Examination - Neurological

Question 1

What is the main differential of an abnormal gait with a flexed arm?

Answer 1

Hemiplegia

Question 2

What are the 4 cardinal features of upper motor neurone hemiplegia?

Answer 2

• increased tone
• > 5 beats of clonus
• hypereflexia
• +ve Babinski reflex

Question 3

What type of gait is seen in hemiplegia with a flexed arm and extended leg?

Answer 3

Circumductive

Question 4

What signs indicate bulbar involvement of stroke?

Answer 4

CN9, 10, 11, 12
pseudobulbar - UMN - increased gag reflex and jaw jerk
bulbar - LMN - reduced gag reflex and jaw jerk

Question 5

How is power graded?

Answer 5

0 = none 
1 = flicker 
2 = moves with gravity 
3 = moves against gravity
4 = reduced power against resistance
5 = normal

Question 6

How are strokes classified?

Answer 6

Bamford classification

• Total anterior circ stroke = hemiplegia, homonymous hemianopia, higher cortical dysfunction (unlikely to have in OSCE)
• Partial anterior circ stroke = 2 of the 3
• Lacunar circ stroke = hemimotor or hemisensory stroke only
• Posterior circ stroke

Question 7

What is the main differential for an abnormal slow shuffling gait?

Answer 7

Parkinsonism

Question 8

What are some of the signs of parkinsonism?

Answer 8

Bradykinesia
Rigidity
Shuffling gait 
Resting tremor pill-rolling
Cogwheel rigidity
Glabellar tap +ve (Parkinsons patients will blink repeatedly) - always ask permission 
Reduced arm swing

Features are usually worse on one side

Question 9

Why would you want to measure the lying and standing BP in a patient with parkinsonism?

Answer 9

To rule out multisystem atropy

Question 10

Why would you want to assess the eye movements in a patient with parkinsonism?

Answer 10

to rule out progressive supranuclear palsy

Question 11

Why would you want to assess higher cognitive function in a patient with parkinsonism?

Answer 11

to rule out Lewy-Body dementia or Parkinsons dementia

Question 12

What are the causes of parkinsonism?

Answer 12

• Idiopathic Parkinsons disease
• Multisystem atrophy - postural hypotension
• Progressive supranuclear palsy - palsy of vertical eye movements
• Lew-body dementia - dementia onset <12 months after parkinsonism
• Corticobasal degeneration - apraxia, acalculia, myoclonus
• Drug-induced - Hx of antipsychotics

Question 13

How is Parkinsons disease treated?

Answer 13

Symptom control (do not alter disease progression)

• L-dopa
• Co-beneldopa -
• Pergolide
• Apomorphine
• Selegiline
• Entacapone
• Procyclidine

Question 14

What is the main differential of an abnormal gait that is broad and unsteady with poor heel to toe balance?

Answer 14

Cerebellar syndrome

Question 15

What are the features of cerebellar syndrome?

Answer 15

DANISH 
Dysdiadokinesis
Ataxia
Nystagmus
Intention tremor
Slurred speech
Hypotonia

Question 16

Where is the cerebellar lesion localised when there is truncal ataxia with minimal limb signs?

Answer 16

Cerebellar vermis

Question 17

Where is the cerebellar lesion localised when there is ipsilateral limb signs with less truncal involvement?

Answer 17

Cerebellar hemisphere

Question 18

What is the most likely cause of the cerebellar syndrome if the patient is younger, female with spasticity and internuclear opthalmoplegia?

Answer 18

Multiple sclerosis

Question 19

What is the most likely cause of the cerebellar syndrome if the patient is older with atrial fibrillation, CABG scarring and tar staining?

Answer 19

Stroke

Question 20

What is the most likely cause of the cerebellar syndrome if the patient has a comorbidity of chronic liver disease?

Answer 20

Alcoholism

Question 21

What is the most likely cause of the cerebellar syndrome if the has coarse facial features and gingivial hypertrophy?

Answer 21

Phenytoin use

Question 22

Where is the lesion that causes internuclear opthalmoplagia?

Answer 22

Medial longitudinal fasciculus - failure of conjugate gase so eyes do not move in synchrony

Question 23

How does internuclear opthalmoplegia present on examination?

Answer 23

Ipsilateral failure of adduction and contralateral nystagmus when in abduction

Question 24

How is multiple sclerosis treated?

Answer 24

Methylprednisolone to shorten the duration of acute attacks.
Baclofen for muscle spasm.
Disease modifiers [reduce the frequency and duration of flare-ups]: interferone-beta, galtriamer, alemtuzumab

Question 25

What are the two differentials of facial weakness?

Answer 25

Lower CN7 palsy - ipsilateral

Upper CN7 palsy - contralateral and forehead sparing

Question 26

What is the likely diagnosis in CN 5, 6 and 8 palsy?

Answer 26

Acoustic neuroma

Question 27

What is the likely diagnosis in isolated CN8 palsy?

Answer 27

Cholesteatoma - inner ear affected

Question 28

What is the likely diagnosis in facial palsy with parotid swelling/scar?

Answer 28

Parotid tumour

Question 29

What is the likely diagnosis in a facial palsy associated with a vesicular rash on the ear?

Answer 29

Ramsay-Hunt Syndrome

Question 30

What are the secondary causes of facial nerve palsy?

Answer 30

• Stroke
• MS
• Myaesthenia gravis
• Ramsay-Hunt syndrome
• Lyme disease
• Diabetes mononeuropathy
• Tumour
• Gullarin-Barre sydrome
• Sarcoidosis

Question 31

What is the likely diagnosis in bilateral facial palsy with bullseye-lesions on the skin?

Answer 31

Lyme disease

Question 32

What is the treatment of Bell’s palsy?

Answer 32

eye protection & prednisolone

Question 33

What is the most likely diagnosis for weakness with fasciculations, increased tone, mixed UMN and LMN signs, upgoing plantars, bulbar involvement and a normal sensory examination?

Answer 33

Motor neurone disease

Question 34

What are the differential diagnoses for mixed UMN and LMN signs?

Answer 34

• MND
• Dual pathology e.g. peripheral neuropathy + stroke
• Conus medullaris lesion - L1 lesion
• B12 deficiency - subacute combined degeneration of the cord

Question 35

Does multiple sclerosis have UMN or LMN signs?

Answer 35

UMN ONLY