markers without headache, jaw claudication, shoulder or hip girdle stiffness, or visual disturbances.
Patients with large-vessel stenoses (approximately 10% to 15% of patients) may present with claudication of (usually) upper extremities, asymmetric blood pressures, or decreased pulses.[3] Rarely, involvement of lower extremity vessels results in leg claudication.
A 56-year-old man presents with a 25-year history of constant headache. The onset was insidious and he is certain that the only time he is headache-free is when he sleeps. He states the headache is generalised and his neck and shoulders are always ‘tight’. He denies any associated autonomic symptoms including eye tearing, nasal congestion, light and sound sensitivity, nausea, or vomiting.
Tension-type headache
A 60-year-old man presents with right foot drop, which has developed gradually over the last year and progressed to involve more proximal areas in the last 2 months. The patient reports associated muscle twitching and painful muscle cramps involving the same areas. The neurological examination is pertinent for bilateral lower-extremity weakness, more severe on the right, with associated spasticity, atrophy of the right foot intrinsic muscles, diffuse fasciculations, and hyper-reflexia, with deep tendon reflexes being brisker on the right lower extremity, and a positive right Babinski’s sign. Sensation is preserved throughout. Several other family members have been diagnosed (some have died) with a pattern suggesting autosomal dominant disease.
Motor neurone disease
A 32-year-old woman presents with a 13-year history of 1 to 3 attacks per month of disabling pounding pain over one temple, with nausea and sensitivity to light. She says that her headaches can be triggered by lack of sleep and made worse by physical exertion, and are more common during menstrual bleeding. Untreated, they last for 2 days. On 4 occasions, headaches were preceded by the gradual appearance of a shimmering, zigzag line that enlarged, moved to the peripheral visual field, and then faded away over 45 minutes. Examination is normal.
Migraine
