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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
what differentiates papillitis from papilloedema
there is no pain on eye movement in papiloedema
26
what is the pathology if the lesion is in the spinal cord
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
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
Multiple Sclerosis as they have 2 lesions (spinal cord and optic nerve) and they are separated in time and space
28
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
Meralgia paraesthetica - compression of lateral femoral cutaneous nerve as it passes under the inguinal ligament because he is overweight
29
how to manage meralgia paraesthetia
reassure, avoid tight garments and lose weight. if persistent (neuropathic pain) - carbamazepine or gabapentin
30
what is radiculopathy
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
what can cause compression in radiculopathy
disc herniation or spinal canal stenosis
32
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
progressive supranuclear palsy due to upgaze abnormality.
33
parkinsons diease features
tremor rigidity bradykinsia
34
lewy body dementia features
features of alzhemers diease, parkinsons n hallucinations
35
DDx of confusion/decreased consciousness
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
other causes of apparent confusion/decreased amts (abbreviated mental test score)
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
What is the Abbreviated Mental Test (AMTS)
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
What is the Glasgow Coma Scale
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
Important causes of headache to exclude in A+E
meningitis, subarachnoid haemorrhage, giant cell arteritis, migraine
40
how does meningitis present
Fever, neck stiffness, Kernig’s sign (pain occurs whilst straightening the leg when the hip is flexed to 90 degrees.)
41
how does subarachnoid haemorrhage present and investigations to do
Sudden onset | CT. Lumber Puncture (xanthochromia- breakdown product of Hb = yellow CSF)
42
how does giant cell arteritis present
Can present with polymyalgia rheumatica. Shoulder girdle pain, stiffness, constitutional upset (fever, malaise, weight loss). >50 years
43
giant cell arteritis ix and tx
high esr, temporal artery biopsy. give steroids to prevent blindness (do not delay treatment as ophthalmic artery is involved)
44
how does migraine present
throbbing, vomiting, photo/phonophobia, fhx, aura (flashing lights, zigzag lines black holes)
45
how to treat migraine
aspirin, NSAIDS, sumitriptan
46
how to manage stroke that is <4.5 hours
CT: no haemorrhage Thrombolysis (if no contraindications) = IV tPA If there are contraindications you give 300mg aspirin
47
how to manage stroke that is >4.5 hours
1. CT head (exclude haemorrhage) 2. Aspirin (300mg), swallow assessment 3. Maintain hydration (NBM), oxygenations, monitor glucose
48
what are some contraindications of thrombolysiss in stroke
- 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
how to manage TIA
- 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
What is the most likely diagnosis of this case: backache, lmn weakness
guillain barre
51
why is it important to monitor FVC
if it drops below a certain level need to go to ITU (20ml/kg) for intubation and ventilation
52
causes of collapse
1. low glucose 2. heart - vasovagal, arrhythmia, outflow obstruction, postural hypotension 3. brain - seizure
53
how does cauda equina present
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
how does polio present
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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