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Clinical FRACP > Neurology > Flashcards

Neurology Flashcards

1
Q

Gait exam

A
  1. Growth parameters: HC, length, weight => plot on centiles chart
  2. Exposure: Shirt off, shorts, shoes and socks off
  3. Inspection:
    - Examine posture, legs, spine/back, head (evidence of shunts, prev surgeries/scars), stigmata of neurocutaneous disease (cafe au lait spots)
    - Look around room for gait aids - wheelchair (electric vs manual), AFOs, special shoes or orthotics
  4. Walking
    - Ask if safe to walk
    - Ask to walk them in the hallway (probably will say no, stay in room)
    - Normal gait
    - Walk on toes (plantar flexion S1)
    - Walk on heels (dorsiflexion L5; DMD/CP/periph neurop)
    - Frog test (walk on outside of feet -> bring out hemiplegia)
    - Run (also will bring out a hemiplegia)
    - Tandem gait
    - Stand on each foot, hop (prox myopathy)
    - Jump
    - Squat (screen for prox myopathy)
    - Gower’s only if evidence of prox muscle weakness ie waddling gait and can’t squat (lie on back, ask them to sit up and stand)
    - Romberg’s: feet together, arms up (holding a pizza) with eyes open then with eyes closed
    - if break stance with eyes closed = proprioception/dorsal column defect/periph neuropathy
    - if break stance with eyes open = cerebellar defect

Summarise findings and then what you’ll do next

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2
Q

Neuro tick box spiel

A

‘In regards to pertinent findings…’

Growth - appropriate for age?
Developmental delay?

Gait - type of gait

LL neuro exam - supportive or not supportive of underlying pathology

  • UL/BL
  • ULN vs LMN
  • prox vs distal
  • sensory affected?

If weak on one side move on to quick UL neuro tone/power

CN involvement?
- close eyes, clench teeth etc

Dysmorphism (underlying genetic diagnosis)

Murmur - Possible cardiac disease? (stroke)
Scar/shunt? post tumour resection?

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3
Q

Antalgic gait

A

Indicates rheum condition -> move to MSK exam

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4
Q

High stepping gait

A

Indicates peripheral neuropathy

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5
Q

Hemiplegic gait

A

Indicates tumour, stroke, haemorrage

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6
Q

Trendelenburg

A

Indicates prox weakness

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7
Q

Spastic gait

A

Indicates CP

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8
Q

Ataxic gait

A 
Indicates
- cerebellar
- peripheral neuropathy
- vestibular
- posterior column
Defects
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9
Q

Differentials for cerebellar lesions

A

Vascular - haemmhorage/stroke

Infective- viral cerebellitis

G- genetic (Frederich’s ataxia)

Tumour (medulloblastoma)

metabolic - Lysosomal storage disorder

Demyelinating (GBS, ADEM)

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10
Q

Peripheral neuropathy ddx

A

BITCHM

B12 deficiency
Infective - Post infectious GBS
Tumour - lymphoma or NG1
Chemotherapy such as vincristine
Hereditary sensory motor disease (CMT)
Metabolic - diabetes

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11
Q

LL neuro exam

A
  1. Tone and clonus
  2. Power
    - note only do foot eversion/inversion if suspect perineal nerve injury
  3. Reflexes
    - use reinforcing manoeuvres
    - knee
    - ankle
    - plantar reflex (hold foot to avoid withdrawal)
    - if suspected UMN defect (hypertonic), perform cross adductor and spreading reflexes
  4. Coordination
    +/- Sensory (only spend time doing this if you’ve got a peripheral neuropathy, checking for glove and stocking distribution)
    –> soft touch ONLY. don’t bother with pain - will get marked down if testing pain on kids.
  5. If have peripheral neuropathy, do proprioception at toe and vibration
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12
Q

UMN lesion (floppy strong) ddx and ix

ddx

A

Acquired
- Stroke (bleed or ischaemia)
- Infectious (TORCH, meningitis, encephalitis)
- Tumour
- Trauma
- Endocrine (hypothyroid, hypopit)

Inherited
- Genetic (Down’s, PWS)
- Metabolic (MPS, AA-opathies)
- Structural (lissencephaly)

Ix:
- TFTs
- Urine metabolic screen
- Serum lactate
- Neuroimaging
- Karyotype and microarray

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13
Q

LMN lesion (floppy weak) ddx and ix

ddx

A

Anterior horn
- SMA

Peripheral nerve
- CMT
- GBS and CIDP
- Vit B12

NMJ
- myasthenia gravis (assess for fatiguability, pronator drift or repetitive squatting)
- botulism

Muscle
- congenital myopathy (normal CK)
- musc dystrophy (incr CK)

Ix:
- CK (muscle)
- EMG (NMJ nad muscle)
- Nerve conduction studies (nerve)
- Muscle biopsy (muscle)
- Genetic WES
- Serology (MG - anti-ACH R Abs)

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14
Q

CN exam

A

Initial intro/spiel

  • Position patient
  • Unwell/well
  • Growth - HC, L, W -> plot
  • Vitals - BP and HR
  • Iatrogenic - hearing aids, glasses, shunts, scars (look at face, head, trunk - back, front)
  • Dysmorphisms
  • Exposure - shirt off
  • Ask about pain

CN1

  • shut eyes, cover each nostril in turn: ‘say yes when you smell something new’
  • if any abnormalities, look in nostrils for ?polps ?mucosal abnormalities

CN2

  • Acuity (do this first!)
  • -> with glasses if they wear them. not without
  • Fields (without glasses)
  • Fundoscopy (dim lights)

Pupils

  • symmetry (coloboma)
  • direct and consensual reflex
  • accommodation (look at cieling then at finger - will tell u if glass eye)

CN3, 4, 6 (isolated 4th, 6th n palsies are common)

  • H test
  • note: Rectus looks away, obliques turn towards nose
  • supra nuclear palsy: loss of gaze B/L = MS
  • if ptosis, test for fatiguability up asking them to look up for 30sec
  • nystagmus? (extremes of lat vision is a variant of normal)

CN5

  • sensation to ophthalmic (forehead), maxillary, mandibular division
  • corneal reflex (offer to do this)
  • motor
  • -> jaw wasting
  • -> open mouth
  • -> clench jaw
  • -> jaw jerk (positive in UMN lesion)

CN7

  • Raise eyebrows (forehead sparing if UMN)
  • clench eyes shut
  • puff cheeks
  • smile (so I can see teeth)
  • signs of Ramsey hunt (vesicles in ear)

CN8

  • crude hearing (obstruct opposite ear, whisper 99, get them to repeat it)
  • Webers test
  • Rinnes test

CN9

  • voice (hoarse in RLN palsy)
  • cough (characteristic bovine cough in RNL palsy)
  • ‘ahhh’ (deviates to normal side w CN 10 palsy)
  • gag (sensory 9, motor 10)

CN 11

  • Shrug shoulders
  • Turn head to each side

CN 12
- Poke out tongue: look for Wasting and fasciculation’s
- poke tongue to left then right, put it inside cheek and don’t let me push it back
(deviates to weak side)
- articulation (dysarthria): ask them to say baby hippopotamus, British constitution, west register street

‘Let us move on to…
- cerebellar, UL and LL assessment)

Commonly

  • LMN facial N palsy
  • Congenital myopathy
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15
Q

Cerebral Palsy/CP-like conditions check list

A 
Seizures
Vision
Hearing
Dentition 
Sialorrhea (drooling or excessive salivation)/oromotor function 
Aspiration risk/recurrent check infection
Reflux 
Nutrition/feed assistance
Constipation 
Continence

Scoliosis
Hip subluxation
Contractures
Pressure sores

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16
Q

Seizure management

A
  • Seizure plan in verbal and written form (copies for all carers_
    - Ensure all family members and carers there
    - Additional information for school
    • Emergency action plan
      • Consider midazolam if not already prescribed (esp if previous hospital admissions for prolonged seizures or compromising seizures or lives far from hospital)
      • Know when to call an AV
    • Additionally skills training
      • First aid or CPR course
      • Midazolam administration (demonstrate how to give)
    • Medicalert bracelet
    • No swimming unattended, supervision around water at all time
    • Consult with neurology team if already involved or new seizure semiology
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17
Q

What do you do if you find ptosis on exam?

A

Work out if it is myogenic (Myasthenia, myotonic dystrophy, congenital ptosis) or neurogenic (CN3 palsy or Hroner’s)
* Myogenic : Test for fatiguability up asking them to look up for 30sec (MG)
* Neurogenic:
* ptosis + large pupil = CN3
* Ptosis + small pupil = Horners (post cardiac surgery most commonly)

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18
Q

how do you distinguish UMN from LMN pathology with a facial palsy ?

A

UMN. forehead sparing

19
Q

Dermatomes of LL power

A

Hip flexion - L1-3
Hip extension L5-S2

Knee flexion L5-S1
Knee extension L3-4: ‘Three four kick the door’

Ankle plantar flexion S1: ‘one two buckle my shoe’ (push down)
Ankle dorsiflexion L4-5 (push up)

20
Q

Management plan for seizures

A
  • Seizure plan in verbal and written form (copies for all carers_
    - Ensure all family members and carers there
    - Additional information for school
    • Emergency action plan
      • Consider midazolam if not already prescribed (esp if previous hospital admissions for prolonged seizures or compromising seizures or lives far from hospital)
      • Know when to call an AV
    • Additionally skills training
      • First aid or CPR course
      • Midazolam administration (demonstrate how to give)
    • Medicalert bracelet
    • No swimming unattended - supervision around water, roads, biking, heights at all time
    • Consult with neurology team if already involved or new seizure semiology
21
Q

Cranial nerves in order

A

1 - Olfactory
–> Smell something and identify it (or identify a change in smell)

2- Optic (vision)
–> Visual acuity with snellen chart
–> Visual fields
–> Fundoscopy

3 - Oculomotor (EOM and pupil)
–> Pupil response to light
–> Accommodation
–> H test (also assess for nystagmus)

4 - Trochlear (superior oblique - intorsion)
–> H test

5 - Trigeminal (sensation to opthalmic, maxillary and mandibular regions + motor muscles of mastication)
–> Sensation to face
–> Clench jaw (feel temporalis and masseter)

6 - Abducens (lateral rectus - abducts the eye)
–> H test

7 - Facial (muscles of facial expression)
–> Raise eyebrows
–> Close eyes shut
–> Blow out cheeks
–> Smile

8 - Vestibulocochlear (hearing and balance)
–> Hearing can be assessed by whispering a number into each ear separately, making a distracting noise with your fingers in the contralateral ear, and asking the patient to repeat. If any hearing loss suspected, perform Rinne’s (mastoid bone then next to ear) and Weber’s test (tuning fork to forehead)

9 - Glossopharyngeal
–> Open mouth and say ‘Ahhh’, look at movement of palate and uvula, should be upward, central and midline

10 - Vagus
–> Ask patient to cough

11 - Spinal accessory (trapezius and sternocleidomastoid)
–> Turn head to either side and shrug against resistance

12 - Hypoglossal (tongue muscles)
–> Inspect the tongue for any wasting or fasciculation
–> Protrude tongue and move it from side to side

22
Q

How do you express visual acuity

A

*VA is expressed as the distance between the patient and the chart over the number next to the smallest line that was read (e.g. 6/24 is an individual standing 6m away from the chart and can only read letters that a normal individual can read from 24m

23
Q

Interpretation of rinner and weber’s tests

A

Perform it if suspected hearing loss, to help distinguish between SNHL and conductive hearing loss

Rinner: Air should be louder than bone (so patient hears the sound louder or longer in air than when tuning fork is placed on their bone). IF Bone > Air = CHL . Air > Bone = normal or SNHL

Weber: Sound should not localise to one side in healthy individuals. If SNHL, sound localises to healthy ear. If CHL, sound localises to diseased ear.

24
Q

4 Ss of the neuro inspection

A

Shunts
Scars
Spine
Stigmata

25
Q

SMA clinical features

A

Floppy weak (LMN/anterior horn) - hypotonic, fasciculations, areflexia, reduced power

Pattern - proximal > distal weakness and LL > UL weakness
- Tongue fasciculations ++++
- Face is relatively preserved and eyes are spared

26
Q

Peripheral neuropathy (GBS, CMT etc) clinical features and ix

A

Floppy weak (peripheral nerve) - hypotonic, fasciculations, areflexia, reduced power

Pattern
- Distal weakness
- Face and eyes are preserved
* Distal sensory loss
* High stepping gait, foot drop
* Peripheral (calf) wasting
* CMT (AD inheritance) - High arch and claw toes, LL affected first (difficulty with dorsiflexion and areflexia)

Ix - nerve conduction studies +/- genetics (CMT)

27
Q

NMJ (MG and botulism) clinical features

A

Floppy weak (peripheral nerve) - hypotonic, areflexia, reduced power

Pattern: proximal or distal weakness
* Ptosis or opthalmolegia (eyes > limbs)
* Fatiguability (eye raising, hands above head, lift neck when supine)

Note - MG is assoc w thyroid conditions and SLE

28
Q

Clinical features - muscular dystrophy (eg DMD)

A

Floppy weak (peripheral nerve) - hypotonic, areflexia, reduced power

Pattern: PROXIMAL weakness
-Reduced face strength
-Normal EOM

Ix: increased muscle enzymes (vs myopathy - normal CK)

29
Q

Key cerebellar signs

A

DASHING

Dysdiadokinesis (can’t do rapid alternating movements) and Dysmetria (past pointing)
Ataxia
Slurred speech
Hypotonia and reduced power with pendular reflexesB
Intention tremor
Nystagmus
Gait - broad based

30
Q

Differentials for cerebellar pathology

A
  • Chemical: alcohol
  • Genetic: Friedrichs ataxia, Joubert, Ataxia Telangiectasia, Angelmans syndrome
  • CP
  • Infectious
  • Neoplastic
  • Inflammatory
  • Genetic
  • Metabolic (Wilson’s)
  • Structural (congenital cerebellar hypoplasia)
31
Q

Cerebellar exam

A
  • Inspection as above
    • Skin - telangiectasia (AT)
  • Speech : Ask them age, name
    • ?Dysarthria: ‘Sizzling sausage’ and ‘British constitution’
    • Cognition - intact in FA; impaired in AT
  • Horizontal Nystagmus (maximal TOWARDS lesion)
  • Sit up from lying down (truncal ataxia)
  • Gait exam
    • Walk normally
    • Heel toe/tandem gait
    • Walk around chair (stagger TOWARDS AFFECTED side)
  • Head/neck:
    • Eyes and earlobes ?telangiectasia ?keiser Fleischer rings
    • H test: Nystagmus or oculomotor apraxia (random, darting discordant eye movements)
  • UL
    • Raise arms in front 15sec - tremor? Pronator drift?
    • Romberg’s (positive if unsteadiness worsening when eyes are closed = proprioception/dorsal column problem)
    • Tone
    • Finger point (intention tremor or past pointing/’Dysmetria’)
    • Tap fingers to thumb one by one
    • Disdiadokinesis (patty cake pan)
  • Lower limb
    • Tone, power, reflexes
    • LL coordination
      • Heel-shin
      • Toe-finger
  • Then say you would examine
    • CN
    • Liver (HSM in metabolic, NB)
    • ENT (infection in AT)
32
Q

Ix for cerebellar ataxia

A

Neuroimaging - if no lesion on CT/MRI, then go on to perform metabolic and genetic screen

FBE, UEC, lFT
Toxicology - blood and urine
Metabolic screen - AA, lactate, ammonia, pH, ketones, pyruvate
VMA/HVA urine if suspected NB

33
Q

Ddx ataxia

A

Cerebellar causes
- Chemical: alcohol
- Genetic: Friedrichs ataxia, Joubert, Ataxia Telangiectasia, Angelmans syndrome
- CP
- Infectious
- Neoplastic
- Inflammatory
- Genetic
- Metabolic (Wilson’s, leukodystrophies, Lysosomal storage disorders)
- Structural (congenital cerebellar hypoplasia)

Peripheral neuropathy causes
- B12
- Diabetes
- Hypothyroidism
- GBS (motor > sensory)
- Drugs (certain chemo agents - vincristine, cisplatinl; etoH)
- Tumour: Leukaemia, lymphoma

Vestibular disease
- Labrynthitis (middle ear infection, vertigo)

34
Q

Clinical Features of FA

A

Cerebellar ataxia
Skeletal - kyphoscoliosis, pes cavus (high arch), hammer toes
Endocrine - diabetes
Heart - HOCM
ENT - SNHL

Note mixed picture -
Upgoing plantar reflexes
Absent knee and ankle jerks
Positive Romberg
Loss of sensory and proprioception and vibration distal

35
Q

Clinical features of AT

A

Onset early childhood
Cerebellar ataxia
Cutaneous telangiectasia to: eyes, ears, cub fossa, nares
Impaired cognition
Predisposed to infection and cancer
- Recurrent Ear/lung infections -> bronchiectasis
- Leukaemia, lymphoma
Gonadal atrophy

36
Q

Floppy baby exam

A

IHUGVIDEP
- Exposure: nappy only
- Inspection:
- Alertness
- Antigravity movements
- Posture (frog leg?)
- Head size
- Facial features
- Fisted hands
- Neurocutaneous stigmata
- Tachypnoea/WOB
- Iatrogenic
- NG tube
- O2
- IV
- Trache
- PEG
- INSPECT MOTHER’S FACE (for signs of myotonic dystrophy or myasthenia graves)
- If suspected, ask her to make a fist and then open hand quickly
- Growth
- Measure HC
- Iatrogenic things
- NGT/OGT
- O2
- IV fluids
- Central line
- Head
- Comment on shape and fontanelles
- 180 degree manoeuvre
- Supine
- Note posture
- Fencing reflex (head turned to one side and the leg and arm will extend on THAT side vs flexion on opposite side)
- Involuntary movements? (CP)
- Paucity of movements? (LMN)
- Scarf sign (bring arm across chest and try to pull it towards the shoulder - if can bring elbow beyond midline or hand further then shoulder this = hypotonia
- Pull to sit
- Comment on head lag
- Comment on head and trunk control
- Back - straight or rounded?
- Ability to sit unsupported
- Attempt at weight bare
- Hypotonia or weakness
- Scissoring (CP
- Advanced weight baring (CP)
- Ventral suspension
- Describe posture
- Tone
- Increased extensor tone (CP - may have extensor posture)
- Place prone
- Observe ability to raise head, trunk above horizontal
- Limbs
- Inspect (small hands, feet with PWS)
- Tone
- Power
- Reflexes
- Reflexes
- Primitive: Root, suck, grasp, stepping
- MORO
- Peripheral reflexes
- Head
- Inspect, palpate
- Tongue (fasciculations)
- Eyes (red eye reflex and movements)
- Hearing (test w bell/rattle) - evidence of hearing loss from TORCH infections, kernicterus, CP, abx
- Abdomen
- HSM (metabolic)
- Genitalia (hypoplastic in PWS)
- Auscultate heart ?dilated cardiomyopathy (Rubella info, metabolic disease)

37
Q

Ptosis (Droopy eyelid) = ? pathology

A

CN palsy
- 3rd nerve palsy (dilated but reactive)
- Horner’s palsy (constricted pupil)

Myogenic
- Myaesthenia gravis (test for eye fatiguability - look up 30sec)
- Myotonic dystrophy

38
Q

When should anterior and posterior fontanelles close

A

ant - 18mo
post - 4mo

39
Q

Clinical features - congenital myotonic dystrophy

A

LMN (floppy weak) features - hypotonic, areflexia, reduced power

Muscle weakness distal > proximal (*hands affected first)
*Myopathic facies - fish shaped mouth, narrow head, high arched palate, thin cheeks

*Cardiac - heart block, arrhythmias
*Endo - DM, hypothyroid, delayed puberty, testicular atrophy, male infertility etc
*GIT - reduced transit time
*Immune - low IgG

40
Q

Gag reflex tests what nerves

A

Gag reflex
Sensory 9
Motor 10

41
Q

Corneal reflex tests what nerves

A

Sensory 5
Motor 7

42
Q

Pupil reflex tests what nerves

A

Sensory 2
Motor 3

43
Q

What signs does RLN palsy cause?

A

Vocal cord palsy
- hoarse voice
- bovine cough
- stridor
- aspiration risk

44
Q

RLN is branch of what nerve

A

Vagus CN 10

Clinical FRACP (11 decks)

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