Common Neuro Presentations - Muscle Weakness, Sensation Changes

Question 1

Presenting complaint

-key questions

Answer 1

Timeline - start, duration, end, no of episodes
Triggers
Progression
Return to normal

Affected body parts?
-dominant hand

Falls?

Question 2

Systemic reviews

Answer 2

Systemic

• fever, recent infection
• fatigue, lost appetite, weight loss

Neuro

• LOC
• headache, vision/hearing changes
• neck stiffness
• difficulty speaking - ability to understand/communicate, slurred?
• difficulty swallowing?
• difficulty walking
• N+V

Cardioresp

• palpitations, SOB, chest pain
• DIFFICULTY BREATHING

Question 3

Past medical, drug, family histories, allergies

Answer 3

Past medical history

• Neuro history - past strokes, TIA
• CV history - HTN, DM, cholesterol, AF, heart surgery

Medication

• CV meds
• AC/AP use
• COCP, HRT

FHx
-heart, stroke, TIA

Question 4

Social history

Answer 4

Living

• type of accommodation
• other people, deependents
• ability to do ADLs
• carer input
• exercise and diet

Occupation

• work
• has episode arisen during work/driving

Substances
-alcohol, smoking, recdrugs

Question 5

TIA

• risk factors
• core features
• investigations
• management

Answer 5

CVD risks - smoking, alcohol, HTN, DM, high cholesterol, AF, CVD
FHx

Can use
-GP - FAST
-ED - ROSIER scaler
Weakness, sensory, vision, speech, swallow difficulties
Walking problems
LOC

TIA

• U1wk => same day TIA clinic assessment
• 1wk+ => same week TIA clinic assessment

Bedside
-FBC, platelets, U&E - exclude infection, electrolyte issues
-coagulation - exclude coagulopathy
-BP, cap glucose, ECG
Bloods
-lipid profile, HbA1c,
Imaging
-urgent CT - rule out hemorrhagic in AC users

Aspirin 300mg immediately if not on it => clopidogrel, high dose statin long term, AC in AF

Question 6

Bells palsy

• risk factors
• core features
• investigations
• management

Answer 6

Recent URTI

Unilateral facial droop - eyelids, mouth, FOREHEAD NOT SPARED
Dry eyes
Develops within 72hrs
May have rash around ears/eyes if HZV

Investigations AIM TO RULE OUT MIMICS
Bedside
-Cranial nerve - FOREHEAD 
-UL,LL exam 
Bloods
-FBC, CRP - inflammatory mimics (otitis media => facial palsy)
Imaging
-CT head - rule out stroke/tumour

Reassurance - self limiting

• eye patch, lubricating drops
• PO CS
• Antiviral if signs of Ramsey Hunt/HZOpthalmicus

Question 7

Guillain Barre

• risk factors
• core features
• investigations
• management

Answer 7

Recent GI/resp infection

Ascending paralysis, weakness of legs => arms => trunk

Bedside
-Limb neuro - LMN signs, reduced sensation
-Peak flow, spirometry - lung function
Bloods
-FBC CRP - inflammation
-U&E - electrolyte derangement related weakness
-B12, folate, HbA1c - neuropathy
Special
-nerve conduction studies 
-LP, CSF analysis

Supportive - may require ventilator support
IVIG, plasmapheresis

Question 8

Trigeminal neuralgia

• risk factors
• core features
• investigations
• management

Answer 8

Increased age
MS

Episodic severe, electrical shooting pains that last for seconds
Hyperesthesia
ASSESS FOR ANY CN7, 8 INVOLVEMENT

Bedside
-cranial nerve, UL/LL exam - 
Bloods
-FBC, CRP - GCA inflammation
-B12, folate, HbA1c - neuropathy workup
Imaging
-MRI of CPA - blood vessel/acoustic neuroma compressing trigeminal

1st line - Carbemazepine
May need surgical intervention to decompress trigeminal

Question 9

Migraine

• risk factors
• core features
• investigations
• management

Answer 9

FHx
Triggers - stress, dehydration, lack of sleep, caffeine

1hr prodrome - focal neurology
Headache - pulsating, unilateral, photophobia, phonophobia, worse on movement
Postictal fatigue

Bedside
-cranial nerve, UL/LL exam - normal 
Bloods
-FBC, ESR - high in GCA
Imaging
-CT head, MRI brain - SOL, SAH
Special tests
-LP, CSF - rule out nervous system infection

Avoid triggers - migraine diary
Simple analgesia => sumatriptan
Preventative - topiramate, propanolol

Question 10

PMR

• risk factors
• core features
• investigations
• management

Answer 10

GCA
Older age, female

Shoulder morning stiffness, pain
Acute onset
Fever, weight loss, appetite loss, fatigue
GCA signs - temple/jaw pain, vision changes

Bedside
-Cranial nerve, fundoscopy
-UL,LL neuro
Bloods
-FBC, CRP, ESR - inflammation
-RF, CCP - rule out RA

Low dose CS

Question 11

MS

• risk factors
• core features
• investigations
• management

Answer 11

FHx, female

Focal asymmetrical neuro deficits that come and go, not accompanied by fever

Bedside
-Cranial, UL/LL neuro exam - UMN signs
Bloods
-FBC, ESR, CRP - rule out lymphoma, lupus
-B12, folate, HbA1c - rule out other neuropathies
-ANA - SLE
Imaging
-MRI head, spine - demyelinated plaques
Special
-LP for oligoclonal banding

Acute - methylpred
Maintenance - InterferonB
Lifestyle changes
-regular exercise and eating well, physio
-CBT

Question 12

Stroke

• risk factors
• core features
• investigations
• management

Answer 12

CVD risks - smoking, alcohol, HTN, DM, high cholesterol, AF, CVD
FHx

Can use
-GP - FAST
-ED - ROSIER scaler
Weakness, sensory, vision, speech, swallow difficulties
Walking problems
LOC

B
-cap glucose
-ECG
B
-FBC, coagulation
-U&E - rule out electrolyte derangements
-lipids, HbA1c - CV risk
I
-Head CT - ischemic or hemorrhagic

Ischemic - aspirin => clopidogrel long term, high dose statin, CV risk factors
U4.5hrs => thrombolysis
4.5hrs+ => mech thrombectomy

Hemorrhagic
Lower BP, reverse AC, AEDs => neurosurgery referral