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