Neurological Conditions Flashcards

1
Q

Brain tumour (parietal, frontal, occipital)

A

Parietal
- Presentation: seizures, numbness or paralysis, difficulty with handwriting, inability to perform simple mathematical
problems, difficulty with certain movements, and loss of the sense of touch.
Frontal
- Presentation: personality change, intellectual impairment, urinary incontinence and mono or hemiparesis.
Occipital
- Presentation: visual field and visuospatial defects.

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2
Q

Cerebellar disease (key features)

A

Key features: Fred’s ataxia, dysarthria and intention tremor

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3
Q

Wernicke’s encephalopathy (cause, presentation, treatment)

A

Cause: Poor nutrition (cancer, chronic diarrhoea), alcoholism resulting in low thiamine
Presentation: ophthalmoplegia, ataxia and confusion
Treatment: Thiamine 300 mg IV or IM for 3 days → 100mg IV/IM TDS for 1-2 weeks → 100mg PO daily

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4
Q

Delirium - Causes

A
Medical 
● Infections
● Metabolic
● Drugs
● Organ failure
● Intracerebral
● Cardiac
● Seizure
● Withdrawal
● Pain
Medication 
● Anticholinergics (sedating antihistamine,
oxybutynin, amitriptyline, benztropine)
● Benzodiazepines
● Opioids
● Corticosteroids
● NSAIDs
● Dopaminergic (levodopa)
● Sotalol and propranolol
● Alcohol and illicit drugs
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5
Q

Delirium - prevention, non-pharmacological management

A
Prevention:
● Adequate hydration and nutrition
● Adequate pain relief
● Promotion of sleep
● Correction of visual or hearing impairments
● Avoidance of restraints
● Provision of lighting appropriate to the time of day
● Quiet
● Availability of clock and calendar
● Involvement of family members
Non-pharmacological management:
● Close observation
● Monitoring of hydration nutrition and pain relief
● Calm and quiet atmosphere
● Frequent prompts for orientation
● Approach from the front
● Involve a familiar person
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6
Q

Delirium - pharmacological management

A

Delusions/hallucinations causing stress → antipsychotic

Oral 
- Haloperidol 0.5mg PO single dose
- Olanzapine 2.5mg PO as single dose
- Risperidone 0.5mg PO as single dose
Intramuscular
(severe)
- Haloperidol 0.5mg IM as single dose
- Olanzapine 2.5mg IM as single dose
Caution 
Parkinson’s 
- Avoid haloperidol (EPSE)
- Avoid metoclopramide (exacerbates symptoms)
Non-ETOH related withdrawal or
seizures
- Avoid benzodiazepines due to increased risk of delirium and long-term
complications
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7
Q

Alzheimer - pharmacological treatment

A

Key words: insidious onset, memory impairment with dysphasia, dyspraxia and personality change.

Pharmacological treatment
Acetylcholinesterase inhibitor
- Mechanism: reduce breakdown of acetylcholine
- Indication: mild-moderate Alzhiemers
- PBS criteria: diagnosis confirmed by
geriatrician/neurologist/psychiatrist + MMSE >=10.
- Medications: donepezil, galantamine and rivastigmine
- ADRs: GI-related, dizziness, drowsiness, bradycardia
and syncope, anorexia, depression, headache, vivid
dreams and muscle cramps.
Memantine
- Mechanism: reduces glutamate-induced neuronal
degradation
- Indication: moderate-severe Alzheimers, intolerance to
AChEIs
- Contraindication: history of seizure
- ADR: GI upset, confusion, dizziness, drowsiness,
headache and agitation,

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8
Q

88F, nursing home resident, with advanced Alzheimer’s disease. Her behaviour has been different for the past 2
days. Complaining of nausea. Hx of depression, OA, osteopenia. Medications: sertraline, quetiapine, galantamine,
paracetamol, tramadol.

  1. What are the 4 possible causes for this presentation?
  2. Your physical examination and bedside tests are all unremarkable. What initial investigations will you organise for Shirley at this stage?
  3. What are your 3 management strategies while waiting for the investigation results?
A

What are the 4 possible causes for this presentation?
● Serotonin syndrome - due to combination of tramadol and sertraline
● Polypharmacy - due to sedative effects of tramadol and quetiapine
● Occult infection - due to UTI
● Cerebrovascular event - due to advanced age vasculopathy
● Hyponatraemia - due to sertraline
Your physical examination and bedside tests are all unremarkable. What initial investigations will you organise for
Shirley at this stage?
● FBE
● UEC
● Urine MCS
What are your 3 management strategies while waiting for the investigation results?
● Cease tramadol
● Change paracetamol from PRN to regular
● Give metoclopramide 10mg TDS for nausea
● Close monitoring by nursing staff

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9
Q

Dementia - frontal, Lewy body, vascular

A

Frontal
- Key words: personality change, social disinhibition, apathetic and withdrawn.

Lewy body

  • Any two of: visual hallucinations, parkinsonism, fluctuations in mental state in absence of clear cause for delirium.
  • Management of cognitive impairment: donepezil 5 mg PO at night for 4 weeks, then increase to 10mg at night (if tolerated).

Vascular
- Key words: sudden, focal neurology with imaging evidence, evidence of atherosclerotic disease elsewhere.

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10
Q

38M with Down syndrome living in a supported group home. Staff have reported incidents of increased aggression.
Has been throwing cutlery in the dining room. Calm during review.

  1. What are the 5 most important causes to consider for Simon’s presentation?
  2. Staff members are concerned that Simon may become agitated again so they are asking you for help. What are 5
    non-pharmacological measures that you would advise the staff to consider?
A

What are the 5 most important causes to consider for Simon’s presentation?
● Depression
● Pain
● Sleep disturbance
● Constipation
● Urinary tract infection
● Early onset dementia of Down syndrome
Staff members are concerned that Simon may become agitated again so they are asking you for help. What are 5
non-pharmacological measures that you would advise the staff to consider?
● Ensure low stimulus environment
● Involve family members for support
● Advise staff to lock away sharp objects
● Provide one on one nursing
● For Simon to receive care from staff members that are more familiar with him
● Provide constant orientation to time, person and place

** Adults with Down syndrome usually develop changes typical of Alzheimer disease by 60

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11
Q

Diplopia (key points, office test, tests)

A

Key point
● Should be differentiated from blurred vision
● Exclude 3rd/6th nerve palsy (can be secondary to life-threatening cause)
● Refer urgently if diplopia is binocular, of recent onset and persistent

Office test
● Test for double vision with each eye occluded
● If persists then uniocular
● If disappears when either eye is covered then defect of one of the muscles
○ 3rd nerve - eye turned out, divergent squint
○ 6th nerve - failure to abduct, convergent squint

Laboratory test: ESR

** LR6SO4 (everything else 3)

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12
Q

Distal symmetrical polyneuropathy (key points, treatment)

A

Key points
● Up to 50% experience pain
● Exclude other causes inc. B12 deficiency, myeloma

Treatment:
● Amitriptyline 25mg PO nocte, slowly increase up to 150mg nocte
● If not well tolerated can add capsaicin cream

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13
Q

Essential tremor (clinical features, management)

A

Key point
● Most common movement disorder

AKA: benign, familial, senile or juvenile tremor

Clinical features:
● Autosomal dominant disorder
● Early adult life
● Head, chin and tongue involvement (maybe)
● Affect writing (not micrographic), handling cups of tea
● May affect speech (bulbar musculature)
● Relieved by alcohol

Management:

  1. Reassurance and explanation (most cases)
  2. Medication (if necessary) - propranolol (10-20mg BD) or primidone (62.5mg nocte)
  3. Modest alcohol intake
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14
Q

Brain abscess (key point, RF, history)

A

Key point
● Uncommon cause of headache but most serious
Risk factors: Hx bronchiectasis, recent hx of sinus and middle ear infection
History: nature (localised, constant, worsening, worst in the morning), neurological symptoms (irritability, aphasia)

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15
Q

Huntington disease (buzzwords, features, genetic testing indications)

A

Chorea + abnormal behaviour + dementia + family history of Huntington disease

Key points:
● Autosomal dominant disease

Clinical features:
● Chorea
● 35-55 years
● Mental changes (behaviour and intellectual)
● Motor symptoms (flicking movements, lilting gait, facial grimacing, ataxia, dystonia)

Genetic testing indications:
● Symptomatic adult with unequivocal motor signs
● At risk family members
● Family planning if parents would consider terminating if foetus tests positive

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16
Q

25M, presenting with his pregnant wife, enquiring about genetic testing. His father has been diagnosed with dementia
mixed with a movement disorder (age 50). His grandfather also diagnosed with same and died at 49 years.

  1. What is the percentage of Scott acquiring the disease?
  2. What are the 6 points you would discuss with Scott before you refer him for genetic testing?
  3. Scott and his wife are asking for testing options for their unborn child should Scott’s tests come back positive. What
    methods can be used to acquire a specimen from the foetus for genetic testing?
A

What is the percentage of Scott acquiring the disease?
● 50% (autosomal dominant)
What are the 6 points you would discuss with Scott before you refer him for genetic testing?
● Huntington disease is incurable
● If positive he will definitely develop the disease
● Potential impact of his positive diagnosis on his children with 50% chance of passing on the gene
● The test will not predict the age of onset of the disease
● The positive result may impact his career
● The positive result may alleviate the issues related to uncertainty
● Positive result with have significant implications on his life or health insurance or income protection
Scott and his wife are asking for testing options for their unborn child should Scott’s tests come back positive. What
methods can be used to acquire a specimen from the foetus for genetic testing? (Options below safe for 15 weeks
gestation)
● Amniocentesis
● Chorionic villus sampling

17
Q

Mononeuritis multiplex (presentation, risk factors)

A

Presentation: acute onset of peripheral neuropathy with pain occurring in multiple dermatomes
Risk factor: diabetes
● Often presents with acute onset of severe unilateral thigh pain followed by rapid weakness and atrophy of
anterior thigh muscles and loss of knee reflex (L2/3 → L4/5)

18
Q

Motor neurone disease (key points, main patterns, signs and symptoms)

A

Key points
● Clinical diagnosis
● Sensory system, cranial nerves and eye muscles are not involved
● 5-50% is inherited with autosomal dominant pattern
Main patterns:
● Amyotrophic lateral sclerosis (Loud Gehrig disease) - LMN muscle + UMN hyper-reflexia
● Progressive muscle atrophy
● Progressive bulbar (LMN)
Signs and symptoms: weakness or muscle wasting, stumbling (spastic gait), difficulty swallowing, fasciculation

** Refer to table on page 213 of GP Study Notes

19
Q

Parkinson’s disease (common misconceptions, features, non-motor complications, treatment)

A

Key points
● Bradykinesia is a core feature
● Cogwheel rigidity is combination of lead-pipe rigidity and tremor
● Avoid metoclopramide or prochlorperazine (use domperidone instead)

Common misconceptions:
● Age: 10-15% are <50 years at onset
● Gender: belief that it is a disease of men (M = F)
● Absence of resting tremor (only 50% have at onset)

Features suggesting diagnosis other than Parkinsons:
● Onset of symptoms coinciding with dopamine agonist treatment
● No response to large doses of levodopa (if malabsorption is excluded)

Features supporting diagnosis: unilateral rest tremor, excellent response to levodopa, a progressing disorder and
persistent asymmetry.

Examples of non-motor complications: fatigue, neuropsychiatric symptoms, sleep disturbance, autonomic symptoms,
pain and other sensory symptoms, and dysphagia.

Aims of treatment:

  1. Preserve function
  2. Review medications to reflect disease stage and main symptoms

Treatment:
● First line - levodopa
● Start low and gradually increase over days to weeks

20
Q

Radial neuropathy (cause, prognosis, examination, investigation, treatment)

A

AKA: Saturday night palsy
Cause: Prolonged pressure
Prognosis: good, 3-4 months until recovery
Examination: Triceps 5/5, weakness of wrist extensors/finger extensors/brachioradialis, sensory loss over dorsum of
hand.
Investigation: Electrodiagnosis can assist with localisation, severity and prognosis.
Treatment: Conservative management
● Physical therapy, wrist splinting, pain management

21
Q

Clinical examination - Radial nerve

A
Wrist extension
Finger extension
Supination 
'Thumbs up' sign 
Sensation: first dorsal web space
22
Q

Clinical examination - median nerve

A
Thumb opposition 
Pincer function (thumb and index finger)
Pronation 
'A-OK' sign 
Sensation: index finger volar tip
23
Q

Clinical examination - ulnar nerve

A

Finger abduction
Finger adduction
Sensation: little finger volar tip

24
Q

Seizure - classification and management

A

** Refer to page 260 of GP Study Notes

25
Q

Complex partial seizure (key points, possible manifestations, diagnosis)

A

Key points
● AKA temporal lobe epilepsy
● Commonest type of focal epilepsy
● May make simple verbal responses, follow simple commands, or perform simple behaviours
Possible manifestations
● Common: slight disturbance of perception and consciousness
Diagnosis: EEG (in 50-60%), CT or MRI to exclude tumours

26
Q

Simple partial seizure

A

Key points
● No loss of consciousness
Common presentation: jerking movements (begin at angle of mouth/thumb/index finger then involve the rest of the body)

27
Q

Absence seizure (key points, presentation, significance, type, diagnosis)

A

Key points
● Children from 4 yrs to puberty
Presentation: child ceases activity → may be lip=-smacking → lasts 5-10 secs → then carries on
Significance: may lead to generalised seizures in adulthood
Type: childhood or juvenile
Diagnosis: EEG

28
Q

Sixth cranial nerve palsy (history, causes, differentials, imaging, prognosis)

A

History: Binocular horizontal diplopia that worsens with gaze toward the paretic lateral rectus muscle.
Serious causes: tumours, trauma, increased intracranial pressure, congenital causes.
Differentials: thyroid disease, myasthenia gravis, supranuclear disorders.
Imaging: MRI brain is indicated in most patients.
Prognosis: Most isolated palsies will recover spontaneously.

29
Q

Transient global amnesia (key point, clinical syndrome, exclude, evaluation/treatment)

A

Key point
● Clinical diagnosis
Clinical syndrome:
● Abrupt onset of memory difficulty (reliable witness)
● Prominent anterograde amnesia
● No antecedent head trauma or change in consciousness during episode
● No focal neurological symptoms during or after episode
● Clinical symptoms last > 1 hour but less than 24 hours
Exclude:
● TIA/stroke
○ Rare if there are no neurological symptoms
○ Consider if there are vascular risk factors
Evaluation/treatment:
● Exclude other diagnoses
● Monitor in hospital if symptomatic on presentation until amnesia resolves
● Discharge one evaluation normal and safe to do so
○ Anxiety can cause tachycardia and hypertension

30
Q

Trigeminal neuralgia (presentation, approach, treatment)

A

Presentation: recurrent, unilateral, shock-like pain
Approach: request imaging to exclude a structural cause ( request views of trigeminal nerve and ganglion )
Treatment: Carbemazepine MR 100mg PO BD

31
Q

Vertigo - causes

A
BPPV
Meniere's disease 
Vestibular neuritis 
Vestibular migrain
Cerebellar infarction 
Vertebrobasilar insufficiency
32
Q

Benign peripheral postural vertigo

A

Time course: seconds, recurrent
Clinical features: Exacerbated by movements or positions
Examination: peripheral nystagmus
Investigations: Dix-Hallpike manoeuvre

33
Q

Meniere’s disease

A

Time course: minute to hours
Clinical features: spontaneous, aural fullness, tinnitus, hearing loss
Examination: peripheral nystagmus, Fukuda stepping test localises to affected side
Investigation: low-frequency sensorineural hearing loss

34
Q

Vestibular neuritis

A

Time course: day, acute onset
Clinical features: viral prodrome.
Examination: peripheral nystagmus
Investigations: head thrust usually abnormal

35
Q

Vestibular migraine

A

Time course: minutes to hours
Clinical features: migrainous symptoms
Examination: central of peripheral nystagmus

36
Q

Cerebellar infarction

A

Time course: sudden onset
Clinical features: vascular risk factors, usually headache
Examination: central nystagmus, postural ataxia

37
Q

Vertebrobasilar insufficiency

A

Time course: days, sudden
Clinical features: vascular, cervical trauma
Examination: central nystagmus
Investigations: MRI

38
Q

Vestibular neuronitis (key points, symptoms, diagnostic triad, natural course)

A

Key point
● If there is deafness or tinnitus then consider Meniere’s or acoustic neuroma
● Multiple sclerosis may have vertigo as initial symptom

Triad
- Acute vertigo + nausea + vomiting

Symptoms: Severe vertigo with nausea, vomiting and nystagmus

Natural course: Symptoms can last for a week, residual symptoms can remain with head movements

39
Q

Vestibular schwannoma

A

MRI Brain

** Refer to page 303 of GP Study Notes for audiogram