Neuro examinations

Question 1

At what age does Babinski’s sign disappear in children?

Answer 1

Aged 2

Question 2

Other than motor neurone diseases, what causes absent refelxes?

Answer 2

Peripheral neuropathies

Eg, diabetes, alcoholism, amyloidosis, uraemia, vitamin deficiencies, toxins including lead, arsenic, isoniazid, vincristine, diphenylhydantoin

Question 3

How is visual acuity recorded?

Answer 3

The chart distance (usually 6m) over the number of the lowest read line

If all the lines are read but 2 letters were wrong, then the score is 6/6 (-2). If more than 2 were wrong then the previous one should be noted instead (6/5)

Question 4

What is the accommodation reflex?

Answer 4

Ask patient to look into the distance, then place your finger 20-30sm away from patients face and watch their pupils constrict and converge bilaterally

Question 5

What is the Edinger-Westphal nucleus?

Answer 5

Controls pupil constriction and lens accommodation

It’s a small parasympathetic motor nucleus in the midbrain found on both sides

Question 6

What causes abnormal pupillary responses?

Answer 6

Both the afferent and efferent reflexes need to be intact

Question 7

What are the different afferent and efferent limbs of the pupillary reflex?

Answer 7

Afferent: ipsilateral pretectal nucleus (for acute light changes)
- Sensory input is transmitted from the retina, along the optic nerve to the ipsilateral pretectal nucleus in the mid brain

Efferent: pretectal nucleus and Edinger-Westphal nuclei
- Motor output travels from the pretectal nucleus to the Edinger-Westphal nuclei on both sides of the brain, the fibres travel in the oculomotor nerve to innervate the ciliary sphincter and enable pupillary contraction

Question 8

What are some acquired causes of colour vision deficiency?

Answer 8

• Optic neuritis: results in a reduction of colour vision (typically red).
• Vitamin A deficiency
• Chronic solvent exposure

Question 9

What are some types of visual field defect?

Answer 9

Bitemporal hemianopia: loss of the temporal visual field in both eyes causing central tunnel vision
- Caused by optic chiasm compression by a tumour (e.g. pituitary adenoma, craniopharyngioma)

Homonymous field defects: affect the same side of the visual field in each eye
- Caused by stroke, tumour, abscess
(Quadrantanopia’s if a quarter of the vision is affected)

Scotoma: an area of absent or reduced vision surrounded by areas of normal vision
- Caused by demyelinating disease (e.g. MS) and diabetic maculopathy

Monocular vision loss: total loss of vision in one eye secondary to optic nerve pathology (e.g. anterior ischaemic optic neuropathy) or ocular diseases (e.g. central retinal artery occlusion, total retinal detachment)

Question 10

How do you test for stratusbus?

Answer 10

Light reflex test: As patient to focus in the distance, shine and light and the light reflex should be positioned centrally and symmetrically in each pupil

Cover test: ask patient to focus on a distant object and cover one eye and observe the contralateral eye for a shift in fixation

Question 11

Which division of the facial nerve has a motor component?

Answer 11

The mandibular division innervates muscles of mastication

• Inspect temporalis and masseter muscles for wasting, appears as hollowing of the temples
• Palpate muscles while patient is clenching jaw for symmetry
• Test jaw opening against resistance

Question 12

What is Rinne’s test?

Answer 12

Place a vibrating tuning fork on the mastoid process and when the patient can no longer hear it, move it in front of the ear

Healthy ears: air conduction is better than bone conduction (Rinne’s positive)
- Negative if bone conduction is better

Question 13

What is Weber’s test?

Answer 13

Place a vibrating tuning fork in the middle of the forehead and ask where the patient can better hear the sound

• Normal: sound equal in both ears
• Sensorineural deafness: sound is heard louder on the side of the intact ear
• Conductive deafness: sound is heard louder on the side of the affected ear

Question 14

What is the pronator drift test?

Answer 14

It tests for upper limb weakness and spasticity

Patient puts their arms out with wrists up in front of them for 30secs, can be repeated with eyes closed to accentuate effects

Positive test: if there is pronation

Question 15

What is the difference between spasticity and rigidity?

Answer 15

Spasticity: Velocity dependent, so the faster you move the limb, the worse it gets. Typically tone is increased first and then suddenly reduces. Accompanied by weakness
- Associated with pyramidal tract lesions (e.g. stroke)

Rigidity: velocity independent, so feels the same if the limb is moved slowly or quickly
- Associated with extrapyramidal tract lesions

Question 16

What are the 2 different types of rigidity?

Answer 16

Cogwheel: involves a tremor superimposed on the hypertonia, resulting in intermittent increases in tone during movement of the limb
- Associated with Parkinson’s disease

Lead pipe rigidity: uniformly increased tone throughout the movement of the muscle
- Associated with neuroleptic malignant syndrome

Question 17

What is neuroleptic malignant syndrome?

Answer 17

A life-threatening neurologic emergency associated with the use of antipsychotic (neuroleptic) agents and characterized by a distinctive clinical syndrome of mental status change, rigidity, fever, and dysautonomia

Question 18

What is a reinforcement manoeuvre when testing reflexes?

Answer 18

It increases reflex activity

Eg. ask patient to clench teeth, or squeeze both knees together

Question 19

Which spinal tracts are involved in light touch sensation?

Answer 19

Dorsal columns and spinothalamic tracts

Question 20

Which spinal tracts are involved in pain sensation?

Answer 20

Spinothalamic tracts

Question 21

Which spinal tracts are involved in vibration sensation?

Answer 21

Dorsal columns

Question 22

What are the most common causes of peripheral neuropathy?

Answer 22

Diabetes mellitus
Chronic alcohol excess

Question 23

What is a radiculopathy?

Answer 23

Caused by damaged to a nerve root
Eg. compression by a herniated intervertebral disc

Question 24

What is a myopathy?

Answer 24

Disease that affects muscles of voluntary movement

Often causes symmetrical muscle weakness

Question 25

What causes dysdiadochokinesia?

Answer 25

(The inability to perform rapid, alternating movements)

Indicates ipsilateral cerebellar pathology

Question 26

Which pathology is tandem gait particularly sensitive to?

Answer 26

Cerebellar vermis (alcohol-induced cerebellar degeneration)

Question 27

What is ataxic gait?

Answer 27

Broad-based, unsteady and associated with either cerebellar pathology or sensory ataxia

• Proprioceptive sensory ataxia: patients watch their feet intently to compensate for the proprioceptive loss
• Cerebellar lesion: patients may veer to the side of the lesion

Question 28

What is Parkinsonian gait?

Answer 28

-Small, shuffling steps
-Stooped posture
- Reduced arm swing (initially unilateral)
- Several small steps required to turn around
- Gait appears rushed (festinating) and may get stuck (freeze).
- Hand tremor may also be noticeable

Question 29

What is high-stooping gait?

Answer 29

Caused by foot drop (weakness of ankle dorsiflexion)

Patient also won’t be able to walk on their heels

Question 30

What is a waddling gait?

Answer 30

Shoulders sway from side to side, legs lifted off ground with the aid of tilting the trunk

Waddling gait is commonly caused by proximal lower limb weakness (e.g. myopathy)

Question 31

What is a hemiparetic gait?

Answer 31

One leg held stiffly and swings round in an arc with each stride (circumduction)

Associated with stroke patients

Question 32

What is spastic paraperesis?

Answer 32

Similar to hemiparetic gait but bilateral, with both legs stiff and circumduction

The patient’s feet may be inverted and “scissor”

Associated with hereditary spastic paraplegia

Question 33

What is hereditary spastic paraplegia?

Answer 33

A group of rare inherited disorders that cause weakness and stiffness in the leg muscles

Question 34

What is Romberg’s test?

Answer 34

Put feet together, arms on the side, and close eyes

Tests for sensory ataxia, not cerebellar issues. Based on the premise that a patient requires at least two of the following three senses to maintain balance whilst standing:

• Proprioception: the awareness of one’s body position in space
• Vestibular function: the ability to know one’s head position in space
• Vision: the ability to see one’s position in space

Question 35

What is Pick’s disease?

Answer 35

AKA Frontotemporal dementia

Question 36

How does Alzheimer’s present?

Answer 36

Slow and insidious onset affecting short term memory first before the development of subsequent behavioural and language problems

Question 37

What is the drug Donepezil used for?

Answer 37

It improves memory and cognition in Alzheimer’s dementia but doesn’t slow down progression of disease
- Rivastigmine and Galantamine have similar action

Memantine is used if the others are not well tolerated