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Year 3 MedEd > Neuro2 > Flashcards

Neuro2 Flashcards

Cranial nerves and ophthalmology

1
Q

What are the common pathologies which can affect a cranial nerve?

A 
Diabetes mellitus
MS
Tumours
Sarcoid
Vasculitis
SLE
Syphilis
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2
Q

What should you look for on general inspection when performing a cranial nerve exam?

A 
Dysarthria
Asymmetry
Ptosis
Horner's/Bell's
Glasses
Hearing aids
Eye patch
Walking stick
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3
Q

What is the medical term for a loss of sense of smell?

A

Anosmia

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4
Q

What can cause anosmia?

A 
Ageing
Traumatic brain injury
Parkinson's
Alzheimer's
Tumour
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5
Q

What should you assess for in the optic nerve?

A 
Acuity
Fields
Reflexes
Ophthalmoscope
Colour
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6
Q

How should you assess the Pt’s acuity?

A

Using a Snellen Chart from 6m away

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7
Q

What are the causes of a loss of acuity?

A 
Refractive error
Ocular media
-cataracts
-diabetes
Retina
-age related macular degeneration
-diabetic retiniopathy
Optic neuropathy
-MS
-ischaemia
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8
Q

What is conjunctivitis?

A

Inflammation of the conjunctiva

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9
Q

What are the symptoms of conjunctivitis?

A 
Conjunctival hyperaemia
Chemosis (conjunctival swelling)
Crust/discharge
Foreign body sensation
Photophobia
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10
Q

What are the causes of conjunctivitis?

A

Bacterial
Viral
Allergic

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11
Q

How can you typically differentiate a bacterial conjunctivitis from viral conjunctivitis?

A

B- unilateral, thick discharge, reduced vision, ?urethritis/vaginal discharge
V- bilateral, watery discharge, normal vision, signs of viral infx

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12
Q

What is allergic conjunctivitis?

A

Type 1 hypersensitivity reaction

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13
Q

What are the common triggers of allergic conjunctivitis?

A

Pollen, dust, chemical scents

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14
Q

What are the clinical features of allergic conjunctivitis?

A

Conjunctivitis
Itching
Sneezing
Red, watery, oedematous eye

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15
Q

What are cataracts?

A

Clouding of the lens of the eye

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16
Q

What are the clinical features of cataracts?

A

Visual impairment
Glare/halos around light
Painless
Reduced red reflex

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17
Q

What are the risk factors for cataracts?

A

Old age
Congenital
Diabetes
Steroids

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18
Q

What is glaucoma?

A

Vision loss from optic nerve damage due to raised intraocular pressure
2nd leading cause of blindness
In an acute red painful eye, you need to rule out closed-angle glaucoma

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19
Q

What is affected in open-angle glaucoma?

A

Dysfunction of trabecular meshwork

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20
Q

What is affected in closed-angle glaucoma?

A

Compression of trabecular meshwork

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21
Q

What are the differences between open-angle and closed-angle glaucoma?

A

OA- 90%, bilateral, progressive vision loss, initially asymptomatic, non specific symptoms
CA- 10%, unilateral, sudden onset, severe pain, N+V, cloudy cornea, headache, dilated pupil

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22
Q

What are the investigations for glaucoma?

A

Fundoscopy
Gonioscope
Slit lamp
Tonometry

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23
Q

What is the uvea made up of?

A

Choroid
Ciliary body
Iris

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24
Q

What is uveitis?

A

Inflammation of the uvea

Can be anterior, posterior, complete, and intermediate

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25
Q

What are the causes of uveitis?

A

Systemic inflammation

Infection

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26
Q

What is affected in anterior uveitis?

A

Iris
Ciliary body
Most common

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27
Q

What is affected in posterior uveitis?

A

Vitreous body
Choroid
Retina

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28
Q

What are the investigations for uveitis?

A

Fundoscopy

slit lamp examination

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29
Q

What visual defect will present in a chiasmal lesion?

A

Bitemporal hemianopia

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30
Q

What visual defect will present in a pre-chiasmal lesion?

A

Ipsilateral monocular loss

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31
Q

What are the causes of a pre-chiasmal lesion?

A

Ischaemia- TIA (amaurosis fugax)

Inflammation- MS

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32
Q

What are the causes of a chiasmal lesion?

A

Pituitary adenoma

Chraniopharyngioma

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33
Q

A lesion in which part of the optic pathway can cause a contralateral homonymous hemianopia?

A

Optic tract lesion

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34
Q

A lesion in which part of the optic pathway can cause a contralateral homonymous superior quadrantanopia?

A

Lateral optic radiation lesion

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35
Q

A lesion in which part of the optic pathway can cause a contralateral homonymous inferior quadrantanopia?

A

Medial optic radiation lesion

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36
Q

A lesion in which part of the optic pathway can cause a macular sparing contralateral homonymous hemianopia?

A

Occipital visual cortex lesion

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37
Q

What is the cause of visual neglect?

A

Damage to the contralateral parietal lobe

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38
Q

What are some causes of Marcus Gunn pupil (RAPD)?

A

Optic neuritis

Retrobulbar optic neuritis

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39
Q

What is anisocoria?

A

Unequal size of the pupils

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40
Q

What does Horner’s syndrome consist of?

A

Ptosis
Miosis
Anhydrosis

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41
Q

What are some causes of Horner’s syndrome?

A 
Loss of sympathetic innervation due to either:
Carotid artery dissection
Pancoast tumour
SOL/stroke
MS
Cavernous sinus thrombosis
42
Q

What is the sympathetic pathway that supplies the eye?

A 
Hypothalamus
T1
Superior cervical ganglion
Carotid artery
Cavernous sinus
Target sites (dilator pupillae, lacrimal gland)
43
Q

What are the investigations for Horner’s syndrome?

A

CXR (Pancoast)
CT Head (stroke)
MRI/MRA (tumour/dissection)
Refer

44
Q

What signs may you see on fundoscopy?

A

Diabetic retinopathy
Hypertensive retinopathy
Papilloedemea

45
Q

How will a Pt with a CN3 palsy present?

A

Ipsilateral pupil looking down and out
Ipsilateral ptosis
Mydriasis (as pSymp fibres run with CN3)

46
Q

Why doesn’t every patient with a CN3 palsy present with both mydriasis and ophthalmoplegia?

A

The parasympathetic fibres run outside the nerve, whereas the oculomotor fibres run on the inside. Usually only one is affected, causing mydriasis (surgical palsy) or ophthalmoplegia (medical palsy)

47
Q

What are the causes of a medical CN3 palsy?

A

DM

Vasculitis

48
Q

What are the causes of a surgical CN3 palsy?

A

Raised ICP

Aneurysm rupture

49
Q

How may a Pt with a CN4 palsy present?

A

Ipsilateral pupil looking up and in

Tilted head to contralateral side

50
Q

What are the commonest causes of a CN4 palsy?

A

Idiopathic
Head trauma
Diabetes

51
Q

How may a Pt with a CN6 palsy present?

A

Failure to abduct ipsilateral eye

52
Q

What are the causes of a CN6 palsy?

A 
Stroke
Trauma
Viral illness
SOL
Inflammation
53
Q

How does a Pt with internuclear ophthalmolegia present?

A

Ipsilateral eye has an inability to adduct, and contralateral eye elicits horizontal nystagmus upon abduction

54
Q

What are the causes of internuclear ophthalmoplegia?

A

If young and bilateral, MS

If old and unilateral, stroke

55
Q

What are the pathways for the corneal reflex?

A

V1 -> VII

56
Q

What are the pathways for the jaw jerk reflex?

A

V3 -> V

57
Q

Which part of the trigeminal nerves would be affected if there was a higher central lesion?

A

Contralateral nerves

58
Q

What are the causes of a higher central trigeminal lesion?

A

Stroke

59
Q

Which part of the trigeminal nerves would be affected if there was a brainstem lesion?

A

Ipsilateral nerves

60
Q

What are the causes of a brainstem trigeminal lesion?

A

Stroke

Raised ICP

61
Q

Which part of the trigeminal nerves would be affected if there was a peripheral lesion?

A

Branch distribution

62
Q

What are the causes of a peripheral trigeminal lesion?

A

Raised ICP

Trauma

63
Q

What are the branches of the facial nerve?

Two
Zebras
Bit
My (Massive)
Cock
A 
Temporal
Zygomatic
Buccal
Marginal mandibular
Cervical
64
Q

What is Bell’s palsy?

A

Facial paralysis of the ipsilateral side

65
Q

What are the causes of Bell’s palsy?

A

Idiopathic
Compression of the facial nerve
Inflammation (eg. viral)
-herpes simplex type 1, varicella zoster

66
Q

What are the risk factors for Bell’s palsy?

A

Diabetes

67
Q

What are the investigations for Bell’s palsy?

A

Serology

-Lyme, herpes, zoster

68
Q

What is the management for Bell’s palsy?

A

Prevent corneal abrasions- wear an eye patch

Steroids- prednisolone

69
Q

What is Ramsay Hunt syndrome?

A

LMN facial palsy due to varicella zoster

70
Q

What are the features of Ramsay Hunt syndrome?

A

Pain
Vesicles in ipsilateral ear, hard palate, anterior tongue
Deafness/vertigo/other CN features

71
Q

If the forehead is spared in a CN7 pathology, where is the lesion?

A

UMN lesion

72
Q

What is Weber’s test assessing for?

A

Sensorineural and conductive hearing loss

73
Q

What is Rinne’s test assessing for?

A

Conductive hearing loss

74
Q

What is a Rinne’s positive sign?

A

Air is louder than bony conduction

75
Q

What is the diagnosis:
Weber’s: lateralises to the left
Rinne’s L: negative
Rinne’s R: positive

A

Left conductive hearing loss

76
Q

What is the diagnosis:
Weber’s: lateralises to the right
Rinne’s L: negative
Rinne’s R: positive

A

Mixed hearing loss

77
Q

What is the diagnosis:
Weber’s: lateralises to the left
Rinne’s L: positive
Rinne’s R: positive

A

Right sensorineural hearing loss

78
Q

What is the diagnosis:
Weber’s: no lateralisation
Rinne’s L: positive
Rinne’s R: positive

A

No abnormality

79
Q

What are the causes of conductive hearing loss?

A 
EAM:
-wax
-foreign body
-otitis externa
Drum:
-perforation
Middle ear:
-acute/serous otitis media
Oval window:
-otosclerosis
80
Q

What are the causes of sensorineural hearing loss?

A 
Inflammation:
-meningitis
-MMR
Tumour:
-acoustic neuroma (neurofibromatosis T2)
Ototoxic drugs:
-aminoglycoside ABx
-aspirin overdose
-loop diuretics
Trauma
Meniere's disease
81
Q

What are the inheritance patterns for neurofibromatosis type 1 and 2?

A

Autosomal dominant

82
Q

What is the gene and chromosome affected in NF1?

A 
NF1
Chr 17 (neurofibromatosis: 17 letters)
83
Q

What is the gene and chromosome affected in NF2?

A

NF2

Chr 22

84
Q

What is the presentation of NF1?

A 
Cafe-au-lait spots
Freckling in skin folds
Neurofibromas
Lisch nodules
spinal scoliosis
Short stature
Mild intellectual disability
85
Q

What is the presentation of NF2?

A

Sensorineural hearing loss
Bilateral acoustic neuromas
Symptomatic at the age of 20
Possible tinnitus/vertigo

86
Q

What can you do/look at to assess CN IX and X?

A 
Soft palate and uvula
Gag reflex
Cough
Swallow
Assess speech quality and hoarseness
87
Q

What two muscles are supplied by CN XI?

A

Sternocleidomastoid

Trapezius

88
Q

What are you looking for when assessing CN XII?

A

Wasting
Fasciculations
Deviation of the tongue
Power of the tongue

89
Q

What is a bulbar palsy?

A

Lesion affecting the medulla oblongata and its associated cranial nerves IX-XII

90
Q

What are the clinical features of a bulbar palsy?

A 
Absent gag reflex
Wasting/fasciculation of the tongue
Absent palatal movement
Absent/normal jaw jerk
Nasal speech
Normal emotions
Signs of underlying cause eg. limb fasciculations

(UMN signs)

91
Q

What is a pseudobulbar palsy?

A

Lesion affecting the UMN supplying the medulla oblongata

92
Q

What are the clinical features of a pseudobulbar palsy?

A 
Increased/normal gag reflex
Spastic tongue
Absent palatal movement
Increased jaw jerk
Monotonous, slurred, high-pitched Donald Duck dysarthria
Labile emotions
Bilateral UMN limb signs

(LMN signs)

93
Q

What are some causes of a bulbar palsy?

A

MND

Guillain-Barre

94
Q

What are some causes of a pseudobulbar palsy?

A

Stroke
MND
MS

95
Q

A 24 year old woman presents to her GP with a red painful eye with blurry vision. She has noticed a lot of clear discharge coming from her eye. She has otherwise been well, apart from some recent diarrhoea. What is the most likely diagnosis?

A. Viral conjunctivitis
B. Bacterial conjunctivitis
C. Anterior uveitis 
D. Posterior uveitis
E. Closed angle glaucoma
A

C. Anterior uveitis

Firstly, because this is not an acute presentation (she’s presented to her GP), we can rule out closed angle glaucoma.
Posterior uveitis and viral conjunctivitis are usually painless making them unlikely.
Although bacterial conjunctivitis is painful, it normally gives thick muculopurent discharge.
The clear discharge is most likely to be increased lacrimation, which is in keeping with anterior uveitis.

96
Q

A 50 year old patient presents to A&E with diplopia. The doctor examines their cranial nerves and finds a palsy in the oculomotor nerve. Peripheral nerve exam demonstrated a length dependent sensory neuropathy. What did the doctor most likely see during the cranial nerve examination:

A. Internuclear ophthalmoplegia 
B. Anhidrosis, miosis and ptosis
C. Down and out pupil
D. Mydriasis
E. Down and out pupil with mydriasis
A

C. Down and out pupil

The palsy is why the patient has diplopia. The length dependent sensory neuropathy is indicative of diabetes, and if the peripheral sensory nerves are affected then a cranial nerve may be affected.
DM can cause a medical palsy, so the oculomotor nerve is affected first before the sympathetic, therefore will see down and out pupil. Wont see mydriasis yet until parasympathetic is affected, ruling out D and E.
A is not associated with DM, and B is describing Horner’s.

97
Q

A 28 year old lady presents to A&E thinking she is having a stroke, worried as she cannot move the right side of her face. On examination, the patient cannot smile, puff up her cheeks or wrinkle her forehead on the right side. Serology comes back positive for herpes simplex virus 1. What is the most likely diagnosis?

A. Stroke
B. Bell’s Palsy
C. MS
D. Ramsay Hunt syndrome 
E. Horner’s
A

B. Bell’s Palsy

As the patient is young a stroke is very unlikely, given she cannot wrinkle her forehead. This also makes MS unlikely.
MS also unlikely as there is an infective cause, but not Ramsay Hunt since this would normally be varicella zoster, not HSV1.

98
Q

A 20 year old lady sees her GP after having some hearing difficulties in the last week. On examination, Weber’s test lateralises to her left ear. Rinne’s test is negative in her left ear also, but positive in the right ear. She reported having a cold at the start of the month. Which of these is most likely?

A. Meningitis
B. Otitis media
C. Foreign body
D. Meniere's disease
E. Neurofibromatosis type 2
A

B. Otitis media

As Rinne’s test is negative in the left ear we know it is a conductive problem in left ear, further supported by fact Weber’s lateralises to the left as well. This rules out meningitis and NF2 as they are a sensorineural problem, as is Meniere’s – Meniere’s is triad of sensorineural hearing loss, vertigo and tinnitus.
the fact they had a cold earlier points more towards B as this is an inner ear infection.

99
Q

A 60 year old man presents to his GP with dysphagia. The GP notices he speaks with a nasally voice. Examination demonstrates a reduced gag reflex, as well as fasciculations and wasting of the tongue. Jaw jerk is normal. Which of these is the most likely cause of their dysphagia?

A. Stroke
B. Parkinson’s
C. Motor neuron disease 
D. MS
E. Achalasia
A

C. Motor neuron disease

With this question the patient is old, making MS and achalasia unlikely – this is further supported by the LMN signs.
Stroke and Parkinson’s would give UMN signs, although both can cause dysphagia. The jaw jerk is normal suggesting that CNV is not affected, as is the case with a bulbar palsy.

100
Q

A 66 year old woman presents with left sided upper and lower facial weakness as well as vertigo, which has worsened over the past few days. She is also suffering from a burning sensation over the left side of her face . This morning, she noticed a new rash in her left ear. On examination, clusters of vesicles on an erythematous base are noted in the patient’s left ear.

A. Bells Palsy
B. Ramsay Hunt syndrome
C. NF T2
D. Stroke

A

B. Ramsay Hunt syndrome

Year 3 MedEd (29 decks)

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