neuro interactive cases Flashcards
what are the 2 things youve got to determine for neuro ddx
anatomy
pathology
where is the anatomy that the path can be
Brain Spinal cord Nerve roots Peripheral nerve(s) Neuromuscular junction
what can the pathology be
Vascular Infection Inflammation/Autoimmune Toxic/Metabolic Tumour/Malignancy
Hereditary/congenital
Degenerative
timescale of stroke and CVS
sudden onset
characteristic of inflammation
flare ups
associated symptoms with neuro
visual swallowing hearing neck stiffness weakness paresthesia bowel and bladder control
cranial nerves
I: sense of smell II: VA, VF, pupils, fundoscopy III, IV, VI: diplopia V: sensation, corneal reflex VII: facial palsy VIII: hearing IX, X: Speech, swallowing XI: Sternocleidomastoid, trapezius XII: tongue movements
order to test the optic nerve
AFRO
if can say number of fingers hold up - say do formally with snellen chart
if cant - do movement and light perception
order of upper and lower limb exam
Inspection Tone Power Reflexes Coordination Sensation Gait - at end because takes time in exam Back
UMN signs
increased tone - spasticity
reduced power
hyperreflexia
upgoing plantar reflex
LMN signs
reduced tone - flaccid
reduced power
hyporeflexia
diagnosis? Diplopia (bilateral 6th) Bilateral ptosis Slurred speech Dysphagia Sluggish pupillary response to light Descending symmetric muscle weakness Multiple skin abscesses on arms & legs
o Flaccid paralysis
o Power low
o Reflexes diminished
o So LMN lesion
o If stroke affecting CN6 and CN further down – pt wouldn’t be alive
o Not a problem in brain ¬– if had abscess in brain lobe = unilateral contralateral
o Brainstem – if all way up affecting CN6 and lower cranial – pt would be dead
o Spinal cord –would cause paralysis, spastic paraopesisis
o Peripheral – would cause peripheral neuropathy
o All of these things mean– neuromuscular problem – IV drug user – presented with botulinism which impairs neuromuscular transmission – block Ach release
ddx = miller fisher variant of Guillian Barre
miller fisher variant of Guillain Barre
typically characterized by a triad of ataxia, areflexia, and ophthalmoplegia
what do you get with NMJ problem
o Bilateral cranial neuropathy and descending muscle weakness
what is spastic paraperesis
weakness of both legs
increased tone - lift leg up - whole leg off bed
brisk reflexes
upgoing planters
cerebellar signs
Ataxia - unsteady gait
Nystagmus
Dysdiadochokinesia (test rapidly alternating movements)
Intention tremor (finger-nose-finger test - past pointing and dysmetria )
Speech: slurred, scanning
loss of sensation if cerebral cortex lesion
hemisensory loss - contralateral
loss of sensation of spinal cord lesion
up to a level - eg up to umbilicus
loss of sensation if nerve root lesion (radiculopathy)
dermatomes
loss of sensation of mononeuropathy lesion
loss at specific area
loss of sensation of polyneuropathy
glove and stocking pattern
what is postural tremor
when holding particular position eg holding out arms
55 yr old man Numbness & tingling in hands & feet PMH: type 1 DM On basal/bolus insulin HbA1C: 50 mmol/mol B12: 500 pg/ml (200 – 900) eGFR: 90 reduced sensation to pinprick - glove and stocking distribution
what would you prescribe
o Hands and feet – thinking peripheral neuropathy – dm
o Bolus – with each meal
o Get long acting and then bolus
o Duloxetine – treatment of peripheral neuropathy with dm
pathology of peripheral neuropathy
o Infection – retroviral disease - HIV
inflammation - Guillain Barre
toxic/metabolic - dm, alcohol, b12 deficiency, uraemia, amyloidosis
tumour - paraneoplastic feature of a malignancy
toxic/metabolic causes of peripheral neuropathy and clinical clues
Drugs - Hx Alcohol - Hx, high GGT and MCV B12 deficiency - macrocytic anaemia Diabetes - history, glucose/HbA1c, polyuria, polydipsia Hypothyroidism - TFT Uraemia - UE
Amyloidosis - History of myeloma or chronic infection/inflammation
Inflammation/Autoimmune
causes of peripheral neuropathy
Vasculitis, CTD, inflammatory demyelinating neuropathy
