Neuro Flashcards
LL Neuro Schpiel
Today I examined ____ lower limb.
Pertinent findings were weakness in XXX with tone/reflexes/co-ordination/sensory findings of ____.
These findings are in keeping with an upper/lower/mixed motor neuron pattern consistent with a lesion at the XXXX.
My differentials are ….
Schpiel (Gait)
Today I was asked to examine ____ gait, which was ____.
Given these findings I went on to examine lower limb neuro, co-ordination/cerebellar/Parkinson’s.
My findings were ___ consistent with ____ and my differentials are _____.
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Predominant sensory peripheral neuropathy causes
- Diabetes
- ETOH
- Hypothyroidism
- Uraemia
- Sarcoidosis
- Paraneoplastic
- B12 deficiency
- Infections, e.g., leprosy, HIV, Lyme disease
- Amyloidosis
- Drugs (isoniazid, metronidazole, hydralazine, disulfiram, chloroquine, pyridoxine, colchicine, flecanide).
Predominant motor peripheral neuropathy causes
- CIPD/GBS
- Drugs (Dapsone)
- Porphyria
- Lead
- Diptheria
Pes Cavus (inherited neuropathy) causes
- CMT
- Friedrich ataxia
- Muscular dystrophy
- Cerebral palsy
- Spinal cord tumour
- Poliomyelitis
- Syringomyelia
- HSP
Axonal loss signs
(Diabetes, ETOH, malignancy)
- Distal reflex loss
- Distal proprioception/vibration loss
Demyelinating loss signs
(HIV, drugs, MS)
- global areflexia
- decreased proprioception/vibration
- preserved pin-prick
Proximal limb weakness causes
Proximal myopathy:
- steroids, ETOH, statins
- diabetes, diabetic amyotrophy
- thyrotoxicosis
# IBM (quads) # Polymyositis/dermatomyositis # Mitochondrial myopathies # Hereditary causes - muscular dystrophies, fascioscapulohumeral dystrophy
Distal myopathy causes
- Myotonic dystrophy - facial and distal limb weakness, myotonia
- IBM (distal in UL)
Lower limb weakness differentials
# Mix of UMN & LMN with no sensory findings: - MND, cerebral palsy, lacunar infarct
UMN in upper and lower limbs, bilaterally:
- High cervical stenosis
- MS
- Arnold chiari malformation
LMN lesion in UL and UMN lesion in LL
- Syringomyelia
- Cervical lesions
Sensori-motor peripheral neuropathies:
- Inherited: CMT
- Acquired: Diabetes, CIDP
Neuromuscular disease:
- Myasthenia
- Lambert Eaton
Foot drop causes
Weak tibialis anterior
Common peroneal lesion - loss of eversion, sensory loss over lateral calf/dorsum of foot
L4/L5 root weakness - loss of eversion and inversion, expect dermatome sensory findings, may have hip abduction weakness
Bilateral peripheral neuropathy - all movements weak in glove/stocking sensory loss and areflexia.
UMN pattern:
- bilateral spastic paraparesis - spinal cord lesion, bilateral stroke, MND
- One leg weak - cortical infarct/lesion, Brown-Sequard
- Hemiparesis - Upper and lower limb weakness same side - ? stroke
Sciatic nerve lesions - loss of eversion/inversion and ankle jerk.
Anterior horn cell disease - polio
Other neuro spiel
- It is best to mention abnormalities as patterns rather than coming up with a diagnosis first up, e.g.,:
- UMN vs LMN or a combination
- Cerebellar dysfunction +/- other signs
- Peripheral neuropathy (sensory/motor)
You can then mention a list of possible diagnoses.
Neuro Cases
- Polyneuropathy - others (pure motor, sensorimotor - 21%
- Muscular dystrophy - myotonic - 14%
- CN lesions including pituitary tumours - 13%
- Multiple Sclerosis - 12%
- Myopathy/myositis - 12%
- Polyneuropathy - CMT - 7%
- MND - 7%
- Parkinson’s disease/PSP/Huntington’s
- Stroke - 7%
- Polyneuropathy - Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP)
Ability to stand on toes?
S1
Ability to stand on heels?
L4,5 –> foot drop
Romberg test
Steady with eyes open, unsteady with eyes closed:
- posterior column
- peripheral neuropathy
- vestibular function
Unsteady with eyes open & closed:
- cerebellar
*Unlikely to be related to cerebellar function in exam
Diplegic/paraparetic gait causes (5):
- SC lesion
- Cerebral palsy
- Bilateral strokes
- HSP
- MS
CP Lesion (foot drop)
CP CAN invert whereas L4/L5 or Sciatic lesions unable to invert.
CP, L4-5 or sciatic lesions CAN’T evert.
Ankle jerk preserved
Unilateral high stepping gait (unilateral foot drop) causes:
Distal weakness:
- L5 lesion
- CPN lesion
- Sciatic neuropathy - patient can walk on toes but not heel of affected side
Bilateral high stepping gait (bilateral foot drop) causes:
- Lumbosacral polyradiculopathy
- MND
- Distal polyneuropathy e.g., CMT (patient can’t walk on heels or toes), CIDP
- MD
High stepping gait of sensory neuropathy (sensory ataxic gait) causes:
Maybe wide-based, clumsy, slapping down of feet + Romberg’s:
- Peripheral sensory neuropathy
- Syphilis
- Subacute combined degeneration of the spinal cord
UL/LL Neuro *Don’t forget:
1) Scars, back, neck
2) Catheters
3) Peri-anal sensation, anal tone
Gerstmann’s syndrome (Dominant) - 4
1) Agraphia
2) Acalculia
3) Finger agnosia
4) Left-Right Confusion
Subcortical lesion:
- Internal capsule
- Basal Ganglia (Globus pallidus & Putamen)
- Thalamus
- Absent cortical signs
- Face, arm & leg equally affected
- Unusual movements (basal ganglia)
- Dense sensory loss (thalamus), maybe associated with hemiplegia