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Clinical Examination > Neurological examination > Flashcards

Neurological examination Flashcards

1
Q

What are causes of horner’s syndrome? (6)

A
  1. carcinoma of lung apex (usually SCC)
  2. Neck - thyroid malignancy, taruma
  3. Carotid artery lesion - aneurysm, dissection, pericarotid tumour, cluster headache
  4. Brain stem lesions - vascular disease (Esp LMS), syringobulbia, tumour
  5. Retro-orbital lesions
  6. Syringomyelia
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2
Q

What are causes of anosmia?

A

Bilateral:

  1. URTI
  2. Meningioma of the olfactory groove (late)
  3. ethmoid tumours
  4. head trauma (including crimbriform plate #)
  5. meningitis
  6. hydrocephalus
  7. congenital - Kallman’s syndrome (hypogonadotrophic hypogonadism)

Unilateral:

  1. meningioma of the olfactory groove (early)
  2. Head trauma
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3
Q

What are causes of absent light reflex but present accomodation?

A
  1. midbrain lesion (Argyll Robertson pupil)
  2. Ciliary ganglion lesion (e.g. Adie’s pupil)
  3. Parinaud’s syndrome
  4. Bilateral anterior visual pathway lesions (bilateral afferent pupil deficits)
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4
Q

What are causes of absent convergence but intact light reflex?

A
  1. Cortical lesion - cortical blindness

2. midbrain lesions - rare

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5
Q

What are causes of constricted pupils?

A
  1. Horner’s syndrome
  2. Argyll Robertson pupil
  3. Pontine lesion - often bilateral, but reactive to light
  4. Narcotics
  5. Pilocarpine drops
  6. Old age
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6
Q

What are causes of dilated pupils?

A
  1. Mydriatics, atropine poisoning of cocaine
  2. Third nerve lesion
  3. Adie’s pupil
  4. Iridectomy, lens implant, iritis
  5. Post-trauma, deep coma, cerebral death
  6. Congenital
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7
Q

What is the cause and features of Adie’s pupil?

A

Lesion in efferent parasympathetic pathway.

  1. dilated pupil
  2. decreased/absent reaction to light (direct and consensual)
  3. Slow or incomplete reaction to accommodation with slow dilation afterwards
  4. Decreased tendon reflexes
  5. patients commonly young women
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8
Q

What are causes of Argyll Robertson pupil?

A

Lesion of iridodilator fibres in the midbrain:

  1. syphilis
  2. diabetes mellitus
  3. alcoholic midbrain degeneration (rarely)
  4. other midbrain lesions
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9
Q

What are features of Argyll Robetson pupil?

A
  1. small, irregular, unequal pupil
  2. nil reaction to light
  3. prompt reaction to accommodation
  4. if tabes associated, decreased reflexes
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10
Q

What are causes of papilloedema?

A
  1. SoL - causing raised ICP or retro-orbital mass
  2. Hydrocephalus (associated with enlarged ventricles)
    a. obstructive - block in 3rd ventricle, aqueduct or outlet to 4th ventricle (e.g. tumour)
    b. communicating
    c. increased formation - choroid plexus papilloma
    d. decreased absorption - tumour causing venous compression, subarachnoid space obstruction from meningitis
  3. Benign intracranial hypertension
    a. idiopathic
    b. OCP
    c. Addison’s disease
    d. drugs - nitrofurantoin, tetracycline, vit a, steroids
    e. lateral sinus thrombosis
    f. head trauma
  4. HTN - grade 4
  5. Central retinal vein thrombosis
  6. Cerebral venous sinus thrombosis
  7. High CSF protein level - GBS
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11
Q

What are causes of optic atrophy?

A
  1. Chronic papilledema or optic neuritis
  2. Optic nerve pressure or division
  3. Glaucoma
  4. Ischaemia
  5. Famililal - retinitis pigmentosa, leber’s disease, friedreich’s ataxia
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12
Q

What are causes of optic neuropathy?

A
  1. MS
  2. Toxic - ethambutol, chloroquine, nicotine, alcohol
  3. Metabolic - B12 def
  4. Ischaemia - DM, temporal arteritis, atheroma
  5. Familial - Leber’s disease
  6. Infective - infectious mononucleosis (glandular fever)
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13
Q

What are causes of cataract?

A
  1. Old age - senile cataract
  2. endocrine - DM, steroids
  3. Hereditary or congenital - dystrophica myotonica, refsum’s disease
  4. Ocular disease - glaucoma
  5. Irradiation
  6. trauma
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14
Q

What are causes of ptosis?

A
  1. Myasthenia gravis
  2. Myopathy (hereditary, congenital, mitochondrial)
  3. Horner’s syndrome
  4. CNIII palsy
  5. Senile ptosis, due to dehiscence of the levator palpebrae muscle
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15
Q

What are causes of diplopia?

A

Eye muscle problem:
- CN, INO
- Myasthenia, myopathy, thyroid eye disease
Nystagmus

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16
Q

What are causes of poor vision?

A
  1. MS
  2. Stroke
  3. Ischaemic optic neuropathy
  4. Pituitary lesions
  5. Diabetes-cataracts, retinopathy
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17
Q

What should be tested in a patients with ptosis or diplopia?

A
  1. pupillary response (direct, indirect, RAPD)
  2. EOM - puruit
  3. Fatigue of upgaze
  4. Visual fields
  5. Visual acuity
  6. Fundoscopy
  7. Check for weakness of other facial muscles
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18
Q

What should be tested in a patient with poor vision?

A
  1. Visual acuity
  2. Fundoscopy
  3. Visual fields +/- neglect
  4. Pupillary response - Direct, indirect, afferent pupillary defect
  5. EOM - pursuit
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19
Q

What are causes of a CNIII palsy?

A
  1. PCOM aneurysm
  2. DM/hypertension (generally pupil sparing)
  3. Brainstem lesion (stroke, tumour or demyelination)
  4. Sphenoid wing meningioma
  5. Cavernous sinus lesion
  6. Infection - basal meningitis
20
Q

What are causes of a CNVI palsy?

A
  1. Ischaemia, DM, HTN
  2. False localising sign in high ICP
  3. Cavernous sinus lesions
  4. Acoustic neuroma
  5. Nasopharyngeal CA
  6. Basal meningitis
21
Q

What distinguishes horners and brainstem/pancoast’s

A

BSL - horners + ipsilat loss of pain/temp on face, contralat limbs.

Pancoast’s - weakness and loss of reflexes in ipsilateral limb

22
Q

What are examples of synucleoopathies?

A

Idiopathic parkinson’s disease

Multi-system atrophy

23
Q

What are examples of tauopathies?

A

Cortico-basal degeneration (CBD)

Progressive supranuclear palsy (PSP)

24
Q

What are DDx of movement disorders?

A
  1. Parkinson’s disease
  2. Parkinson’s mimics:
    - essential tremor
    - drug induced PD
    - Progressive supranuclear palsy
    - corticobasal degeneration
    - multisystem atrophy
25
Q

What are components of the movement disorder examination?

A
  1. Gait
  2. Rigidity and muscle-coactivation
  3. bradykinesia
  4. tremor assessment - distraction techniques.
    - check tremor at rest, posture and action
    - writing
    - vocal tremor
  5. Saccadic eye movements
  6. Dyspraxia
  7. Glabellar tap
  8. Postural reflexes
26
Q

What are clinical features of parkinson’s disease?

A

Bradykinesia + at least one of:

  1. rigidity
  2. rest tremor (3-6Hz) of hands, legs, eyelids, jaw and lips
  3. postural instability
27
Q

What are supportive criteria for IPD?

A

At least 3 for diagnosis of definite IPD:

  1. unilateral onset
  2. persistent asymmetry affecting side of onset most
  3. rest tremor present
  4. progressive
  5. excellent response to levodopa
  6. levodopa response at least 5 years
  7. clinical course greater than 10y
  8. severe levodopa induced chorea
28
Q

What are non-motor aspects of parkinson’s disease?

A

Autonomic - bowel and bladder
Mood - depression/anxiety
REM sleep disturbance
Cognition - slowing, dementia in later stages

29
Q

What are features of essential tremor?

A
  1. Bilateral action tremor
  2. exacerbated by posture holding and action
  3. Upper limbs > head > voice
  4. Head tremor can be induced by phonation
30
Q

What are drugs implicated in Drug induced PD?

A

Anti emetics
Neuroleptics
Antidepressants - Fluoxetine/sertraline
Calcium antagonists - diltiazem, nifedipine, verapamil
Anti-epileptics - phenytoin, valproic acid
Anti-arrhythmics - amiodarone
Anti-hypertensives - captopril, methyldopa
OCP
Lithium

31
Q

What clues are suggestive of atypical parkinsonism?

A
  1. marked symmetry early
  2. truncal more than appendicular
  3. early onset dementia
  4. early hallucinations
  5. early postural instability
  6. impaired vertical gaze
  7. square wave jerks
  8. apraxia of eyelid opening/closing
  9. prominent motor apraxia
  10. alien limb phenomenon
  11. pyramidal signs
  12. autonomic symptoms
32
Q

What are key features of PSP?

A

Gradually progressive, 40 older

Postural instability and falls in 1st year AND vertical supranuclear palsy

33
Q

What are detailed features of PSP?

A
  1. astonished facial expression
  2. low blink rate with gritty eyes
  3. vertical supranuclear gaze paralysis
  4. dysphagia/dysarthrophonia
  5. early postural instability and falls
  6. hummingbird sign (midbrain)
  7. tau positive
  8. limb dystonia
  9. urinary incontinence uncommon and late
34
Q

What are behavioural features of PSP?

A
  1. Apathy for disability
  2. frontal impulsivity, rocket sign and reckless turns
  3. frontal disinhibition - applause sign, pallilalia
  4. depression greater than 50%
35
Q

What are supportive criteria for PSP?

A
  1. symmetric akinesia or rigidity
  2. retrocollis
  3. poor response to levodopa
  4. early dysphagia/dysarthria
  5. early cognitive impairment
  6. normal smell
  7. nil visual hallucinations
  8. no REM behaviour disorder
36
Q

What are features of corticobasal degeneration?

A
  1. insidious and progressive
  2. no response to levodopa
  3. akinetic rigid syndrome
  4. focal or segmental myoclonus
  5. asymmetrical dystonia
  6. limb apraxia/alien limb phenomenon
  7. cortical sensory loss/dyscalculia
  8. speech and language impairment
  9. frontal executive dysfunction
  10. visuospatial deficits
37
Q

What are features of Multiple System Atrophy?

A

Autonomic failure - postural drop, urinary incontinence or erectile dysfunction

Plus (Parkinsonism) - bradykinesia+rigidity/tremor/postural instability/poorly levodopa responsive

OR

Cerebellar - gait ataxia w cerebellar dysarthria, limb ataxia, cerebellar eye signs less common early

38
Q

When should a myopathy or NMJ disorder be considered?

A

Symmetric, proximal weakness +/- wasting
Normal sensation

If normal/reduced reflexes - myopathy, MG

If reflexes absent - spinal muscular atrophy, LEMS

39
Q

What should be checked in myopathy or NMJ disorders?

A

Waddling gait?
Facial muscle/neck strength
Winging of scapula?
Fatiguability? - MG
Clues: dermatomyositis - heliotrope rash, gottron’s sign, mechanics hands
Mitochondrial - short stature, low set ears, may have ptosis
Myotonic dystrophy - frontal balding, ptosis, hatchet like facies

40
Q

What are hereditary causes of myopathy?

A

Muscular dystrophies - Duchenne’s, Becker’s, Limb-girdle, fascioscapulohumeral, Oculopharyngeal, Emery Dreifuss

Myotonic dystrophy
Distal myopathies - Nonaka, Welander, Miyoshi

Mitochondrial myopathy

Metabolic myopathies

41
Q

What are acquired causes of myopathies?

A

Autoimmune - polymyositis, dermatomyositis, necrotising autoimmune myopathy, Anti-synthetase myositis, inclusion body myositis

Toxic - EtOH and drugs (steroids, statins, amiodarone, Li)

Endocrine - hypothyroidism, hyperthyroidism, acromegaly, hypopituitarism, cushing’s syndrome

Periodic paralysis
Osteomalacia
Sarcoidosis
HIV

42
Q

What are anti-Jo-1 Ab assocaited with?

A

antisynthetase antibodies

- autoimmune muscle disease, interstitial lung disease, arthritis, raynaud’s, fever and or mechanics hands

43
Q

What are dermatomyositis antibodies?

A

Anti-TIF1: strong association w cancer
Anti-MDA5 - severe skin ulceration and severe ILD
Anti-Mi-2: skin manifestations that respond well to Rx

44
Q

What are antibodies associated with necrotising autoimmune myopathy?

A

Anti-SRP: severe myopathy, possible cardiac involvement

Anti-HMG-CoA reductase - statin associated autoimmune myopathy

45
Q

What are features of myotonic dystrophy?

A

AD, DMPK, CTG repeat, genetic anticipation, 2nd-4th decade

CM, Conduction defects, early christmas tree cataracts, somnolescence

46
Q

DDx of multiple CNS lesions?

A
  1. SLE
  2. Sjogren’s syndrome
  3. Behcet’s disease
  4. Small vessel ischaemia
  5. Acute disseminated encephalomyelitis
  6. Meningovascular syphilis
  7. Sarcoidosis
  8. Paraneoplastic
  9. Multiple emobli

Clinical Examination (3 decks)

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