Clinical Examination Flashcards
Name the signs and symptoms of drug induced hyponatraemia?
Muscle cramps, malaise, nausea/vomiting - if severe can include hypertension, seizures, lethargy, confusion and coma
When performing tasks inside a scanner what area often gets highlighted?
Primary motor cortex
How does L or R hemispheral damage affect a patients ability to copy a picture with regards to global and specific details
L hemisphere damage - patient misses the finer details but can give a global picture
R hemisphere damage patient can do the fine details but misses the “gestalt” or global picture
What does diffusion tensor imaging allow?
Assessment of myelination of white matter tracts at macrosopic level
Uses information derived from water molecules within the tracts
What cognitive changes occur in normal ageing even in an individual without dementia?
- Reduced problem solving ability
- Psychomotor slowing
- Good memories for distant personal events of significance
- Reduced capacity of working memory
In metabollic encephalopathy what changes to the EEG may occur?
Generalised slowing - generalised slowing of theta and with bilateral synchronous gamma waves
Sometimes there is a frontal maximum - intermittent frontal rhythmic delta activity
What is a confrontation test?
Cover eyes and assessing visual fields - it assess vision of the optic tract
How long can amphetamines be detected in a UDS?
48 hours
How do PET and SPECT differ with regards to measures of neuronal metabolism they can detect?
PET can detect neuronal blood flow and glucose metabolism
SPECT can only detect neuronal blood flow
Outline the presentation of acute intermittent porphyria?
Women of childbearing age and autosomal dominant cause
Acute attacks that may be catamenial (i.e occur between ovulation and menstruation due to rise in progesterone), or triggered by certain medications.
Note acute intermittent porphyrias do not present with a rash
OCP, barbituates, benzodiazepines or diclofenac
Symptoms:
- Sudden attack of abdominal pain, nausea and vomiting with subtle neurological symptoms (weakness, altered affect, dysaesthesia - unpleasant sensation when touched)
Can be detected by elevated plasma or urinary porphobilinogen (note not included in porphyria screen that only assess for cutaneous porphyrias).
Treated by administering haemin
Name some cognitive domains/tests that Schizophrenia patients may have deficits in?
Flexible shifting between cognitive domains - speech sounds test, trail B from halstan reitan battery
Higher order reasoning - Wisconsin card test & category testing
In anomic aphasia where is the lesion?
Temporal-parietal area
Typically non-dominant
Here naming is impaired - comprehension is intact
Grammar and repetition are good too
In Lewy-Body dementia where are Lewy bodies located?
Intraneuronal intracytoplasmic inclusions composed of alpha synuclein and ubiquitin
In Schizophrenia what area of the brain has consistently shown decreased grey matter volume?
The insula
What tests for narcolepsy may be helpeful?
Polysomnogaphy - sleep EEG, multiple sleep latency: increased N1 with multiple awakenings and specific sleep onset REM
CSF - hypocretin levels
HLA testing
MRI testing
How does psychogenic polydipsia or diabetes insipidus differ in urine/plasma osmolalities?
Both conditions where there is polydipsia and polyuria
In psychogenic polydipsia: - low plasma sodium concentration (and osmolality) AND low urine osmolality
In diabetes insipidus: normal/high plasma osmolality with a low urine osmolality
What type of imaging may be helpful at diagnosing dementia with lewy body?
DAT imaging (dopamine transporter uptake) from basal ganglia - from PET or SPECT scans
78% sensitivity
90% specificity
What is a senile pupil?
Occurs with ageing - a individuals pupil may decrease in size and there be slowness of response to accommodation and light
Antecedant - behaviour and consequence charts are a type of…
Functional analysis
What is a lactate infusion used to help diagnose (rarely done now)?
Panic attacks - IV injection of sodium lactate (inhibited by BDZ and TCA but not beta-blockers)
What is narcoanalysis?
Interviewing under the influence of medication - can be helpful for dissociative or fugue disorders
Medications used are amobarital and BDZ
Apart from spot urine for porphobilinogen for acute attacks what other tests exist for porphyrins?
24-hour urine for porphyrin and delta-aminlevulinic acid
What receptors have autoimmune antibodies that may trigger and autoimmune encephalitis?
Voltage gated potassium channel complex (LGl1, CASPR2, contactin-2)
NMDA
AMPA
GABA-B
Glycine
What investigations may help detect NMDA-R encephalitis?
Serum NMDAR and VGKC
ANA, CRP, ESR, FBC & U&E (note low sodium seen in anti-VBKC abs)
EEG - disorganised theta and delta activity
MRI brain (medial temporal hyper-intensity - T2 or flair sequences in hippocampi, frontobasal, insular and basal ganglia)
To confirm:
- CSF - lymphocytic pleocytosis, elevated protein, oligoclonal bands
Non-specific - elevated CK
Conducted pelvis US or CT in females to detect ovarian teratoma
How is NMDA-R encephalitis treated?
3 days of methylpred followed by oral prednisolone
Plasma exchange is also conducted
Remission may be maintained with steroids alone or use of azathioprine, mycophenolate mofetil or rituximab
Outline the physical abnormalities expected in anorexic patients?
Bloods:
- Low sex hormones - LH, FSH, oestrodiol
- Low T3/T4 (may be of normal range), normal TSH
- Raised plasma cortisol
- Raised GH
- Low leptin
- FBC –> low platelets, low WCC, low Hb (normocytic normochromic), may have elevated lymphocytes
- High cholesterol
- U&E –> low K if vomiting. If laxative misuse low K, low Na but acidotic (metabolic)
ECG - bradycardia, prolonged QT
Gastrointestinal:
- Delayed gastric emptying
- Decreased colonic motility (can comes secondary to laxative misuse)
- Acute gastric dilatation (rare and secondary to excessive re-feeding)
Bone imaging:
- Osteopenia and osteoporosis
What is the single best test for detecting alcohol in the last 10 days
Carbohydrate deficient transferrin (blood test).
Used by DVLA for high risk offenders
Outline some risk factors for prolonged QTc?
Congenital long QT
Female
V old/v young age
Hypokalemic, hypocalcaemia, hypomagnesemia
Stimulant drug use
Starvation or anorexia
High physical exertion/agitation
Underlying heart disease, bradycardia, heart failure and ischaemic disease
Name some physical signs seen in eating disorders?
Presence of lanugo hair
Russells signs - callous on knuckles (sign of purging)
Parotid swelling (bulimia)
Outline some meningeal signs?
Brudzinski’s signs - flexion of knees and hips when trying to flex neck
Kernig’s sign - with hip and knee flexed when extend knee there is hamstring spasm or the other knee extends
Lasegue or straight leg raise - passively flexing the hip with the knee straight while the patient is supine - there may be limited flexion due to hamstring spasm or pain - irritation of local nerve roots
Reverse SLR - instead patient is prone and hyperextend hip with straight leg. May be thigh spasm or pain due to irritation of upper lumbar nerve roots
What is stereognosis?
Perception of depth - controlled by somatosensory cortex
What is asterixis?
Hepatic flap
What may pronator drift indicate?
Hemiparetic weakness
When is babinskis positive?
If the big toe moves up (dorsiflexion) and toes fan out - this is abnormal:
- It may indicate an UMN or loss of LMN (affecting L4/L5)
- Could indicate absence of cutaneous innervation of S1
What spinal roots make up biceps, brachioradialis, triceps, patellar and achilles?
BICEPS C5,C6
Brachioradialis C6
TRICEPS C7
Patellar L2-L4
Achilles S4
What groups of neurological signs are collectively known as “soft signs”
Abnormalities of sensory integration
Abnormalities of motor coordination
Signs of cortical inhibition
Outline the functional structure of the cerebellum?
Vestiblocerebellum - involved in balance and spatial recognition (also known as the flocculonodular lobe or archicerebellum)
cerebrocerebellum (lateral portions of anterior and posterior lobes) involved in planning of motor movement and conscious assessment of movement
spinocerebellum (medial portions of anterior and posterior lobes) involved in fine motor movements
Midline vermis controls truncal tone, speech and eye movements
Name some superficial reflexes?
Corneal and conjunctival reflex
Abdominal reflex - movement of umbilicus to direction line is drawn with a finger
Cremasteric reflex - stroking of thigh leads to upward movement of ispliateral testis
Babinskis reflex
- These reflex rely upon intact cutaneous innervation and motor outflow
How does superficial and deep tendon reflexes differ?
Both require intact cutaneous sensation and motor outflow however deep tendon reflexes require intact cortical input to the corresponding spinal segment
Outline the presentations of the following types of gait and their causes
a) Festinating
b) Antalgic
c) Ataxic
d) Waddling (myopathic)
e) Steppage (neuropathic)
f) Spastic (scissor diplegia)
g) Pigeon
a) Short and shuffling steps with a tendency to accelerate (festinating). Parkinson’s
b) Stance phase shortened relative to swing phase
c) Unsteady - elicited by walking on a tight rope. If large lateral lesion may veer to affected side (cerebellum)
d) Broad based with duck like waddling due to pelvis dropping to side of leg being raised. May be compensatory forward curvature of the spine. Seen in congenital hip dislocation, proximal myopathy and pregnant women
e) High steps like climbing a stair due to proximal peripheral neuropathy i.e foot drop and dorsal column disorders
f) Rigidity and excessive adduction of the leg in swing , plantar flexion of the ankle, flexion at the knee, adduction and internal rotation at the hip, and contractures of all spastic muscles. Caused by cerebral palsy
g) Pigeon gait - in-pointing toes. Seen in hip dysplasia’s
Outline the presentations of the following types of gait and their cause
a) Stomping
b) Magnetic
c) Choreoform
d) Sensory
e) Hemiplegic
a) Bilateral high steppage due to abnormal proprioreception - Friedrich’s ataxia
b) As if feet stuck to the floor - normal pressure hydrocephalus
c) Irregular, jerky, involuntary movements in all extremities. Walking may accentuate their baseline movement disorder - Huntington’s
d) Patient will stamp foot hard on the floor to know where it is - peripheral neuropathy i.e. B12 difficulties or diabetes
e)
What presentations may give:
a) Absent ankle jerk (clonus) and upgoing plantar
b) Anisocoria (pupillary asymmetry)
c) Beevor sign
d) Tonic pupil with absent patellar and achilles reflexes
e) Ptosis, anhidrosis, miosis, endoptholomos (sunken eyes), loss of ciliospinAI reflex
f) Marcus Gunn-Pupil
b) Strange as absent ankle jerk more indicative of LMN whereas babinskis indicates an UMN lesion - may arise in subacute combined degeneration of the spinal cord, syphilitic taboparesis, Friedrich’s ataxia and motor neurone disorder
b) PS or sympathetic defect. Sympathetic causes horner’s syndrome - small but reactive eye. Parasympathetic defect (PS) results in tonic pupil
c) Bilateral lowe abdominal paralysis –> it is the upward deviation of the umbilicus when the patient tries to raise their head and sit up from a supine position
d) Holmes-Adie Syndrome
e) Sympathetic chain on the same side - i.e. apical lung tumour, carotid aneurysms
f) Afferent pupillary (optic nerve) defect - paradoxical dilatation of pupil on swinging light test ipsilateral - lesion in optic nerve ipsilateral to sign. No anisocoria
In Brown Sequard Syndrome what are the symptoms if the following are affected
a) Lateral corticospinal damage
b) Posterior column damage
c) Lateral spinothalamic damage
a) Ipsilateral paralysis, ipsilateral babinskis, ipsilateral increased reflexes
b) Ipsilateral loss of tactile, vibratory and proprioreception below lesion level
c) Contralateral loss of pain, and temperature. Occurs 2-3 segments below of lesion
(note anterior spinothalamic carries coarse touch and pressure
How does subacute combined degeneration of the cord present?
Depends which tract it affects
Lateral corticospinal - bilateral spastic paresis
Dorsal column - bilateral loss of vibration and proprioreceotion
Spinocerebellar tracts - ataxia
Caused by B12 deficiency or vit E deficiency
What is mononeuritis multiplex?
A painful asymmetric asynchronous sensory and motor peripheral neuropathy caused by damage to at least 2 separate nerves.
Causes include diabetes, vasculitis, amyloidosis, direct tumour involvement, autoimmune disorders and paraneoplastic syndromes
What is myerson sign?
Continued blinking on glabellat tap - seen in Parkinson’s
How does optic neuritis present?
Loss of vision, eye pain and dyschromatopsia - 70% unilateral
Uhtoff symptom is reduced vision by heat or exercise
Afferent afferent light defect - direct pupil reflex lost but consensual present
How do pseudobulbar and bulbar palsy compare and contrast (cause and symptoms)?
Bulbar palsy - LMN affecting CN 9-12 - MND, polio, botulism, myasthenia gravis and muscular dystrophy
- Tongue atrophy and fasciculations
- Nasal speech
- Jaw jerk lost and lost gag reflex
Pseudobulbar palsy (UMN - MND, MS, multiinfarct dementia, and severe head injury)
- Bilateral supranuclear palsy affecting lower CN nerves
- Stiff tongue (wasting only later)
- Exaggerated jaw jerk and gag reflex still there
- Emotional liability
- Donald duck speech
Name some cons of the MMSE
Not good at detecting early changes
Doesn’t test frontal executive deficits
Can be a practice effect
Lower scores if < 9 years in formal education (dementia cut off 21/12 rather 23/24)
