1 - Neurology History, Examination and Localisation Flashcards

1
Q

If a patient presents with the following neurological symptoms, what are some important further questions to ask?

  • Headache
  • Muscle weakness
  • Visual disturbance
  • Dizziness
A

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?

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2
Q

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
A

- 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?

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3
Q

If there is a doubt about a patients cognitive state, what test can you do?

A

AMTS - Any score of 6 or less suggests cognitive decline

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4
Q

What are some patients that you cannot use AMTS score in?

A
  • Deaf
  • Dysphasic
  • Depressed
  • Uncooperative
  • English not first language
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5
Q

What questions in the PMHx, DHx and SHx can you ask a patient with a neurological presentation?

A

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?

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6
Q

What is cramp and what are some causes of this?

A

Painful muscle spasm

  • Salt depletion
  • Muscle ischaemia (claudication, DM)
  • Myopathy
  • Dystonia
  • MND (forearms)
  • Drugs e.g Diuretics, Domperidone, Salbutamol
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7
Q

What are some causes of paraesthesia? (‘pins and needles’, numbness, tingling)

A

- 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

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8
Q

What is a tremor and what are some of the different kinds of tremor?

A

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

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9
Q

What is a Benign Essential Tremor , how can it be managed and how can you distinguish it from a PD tremor?

A
  • 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

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10
Q

What are some neurological causes of facial pain?

A
  • Trigeminal neuralgia
  • Migraine
  • Post-herpetic neuralgia
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11
Q

How do you do a cerebellar examination?

https://geekymedics.com/cerebellar-examination-osce-guide/

A

- 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

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12
Q

What are some causes of cerebellar disease?

A
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13
Q

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

A

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

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14
Q

If someone has a headache how can you rule out meningitis?

A

If they can shake their head side to side there is no meningism

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15
Q

What are some causes of cranial nerve palsies? (example for each CN)

A

IMPORTANT CARD PLEASE SIT AND REMEMBER!

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16
Q

What are the dermatomes of the head, upper limb, lower limb?

A

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

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17
Q

What nerve root is the bladder and rectum motor supply?

A

S4

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18
Q

Where does the cervical plexus innervate?

A

Diaphragm, shoulders and neck

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19
Q

What are the phases of the gait cycle?

A
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20
Q

What are some causes of the following gaits?

  • Hemiplegic
  • Diplegic/Scissoring
  • Parkinsonian’s
  • Ataxic
A

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

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21
Q

What are some causes of the following gaits?

  • Neuropathic/High-steppage
  • Myopathic/Waddling
  • Choreiform/Hyperkinetic
  • Antalgic
A

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

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22
Q

What are the features of a Parkinsonian gait?

A

Also will have tremor, rigidity, bradykinesia

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23
Q

How can you tell the difference between cerebellar, sensory and vestibular ataxia and what are some causes of each of these?

IMPORTANT CARD

A

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
24
Q

What GCS do you need to be worried about a patient’s airway?

A

8!!!!!

25
Q

How do you calculate GCS?

IMPORTANT CARD

A

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

26
Q

What is decorticate and decebrate positioning and what do they both indicate?

A

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

27
Q

What are the different points on the MRC power scale?

A

3 Gravity (Rhymes)

Remember Neil laying on side for 2

28
Q

How do you do a lower limb neurological examination?

https://oscestop.com/Lower%20limb%20neurological%20exam.pdf

A

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

29
Q

How do you do an upper limb neurological exam?

https://oscestop.com/Upper%20limb%20neurological%20exam.pdf

A

- 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?

30
Q

How do you do a Parkinson’s focused neurological examination? (use link more)

https://oscestop.com/Parkinsons_exam.pdf

A

- 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

31
Q

What are the features of a resting tremor in Parkinson’s?

A

Resting tremors occur when a body part is at complete rest against gravity and cease during active movement

32
Q

What is a HINTS examination?

A

Head Impulse, Nystagmus, Test of Skew examination

Way to assess a patient to see if central or peripheral vertigo

33
Q

How do you perform a HINTS examination?

A
34
Q

How do you perform a comprehensive neurological examination?

A
  1. Mental Status
  2. Cranial Nerves
  3. Motor Function
  4. Reflexes
  5. sENSATION
35
Q

How do you perform a neurological examination on a patient with an altered level of consciousness (either unconscious or semi-conscious)?

A
  1. Level of consciousness (GCS)
  2. Pupil responses
  3. Fundoscopy
  4. Brain stem reflexes
  5. Deep tendon reflexes
  6. Plantar response
36
Q

What are some cerebellar signs?

A

D - Dysdiadochokinesis

A - Ataxic gait

N - Nystagmus

I - Intention tremor

S - Slurred/Staccato speech

H - Hypotonia and reduced power

37
Q

How can you localise a lesion when thinking of the pattern of motor loss?

A
  • 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?
38
Q

What are the different motor systems in the CNS?

A

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
39
Q

If there is a cord lesion do you expect LMN signs or UMN signs?

A
  • At the level of the lesion LMN
  • Below level of lesion UMN
40
Q

If there is a cranial nerve palsy contralateral to a hemiparesis, where does this localise the lesion to?

A

The brainstem on the side of the cranial nerve palsy

41
Q

What are the different sensory pathways in the CNS?

(make sure you can draw diagrams)

A

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

42
Q

What are signs of an UMN lesion?

A
  • 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)

43
Q

What are signs of a LMN lesion?

A

- Hyporeflexia

- Hypotonia/Flaccid

- Absent reflexes

- Fasiculations

- Severe dennervation atropy

44
Q

How can you tell the difference between a LMN lesion due to muscle disease and due to peripheral neruropathy?

A

Muscle disease: will be bilateral and no sensory loss

Peripheral neuropathy: sensory loss and reflexes lost faster

45
Q

What are negative and positive extra-pyramidal symptoms?

A

Negative: bradykinesia, loss of postural reflexes

Positive: tremor, rigidity, involuntary movements e.g chorea, hemiballismus

46
Q

What is the blood supply to the brain?

(memorise image)

A

Circle of Willis

  • Anastomosis of vertebral artery and ICAs
  • Anterior and Middle cerebral arteries come from ICA. Posterior cerebral artery comes from vertebral
47
Q

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?

A

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

48
Q

What are some examples of neurotransmitters?

A

- Amino acids: Glutamate and Aspartate are excitatory, GABA is inhibitory

- Dopamine

- Serotonin

- Adrenaline and Noradrenaline

- Acetylcholine

49
Q

What are some examples of drugs that increase and decrease neurotransmitter activity?

A
50
Q

What is a pyramidal pattern of muscle weakness?

A

In UMN lesions

  • Extensors weaker than flexors in arms
  • Flexors weaker than extensors in legs

STROKE - HEMIPARESIS

51
Q

What is the difference between spasticity and rigidity?

A

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

52
Q

What is the pattern of sensory loss in the following:

  • Mononeuropathy
  • Peripheral neuropathy
  • Radiculopathy
  • Spinal cord damage
  • Thalmic lesions e.g stroke
  • Myopathy
A

- 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

53
Q

How do you do an upper limb neurological examination?

A
54
Q

How do you do a lower limb neurological examination?

A
55
Q

How do you do a cranial nerve examination?

A