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Year 3 Medicine > Amir Sam: Neurology > Flashcards

Amir Sam: Neurology Flashcards

1
Q

Causes of collapse (groups)

A
  1. Low glucose (hypoglycaemia)
  2. Heart:
    - Vasovagal
    - Arrythmia
    - Outflow obstruction
    - Postural hypotension
  3. CNS: seizure
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2
Q

Cardiac causes of collapse

A

Vasovagal
Arryhtmia (fast/slow)
Outflow obstruction (left: aortic stenosis; right: PE)
Postural hypotension

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3
Q

59 yr old man
Long-standing HTN
Exertional chest pain
Normal ECG

What is the most likely diagnosis?

A. Coronary artery stenosis
B. Musculoskeletal
C. Pericarditis
D. Relapsing polychondritis
E. Vasculitis
A

A. Coronary artery stenosis

HTN
Exertional chest pain
Normal ECG

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4
Q

Crease on ear lobe

A

Frank’s sign: diagonal crease along the tragus

Thought to be associated with coronary artery disease

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5
Q

Neurology problem: Anatomy

A 
Brain
Spinal cord
Nerve roots
Peripheral nerve(s)
Neuromuscular junction
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6
Q

Neurological problem: Pathology

A 
VIITT
Vascular
Infection
Inflammation/Autoimmune
Toxic/Metabolic
Tumours/Malignancy

Hereditary/congenital
Degenerative

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7
Q

Neurology problem: Where? Anatomy

A 
(level of the lesion/problem)
Brain
Spinal cord
Nerve roots
Peripheral nerve(s)
Neuromuscular junction
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8
Q

Neurological problem: What? Pathology

A

VIITT
Vascular (bleed/infarction)
Infection (meningitis/ encephalitis/ abscess)
Inflammation/Autoimmune (demyelination central: MS, peripheral: Guillain Barre. Also vasculitides (CTDS: SLE)
Toxic/Metabolic (DM, B12 deficiency)
Tumours/Malignancy (tumour directly causing symptoms or paraneoplastic manifestation- Pancoast’s)

Hereditary/congenital
Degenerative

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9
Q

Signs of UMN lesion

A

Tone: increased (spasticity)
Power: decreased
Reflexes: increased (upgoing plantars)

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10
Q

Signs of LMN lesion

A

Tone: reduced (flaccid)
Power: reduced
Reflexes: reduced

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11
Q

Cerebellar symtpoms

A

DANISH
Dysdiadokineses/Dysmetria (past pointing)
Ataxia (coordiantion/balance)
Nystagmus
Intention tremor (finger-nose test)
Slurred speech/ scanning (staccato speech)
Hypereflexia/hypotonia

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12
Q

Causes of cerebellar disease:

A

PASTRIES

Do a CT scan

Posterior fossa tumour
Alcohol
Stroke
Trauma
Rare
Inherited (Friedrich's ataxia)
Epilepsy drugs (carbamazepine, phenytoin)
Sclerosis (MS)

OR
Vascular (bleed/clot- Stroke)
Infection (varicella (chicken pox), toxoplasmosis)
Inflammation (demyelination- MS)
Malignancy/Tumour (primary (posterior fossa tumour) or metastasis)
Metabolic/Toxic (B12 deficiency, Alcohol)

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13
Q

Spastic paraparesis
Increased tone in legs, but weakness
Peripheral neuropathy

A

Subacute combined degeneration

Vitamin B12 deficiency (but can also present in other ways)

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14
Q

Hemisensory loss

A

Cerebral cortex (contralateral)

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15
Q

Sensory loss below a level (eg- umbilicus)- eg- with pin prick test

A

Spinal cord

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16
Q

Sensory loss in a dermatome(s)

A

Nerve roots (eg- radiculopathy)

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17
Q

Sensory loss in a specific area

A

Mononeuropathy

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18
Q

Glove and stocking distribution of sensory loss

A

Polyneuropathy (diabetic peripheral neuropathy)

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19
Q

Glove and stocking distribution of sensory loss

A

Polyneuropathy (diabetic peripheral neuropathy)

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20
Q

Reduced pin prick sensation in there left arm and left leg

A

Right cerebral cortex

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21
Q

Glove and stocking distribution of sensory loss. Causes:

A

Polyneuropathy:
The most common is diabetes

Infection: HIV
Inflammation: chronic inflammatory demyelinating polyneuropathy (CIDP)
Malignancy: Paraneoplastic; Paraproteinaemia
Metabolic: Diabetes, Alcohol, B12 deficiency

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22
Q

Glove and stocking distribution of sensory loss. Causes:

A

Polyneuropathy:
The most common is diabetes

Infection: HIV
Inflammation: chronic inflammatory polyneuropathy disorder (CIPD)
Malignancy: Paraneoplastic; Paraproteinaemia
Metabolic: Diabetes, Alcohol, B12 deficiency

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23
Q

Wasted, shortened lower limb
Reduced T,R,P unilaterally
Scars on leg
Sensation normal

A

Polio myelitis (favourite for OSCE)

Pure motor neuropathy (LMN- reduced TRP)
Wasted shortened limb (chronic)
Normal sensation
Lots of scars- corrective surgery as person grows

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24
Q

Toxic/metabolic causes of peripheral neuopathy:

A 
Drugs: (amiodarone; psychotoxic drugs- phenytoin)
Alcohol (high MCV, high GGT)
B12 deficiency (high MCV)
Diabetes: (HbA1C)
Hypothyroidism
Uraemia (high urea/creatinine)

Amyloidosis (chronic infection/inflammation or Myeloma)

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25
Toxic/metabolic causes of peripheral neuopathy:
``` Drugs: (amiodarone; psychotoxic drugs- phenytoin) Alcohol (high MCV, high GGT) B12 deficiency (high MCV) Diabetes: (HbA1C) Hypothyroidism Uraemia (high urea/creatinine) ``` Amyloidosis (chronic infection/inflammation or Myeloma)
26
Toxic/metabolic causes of peripheral neuopathy:
``` Drugs: (amiodarone; psychotoxic drugs- phenytoin) Alcohol (high MCV, high GGT) B12 deficiency (high MCV) Diabetes: (HbA1C) Hypothyroidism Uraemia (high urea/creatinine) ``` Amyloidosis (chronic infection/inflammation or Myeloma)
27
``` 55 year old man Numbness and tingling in hands and feet PMH: T1DM On basal/bolus insulin HbA1C: 50mmol/L B12: 500pg/ml (200-900) eGFR: 90 ``` Reduced sensation to PP (glove and stocking distribution) 1. Codeine 2. Duloxetine 3. Hydroxocobalamin 4. Paracetemol 5. Pregabalin
2. Duloxetine (first linbe- NICE) (also used for premature ejaculation) Codeine/Paracetemol won't work Hydroxocobalamin- used in B12 deficiency Pregabalin- used but not first line (considered if duloxetine is not effective)
28
``` 55 year old man Numbness and tingling in hands and feet PMH: T1DM On basal/bolus insulin HbA1C: 50mmol/L B12: 500pg/ml (200-900) eGFR: 90 ``` Reduced sensation to PP (glove and stocking distribution) 1. Codeine 2. Duloxetine 3. Hydroxocobalamin 4. Paracetemol 5. Pregabalin
2. Duloxetine (first linbe- NICE) (also used for premature ejaculation) Codeine/Paracetemol won't work Hydroxocobalamin- used in B12 deficiency Pregabalin- used but not first line (considered if duloxetine is not effective)
29
``` 55 year old man Numbness and tingling in hands and feet PMH: T1DM On basal/bolus insulin HbA1C: 50mmol/L B12: 500pg/ml (200-900) eGFR: 90 ``` Reduced sensation to PP (glove and stocking distribution)
Diabetic peripheral neuropathy
30
Toxic/metabolic causes of peripheral neuopathy:
``` Drugs: (amiodarone; psychotoxic drugs- phenytoin) Alcohol (high MCV, high GGT) B12 deficiency (high MCV, anaemia) Diabetes: (HbA1C) Hypothyroidism (TFTs) Uraemia (high urea/creatinine) ``` Amyloidosis (chronic infection/inflammation or Myeloma)
31
``` 55 year old man Numbness and tingling in hands and feet PMH: T1DM On basal/bolus insulin HbA1C: 50mmol/L B12: 500pg/ml (200-900) eGFR: 90 ``` Reduced sensation to PP (glove and stocking distribution)
Diabetic peripheral neuropathy
32
``` 55 year old man Numbness and tingling in hands and feet PMH: T1DM On basal/bolus insulin HbA1C: 50mmol/L B12: 500pg/ml (200-900) eGFR: 90 ``` Reduced sensation to PP (glove and stocking distribution)
Diabetic peripheral neuropathy
33
Non metabolic causes of peripheral neuropathy:
Infection: HIV | Inflammation/Autoimmune: vasculitis, CTD (SLE), inflammatory demyelinating neuropathy (GBS acute, CIDP)
34
Non metabolic causes of peripheral neuropathy:
Infection: HIV Inflammation/Autoimmune: vasculitis, CTD (SLE), inflammatory demyelinating neuropathy (GBS acute, CIDP) Tumour/malignancy: paraneoplastic, paraproteinaemia Hereditary: hereditary sensory, motor neuropathy (eg- if have pers cavus- arch in foot- so peripheral neuropathy has been there a long time)
35
Non metabolic causes of peripheral neuropathy:
Infection: HIV Inflammation/Autoimmune: vasculitis, CTD (SLE), inflammatory demyelinating neuropathy (GBS acute, CIDP) Tumour/malignancy: paraneoplastic, paraproteinaemia Hereditary: hereditary sensory, motor neuropathy (eg- if have pers cavus- arch in foot- so peripheral neuropathy has been there a long time)
36
``` 34 year old man Weakness in legs Blurred vision Legs: T: Increased; P: decreased; R: brisk, decreased pin prick sensation Fundoscopy: shows blurred optic disc ``` ``` Most likely causes of blurred vision? A. Amaurosis fugax B. Anterior uveitis C. Papillodoema D. Pailiitis E. Vitreous haemorrhage ```
Weakness in both legs, increased tone- spastic paraparesis (not LMN) There is a level of sensory loss (legs) Lesion is in the spinal cord- inflammation in CNS so MS D. Pappilitis- inflammation at the head of the optic nerve DDx of blurred optic disc is papilloedema or papillitis
37
Blurred optic disk of fundoscopy:
1. Papilloedema 2. Papillitis Both may have blurred vision (more likely in papillitis) and optic disc won't be clear. However- papillitis will have pain when moving the eye (inflammation)
38
``` 34 year old man Weakness in legs Blurred vision Legs: T: Increased; P: decreased; R: brisk, decreased pin prick sensation Fundoscopy: shows blurred optic disc ``` ``` Most likely causes of blurred vision? A. Amaurosis fugax B. Anterior uveitis C. Papillodoema D. Pailiitis E. Vitreous haemorrhage ```
Weakness in both legs, increased tone- spastic paraparesis (not LMN) There is a level of sensory loss (legs) Lesion is in the spinal cord- inflammation in CNS so MS D. Pappilitis- inflammation at the head of the optic nerve DDx of blurred optic disc is papilloedema or papillitis
39
Blurred optic disk of fundoscopy:
1. Papilloedema 2. Papillitis Both may have blurred vision (more likely in papillitis) and optic disc won't be clear. However- papillitis will have pain when moving the eye (inflammation)
40
``` 34 year old man Weakness in legs Blurred vision Legs: T: Increased; P: decreased; R: brisk, decreased pin prick sensation Fundoscopy: shows blurred optic disc ```
Multiple sclerosis ``` In CNS (spastic pareisis) In spinal cord (sensory loss in both legs- a level- otherwise would be one side and in arm as well). ``` Blurred vision Therefore inflammation in spinal cord and in optic nerve: 2 lesions separated in space/time- MS
41
Blurred optic disc margins (fundoscopy) Blurred vision Pain on eye movement Where and what?
``` Optic nerve Optic neuritis (papillitis) ``` Inflammation of optic nerve (eg- in MS)
42
Blurred optic disc margins (fundoscopy) Blurred vision Pain on eye movement Where and what?
``` Optic nerve Optic neuritis (papillitis) ``` Inflammation of optic nerve (eg- in MS)
43
Weak legs Upgoing planatars, hypereflexia Fevers, night sweats
Pott's Disease: TB of the spine- abscess compressing spinal cord MRI: diagnosis Neurosurgeons and and TB treatment
44
Causes of spastic paraparesis: | weak legs, hypertonia, upgoing plantars
Vascular: infarction in anterior spinal artery Infection: Abscess (Pott's disease TB) Inflammation: MS, transverse myelitis (associated with Mycoplasma pneumoniae) Toxic/metabolic: B12 deficiency Tumour/Malignancy: Tumour of spinal cord
45
Multiple Sclerosis:
Two lesions | Separated in time/space
46
Multiple Sclerosis:
Two lesions | Separated in time/space
47
``` 60 year old pain and paraesthesia in right anterolateral thigh PMH: T2 diabetes Metformin HbA1C: 60 mmo ``` BMI: 30 Reduced pin prick sensation in anteriolateral thigh ``` Next step? A.Lose weight B. Insulin C.Statin D.Aspirin E.MRI brain ```
A. Lose weight Where? What? Anterolateral thigh, pain and paraesthesia (prickling)- one area- so mononeuropathy He has meralgia parasthetica: compression of the lateral femoral cutaneous nerve (as it passes inguinal ligament) Reassure, avoid tight garments, LOSE WEIGHT If persistent: carbamazepine, gabapentin
48
Sensory innervation of hand: lateral 3 1/2 digits (index and middle finger)
Median nerve
49
Sensory innervation of the hand: Medial 1 1/2 digits (little finger)
Ulnar nerve
50
Sensory innervation of the hand: Medial 1 1/2 digits (little finger)
Ulnar nerve
51
Sensory innervation of the hand: base of thumb (dorsal)
Radial nerve
52
Sensory innervation of the hand: base of thumb (dorsal)
Radial nerve | check to see if sensation at base of the thumb- anatomical snuffbox
53
Radial nerve palsy:
wrist drop, sensation lost at base of hand and back and proximal of first 3 fingers
54
Pain in buttock, radiating down the leg below the knee
Sciatica- compression of lumbosacral nerve roots (radiculopathy) Compression by disc herniation, spinal canal setnosis Radiculopathy (disease of nerve roots)
55
wrist drop, loss of sensation at base of thumb
Radial nerve palsy
56
wrist drop, loss of sensation at base of thumb
Radial nerve palsy
57
``` 60 year old man Recurrent falls Tremor at rest Rigidity More forgetful Dysphagia Microphagia (small handwriting) Limited upgaze ``` Most likely diagnosis? ``` A. Progressive supranuclear palsy B. Lewy body dementia C. Stroke D. Epilepsy E. Alzheimer's disease ```
Parkinsonian features PLUS limited upgaze A. Progressive supranuclear palsy Parkinson's (tremor, rigidity, bradykinesia) PSP (Steele-Richardson syndrome): parkisnonian features, upgaze abnormality
58
Triad of tremor, rigidity, bradykinesia
Parkinson's disease
59
Alzheimer's and Parkinsonian features | PLUS hallucinations
Lewy Body dementia
60
``` 55 yr-old man confusion and chest pain no headache or neck stiffness recently moved to new house Temp: 37 PR: 100, BP: 120/60 Normal CVS/Resp/GI/Neuro exam ECG: sinus tachycardia, widespread ST depression Blood glucos: 7 mmol/L WCC/CRP normal CT head normal ```
New house: CO poisoning Rule out other things (normal)
61
``` 55 yr-old man confusion and chest pain no headache or neck stiffness recently moved to new house Temp: 37 PR: 100, BP: 120/60 Normal CVS/Resp/GI/Neuro exam ECG: sinus tachycardia, widespread ST depression Blood glucos: 7 mmol/L WCC/CRP normal CT head normal ```
New house: CO poisoning Rule out other things (normal)
62
Causes of confusion (reduced AMTS):
VIITT/VIMM and others Hypoglycaemia!!! ``` Vascular: bleed Infection: meningitis, encephalitis Inflammation: cerebral vasculitis Metabolic/Toxic: CO poisoning Malignancy/Tumour ``` Other causes: post-ictal (history of seizure) Dysphagia (receptive/expressive)- not confused but can't communicate- stroke/TIA Dementia: Alzheimer's, Vacular (multi-infarct- history of IHD/PVD), alcoholic (signs of excess alcohol), Inherited eg- Huntington's (other features- chorea) Depressive pseudodementia (depression): elderly, withdrawn, poor eye contact. Often a precipitating factor
63
Causes of confusion (reduced AMTS)
VIITT/VIMM and others Hypoglycaemia!!! ``` Vascular: bleed: headaches, collapse. Subdural haematoma (fall, fluctuating conciousness) ``` Infection: meningitis, encephalitis (?temp, ?intracranial (meningitis/enceph), ?extra-cranial (chest/UTI in elderly) Inflammation: cerebral vasculitis, autoimmune encephalitis Metabolic/Toxic: CO poisoning, drugs, U&Es, LFTs, Vit deficiency, Endocrinopathies Malignancy/Tumour Other causes: post-ictal (history of seizure) Dysphagia (receptive/expressive)- not confused but can't communicate- stroke/TIA Dementia: Alzheimer's, Vacular (multi-infarct- history of IHD/PVD), alcoholic (signs of excess alcohol), Inherited eg- Huntington's (other features- chorea) Depressive pseudodementia (depression): elderly, withdrawn, poor eye contact. Often a precipitating factor
64
Causes of confusion (reduced AMTS)
VIITT/VIMM and others Hypoglycaemia!!! ``` Vascular: bleed: headaches, collapse. Subdural haematoma (fall, fluctuating conciousness) ``` Infection: meningitis, encephalitis (?temp, ?intracranial (meningitis/enceph), ?extra-cranial (chest/UTI in elderly) Inflammation: cerebral vasculitis, autoimmune encephalitis Metabolic/Toxic: CO poisoning, drugs, U&Es, LFTs, Vit deficiency, Endocrinopathies Malignancy/Tumour Other causes: post-ictal (history of seizure) Dysphagia (receptive/expressive)- not confused but can't communicate- stroke/TIA Dementia: Alzheimer's, Vacular (multi-infarct- history of IHD/PVD), alcoholic (signs of excess alcohol), Inherited eg- Huntington's (other features- chorea) Depressive pseudodementia (depression): elderly, withdrawn, poor eye contact. Often a precipitating factor
65
GCS:
``` Eyes (4) Verbal response (5) Motor response (6) ```
66
GCS Eyes:
1: no response 2: open to pain 3: open to speech 4: spontaneous opening
67
GCS Motor:
Motor (6) 1: no response to pain 4: withdraws to pain 5: localising response to pain 6: obeying commands
68
GCS Verbal:
Verbal (5) 1: none 2: sounds 3: words 4: confused conversation 5: orientated
69
GCS Verbal:
Verbal (5) 1: none 2: sounds 3: words 4: confused conversation 5: orientated
70
Abbreviated Mental Test:
``` DOB Age Time Year Place Recall (3 words) Recognise doctor/nurse Prime minister Second WW Count backwards from 20 ```
71
Abbreviated Mental Test:
``` DOB Age Time Year Place Recall (3 words) Recognise doctor/nurse Prime minister WWII Count backwards from 20 ```
72
Abbreviated Mental Test:
``` DOB Age Time Year Place Recall (3 words) Recognise doctor/nurse Prime minister WWII Count backwards from 20 ```
73
Abbreviated Mental Test:
``` DOB Age Time Year Place Recall (3 words) Recognise doctor/nurse Prime minister WWII Count backwards from 20 ```
74
Headache in the Emergency Department (serious causes):
Meningitis (fever, neck stiffness, meningism, Kernig's sign)- treat with ceftriaxone Subarachnoid haemorrhage: (sudden onset, thunderclap. CT, LP (xanthochromia- yellow CSF- breakdown products of RBCs)) Giant cell arteritis: polymyalgia rheumatic, (shoulder girdle pain, stiffness, jaw claudication, malaise, fever). >50years. Give high dose steroids Also: Migraine: throbbing, vomiting, photo/phonophobia, FHx, Aura
75
Headache in the Emergency Department (serious causes):
Meningitis (fever, neck stiffness, meningism, Kernig's sign)- treat with ceftriaxone Subarachnoid haemorrhage: (sudden onset, thunderclap. CT, LP (xanthochromia- yellow CSF- breakdown products of RBCs)) Giant cell arteritis: polymyalgia rheumatica(shoulder girdle pain, stiffness malaise, fever) or alone. >50years. Give high dose steroids Also: Migraine: throbbing, vomiting, photo/phonophobia, FHx, Aura
76
Headache in the Emergency Department (serious causes):
Meningitis (fever, neck stiffness, meningism, Kernig's sign)- treat with ceftriaxone Subarachnoid haemorrhage: (sudden onset, thunderclap. CT, LP (xanthochromia- yellow CSF- breakdown products of RBCs)) Giant cell arteritis: polymyalgia rheumatica(shoulder girdle pain, stiffness malaise, fever) or alone. >50years. Give high dose steroids Also: Migraine: throbbing, vomiting, photo/phonophobia, FHx, Aura
77
Throbbing headache, vomiting, photo/phonophobia, FHx, Aura
Migraine High dose aspirin (900mg)/ naproxen (NSAIDs)
78
Determining what management of stroke:
Time of onset | 4.5 hours
79
Management of stroke
80
Management of stroke >4.5 hours
>4.5 hours - CT head (exclude haemorrhage) - Aspirin (300mg), assess swallow - Maintain hydration, oxygenations, monitor blood glucose (Don't treat BP acutely unless >220/120- dangerous to bring it down to quickly)
81
TIA
- Aspirin - Don't treat BP actuely (unless >220/120 or other indication) - ECG, Echocardiogram - Carotid Doppler - Risk factor modification
82
Management of stroke
83
Management of stroke >4.5 hours
>4.5 hours - CT head (exclude haemorrhage) - Aspirin (300mg), assess swallow - Maintain hydration, oxygenations, monitor blood glucose (Don't treat BP acutely unless >220/120- dangerous to bring it down to quickly)
84
TIA
- Aspirin - Don't treat BP actuely (unless >220/120 or other indication) Find underlying cause- to see if the patient is a candidate for carotid end arterectomy: - ECG, Carotid Doppler, Echocardiography (thrombus in the heart causing emboli) - Risk factor modification (stop smoking, DM, HTN)
85
TIA
- Aspirin - Don't treat BP actuely (unless >220/120 or other indication) Find underlying cause- to see if the patient is a candidate for carotid end arterectomy: - ECG, Carotid Doppler, Echocardiography (thrombus in the heart causing emboli) - Risk factor modification (stop smoking, DM, HTN)
86
40 year old Back ache LMN weakness (weak legs and depressed reflexes) Admitted to HDU Regular FVC Cardiac monitor IVIG Most likely diagnosis? ``` A. Guillain-Barre B. Stroke C. Cord compression D. Cauda equina syndrome E. Myaesthenia Gravis ```
A. Guillain-Barre LMN, young person Back ache- radiculopathy (nerve roots) Stroke and Cord compression would cause UMN signs (brisk reflexes) Cauda equina- LMN legs, but saddle (perianal) anaesthesia, problems with bowel (is still a DDx- MRI to see any compression)
87
Management of Guillain-Barre
- Admit to HDU - Regular FVC (forced vital capacity- respiratory depression) - Cardiac monitor (autoimmune disturbances) - IVIG (IV immunoglobulins treatment) If FVC drops below 20ml/kg- send to ITU- intubation
88
Management of Guillain-Barre
- Admit to HDU - Regular FVC (forced vital capacity- respiratory depression) - Cardiac monitor (autoimmune disturbances) - IVIG (IV immunoglobulins treatment) If FVC drops below 20ml/kg- send to ITU- intubation
89
Management of Guillain-Barre
- Admit to HDU - Regular FVC (forced vital capacity- respiratory depression) - Cardiac monitor (autoimmune disturbances) - IVIG (IV immunoglobulins treatment) If FVC drops below 20ml/kg- send to ITU- intubation
90
Management of Giant Cell Arteritis:
Giant cell arteritis/Temporal arteritis: If suspected: Start on high dose prednisolone 60mg/d immediately to prevent visual loss Blood: ESR (will be increased) and so will CRP Get a temporal artery biopsy within 7 days of starting treatment (10% will be negative as skip lesions occur)

Year 3 Medicine (17 decks)

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