interactive cases iv

Question 1

What are the possible areas affected in neuro?

Answer 1

Brain

Spinal cord

Nerve roots Peripheral nerves Neuromuscular junction

Question 2

What are the possible causes of pathology in neuro?

Answer 2

V ascular

I nfection

I nflammation/autoimmune

T oxic/metabolic

T umour/malignancy

Hereditary/congenital

Degenerative

Question 3

Compare UMN and LMN lesions

Answer 3

UMN - tone increased (spasticity) - power decreased - reflexes increased, plantar up LMN - tone decreased (flaccid) - power decreased - reflexes decreased/normal

Question 4

Name cerebellar signs

Answer 4

Ataxia Nystagmus Dysdiadochokinesia Speech: slurred, scanning Intention tremor

Question 5

What abnormal sensation would you expect for pathology in the following areas: a) cerebral cortex, b) spinal cord, c) nerve roots, d) mononeuropathy, e) polyneuropathy?

Answer 5

a) Hemisensory loss b) Level, i.e. umbilicus c) Dermatomal d) Specific area e) Glove + stockings distribution

Question 6

What drug can be used to treat neuropathic pain?

Answer 6

Duloxetine

Question 7

What are possible causes of peripheral neuropathy?

Answer 7

Drugs (hx)
Alcohol (hx, raised GGT/MCV)
B12 deficiency (anaemia, raised MCV)
Diabetes (hx, glucose/HbA1c)
Hypothyroidism (TFTs)
Uraemia (U&Es)
Amyloidosis (hx of myeloma or chronic infection/inflammation, i.e. RA)
Infection (HIV)
Inflammation/autoimmune (vasculitis, inflam. demyelinating neuropathy)
Tumour (paraneoplastic, paraproteinaemia)
Hereditary sensory motor neuropathy

Question 8

What sx would you see with papillits?

Answer 8

Optic nerve affected: - blurred optic disc margins - blurred vision - pain on eye movement

Question 9

What sx indicate MS?

Answer 9

Two lesions Separated in time/space

Question 10

How is meralagia paraesthetica managed?

Answer 10

Compression of the lateral femoral cutaneous nerve - reassure not serious - avoid tight clothing - lose weight - if persistent pain, start on carbamazepine/gapapentin

Question 11

What is radiculopathy, including sx and causes?

Answer 11

Disease of the nerve roots Sx include: pain in buttock, radiating down leg below knee (sciatica) Causes include compression by disc herniation or spinal canal stenosis

Question 12

Describe the sx of the following conditions: a) Parkinson’s, b) PSP (Steele-Richardson syndrome), c) Lew body dementia?

Answer 12

a) Tremor, rigidity, bradykinesia b) Parkinsonian features, upgaze abnormality c) Features of Alzheimer’s disease, Parkinson’s and hallucinations

Question 13

Possible ddx for apparent confusion/low AMTS

Answer 13

Post-ictal - hx of seizures Dysphasia (receptive/expressive) - features of stroke/TIA Dementia (vascular, alcohol, Alzheimer’s, inherited: HD) - hx of IHD/PVD, signs of excess ETOH, features of HD Depressive pseudodementia - elderly, withdrawn, poor eye contact, precipitating factor

Question 14

Possible ddx of confusion/low consciousness

Answer 14

Hypoglycaemia
Vascular
- bleed: headache, collapse
- subdural haematoma: fall, fluctuating consciousness
Infection - temperature, intracranial, extra-cranial?
Inflammation
Malignancy
Metabolic/toxic - Drugs, U&E, LFTs, vit. defi., endocrinopathies

Question 15

How to assess GCS

Answer 15

Eyes (4) 4 = Spontaneous 3 = Opens in response to voice 2 = Opens in response to painful stimuli 1 = Does not open Verbal response (5) 5 = Oriented 4 = Confused 3 = Words 2 = Sounds 1 = No sounds Motor response (6) 6 = Obeys commands 5 = Localizes pain 4 = Withdraws to painful stimuli 3 = Abnormal flexion 2 = Extension 1 = No movements

Question 16

How to assess AMTS

Answer 16

Start by telling them an address to remember then ask the following: 1. DOB 2. Age 3. Time 4. Year 5. Place 6. Recall (West Register Street) 7. Recognise doctor/nurse 8. Prime Minister 9. Second WW 10. Count backwards from 20 to 1

Question 17

Possible ddx of headaches

Answer 17

Meningitis - fever, neck stiffness, Kernig’s sign

Subarachnoid haemorrhage - sudden onset, CT, LP (xanthochromia)

Migraine - throbbing, vomiting, aura, photo/phonophobia, FHx

Giant cell arteritis - polymyalgia rheumatica, shoulder girdle pain, stiffness, constitutional upset - >50 y.o - ESR, steroids, Bx

Question 18

How would you manage a stroke?

Answer 18

<4.5 hours - CT: no haemorrhage - Thrombolysis (if no contraindications) >4.5 hours - CT head (exclude haemorrhage) - Aspirin (300mg) - Swallow assessment - Maintain hydration, oxygenation, monitor glucose

Question 19

How would you manage a TIA?

Answer 19

Aspirin Don’t treat BP acutely (unless >220/120 or other indication) ECG, echocardiogram Carotid doppler Risk factor modification

Question 20

What is the most likely diagnosis? - 40 year old - Backacke - LMN weakness - admitted to HDU - regular FVC monitoring - cardiac monitor - IVIG

Answer 20

Guillain-Barre syndrome - immune system produces harmful antibodies that attack the nerves - IVIG is a treatment made from donated blood that contains healthy antibodies (intravenous immunoglobulin)