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DPD COURSE > Interactive neurology cases - amir sam > Flashcards

Interactive neurology cases - amir sam Flashcards

1
Q

where can neurological lesion be

A 
Brain
Spinal cord
Nerve roots
Peripheral nerves
Neuromuscular junction
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2
Q

what kind of distribution do muscle or nmj lesions tend to have

A

proximial

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3
Q

what kind of distribution do peripheral nerve lesions tend to have

A

distal

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4
Q

pathology of neurological condtions

A

Vascular- stroke- infarction, bleeding?

Infection- meningitis, encephalitis, abscess

Inflammation/autoimmune- demylination: CNS (MS) or PNS (chronic inflammatory demyelinating neuropathy)

Toxic/metabolic- diabetes, B12 deficiency

Tumour/malignancy- paraneoplastic (lung cancer causing neuropathy)

Hereditary/congenital

Degenerative

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5
Q

UMN signs

A

hypertonia (spasticity), decreased power , hyperreflexia , plantar reflexes increases

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6
Q

LMN lesions

A

muscle wasting n fasciulations hypotonia (flaccid), decreased power, hyporeflexia

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7
Q

case ddx: diplopia, bilateral ptosis, slurred speech, dysphagia, sluggish pupillary response to light, descending symmetric muscle weakness, Multiple skin abscesses on arms and legs, IV drug user injecting heroin SC

A

Find out where is the lesion and what is it.

  • Miller Fisher variant of Guillain-Barre –> Ataxia, opthalmoplegia, areflexia
  • Myasthenia gravis
  • Botulism – interfers with ACh transmission
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8
Q

what are IV drug users at risk of and why

A

SC or IM injection of heroin that is contaminated with spores of C. botulinum is a major risk factor for the development of wound botulism (interferes w ACh transmission

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9
Q

Miller Fisher sx

A

Ataxia, opthalmoplegia, areflexia

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10
Q

cerebellar signs

A

ataxia, nystagmus, dysdiadochokinesia, intention tremor, slurred scanning speech

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11
Q

if the lesion is in the cerebral cortex how will sensation be affected

A

hemisensory loss on the opposite sid

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12
Q

if the lesion is in the spinal cord how will sensation be affected

A

sensory level - unable to feel until a particular level e.g umbilicus

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13
Q

if the lesion is in the nerve roots how will sensation be affected

A

dermatome distribution

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14
Q

if the lesion is a mononeuropathy how will sensation be affected

A

specific area innervated by nerve is affected

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15
Q

if the lesion is a polyneuropathy how will sensation be affected

A

glove and stocking distribution. reduced sensation in hands and feet

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16
Q

cerebellar pathology

A

Vascular- stroke –> CT

Infection – abscess, toxoplasmosis, varicella –> CT
Inflammation- demyelination (MS)
Tumour/malignancy- (primary or secondary mets)

Toxins- B12 def, alcohol, phenytoin

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17
Q

sensation pathology

A

Vascular: no

Infection: HIV

Inflammation: CIDN

Tumour/Malignancy: paraneoplastic or paraproteinaemia (myeloma)

Toxic/Metabolic: alcohol, diabetes, B12 def

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18
Q

what would you prescribe for this case:
55yo man w numbness n tingling. pmh of t1dm.
raised HbA1. decreased sensation to pin prick (glove n stocking distribution)

A

duloxetine (SSR - as long as the pt doesnt have renal failure), used in diabetic peripheral neuroathy, depression, anxiety, premature ejaculation

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19
Q

toxic/metabolic causes of peripheral neuropathy and their clues

A

drugs (hx),
alcohol (hx and raised gammaGT and MCV),
b12 deficiency (anaemia, raised MCV),
diabetes (Hx and HbA1c), hypothyroidism (TFTs),
uraemia (U&Es),
amyloidosis (Hx of myeloma or chronic infection/inflammation (RA)

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20
Q

other causes of peripheral neuropathy

A
  1. Infection - HIV
  2. Inflammation /Autoimmune - Vasculitis, CTD, inflammatory demyelinating neuropathy (acute= Gillian Barré; chronic= CIDN)
  3. Tumour - Paraneoplastic and Paraproteinaemia
  4. Hereditary - Pes cavus (clawing of the toes)- Charcot-Marie-Tooth disease (hereditary sensory motor neuropathy)
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21
Q

causes of blurred vision

A
  1. Amaurosis fugax (curtain like loss of vision)
  2. anterior uveitis (red painful eye)
  3. papilloedema
  4. papillitis
  5. vitreous haemorrhage (sudden loss of vision)
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22
Q

what is Papillitis

A

inflammation of the head of the optic nerve causes pain on eye movement

23
Q

what is Papilloedema

A

increased intracranial pressure

24
Q

what is the pathology if the lesion is in the optic nerve

A

Optic neuritis (papillitis)

  • Blurred optic disc margins
  • Blurred vision
  • PAIN on eye movement
25
Q

what differentiates papillitis from papilloedema

A

there is no pain on eye movement in papiloedema

26
Q

what is the pathology if the lesion is in the spinal cord

A

Spastic paraparesis
-Vascular: infarction (spinal arteries)

  • Infection: abscess, Potts disease (TB of spine)
  • Inflammation: demyelination (transverse myelitis- mycoplasma pneumoniae, MS, HSV)
  • Toxic/metabolic: B12 def
  • Tumour /malignancy
27
Q

what is the diagnosis of this case: weakness in legs and blurred vision
o/e = legs: increased tone, decreased power and brisk reflexes, decreased pin prick sensation in legs

A

Multiple Sclerosis as they have 2 lesions (spinal cord and optic nerve) and they are separated in time and space

28
Q

what is the most likely diagnosis of this case: 60 yo man presenting w pain and paraesthesia on anterolateral thigh. omh - t2dm, bmi 30, hba1c 60

A

Meralgia paraesthetica - compression of lateral femoral cutaneous nerve as it passes under the inguinal ligament because he is overweight

29
Q

how to manage meralgia paraesthetia

A

reassure, avoid tight garments and lose weight. if persistent (neuropathic pain) - carbamazepine or gabapentin

30
Q

what is radiculopathy

A

disease of nerve roots as they enter/exit the spinal canal. e.g lumbosacral nerve root compression - pain in buttock radiating down the leg below the knee (sciatica)

31
Q

what can cause compression in radiculopathy

A

disc herniation or spinal canal stenosis

32
Q

what is the most likely diagnosis of this case: 60 yo man presenting w recurrent falls. has a tremor at rest, rigidity, ,more forgetful, dysphagia, micrographia, limited upgaze

A

progressive supranuclear palsy due to upgaze abnormality.

33
Q

parkinsons diease features

A

tremor rigidity bradykinsia

34
Q

lewy body dementia features

A

features of alzhemers diease, parkinsons n hallucinations

35
Q

DDx of confusion/decreased consciousness

A
  1. Hypoglycaemia
  2. Vascular
    - Bleed: headache, collapse
    - Subdural haematoma (fall, fluctuating consciousness)
  3. Infection
    - ?Temp
    - ? Intracranial (meningitis and encephalitis) and extra-cranial in elderly (pneumonia, UTI, sepsis)
  4. Inflammation
    - Vasculitis, AI encephalitis
  5. Malignancy
  6. Metabolic/toxic
    - Drugs, U&Es, LFTs , vitamin deficiencies, endocrinopathies, CO poisoning
36
Q

other causes of apparent confusion/decreased amts (abbreviated mental test score)

A
  1. post-ictal (after seizure)
  2. dysphasia (not confused but cannot communicate properly) - receptive or expressive
  3. dementia (not acute) - vascular or alcoholic, alzheimers, huntingtons disease
  4. depressive pseudodementia
37
Q

What is the Abbreviated Mental Test (AMTS)

A

It assess confusion

  1. DOB
  2. Age
  3. Time
  4. Year
  5. Place
  6. Recall (42 West Street)
  7. Recognise doctor/nurse
  8. Prime minister
  9. Second WW
  10. Count backwards from 20 to 1
38
Q

What is the Glasgow Coma Scale

A

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
39
Q

Important causes of headache to exclude in A+E

A

meningitis, subarachnoid haemorrhage, giant cell arteritis, migraine

40
Q

how does meningitis present

A

Fever, neck stiffness, Kernig’s sign (pain occurs whilst straightening the leg when the hip is flexed to 90 degrees.)

41
Q

how does subarachnoid haemorrhage present and investigations to do

A

Sudden onset

CT. Lumber Puncture (xanthochromia- breakdown product of Hb = yellow CSF)

42
Q

how does giant cell arteritis present

A

Can present with polymyalgia rheumatica. Shoulder girdle pain, stiffness, constitutional upset (fever, malaise, weight loss). >50 years

43
Q

giant cell arteritis ix and tx

A

high esr, temporal artery biopsy. give steroids to prevent blindness (do not delay treatment as ophthalmic artery is involved)

44
Q

how does migraine present

A

throbbing, vomiting, photo/phonophobia, fhx, aura (flashing lights, zigzag lines black holes)

45
Q

how to treat migraine

A

aspirin, NSAIDS, sumitriptan

46
Q

how to manage stroke that is <4.5 hours

A

CT: no haemorrhage
Thrombolysis (if no contraindications) = IV tPA
If there are contraindications you give 300mg aspirin

47
Q

how to manage stroke that is >4.5 hours

A
  1. CT head (exclude haemorrhage)
  2. Aspirin (300mg), swallow assessment
  3. Maintain hydration (NBM), oxygenations, monitor glucose
48
Q

what are some contraindications of thrombolysiss in stroke

A
  • if time onset not known i.e. >4.5hrs!!
  • Seizures at presentation
  • uncontrolled BP (over 180/110),
  • previous intracranial bleed,
  • lumbar puncture in the last week
  • ischaemic stroke or head injury in the last 3 months
  • active bleeding, surgery or major trauma within the last 2 weeks.
49
Q

how to manage TIA

A
  • Aspirin
  • Don’t treat BP acutely –> dangerous- if bring BP down rapidly = watershed infarct (the high BP is a compensation mechanism to increase cerebral perfusion)
    o Unless >220/120 or
    o Other indication e.g. want to thrombolyse
  • ECG, Echocardiogram
  • Carotid Doppler – do they need carotid endarectomy
  • Risk factor modification – DM, BP
50
Q

What is the most likely diagnosis of this case: backache, lmn weakness

A

guillain barre

51
Q

why is it important to monitor FVC

A

if it drops below a certain level need to go to ITU (20ml/kg) for intubation and ventilation

52
Q

causes of collapse

A
  1. low glucose
  2. heart - vasovagal, arrhythmia, outflow obstruction, postural hypotension
  3. brain - seizure
53
Q

how does cauda equina present

A

S2,3,4 problems:

  1. severe back pain
  2. saddle anaesthesia,
  3. bladder and bowel dysfunction
  4. sciatica-type pain
  5. weakness of lower legs
  6. absent reflexes (MRI to see if there is any compression)
54
Q

how does polio present

A

pure motor neuropathy (not sensory) - wasted, shortened lower limb (all signs of lmn - reduced tone, reflexes and power). lots of scars due to corrective surgery

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