clinical neurology

Question 1

type of pathologies (mneumonic=vitamin c&d)

Answer 1

• vascular e.g. stroke
  -infection/inflammation e.g. meningitis/encephalitis
• traumatic/toxic e.g. sciatica
• autoimmune/allergic e.g. multiple sclerosis
• metabolic e.g. adrenoleukodystrophy
• iatrogenic/idiopathic e.g. idiopathic neuropathy
• neoplastic e.g. meningioma, glioma (brain tumours)
• congenital e.g. hydrocephalus
• degenerative e.g parkinsons disease

Question 2

what does iatrogenic mean?

Answer 2

medicince has caused it

Question 3

what does idiopathic mean?

Answer 3

we do not know why it has occured

Question 4

what does congenital mean?

Answer 4

present at birth

Question 5

how do we examine the nervous system?

Answer 5

sensory vs motor symptoms
CNS
PNS
cranial nerves
spinal nerves
mental state
examination or MSE
one test often examines multiple functional areas of
nervous system – integrative function

Question 6

stages of a PNS examination

Answer 6

inspection
tone
power
reflexes
co-ordination
sensation
function

Question 7

PNS inspection

Answer 7

what can you see in the patient?
the way they walk
twitching (fasciculation)
muscle wasting
falling
shaking/tremors
clumsy
odd movements

Question 8

PNS tone, power and reflexes

Answer 8

tests motor function
tone – the amount of contraction/resistance in a muscle
power – the amount of strength a muscle can generate
reflexes – an automated response to a stimulus

Question 9

how do we test tone?

Answer 9

move the patient’s relaxed arm

Question 10

how do we test power?

Answer 10

ask the patient to resist movement

Question 11

how do we test reflexes?

Answer 11

tap tendons with a tendon hammer

Question 12

PNS co-ordination

Answer 12

main architect=cerebellum
ability to produce fine, co-ordinated and steady movements
also test ability to recieve and interpret incoming sensory signals about proprioception and balance

Question 13

how do we test co-ordination?

Answer 13

get patient to balance on one leg, arms outstretched
make rapid alternating movements in clapping palm, then back of hand to the other palm – disdiadochokinesia or
DDK
finger to nose test
watch patient walking – ataxia gait

Question 14

PNS sensation

Answer 14

testing sensory tracts
dermatomal mapping- different nerves innervate different parts of body
different sensations:
1. crude touch – finger tip
2. pain – neurofilament
3. fine touch – cotton wool
4. two-point touch – forceps/tweezers
5. temperature – hot and cold water tubes
6. vibration – tuning fork

Question 15

PNS function

Answer 15

a brief assessment of gross and fine motor skills
- walk
- sit down and stand from a chair (or get
up from floor)
- undo buttons on coat, then do up again
- pick up a pen and write a sentence
- pick up a coin from a table
- undo a jam jar

Question 16

olfactory- loss of smell

Answer 16

often, not formally tested; simply ask patient if they’ve noticed a change in their sense of smell or taste
test odours
anosmia (loss of sense of smell)
infection/inflammation eg sinusitis, rhinitis, COVID
nasal polyps
head trauma with associated fracture
frontal tumour eg meningioma

Question 17

lesions of the visual pathways

Answer 17

a. optic nerve eg. optic neuritis (total blindness of ipsilateral eye)
b. optic chiasm eg. pituitary tumour (bilateral heteronymous hemianopsia)
c. partial insult of optic
nerve (ipsilateral nasal hemianopsia)
d. optic tract/optic radiation (contralteral homonymous hemianopsia)

Question 18

occulmotor palsies

Answer 18

dilated pupil
unresponsive to light
no accommodation
down & out eye
ptosis

Question 19

trigeminal testing

Answer 19

touch patient with cotton wool & neuro tip
over forehead, cheek & chin
ask patient to clench jaw & palpate
muscles
trigeminal neuralgia- idiopathic
herpes zoster (shingles)- occurs in dermatomal strips

Question 20

facial nerve testing

Answer 20

ask the patient to raise their eyebrows
ask the patient to close
their eyes; try to open them
ask patient to reveal their teeth
ask patient to blow out their cheeks
corneal reflex (also for CNV): efferent limb innervates
orbicularis oculi, but rarely tested

Question 21

distinguising between upper and lower motor lesions

Answer 21

branch of facial nerve containing LMNs
receives input from both cortices via
UMNs
therefore there is a bilateral innervation
pattern
in an UMN lesion, e.g. stroke, the forehead muscles are spared due to this pathway, so the patient can raise their
eyebrows
in a LMN lesion, e.g. bells palsy, the end
pathway is lesioned, resulting in paralysis,
so the patient cannot raise their eyebrows

Question 22

vestibulocochlear testing

Answer 22

used to diagnose:
conductive loss – pathology in relaying
the sound impulse through the conductive apparatus
sensorineural loss – pathology in the
nerve or its specialised terminals
- need a vibrating tuning fork to test
- weber – place fork in centre of head and
ask where the sound is heard
- rinne – place fork first next to the canal
and then on the mastoid process and ask where is heard loudest

Question 23

glossopharyngeal and vagus testing

Answer 23

tend to be tested together
observe the uvula; is it deviated? →
deviates away from side of lesion in a
LMN lesion
ask patient to speak → CNX through
vocal cord palsy
ask patient to swallow a small amount of water → if poor can be
both CN IX & X or lone CNX
singular lesions of these nerves are
very rare