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neuro interactive cases Flashcards

1
Q

what are the 2 things youve got to determine for neuro ddx

A

anatomy

pathology

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2
Q

where is the anatomy that the path can be

A 
Brain
Spinal cord
Nerve roots
Peripheral nerve(s)
Neuromuscular junction
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3
Q

what can the pathology be

A 
Vascular
Infection
Inflammation/Autoimmune
Toxic/Metabolic
Tumour/Malignancy

Hereditary/congenital
Degenerative

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4
Q

timescale of stroke and CVS

A

sudden onset

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5
Q

characteristic of inflammation

A

flare ups

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6
Q

associated symptoms with neuro

A 
visual 
swallowing 
hearing
neck stiffness  
weakness
paresthesia
bowel and bladder control
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7
Q

cranial nerves

A 
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
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8
Q

order to test the optic nerve

A

AFRO
if can say number of fingers hold up - say do formally with snellen chart
if cant - do movement and light perception

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9
Q

order of upper and lower limb exam

A 
Inspection
Tone
Power
Reflexes
Coordination
Sensation
Gait - at end because takes time in exam 
Back
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10
Q

UMN signs

A

increased tone - spasticity
reduced power
hyperreflexia
upgoing plantar reflex

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11
Q

LMN signs

A

reduced tone - flaccid
reduced power
hyporeflexia

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12
Q 
diagnosis? 
Diplopia (bilateral 6th)
 Bilateral ptosis 
 Slurred speech
 Dysphagia
 Sluggish pupillary response to light
 Descending symmetric muscle weakness
 Multiple skin abscesses on arms & legs
A

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

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13
Q

miller fisher variant of Guillain Barre

A

typically characterized by a triad of ataxia, areflexia, and ophthalmoplegia

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14
Q

what do you get with NMJ problem

A

o Bilateral cranial neuropathy and descending muscle weakness

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15
Q

what is spastic paraperesis

A

weakness of both legs
increased tone - lift leg up - whole leg off bed
brisk reflexes
upgoing planters

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16
Q

cerebellar signs

A

Ataxia - unsteady gait
Nystagmus
Dysdiadochokinesia (test rapidly alternating movements)
Intention tremor (finger-nose-finger test - past pointing and dysmetria )
Speech: slurred, scanning

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17
Q

loss of sensation if cerebral cortex lesion

A

hemisensory loss - contralateral

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18
Q

loss of sensation of spinal cord lesion

A

up to a level - eg up to umbilicus

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19
Q

loss of sensation if nerve root lesion (radiculopathy)

A

dermatomes

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20
Q

loss of sensation of mononeuropathy lesion

A

loss at specific area

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21
Q

loss of sensation of polyneuropathy

A

glove and stocking pattern

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22
Q

what is postural tremor

A

when holding particular position eg holding out arms

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23
Q 
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

A

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

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24
Q

pathology of peripheral neuropathy

A

o Infection – retroviral disease - HIV
inflammation - Guillain Barre
toxic/metabolic - dm, alcohol, b12 deficiency, uraemia, amyloidosis
tumour - paraneoplastic feature of a malignancy

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25
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
26
Inflammation/Autoimmune | causes of peripheral neuropathy
Vasculitis, CTD, inflammatory demyelinating neuropathy
27
what is amyloidosis
deposition of abnormal protein because had infection/inflammation that interfere with structure or function History of myeloma or chronic infection/inflammation in myeloma plasma cells making Ig - form precursers of abnormal protein or making abnormal inflamm markers in infection taht deposit as abnormal protein
28
tumour or malignancy causes fo peripheral neuropathy
Paraneoplastic | Paraproteinaemia
29
hereditory causes of peripheral neuropathy
Hereditary sensory motor neuropathy
30
``` 34 yr old woman Weakness in legs Blurred vision increased tone, reduced power, and brisk reflexes reduced pinprick sensation in leg blurring of optic disk ``` what is cause of blurred vision
papillitis o Pt young female with weakness, blurred vision - think inflammation (papilledema wont affect vision, caused by raised ICP - blurred optic disk) o Spastic paraparesis – spinal cord UMN o Demyelination – MS if 2 lesions separated in time and space o Inflammation of the optic nerve- papiliitis or optic neuritis
31
describe optic neuritis/papillitis
Blurred optic disc margins Blurred vision Pain on eye movement - inflammation = pain
32
causes of spastic paraparesis
in spinal cord - corticspinal/spinothalamic tracts vascular: anterior spinal arteries infection - spinal cord compression by TB (Potts disease) inflammation - demyelination or transverse myelitis toxic/metabolic - vit B12 deficiency tumour/malignancy
33
what is transverse myelitis
inflammation of the spinal cord eg after mycoplasma pneumonia
34
what is MS
2 lesions | separated in time/space
35
``` 60 year old man Pain & paraesthesia on anteriolateral thigh PMH: Type 2 Diabetes Metformin HbA1C: 60 mmol/mol ``` BMI: 30 kg/m2 reduced pinprick sensation on anterolateral thigh most appropriate next step management?
lose weight
36
what is meralgia parasthesia
Compression of lateral femoral cutaneous nerve
37
treatment of meralgia parasthesia
* Reassure * Avoid tight garment * Lose weight if persistent • Carbamazepine • Gabapentine
38
what does the median nerve supply - sensation
lateral 3 dingers and half of ring finger
39
what does the ulnar nerve supply - sensation
medial fingers
40
what does radial nerve supply
back of hand - test base of thumb
41
what is radiculopathy
disease of the nerve roots
42
lumosacral radiculopathy
Pain in the buttock, radiating down the leg below the knee (‘sciatica’) Compression by Disc herniation Spinal canal stenosis eg osteophytes
43
``` 60 year old man Recurrent falls Tremor at rest Rigidity More forgetful Dysphagia Micrographia Limited upgaze ``` most likely dx
progressive supranuclear palsy
44
parkinsons symptoms
Tremor, rigidity, bradykinesia
45
what does parkinsons disease affect
Dopaminergic neurons | Substantia nigra
46
progressive supranuclear palsy (Steele-Richardson syndrome) features
Parkinsonian features, upgaze abnormality
47
lewy body dementia features
Features of Alzheimer’s disease, Parkinson’s & hallucinations
48
``` A 55-yr-old man Confusion & chest pain No headache or neck stiffness Recently moved to a new house. Temp: 37oC PR 110, BP 120/60 Normal CVS/Resp/GI/Neuro exam ECG: sinus tachycardia, widespread ST depression Urinalysis: NAD Blood glucose: 7.0 mmol/L WCC: 7 CRP < 5 CT head: NAD ``` What is the most likely cause of his confusion?
* Not stroke – seen on CT * Not infection – low CRP * No other features of inflammation * Toxic – metabolic – urinalysis, toxic screen – CO possibility
49
causes of apparent confusion and low AMTS - and the clinical clues
post-ictal - history of seizure dysphagia (receptive/expressive) - other features of stroke/TIA dementia - history of IHD/PVD, signs of excess alcohol depressive pseudodementia - Elderly, withdrawn, poor eye contact Precipitating factor
50
types of dementia
Vascular (multi-infarct) Alcoholic Alzheimer’s disease Inherited e.g. Huntington’s disease (HD)
51
ddx of confusion/reduced consciousness
``` Hypoglycaemia Vascular Bleed: sudden onset Headache, collapse Subdural haematoma (Fall, fluctuating consciousness) Infection: ? Temp, ? Intracranial, ? Extra-cranial Inflammation Malignancy Metabolic/Toxic: Drugs, U&Es, LFTs, Vitamin deficiencies, Endocrinopathies ```
52
qns in AMTS (abbreviated mental test score)
``` DOB Age Time Year Place Recall (West Register Street) Recognize doctor/nurse Prime Minister Second WW Count backwards from 20 to 1 ```
53
eyes GCS
``` 4 = Spontaneous 3 = Opens in response to voice 2 = Opens in response to painful stimuli 1 = Does not open ```
54
verbal GCS
``` 5 = Oriented 4 = Confused 3 = Words 2 = Sounds 1 = No sounds ```
55
motor GCS
``` 6 = Obeys commands 5 = Localizes pain 4 = Withdraws to painful stimuli 3 = Abnormal flexion 2 = Extension 1 = No movements ```
56
features of meningitis
fever, neck stiffness, kernig’s sign (lie on back, pain when straighten knee)
57
features of SAH and investigations
Sudden onset | CT, LP (xanthochromia)
58
features and investigations of giant cell arteritis
Polymyalgia rheumatica (Shoulder girdle pain, stiffness, constitutional upset) > 50 years ESR, steroids, Bx
59
treatment of giant cell arteritis
 Steroid – prednisolone – urgent otherwise risk of them going blind
60
feature of migraine
Throbbing, vomiting, photo/phonophobia, FHx, Aura
61
pituitary apoplexy
IV hydrocortisone, bleed into pit tumour – see by endo and neurosurgeon
62
management of stroke
< 4.5 hours CT: no haemorrhage Thrombolysis (if no contraindications) > 4.5 hours CT head (exclude haemorrhage) Aspirin (300mg), Swallow assessment Maintain hydration, oxygenations, monitor glc
63
managment of TIA
``` Aspirin Don’t treat BP acutely unless > 220/120 or other indication ECG, Echocardiogram Carotid Doppler - do they need carotid endarterectomy Risk factor modification ```
64
40 year old Backache LMN weakness Admitted to HDU Regular FVC Cardiac monitor IVIG most likely dx
o When LMN weakness – need to measure FVC and cardiac monitor – risk need admission to ITU for vent support o Cardiac feature – autonomic features o Guillain barre – LMN – get radiculopathy – back ache becasyue the nerve roots are affected o Really need to measure FVC!
65
features of cauda equina syndrome
bowel and bladder symptoms

DPD (38 decks)

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