Neurology Flashcards
Gait exam
- Growth parameters: HC, length, weight => plot on centiles chart
- Exposure: Shirt off, shorts, shoes and socks off
- 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 - 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
Neuro tick box spiel
‘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?
Antalgic gait
Indicates rheum condition -> move to MSK exam
High stepping gait
Indicates peripheral neuropathy
Hemiplegic gait
Indicates tumour, stroke, haemorrage
Trendelenburg
Indicates prox weakness
Spastic gait
Indicates CP
Ataxic gait
Indicates - cerebellar - peripheral neuropathy - vestibular - posterior column Defects
Differentials for cerebellar lesions
Vascular - haemmhorage/stroke
Infective- viral cerebellitis
G- genetic (Frederich’s ataxia)
Tumour (medulloblastoma)
metabolic - Lysosomal storage disorder
Demyelinating (GBS, ADEM)
Peripheral neuropathy ddx
BITCHM
B12 deficiency
Infective - Post infectious GBS
Tumour - lymphoma or NG1
Chemotherapy such as vincristine
Hereditary sensory motor disease (CMT)
Metabolic - diabetes
LL neuro exam
- Tone and clonus
- Power
- note only do foot eversion/inversion if suspect perineal nerve injury - Reflexes
- use reinforcing manoeuvres
- knee
- ankle
- plantar reflex (hold foot to avoid withdrawal)
- if suspected UMN defect (hypertonic), perform cross adductor and spreading reflexes - 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. - If have peripheral neuropathy, do proprioception at toe and vibration
UMN lesion (floppy strong) ddx and ix
ddx
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
LMN lesion (floppy weak) ddx and ix
ddx
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)
CN exam
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
Cerebral Palsy/CP-like conditions check list
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
Seizure management
- 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
- Emergency action plan
What do you do if you find ptosis on exam?
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)
how do you distinguish UMN from LMN pathology with a facial palsy ?
UMN. forehead sparing
Dermatomes of LL power
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)
Management plan for seizures
- 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
- Emergency action plan
Cranial nerves in order
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
How do you express visual acuity
*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
Interpretation of rinner and weber’s tests
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.
4 Ss of the neuro inspection
Shunts
Scars
Spine
Stigmata
