CNS/HN - Body Weakness/Numbness/Tremor

Question 1

Differential Diagnosis - Body weakness

Answer 1

• Stroke - counselling
• Subdural Hematoma
• Transient Ischemic Attack
• Vitamin B12 Deficiency
• Bell’s Palsy
• Benign Essential Tremor

Differential Diagnosis 
- Stroke 
- Peripheral Neuropathy (Diabetes) 
- Alcohol
- Brain tumor
- Vitamin B 12 deficiency
	o Diet (vegetarian)
	o Decreased absorption: gastrectomy
	o Autoimmune: 
		§ Pernicious anemia: 
		§ Atrophic gastritis
		§ Hypothyroidism, Diabetes
		§ Chron;s and Celiac disease 
	o Medications: PPI, H2 blockers, Metformin
Less likely: MS, neurosyphilis, GBS, spinal cord compression

Question 2

Differential Diagnosis - Paralysis of face - Bell’s Palsy

Answer 2

Differential Diagnosis 
- Bell palsy
- CVA (Stroke/TIA)
- Brain tumor
- Ramsay-Hunt Syndrome 
- Parotid cancer
Cholesteatoma

Question 3

Differential Diagnosis - Tremors - BET

Answer 3

Tremors
- Benign tremors (postural)
- Hyperthyroidism (fine tremors)
- Cerebellar (ALS/MS) à(intention tremor)
- Parkinson
- Metabolic: Liver disease (flap; Asterixis [coarse alternating]); uremia
- Drugs -induced: Lithium, caffeine anti-psychotics, salbutamol
- Drug withdrawal: alcohol, amphetamines, narcotics
Anxiety/phobia

Question 4

Key History - Tremors

Answer 4

Key history
•Nature of the tremor: resting, intention, postural (action), pill-rolling, flapping (asterixis), hysterical, mixed
•Family history of tremor
•Evidence of cognitive changes or other neurological problems
•Systems review: respiratory, cardiac, liver, kidneys
•Drug history: prescribed, OTC, illicit drugs, alcohol, caffeine

Question 5

Key examination - Tremors

Answer 5

Key examination
•General appearance and vital signs
•Respiratory, cardiac, abdominal (esp. liver) and neurological examination

Question 6

Key investigations - Tremors

Answer 6

Key investigations According to above:
•FBE and ESR
•thyroid function tests (?hyperthyroidism), 
- LFTs, 
- pulse oximetry/blood gases
•drug screen
•MRI

Question 7

Diagnostic tips - Tremors

Answer 7

Diagnostic tips 
•Essential tremor eased by a small quantity of alcohol.
•Triad of essential tremor: 
- postural or action tremor, 
- head tremor,
-  positive family history.

•Look for Parkinson tetrad:

• resting tremor,
• bradykinesia,
• rigidity,
• postural instability.

•Look for cerebellar tetrad:

• intention tremor,
• dysarthria,
• nystagmus,
• ataxic gait.

•Typical drugs that induce Parkinsonism are

• phenothiazine,
• butyrophenones,
• reserpine

Question 8

Differential Diagnosis - Paresthesia and Numbness

Answer 8

Paraesthesia and numbness Probability diagnosis

Diabetic peripheral neuropathy
Nutritional peripheral neuropathy esp. alcohol, B12, folate
Hyperventilation with anxiety
Nerve root pressure e.g. sciatica, cervical spondylosis
Nerve entrapment esp. carpal tunnel syndrome
Neurotoxic drugs

Serious disorders not to be missed

Vascular:
•CVA/TIA
•Peripheral vascular disease

Infection:
•AIDs
•Lyme disease
•Leprosy
•Some viral infections

Tumour/cancer:
•Disseminated malignancy
•Cerebral/spinal cord tumours

Other:
•CKF: uraemia
•Guillain–Barré syndrome
•Trauma to spinal cord
•Marine fish toxins e.g. toadfish, Ciguatera

Pitfalls (often missed)
Migraine variant with focal signs
Multiple sclerosis/transverse myelitis
Hypocalcaemia

Rarities:
•Chronic inflammatory polyneuropathy
•Charcot–Marie–Tooth syndrome
•Amyloidosis
•Heavy metal toxicity e.g. lead

Masquerades checklist 
Diabetes
Drugs e.g. cytotoxic agents, interferon (see list)
Anaemia: pernicious anaemia 
Thyroid/other endocrine: hypothyroid?
Spinal dysfunction

Is the patient trying to tell me something?
Consider conversion reaction (hysteria),
severe anxiety disorder.

Some cases may be idiopathic.

Question 9

Key history - Paresthesia and Numbness

Answer 9

Key history

Analyse symptoms: 
the nature, distribution, onset and associated neurological symptoms (motor, sensory), such as 
- vertigo, 
- seizures,
-  vision.

Check for other associated general symptoms such as

• fever,
• weight loss,
• pruritus,
• rash,
• weakness.

History of diabetes, migraine, cancer, spinal problems, injury, possible bites, fever/sweating and other symptoms.

Take a travel and diet history, incl. nutrition and alcohol.

Gather a drug history, particularly cancer therapy, interferon, colchicine, thalidomide, statins, alcohol or any illicit drugs.

Check the patient’s occupational history, e.g. exposure to lead, and psychiatric history, esp. anxiety states.

Question 10

Key examination - Paresthesia and Numbness

Answer 10

Key examination

• General health and nutritional status.
• Focused neurological especially sensory, motor function, reflexes.
• Look for ‘glove and stocking’ distribution, muscle wasting e.g. thenar eminence.
• Peripheral vasculature.

Question 11

Key investigations - Paresthesia and Numbness

Answer 11

Key investigations 
First line: 
•urinalysis
•blood sugar
•FBE
•ESR/CRP

Consider:
•serum calcium
•B12 and folate
•LFTs (γGT)
•U & E
•TFTs
•KFTs
•nerve conduction studies

According to clinical findings (refer):
•imaging e.g. spine, carotid vessels, CT or MRI, angiography
•specific blood tests for infection
•lumbar puncture (CSF protein, oligoclonol Ig G, etc)

Question 12

Diagnostic tips - Paresthesia and Numbness

Answer 12

Diagnostic tips

• Take a detailed drug history including the above, alcohol and OTC medications.
• Intermittent perioral paraesthesia indicates hypocalcaemia associated with hyperventilation.
• In many cases of peripheral neuropathy or a sensory symptoms, the diagnosis is not only elusive but may not be identified.

Question 13

Stroke Counselling

Answer 13

• HS
• SPA
• Rapport
• Any other concern?
• Discuss 5C
  1. Condition
• Most likely he has a condition called stroke. It is a condition in which part of our brain stops functioning due to disturbance in the blood supply to that area of the brain (Draw diagram).

The lack of blood flow can be due to blockage of the vessels by a clot which is a thrombus or embolus or leakage of blood which is called hemorrhage. This in turn leads to the symptoms that your husband is having now.

2. Common
3. Cause/ Risk Factors
   - hypertension,
   - diabetes,
   - smoking,
   - aspirin/warfarin,
   - head injury,
   - peripheral vascular disease,
   - lifestyle,
   - dyslipidemia

Ask about contraindication to thrombolysis:

• bleeding disorder or
• recent surgery,
• warfarin/ASA

4. Clinical features/ Symptoms
   - Facial assymetry
   - Arms difficult to raise
   - Speech problems
5. Complications
   It is a serious condition and is a medical emergency if not immediately treated can be life threatening

Management

• Admit
• Seen by specialist - neurologist
• investigations -
• non contrast CT scan or MRI to see the type of stroke
• FBE
• Lipid Profile
• U and E
• LFT
• RFT
• ECG
• Echo

If ischemic

• ASA
• rTPA

If Hemorrhage
- surgery

Once stable, supportive treatment

• Good nursing care
• It is to maintain skin care, feeding, hydration, proper positioning and monitoring of vital signs, giving painkillers, and anti-emetics.
• Is he going to improve? The outcome cannot be predicted at this time because it depends on the area involved and the amount of tissue damage. It can improve or the condition can progress further but we will try to give him the best quality of life by all possible means.
• Long term management: Following initial management, he will be under the care of a MDT for stroke rehabilitation to recover any lost function and return to independent living.

This team will include

• neurologist,
• specially trained nurses,
• speech pathologist,
• physiotherapist,
• occupational therapist,
• social worker and
• GP for regular reviews and follow-ups.
• It is very important to control the risk factors to prevent further attacks and this is where your role is vital.
• Lifestyle modification: SNAP
• I can also arrange for cardiologist review to assess his pacemaker and other factors which can increase his risk
• Reading material. Support groups.
• You are not alone. All support is available for you
• Red Flag: FAST à Facial asymmetry, Arms difficult to raise, Speech problems, and Time à Call 000

Question 14

History - Subdural Hematoma

Answer 14

HOPI

• Can you tell me more about what happened?
• Is it getting worse or improving?
• Any change in your vision? - Any problem with speech? - Did you have any recent head injury?
• How did it happen?
• Any headache after that?
• Any N/V/changes in personality?
• Drowsiness or confusion?
• Episodes of fits?
• Difficulty in walking or ataxia?
• Any past history of heart disease, stroke, DM, increased lipids?
• Medications?
• Do you have enough support?

Question 15

PE - Subdural Hematoma

Answer 15

Physical examination

• General appearance
• Vital signs
• Eyes
• CVS
• CNS examination
• BSL and dipstick

Question 16

Diagnosis - Subdural Hematoma

Answer 16

Condition -

Common
A subdural haematoma is a blood clot that forms between layers in the protective coverings of the brain (meninges), when veins tear as a result of sudden movement of the brain against the skull. It is usually caused by some kind of direct blow to the head as a result of a fall, an assault or a road accident. In the elderly, a relatively slight head injury may be sufficient to produce bleeding

Cause 
Risk factors 
- Elderly patient à brain shrinks (cerebral atrophy)
- Dementia
- Alcoholic
- Warfarin
- Head injury (recurrent falls)

Clinical feature 
Symptoms
- Weakness or numbness
- Headache bending forward or when coughing or when changing head direction
- Confusion 
- Drowsiness
- Personality changes
- Amnesia 
- Seizures

Complication
If left untreated, a subdural haematoma can grow and press on the brain. Pressure on the brain can be harmful. This pressure forces the brain against the skull, causing damage to the brain, as well as hindering the brain’s ability to function properly. This inability to function properly can lead to long-lasting brain damage or, if left untreated, death.

Question 17

Management - Subdural hematoma

Answer 17

• Admit.
• Referral to neurologist and CT scan.
  Tests generally used to diagnose a subdural haematoma are:
• CT scan – computed tomography
• MRI scan – magnetic resonance imaging.
• Baseline laboratory examination including clotting profile and INR.
• Treatment
  o Small: careful observation until it heals by itself or temporary insertion of a small catheter and suctioning the hematoma
  o Large: craniotomy

Question 18

History - Vitamin B12 Deficiency

Answer 18

• Since when?
• Is it in one or both legs?
• Any weakness in any other part of the body?
• Does the problem of the gait came with weakness of the legs?
• Any problem with your speech or vision?
• Since when have you been feeling tired or weak?
• Do you feel light-headedness, chest pain or SOB?
• Can you tell me about your diet?
• How is your appetite?
• Any episode of heartburn or tummy pain?
• Any previous gastric surgery?
• Any problem with your stools or waterworks?
• Have you ever been diagnosed with diabetes?
• Do you drink alcohol?
• How much do you drink?
• Any headache or vomiting?
• Any lack of concentration or irritability?
• Do you have any weather preference?
• In the past, have you ever been diagnosed with pernicious anemia or malabsorption syndromes such as celiac disease?
• Any gastrointestinal problem?
• FHx of autoimmune disease?
• Are you on any medications such as PPI or H2 blockers?

Question 19

Physical examination - Vitamin B12 Deficiency

Answer 19

Physical examination
- General appearance: pallor
- Vital signs
- ENT: Swollen red tongue (glossitis)
- Neurological exam: gait, tone, power, reflexes, sensation, vibration or proprioception, Romberg test may be + depending if the proprioception is lost 
- Abdomen: scars, organomegaly 
Urine dipstick and BSL

Question 20

Investigations - Vitamin B12 Deficiency

Answer 20

Investigations:

• FBE: Hgb low and MCV high
• Vitamin B 12 low and folate level normal
• Iron studies
• Intrinsic factor antibody level + > diagnostic
• LFTs, TFTs, RFTs

First line: 
•urinalysis
•blood sugar
•FBE
•ESR/CRP

Consider:
•serum calcium
•B12 and folate
•LFTs (γGT)
•U & E
•TFTs
•KFTs
•nerve conduction studies

Question 21

Management - Vitamin B12 Deficiency

Answer 21

• Refer to hematologist and neurologist
• Treatment
• Vitamin B IM injection (1000mcg) à body stores are replenished after 10-14 injection given every 2-3 days
• Maintenance with 1000 mcg IM injections every 3rd month
• Can use crystalline oral B12
• Co-therapy with oral folate 5mg/day

Question 22

Diagnosis - Vitamin B12 Deficiency

Answer 22

Condition -
Vitamin B12 is needed to produce an adequate amount of healthy red blood cells in the bone marrow. Good immune system, Nervous system function, Mental energy and memory. Vitamin B12 is available only in animal foods (meat and dairy products) or yeast extracts (such as brewer’s yeast). Vitamin B12 deficiency is defined by low levels of stored B12 in the body that can result in anemia, a lower-than-normal number of red blood cells.

Common

Cause 
- Vitamin B 12 deficiency
o Diet (vegetarian)
o Decreased absorption: gastrectomy
o Autoimmune: 
	§ Pernicious anemia: 
	§ Atrophic gastritis
	§ Hypothyroidism, Diabetes
	§ Chron;s and Celiac disease 
o Medications: PPI, H2 blockers, Metformin

Clinical feature
Symptoms of Vitamin B12 Deficiency

If you have vitamin B12 deficiency, you could become anemic. A mild deficiency may cause no symptoms. But if untreated, it may lead to symptoms such as:

• Weakness, tiredness, or lightheadedness
• Heart palpitations and shortness of breath
• Pale skin
• A smooth tongue
• Constipation, diarrhea, loss of appetite, or gas
• Nerve problems like numbness or tingling, muscle weakness, and problems walking
• Vision loss
• Mental problems like depression, memory loss, or behavioral changes

Complication
. If left untreated, it can result in progressive and irreversible damage to the nervous system

Question 23

History - Bell’s Palsy

sudden onset of paralysis of the face.

Answer 23

History

• I understand that you came to see me because of paralysis of one side of you face?
• Can you tell me how and when it started?
• Have you had any recent ear infection or ear pain?
• Did you notice any difficulty in speech or do you have any weakness in any of your limbs?
• Do you have any headaches or early morning vomiting recently?
• Do you have any hearing problems?
• Do you think your taste has changed?
• Are there any lumps in front of the ear?
• Any past history of diabetes, hypertension, high lipids?
• SADMA?

Question 24

Physicap Examination - Bell’s Palsy

Answer 24

Physical Examination
- General appearance
- Vital signs 
- Cranial nerve examination
	o Inspection: asymmetry, drooping of eyelid, ptosis, flattening of nasolabial fold, palpebral fissure is wider, tearing of eyes, vesicular rash around the ear
	o II – VA, PEARL; visual fields
	o III, IV, VI – EOM, diplopia
	o V – direct corneal reflex positive but patient appreciates discomfort, sensation of face
	o VII – wrinkle forehead (spared if UMN lesion affected); close eye tightly; blow cheek and smile, purse lips to try and whistle 
	o VIII – whiser test, rinne, weber 
	o IX, X – Gag reflex
	o XI – shrug shoulder
	o XII – tongue 
- CNS examination of upper and lower limb
- RS 
- CVS 
- Abd 
- OT - UDS, BSL

Question 25

Diagnosis - Bell’s Palsy

Answer 25

Condition -
You have a condition called bell palsy. It is the acute unilateral paralysis of the 7th nerve

Common
. It is a fairly common condition and the cause is unknown.

Clinical feature

• symptoms are what you are having
• Absence of forehead wrinkling
• Droopy eyelid, dry eye or excessive tearing
• Facial paralysis or weakness
• Drooping corner of mouth, dry mouth, impaired taste

Complication 
If left untreated 
- Eye problems 
- incomplete recovery
- contracture of facial muscles
- reduction or loss of taste sensation

Question 26

Management - Bell’s Palsy

Answer 26

• Corticosteroid 60-80mg/day
• Artificial tears
• Adhesive patch or tape
• Refer to physiotherapist
• Prognosis is very good. 70-80% of people recover within 2 months. 5-10% may take a longer time. A few cases do not recover.
• Do I need to do CT scans? Not at this stage. I am sure that it is Bell’s palsy, but if you’re concerned I am happy to give you a referral to a neurologist.
• We will give you a high dose of steroids for 3 days (75mg), then taper to 0 over the next 14 days.

Question 27

History - Tremors BET

Answer 27

History
- When did it start? How does the shake affect your life? Do you have problems grabbing things? Eating? Drinking? Changing clothes? Do you think it is getting worse? Is it more prominent in one hand? Is it continuous or associated with a particular condition/situation? Does it occur during sleep as well?
- Do you think you are having problems with walking? Getting up from sitting position? Do you have stiffness in your arms or body?
Have you noticed any heat or cold intolerance? Do you think you are more nervous these days? Any family history of similar condition? Have you noticed your voice is shaking as well? Any other symptoms: N/V, yellow discoloration of skin, tummy pain, change in bowel habits? Have you noticed that the shakes get better or worse with anything? Are you drinking more these days? How much and how does it affect you and your life? Any other medical or surgical conditions? Do you smoke? Are you on any medications? Allergies?

Question 28

Physical Examination - BET

Answer 28

Examination
- General appearance: pallor, jaundice, dehydration, BMI
- VS: normal
- Palpable thyroid mass
- Stigmata of chronic liver disease: spider nevi, gynecomastia, ascites)
- Neurologic examination: tone, power and reflexes of UL/LL; do “get up and go test” checking for signs of parkinsonism or cerebellar disease; nystagmus;
Which hand is involved more? I would like to know whether the postural/intentional/rest?

Question 29

Diagnosis - BET

Answer 29

What you have is a condition called benign familiar tremor. It is the involuntary, fine, rhythmic movements mostly involving muscles of upper limb.

Usually there is symmetrical involvement of both limbs.

The exact cause of this tremor is not known but there is a definite genetic predisposition. 60% of cases are seen within families of affected patients. The age at presentation is most commonly between 20 and 30 years. Sometimes, it manifests after 40 years of age (esp. titubation). Unfortunately, the frequency and amplitude of the tremors worsen with age.

Clinical features
The symptoms of essential tremor include:
- affects the voluntary muscles (the muscles that you can consciously move - - head nodding, if the head is affected
- shaky, quivering voice, if the larynx (voice box) is affected
- a small, rapid tremor
tremor that is exacerbated by activity or movement
- tremor that eases when the body part is at rest
- tremor that stops when the person is asleep
- worsening with age
- hands, head and voice are most commonly affected
- other body parts may become affected over time, including the arms and eyelids (the legs are rarely affected).

Not curable

Question 30

Management - BET

Answer 30

• I need to do some test to rule out any other cause including FBE, U/E/C, LFTs, TFTs, and serum copper level (recommended in male patients in the 4th decade with tremor).
• electromyography (EMG) test to check the electrical activity of muscles
• tests to rule out other causes – such as x-rays, blood tests, magnetic resonance imaging (MRI) and computed tomography (CT) scans.
• Treatment involves medications and surgery for resistant cases.
• The most common ones to be used are beta-blockers especially propanolol or primidone (anti-convulsant).
• Please limit intake of alcohol to safe drinking levels – 2 standard drinks not more than 5 days a week).
• Avoid caffeine and try to control anxiety and stress in your life.
• Regarding surgery, it is reserved for severe non-responding tremors and is called Tactile Thalamic Stimulation (previously Thalamomotomy). It is a technique where they place electrodes connected to wires in a device on your shoulder.
• International essential tremor foundation à provide resources (Reading materials) to help you understand this disease and provide home support services for patients with severe degrees of tremors.
• Review once labs are available and may prescribe medications.