1 - Neurology History, Examination and Localisation Flashcards
If a patient presents with the following neurological symptoms, what are some important further questions to ask?
- Headache
- Muscle weakness
- Visual disturbance
- Dizziness
ALWAYS TRY TO GET COLLATERAL HISTORY
- Headache: different to usual? acute/chronic? speed of onset? uni/bilateral? aura? any meningism? worse on waking? any decrease in consciousness? thunderclap?
- Muscle weakness: speed of onset? groups of muscles affected? sensory loss? sphincter disturbance? loss of balance?
- Visual disturbance: blurring? diplopia? speed of onset? photophobia? vision loss? preceding symptoms? pain in the eye?
- Dizziness: vertigo? hearing loss? tinnitus? LOC? tinnitus?
If a patient presents with the following neurological symptoms, what are some important further questions to ask?
- Speech disturbance
- Dysphagia
- Fits/Faints/Funny turns/Involuntary movements
- Abnormal sensations
- Tremor
- Speech disturbance: difficulty in expression, comprehension or articulation?
- Dysphagia: solids and/or liquids? intermittent or constant? difficulty in coordination? odonyphagia?
- Fits/Faints/Funny turns/Involuntary movements: frequency? duration? mode of onset? incontinence? tongue biting? aura? LOC? residual weakness/confusion? FHx?
- Abnormal sensations: numbness? pins and needles? pain? distribution? speed of onset? weakness?
- Tremor: rapid or slow? present at rest? worst on movement? taking B agonists? any thyroid issues? FHx?
If there is a doubt about a patients cognitive state, what test can you do?
AMTS - Any score of 6 or less suggests cognitive decline
What are some patients that you cannot use AMTS score in?
- Deaf
- Dysphasic
- Depressed
- Uncooperative
- English not first language
What questions in the PMHx, DHx and SHx can you ask a patient with a neurological presentation?
PMHx: meningitis? head/spine trauma? seizures? previous operations? risk factors for vascular disease e.g smoking, AF? recent travel? pregnant?
DHx: anticonvulsants? antipsychotics? antidepressants? psychotropic drugs e.g ecstasy? any meds with neurological side effects e.g peripheral neuropathy in isoniazid
SHx: what ADLs can’t they do? FHx of neuro/psychiatric disease? syphillis?
What is cramp and what are some causes of this?
Painful muscle spasm
- Salt depletion
- Muscle ischaemia (claudication, DM)
- Myopathy
- Dystonia
- MND (forearms)
- Drugs e.g Diuretics, Domperidone, Salbutamol
What are some causes of paraesthesia? (‘pins and needles’, numbness, tingling)
- Metabolic: decreased Ca, increased PaCO2
- Vascular: arterial emboli, DVT, high plasma viscosity
- Infection: lyme, rabies
- Cord: MS, myelitis, HIV, B12, lumbar fracture
- Paroxysmal: migraine, epilepsy
- Peripheral neuropathy: glove and stocking
What is a tremor and what are some of the different kinds of tremor?
Rhythmic oscillations of limbs, trunk, head or tongue
Resting: Occurs at rest, gravity dependent, Parkinsons (pill rolling slow tremor 3-5Hz)
Postural: Worst if arms outstretched, rapid 8-12Hz. Can be exagerrated physiological tremor (anxiety, hyperthyroidism, alcohol), Brain damage (syphillis, Wilson’s) or Benign Essential tremor
Intention: Worst on movement, in cerebellar disease with past pointing and dysdiadochokinesis
What is a Benign Essential Tremor , how can it be managed and how can you distinguish it from a PD tremor?
- Usually familial (autosomal dominant) of the arms or head presenting at any age
- May have cogwheeling but no bradykinesia
- Suppressed by alcohol
- Propanolol can help
What are some neurological causes of facial pain?
- Trigeminal neuralgia
- Migraine
- Post-herpetic neuralgia
How do you do a cerebellar examination?
https://geekymedics.com/cerebellar-examination-osce-guide/
- Introduction
- Gait/Tandem Gait
- Romberg’s (sensory ataxia)
- Speech (British Constitutuion, Baby Hippopotamus)
- Nystagmus
- Finger Nose (past pointing)
- Tone (hypo)
- Dysdiadochokinesis
- Reflex (hypo)
- Heel shin test
What are some causes of cerebellar disease?
How do you do a cranial nerve exam?
https: //oscestop.com/Cranial%20Nerves.pdf
https: //geekymedics.com/wp-content/uploads/2020/10/OSCE-Checklist-Cranial-Nerve-Examination.pdf
Intro: any pain?
1: Changes in smell?
2: AFRO Assess pupil size, Pupil reflexes, Swinging Light, Accomodation,Visual Acuity (wear glasses), Visual fields, Fundoscopy
3, 4, 6: Any double vision or nystagmus on eye movements? Cover test
5: Cotton wool and neurotip
7: Muscles of mastication, jaw jerk reflex, corneal reflex
8: Gross hearing, Weber’s + Rinne’s with 512Hz
9, 10: Say ahh, Gag reflex, Cough
12: Stick tongue out and move side to side, tongue strength
11: Shrug shoulders against resistance
If someone has a headache how can you rule out meningitis?
If they can shake their head side to side there is no meningism
What are some causes of cranial nerve palsies? (example for each CN)
IMPORTANT CARD PLEASE SIT AND REMEMBER!
What are the dermatomes of the head, upper limb, lower limb?
Head:
Trigeminal on face
C2/C3 on back
Upper limb:
C4 - shoulder
C5-T1 - arms
Lower Limb:
L1 to S2 - Legs
S4/S5 - perianal area
What nerve root is the bladder and rectum motor supply?
S4
Where does the cervical plexus innervate?
Diaphragm, shoulders and neck
What are the phases of the gait cycle?
What are some causes of the following gaits?
- Hemiplegic
- Diplegic/Scissoring
- Parkinsonian’s
- Ataxic
Hemiplegic:
- CNS lesion leading to unilateral weakness and spasticity. UMN lesion. Spastic flexion of upper limb and spastic extension of lower limb
- Causes: stroke, SOL, trauma, MS
Diplegic: (usually UMN)
- Cord: Prolapsed intervertebral disc, Spinal infarct, Syringomyelia
- Bilateral brain lesion: Cerebral palsy, MS
- Bilateral brain infarcts
- Midline tumour
- Motor neuron disease: associated with LMN findings
Parkinsonian’s:
- Vascular Parkinson’s disease, Dementia with Lewy bodies, Drug-induced Parkinsonism (e.g. antipsychotics, antiemetics)
Ataxic:
- Midline cerebellar disease: alcoholic cerebellar degeneration
- Vestibular disease: labrynthitis
- Loss of proprioception: sensory ataxia
What are some causes of the following gaits?
- Neuropathic/High-steppage
- Myopathic/Waddling
- Choreiform/Hyperkinetic
- Antalgic
Neuropathic/High-steppage
Weakness of the dorsiflexors in the distal lower limb
Causes: Isolated common peroneal nerve palsy (e.g. trauma), L5 radiculopathy (e.g. disc prolapse), Generalized polyneuropathy involving multiple nerves (e.g. diabetic neuropathy, motor neurone disease, Charcot-Marie Tooth disease)
Myopathic/Waddling
Weakness of hip abducters so pelvis tilts downwards towards unsupported side during swing phase
Causes: muscular dystrophies, thyroid issues, polymyalgia rheumatica, polymyositis, dermatomyositis
Choreiform/Hyperkinetic
Gait with involuntary movements e.g oro-facial dyskinesia (grimacing or lip-smacking), choreic movements of the upper and lower limbs
Causes: Huntington’s, Cerebral Palsy, Parkinson’s medication
Antalgic
Pain
Causes: OA, lower limb fracture, sciatica
What are the features of a Parkinsonian gait?
Also will have tremor, rigidity, bradykinesia
How can you tell the difference between cerebellar, sensory and vestibular ataxia and what are some causes of each of these?
IMPORTANT CARD
Cerebellar ataxia:
- Nystagmus
- Ataxic dysarthria
- Dysmetria
- Intention tremor
- Dysdiadokokinesia
Sensory ataxia:
- Positive Romberg’s sign
- Impaired proprioception
- Impaired vibration sensation
- Absence of other cerebellar signs (e.g. dysmetria, nystagmus, dysarthria)
Vestibular ataxia:
- Vertigo
- Nausea
- Vomiting
What GCS do you need to be worried about a patient’s airway?
8!!!!!
How do you calculate GCS?
IMPORTANT CARD
Evaluates the level of consciousness of a patient
If cannot do one of the sections e.g oedema round eyes, paralysed, then write NOT TESTABLE (NT)
3 is lowest, 15 is highest. Always record in notes and say what they score for each
What is decorticate and decebrate positioning and what do they both indicate?
Decorticate
- Abnormal flexion
- Adduction of the arm, internal rotation of the shoulder, pronation of the forearm and wrist flexion
- Indicates damage to cerebral hemispheres, internal capsule and thalamus
Decebrate
- Abnormal extension
- Head is extended, arms and legs also extended and internally rotated. Patient appears rigid with teeth clenched
- Indicates damage to brainstem
- Progression from decorticate to decebrate suggests uncal or tonsillar herniation
What are the different points on the MRC power scale?
3 Gravity (Rhymes)
Remember Neil laying on side for 2
How do you do a lower limb neurological examination?
https://oscestop.com/Lower%20limb%20neurological%20exam.pdf
TOPCARS and SWIFT
- Introduce: any pain, exposure
- Inspection: gait, tremor, wasting, SWIFT
- Tone: leg roll and clonus
- Power: isolate/stabilise joint
- Coordination: heel to shin, toe tap
- Reflexes: knee, ankle, plantar
- Sensation and Proprioception: cotton wool, neurotip, vibration (BIGGER ONE - 128Hz), joint position
How do you do an upper limb neurological exam?
https://oscestop.com/Upper%20limb%20neurological%20exam.pdf
- Introduction: any pain? exposure
- SWIFT
- Pronator drift
- Tone
- Power
- Coordination: dysdiadochokinesis, finger nose
- Reflexes: biceps, triceps, supinator
- Sensation and Proprioception: bigger tuning fork!! make sure they close their eyes!!!! did it feel the same both sides?
How do you do a Parkinson’s focused neurological examination? (use link more)
https://oscestop.com/Parkinsons_exam.pdf
- Inspection: gait, resting tremor with eyes closed and counting back from 20 (asymmetrical resting pill rolling, begins distally, reduced with finger to nose testing), intention tremor
Work downwards:
- Face: Hypomimia, Glabella Tap (Myerson’s sign), Hypophonic speech
- Upper limbs: Tone (lead pipe or cogwheel tremor on increased tone) and Bradykinesia
- Lower limbs: toe tap
- Others: micrographia (write sentence, draw spiral), undo buttons on shirt
What are the features of a resting tremor in Parkinson’s?
Resting tremors occur when a body part is at complete rest against gravity and cease during active movement
What is a HINTS examination?
Head Impulse, Nystagmus, Test of Skew examination
Way to assess a patient to see if central or peripheral vertigo
How do you perform a HINTS examination?
How do you perform a comprehensive neurological examination?
- Mental Status
- Cranial Nerves
- Motor Function
- Reflexes
- sENSATION
How do you perform a neurological examination on a patient with an altered level of consciousness (either unconscious or semi-conscious)?
- Level of consciousness (GCS)
- Pupil responses
- Fundoscopy
- Brain stem reflexes
- Deep tendon reflexes
- Plantar response
What are some cerebellar signs?
D - Dysdiadochokinesis
A - Ataxic gait
N - Nystagmus
I - Intention tremor
S - Slurred/Staccato speech
H - Hypotonia and reduced power
How can you localise a lesion when thinking of the pattern of motor loss?
- Need to think cortex, corona radiata, internal capsule, brainstem, cord, roots, peripheral nerves, neuromuscular junction, muscles
- Is it UMN or LMN?
- Is it unilateral or bilateral?
What are the different motor systems in the CNS?
Corticospinal tracts (pyramidal)
- Skilled, intricate, strong and organised movements
- Defectiveness: loss of skilled voluntary movement, spasticity and reflex changes. Such as hemiparesis, hemiplegia or paraparesis
Extrapyramidal
- Fast, fluid movements that the corticospinal system has generated
- Doesn’t directly innervate motor neurones
- Defectiveness: bradykinesia, rigidity, tremor, chorea
Cerebelllum
- Co-ordinating smooth and learned movement initiated by the pyradimal system and in posture and balance control
- Defectiveness: ataxia, past pointing, action tremor and incoordination
If there is a cord lesion do you expect LMN signs or UMN signs?
- At the level of the lesion LMN
- Below level of lesion UMN
If there is a cranial nerve palsy contralateral to a hemiparesis, where does this localise the lesion to?
The brainstem on the side of the cranial nerve palsy
What are the different sensory pathways in the CNS?
(make sure you can draw diagrams)
Peripheral nerves: sensation from dorsal roots to cord
Dorsal columns:
- Vibration, joint position, light touch and point discrimination
- Decussate in medulla passing to the thalamus
Spinothalamic tracts:
- Pain and temperature
- Decussate in the cord and pass in the spinothalamic tracts to the thalamus and reticular formation
Sensory cortex:
Fibres from thalamus pass to parietal region sensory cortex and motor cortex
What are signs of an UMN lesion?
- Tone: Hypertonia and Clonus
- Reflexes: Hyperreflexia and Babinski
- Atrophy: Late and due to disuse
- Spasticity
- Hoffman’s reflex positive
- Clasp knife rigidity
UMN MAY APPEAR AS LMN FOR FIRST FEW HOURS AFTER INJURY (ACUTE FLACCID PARALYSIS)
What are signs of a LMN lesion?
- Hyporeflexia
- Hypotonia/Flaccid
- Absent reflexes
- Fasiculations
- Severe dennervation atropy
How can you tell the difference between a LMN lesion due to muscle disease and due to peripheral neruropathy?
Muscle disease: will be bilateral and no sensory loss
Peripheral neuropathy: sensory loss and reflexes lost faster
What are negative and positive extra-pyramidal symptoms?
Negative: bradykinesia, loss of postural reflexes
Positive: tremor, rigidity, involuntary movements e.g chorea, hemiballismus
What is the blood supply to the brain?
(memorise image)
Circle of Willis
- Anastomosis of vertebral artery and ICAs
- Anterior and Middle cerebral arteries come from ICA. Posterior cerebral artery comes from vertebral
Which cerebral arteries supply which lobes of the brain and therefore what would be the symptoms if there was an occlusion in one of these arteries?
ACA: Weak numb contralateral leg +/- same with arm. Face sparing
MCA: Contralateral hemiparesis, hemisensory loss, contralateral homonymous hemianopia (optic radiations involved), dysphasia, visuo-spatial disturbance
PCA: Supplies occipital so contralateral homonymous hemianopia with macular sparing
What are some examples of neurotransmitters?
- Amino acids: Glutamate and Aspartate are excitatory, GABA is inhibitory
- Dopamine
- Serotonin
- Adrenaline and Noradrenaline
- Acetylcholine
What are some examples of drugs that increase and decrease neurotransmitter activity?
What is a pyramidal pattern of muscle weakness?
In UMN lesions
- Extensors weaker than flexors in arms
- Flexors weaker than extensors in legs
STROKE - HEMIPARESIS
What is the difference between spasticity and rigidity?
Both in hypertonia, think about velocity
- Spasticity (resistance more in one movement): stroke, MND
- Rigidity (resistance same for all movement, not velocity dependent): PD, neuroleptic syndrome
What is the pattern of sensory loss in the following:
- Mononeuropathy
- Peripheral neuropathy
- Radiculopathy
- Spinal cord damage
- Thalmic lesions e.g stroke
- Myopathy
- Mononeuropathy: Area supplied by one nerve
- Peripheral neuropathy: Symmetrical glove and stocking
- Radiculopathy: Dermatomal
- Spinal cord damage: At and below level in dermatomal pattern
- Thalmic lesions e.g stroke: Contralateral loss
- Myopathy: No loss of sensory, just motor
How do you do an upper limb neurological examination?
How do you do a lower limb neurological examination?
How do you do a cranial nerve examination?
