Clinical examination of nervous system

Question 1

CSF (cerebrospinal fluid)

Normal findings

1. Pressure
2. Color
3. Cells (RBC and WBC count)
4. Protein
5. Microbiology
6. Oligoclonal bands

Answer 1

1. Pressure: 50-250 cm water
2. Clear
3. RBC- 0-4
   WBC-0-4 (×10^6/L).
4. Glucose: 50-60% of normal blood glucose level.
5. Protein: <0.45gm/L
6. Sterile
7. Negative oligoclonal bands

Question 2

CSF findings

1. Raised Polymorphs
2. Hazy/cloudy appearance

Answer 2

1. Acute Bacterial/Pyogenic meningitis
2. Partially treated meningitis
3. Clear/cloudy in (2)

1. Marked rise in neutrophil polymorphs in (1)

1: 1000-5000 polymorphs×10^6/L
2: Normal to raised WBC count; mixed cells

Question 3

CSF findings

Raised lymphocyte count

Answer 3

1. Viral meningitis (10-2000)
2. Tuberculous meningitis (50-5000)
3. Cryptococcal meningitis in HIV infection (20-200)
4. Carcinomatous/lymphomatous meningitis(0-400)
5. Multiple sclerosis (0-50)
6. AIDP (acute inflammatory demyelinating polyneuropathy) (0-50)

Question 4

CSF findings

Raised protein count

Answer 4

1. Subarachnoid hemorrhage
2. AIDP (acute inflammatory demyelinating polyneuropathy)
3. Multiple sclerosis
4. Carcinomatous/lymphomatous meningitis
5. Acute bacterial/pyogenic meningitis
6. Partially treated bacterial meningitis
7. Viral meningitis
8. Cryptococcal meningitis in HIV infection
9. Tuberculous meningitis

1,2: Marked Raise
3,4: Normal/raised

1-4: Non inflammatory causes
5-9: Inflammatory causes
Protein can be normal in 6,7,8

Question 5

Neurological emergencies

Answer 5

1. Status epilepticus
2. Stroke
3. Guillian Barre syndrome
4. Myasthenia Gravis
5. Spinal cord compression
6. Subarachnoid haemorrhage
7. Neuroleptic malignant syndrome

2: If thrombolysis or mechanical thrombectomy available
4: If bulbar and/or respiratory

Question 6

Gait examination

Difficulty raising from a chair

Answer 6

Proximal muscle weakness or joint disorders

Question 7

Gait examination

Difficuty starting to walk, frozen

Gait initiation

Answer 7

Cerebrovascular disease
Parkinsonism

Question 8

Gait examination

1. Stooping
2. Postural instability
3. Narrow-based, short strides, freezing in doorways
4. Enhanced tremor
5. Reduced arm swing
6. Shuffling/festination

Answer 8

Parkinsonism

Reduced arm swing can also be found in upper motor neuron lesions.

Question 9

Gait examination

Slapping, High-stepping gait due to foot drop

Answer 9

L5 radiculopathy or common peroneal nerve lesion

Question 10

Gait examination

Stiff legged, scissors gait

Answer 10

Spastic paraparesis:
* Multiple sclerosis
* Vascular disease
* Spinal cord lesions
Cerebellar lesions

Question 11

Gait examination

Wide based, unsteady, unable to perform tandem gait
Waddling gait

Answer 11

1. Myopathies with proximal weakness (Proximal myopathy)
2. Dermatomyositis, polymyositis

Question 12

Gait examination

High stepping gait/Stamping gait

Answer 12

Dorsal column lesion, Sensory neuropathy

Question 13

Gait examination

Drunken /ataxic gait

Characterstic “broad based” gait

Answer 13

1. Cerebellar lesion (vermis)
2. Lesion in vestibular apparatus or peripheral nerves

Metabolic causes of acquired ataxia: Vitamin E deficiency, hypoparathyroidism

Question 14

Gait Abnormality

Marche a Petits pas

Small, slow steps & marked instability

Answer 14

Small vessel cerebrovascular disease (e.g; Lacunar stroke in basal ganglia)

Question 15

Gait abnormality

Arthralgic gait (gait against pain)

Answer 15

Arthropathy

Question 16

Gait abnormality

Apraxic gait

Answer 16

1. Diffuse bilateral hemisphere disease (e.g; normal pressure hydrocephalaus)
2. Diffuse frontal lobe disease

Gait, power, cerebellar function, propioception are normal on examination, yet patient says their feet appear stuck to the floor, making them unable to walk.

Question 17

Fasiculation

Implies chronic denervation with partial renervation

Answer 17

1. Spinal muscular atrophy
2. Progressive muscular atrophy
3. myasthenic crisis
4. OPC poisoning (nicotinic feature)

lower motor neuron lesions

Question 18

Nerve conduction studies

1. Diffuse?
2. Focal?
3. Multifocal?

Interpretation

Answer 18

1.Hereditary demyelinating peripheral neuropathy
2. Pressure palsies
3. Guillian Barre Syndrome, Mononeuritis multiplex

Question 19

Electromyelography (EMG)

1. Motor neuron disease
2. Guillian Barre syndrome
3. Myasthenia
4. Myopathy

Findings

Answer 19

1. Widespread innervation & reinnervation
2. Conduction block with multifocal motor slowing
3. Jitter and blocking
4. Low amplitude & short duration of response

Question 20

Evolution of symptoms

Sudden onset (minutes to hours)

Evolution: Stable/improvement

Answer 20

1. Vascular (stroke/transient ischemic attack)(TIA)
2. Nerve entrapment syndrome
3. Functional

Question 21

Evolution of symptoms

Gradual (progressive over days)

Answer 21

Inflammation, infection

Question 22

Evolution of symptoms

Gradual (progressive over weeks to months)

Answer 22

Neoplastic/paraneoplastic

Question 23

Evolution of symptoms

Gradual (progressive over months to years)

Answer 23

Genetic/degerative

Question 24

Causes of

Flapping tremor

Answer 24

1. Hepatic encephalopathy
2. Severe cardiac failure
3. Respiratory failure (due to CO2 retention in COPD)
4. Renal failure (azotaemia)
5. Other (rare): Cerebrovascular disease, Drug toxicity (Phenytoin, Barbiturates), Acute focal parietal or thalamic lesion (vascular), Hypoglycaemia, Wilson’s disease.

(1) Commonest cause