Gen Med 4 Neuro Flashcards
What is the gross anatomy of the nervous system?
- Brain
- Spinal cord
- Nerve roots
- Peripheral nerve(s)
- Neuromuscular junction
What are the 12 cranial nerves and what do they control?
- I: sense of smell
- II: VA, VF, pupils, fundoscopy
- III, IV, VI: diplopia
- V: sensation, corneal reflex
- VII: facial palsy
- VIII: hearing
- IX, X: Speech, swallowing
- XI: Sternocleidomastoid, trapezius
- XII: tongue movements
What do you test when examining limbs?
- Inspection
- Tone
- Power
- Reflexes
- Coordination
- Sensation
- Gait
- Back
How do upper and lower motor neurone disease signs differ?
Upper: Brisk reflexes (Upward plantar response), increased tone, decreased power
Lower: Hyporeflexia, hypotonia, low power
What are cerebellar signs?
- Ataxia
- Nystagmus
- Dysdiadochokinesia (test rapidly alternating movements)
- Intention tremor (finger‐nose‐finger test)
- Speech: slurred, scanning
What are the distributions neuropathy can take?
- Hemisensory loss (cerebral cortex)
- Level (e.g. umbilicus) (Spinal cord)
- Dermatome(s) (nerve root)
- Specific area (Mononeuropathy)
- Glove & stockings (polyneuropathy)
• 55 yr old man • Numbness & tingling in hands & feet • PMH: type 1 DM • On basal/bolus insulin • HbA1C: 50 mmol/mol • B12: 500 pg/ml (200 – 900) • eGFR: 90 • Reduced Sensation to PP (glove & stocking distribution)
What would you prescribe?
Duloxetine
What are the toxic/ metabolic causes of peripheral neuropathy?
- Drugs
- Alcohol
- B12 deficiency
- Diabetes
- Hypothyroidism
- Uraemia
- Amyloidosis
[ Clues • Hx • Hx, increased GGT & MCV • Anaemia, Increased MCV • History, glucose/HbA1C • TFTs • U&Es • History of myeloma or chronic infection/inflammation]
Other than diabetes, what are other causes of peripheral neuropathy?
• Infection– HIV
• Inflammation/Autoimmune– Vasculitis, CTD, inflammatory demyelinating neuropathy
• Tumour/Malignancy
– Paraneoplastic
– Paraproteinaemia
• Hereditary – Hereditary sensory motor neuropathy
How does optic neuritis present?
– Blurred optic disc margins
– Blurred vision
– Pain on eye movement
What can spastic paraparesis be caused by?
– Vascular – Infection – Inflammation (demyelination) • Transverse myelitis – Toxic/Metabolic – Tumour/Malignancy
How do you diagnose MS?
- Two lesions
* Separated in time/space
• 60 year old man • Pain & paraesthesia on anteriolateral thigh • PMH: Type 2 Diabetes • Metformin • HbA1C: 60 mmol/mol • BMI: 30 kg/m2 • reduced PP sensation anterolateral thigh
What is the next step in management?
Lose weight
What is meralgia parasthetica and how do you treat it?
• Compression of lateral femoral cutaneous nerve • Reassure • Avoid tight garments • Lose weight • If persistent: – Carbamazepine – Gabapentin
What is the sensation of the hand?
Ulnar- Medial 2 1/2 fingers
Median- Lateral 3 1/2 fingers and tips anteriorly
Radial- On back, lower half of thumb, index and middle and thenar area
What is radiculopathy?
• Disease of the nerve roots • Example: Lumosacral • Pain in the buttock, radiating down the leg below the knee (‘sciatica’) • Compression by – Disc herniation – Spinal canal stenosis
- 60 year old man
- Recurrent falls
- Tremor at rest
- Rigidity
- More forgetful
- Dysphagia
- Micrographia
- Limited upgaze
Diagnosis?
Progressive supranuclear palsy
What are the types of parkinsonian symptoms?
Parkinson’s disease – Dopaminergic neurons – Substantia nigra • Tremor, rigidity, bradykinesia
• PSP (Steele‐Richardson
syndrome)
• Parkinsonian features,
upgaze abnormality
• Lew body dementia
• Features of Alzheimer’s
disease, Parkinson’s &
hallucinations
What are some causes of apparent confusion?
- Post ictal (Hx of seizures)
- Dysphasia (Hx stroke)
- Dementia (IHD, alcohol, FHx, huntingtons)
- Depressive pseudodementia (Elderly, withdrawn, poor eye contact)
Why might someone present with acute confusion and reduced consciousness?
• Hypoglycaemia
• Vascular
– Bleed: Headache, collapse
– Subdural haematoma (Fall, fluctuating consciousness)
• Infection
– ? Temp, ? Intracranial, ? Extra‐cranial
• Inflammation
• Malignancy
• Metabolic/Toxic
– Drugs, U&Es, LFTs, Vitamin deficiencies, Endocrnipathies
What are the questions in AMTSS?
- DOB
- Age
- Time
- Year
- Place
- Recall (West Register Street)
- Recognize doctor/nurse
- Prime Minister
- Second WW
- Count backwards from 20 to 1
What are the parts of the GCS?
Eye opening 4 = Spontaneous 3 = Opens in response to voice 2 = Opens in response to painful stimuli 1 = Does not open
5 = Oriented 4 = Confused 3 = Words 2 = Sounds 1 = No sounds 6 = Obeys commands 5 = Localizes pain 4 = Withdraws to painful stimuli 3 = Abnormal flexion 2 = Extension 1 = No movements
What are the parts of the GCS?
Eye opening 4 = Spontaneous 3 = Opens in response to voice 2 = Opens in response to painful stimuli 1 = Does not open
Verbal 5 = Oriented 4 = Confused 3 = Words 2 = Sounds 1 = No sounds
Motor 6 = Obeys commands 5 = Localizes pain 4 = Withdraws to painful stimuli 3 = Abnormal flexion 2 = Extension 1 = No movements
If someone has a headache in the ED what might it be suggestive of other than stroke?
• Meningitis
• Fever, neck stiffness,
Kernig’s sign
- Subarachnoid haemorrhage
- Sudden onset
- CT, LP (xanthochromia)
• Giant cell arteritis – Polymyalgia rheumatica – (Shoulder girdle pain, stiffness, constitutional upset) • > 50 years • ESR, steroids, Bx
• Migraine
• Throbbing, vomiting,
photo/phonophobia, FHx,
Aura
How do you manage stroke?
• < 4.5 hours
– CT: no haemorrhage
– Thrombolysis (if no
contraindications)
• > 4.5 hours – CT head (exclude haemorrhage) – Aspirin (300mg), Swallow assessment – Maintain hydration, oxygenations, monitor glc
How do you manage a TIA?
• Aspirin • Don’t treat BP acutely – unless > 220/120 or – other indication • ECG, Echocardiogram • Carotid Doppler • Risk factor modification
- 40 year old
- Backache
- LMN weakness
- Admitted to HDU
- Regular FVC
- Cardiac monitor
- IVIG
Most likely diagnosis?
egwhret
What are the simple causes of collapse?
• Low glucose • Heart – Vasovagal – Arrhythmia – Outflow obstruction – Postural hypotension • Brain – Seizure
What are the complex causes of collapse?
- Vasovagal
- Atrial fibrillation
- Ischaemic heart disease
- Thyrotoxicosis
- Sick sinus syndrome
- Hypertensive heart disease
- Cardiomyopathy
- Rheumatic heart disease
- SVT
- Ventricular tachycardia
- Brugada syndrome
- Long QT syndrome
- Complete heart block
- Myocardial infarction
- Electrolyte abnormalities
- Aortic stenosis
- HOCM
- Peripheral neuropathy
- Anti‐hypertensives
- Pulmonary embolism
- Hypoglycaemia
- TIA
- Seizures
- Trauma
- Meningitis/encephalitis
- Brain tumour
