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Clinical medicine > Neurology > Flashcards

Neurology Flashcards

1
Q

Topic 1

A

Taking a history in neurology

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2
Q

What can you ask the patient regarding their presenting symptoms?

A

“DPOT”
Duration of symptoms and any previous episodes
Pattern - constant, intermittent, or progressive
Onset - sequence of events when symptoms first begin
Triggers - warm baths may worsen symptoms caused by demyelination; sensory stimuli can trigger epilepsy; dietary stimuli; tiredness and stress can trigger migraines

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3
Q

What can you ask the patient regarding their past medical history?

A

Atherosclerotic risk factors e.g. hypertension and diabetes
Risk factors for embolic disease - atrial fibrillation, patent foramen ovale

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4
Q

Screening questions that would point towards other relevant features

A

Systemic symptoms - fever, weight loss and anorexia
Raised intracranial pressure symptoms - headaches worse on waking and lying flat, vomiting, diplopia
Visual symptoms - blurring, diplopia, flashing lights
Bulbar symptoms - changes in speech and difficulties swallowing
Motor symptoms - weakness, stiffness, abnormal gait
Sensory symptoms - loss of sensation, neuropathic pain
Loss of coordination - dizziness, staggering gait, loss of fine motor control, altered speech
Loss of consciousness - features suggesting a neurological cause include aura, muscle jerking, tongue biting, incontinence, and drowsy post-ictal phase
Disturbance of higher functions - personality change, cognitive decline, loss of executive control

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5
Q

What can you ask the patient regarding their medication history?

A

Use of any neuroactive medications e.g. antipsychotics

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6
Q

What can you ask the patient regarding their family history?

A

History of inherited neurological disorders e.g. Huntington’s chorea, myotonic dystrophy and Charcot-Marie-Tooth disease in close relatives

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7
Q

What can you ask the patient that would point towards risk factors for functional disease?

A

At work - employment status, job security, stress at work, relationships with colleagues
Personal life - family circumstances, relationship status, conflict, bereavements

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8
Q

What can you ask the patient regarding their disability (if they have one) and their ADLs?

A

Mobility, ability to perform activities of daily living, the current provision of carers

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9
Q

What can you ask the patient regarding their lifestyle factors?

A

Smoking, alcohol consumption, use of illegal drugs

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10
Q

What can you ask the patient regarding their safety?

A

Do they drive? What is their employment? Might their illness pose a risk to themselves or others? Do they take baths or go swimming alone? Any other potentially risky leisure activities?

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11
Q

Topic 2

A

Examination of the patient in neurology

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12
Q

What do you look for in the general examination?

A

Level of consciousness, orientation in time/place/person, gait, speech, cognitive function, abnormal posture of limbs, facial expression, blood pressure, temperature

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13
Q

What do you look for when examining the patient’s face?

A

Eyes - acuity, fields, movements, pupils, fundoscopy
Facial motor control - asymmetry, lifting eyebrows, showing teeth
Facial sensation - dermatomal sensory loss
Speech
Swallowing assessment
Neck stiffness

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14
Q

What do you look for when examining the limbs for motor assessment?

A

Wasting
Fasciculation
Abnormal posture
Tone
Power
Reflexes
Plantar reflexes
Coordination

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15
Q

What do you look for when examining the limbs for sensory assessment?

A

Numbness
Light touch - cotton wool
Pain - pin prick
Joint position sense
Vibration sensation
2-point discrimination
Temperature sensation

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16
Q

Topic 3

A

Formulating a diagnosis in neurology

17
Q

Ask if the lesion is global or focal

A

Global lesions affect all or most brain functions and typically affect cognition and consciousness

18
Q

Ask about the timescale

A
  • Immediate onset symptoms are usually vascular (ischaemia or haemorrhage), electrical (epilepsy) in aetiology.
  • Rapidly progressive symptoms (over days) may represent infective (e.g. meningitis) or inflammatory (e.g. demyelinating) disease
  • Slowly progressive symptoms tend to be caused by degenerative diseases.
19
Q

Diagnose if the motor lesions affect the upper or lower motor neurons

A
  • UMN signs: increased tone (spasticity), weakness, increased reflexes and upgoing planters - a pyramidal pattern of weakness where stronger muscles (upper limb flexors, lower limb extensors) overwhelm weaker ones’
  • LMN signs: flaccid weakness, decreased or absent reflexes, wasting and fasciculations
20
Q

Locate where the lesion is

A
  • Cerebral cortex/internal capsule: contralateral UMN signs
  • Cerebellum: nystagmus, impaired balance/coordination
  • Brainstem: impaired consciousness, global signs, cranial nerve abnormalities
  • Spinal cord: UMN paraplegia/quadriplegia with sensory level
  • Nerve root: LMN myotomal signs; dermatomal sensory loss
  • Single peripheral nerve: LMN signs and sensory loss according to the distribution of nerve
  • All peripheral nerves: “length-dependent” LMN signs (worst in hands/feet), ‘glove and stocking’ sensory loss
  • Neuromuscular junction/muscle: Only motor signs present. Fatiguability common, wasting and fasciculation
21
Q

Ask yourself is there is a functional component

A
  • Are there elements that don’t fit within standard neuroanatomical patterns of disease?
  • Are there risk factors for functional disease?
22
Q

Topic 4

A

Clinical features of neurological disease

23
Q

What are some critical questions to think about when formulating a clinical diagnosis?

A

Where is the site of the lesion?
What is the likely pathology?
Does a recognisable disease fit this pattern?

24
Q

What should you look out for if the patient complains of difficulty walking?

A
  • Spasticity and hemiparesis
  • Look for change in pattern of gait
    Parkinson’s disease: shuffling gait
    Cerebellar ataxia: broad-based gait
    Sensory ataxia: stamping gait
    Lower limb weakness: high-stepping and waddling gait
    Gait apraxia
25
Q

What is spasticity and how does it affect movement/ gait?

A

Spasticity is increased rigidity of muscles due to brain and spinal cord injury. It is more pronounced in extensor muscles (back arm muscles and front leg muscles).
Causes stiff, effortful, slow walking and the pace shortens. Clonus - involuntary extensor rhythmic leg jerking may occur.

26
Q

How does Parkinson’s affect movement/gait?

A

Shuffling gait

  • Stride length shortens, in advanced forms, the gait slows to a shuffle.
  • Posture is stooped
  • Arm swing is reduced (unilaterally)
  • Gait becomes hurried with short, rapid steps
  • Difficulty turning quickly - count number of steps to turn around
  • Eventually gait initiation difficulty and sudden involuntary halts
  • Falls are uncommon but come at later stages
27
Q

How does cerebellar ataxia (e.g. lateral cerebellar lobe disease) affect movement/gait?

A

Broad-based gait

  • Stance becomes broad-based, unstable and tremulous.
  • Incoordination
  • When walking the patient tends to veer towards the affected lobe
28
Q

How does sensory ataxia (e.g. peripheral sensory loss) affect movement/gait?

A

Stamping gait

  • A broad-based high-stepping gait where feet are placed clumsily. Dependant on vision so is worse in the dark.
  • Loss of proprioception causes ataxia.
  • Romberg’s test positive.
29
Q

How does lower limb weakness affect movement/gait?

A

High-stepping and waddling gaits

  • When the weakness is distal (e.g. common peroneal nerve palsy), ankle dorsiflexion is affected. Gait becomes high stepping to avoid tripping.
    Sole returns to the ground with an audible slap.
  • When weakness is proximal (e.g. polymyositis, muscular dystrophy), there is difficulty in rising from sitting and walking becomes a waddle. The pelvis is poorly supported.
30
Q

How does frontal lobe disease (e.g. diffuse cerebrovascular disease, normal pressure hydrocephalus) affect movement/gait?

A

Gait apraxia

  • Walking skills become disorganised
  • Shuffling with small steps
  • Hesitancy
  • Fear of falling
  • Swing and posture is normal
  • Urinary incontinence and dementia usually present
31
Q

What is the difference between apraxia and ataxia?

A

Apraxia: loss of skilled movement. Brain imaging would show a cortical lesion in the inferior frontal gyri.

Ataxia: loss of coordinated movement. Brain imaging would show cerebellar involvement.

32
Q

List of common gait abnormalities

A

Cause Gait abnormality

Stroke Spastic/hemiparetic

Parkinson’s Shuffling/festinated

Cerebellar ataxia Broad-based

Sensory neuropathy Stamping

Position sensory loss High-stepping

Distal weakness/ Slapping
foot drop

Proximal weakness Waddling
e.g. myopathy

Apraxia of gait Incoordinated/gait initiation
e.g. diffuse
cerebrovascular
disease

Normal pressure Hesitant
hydrocephalus

Arthritis and muscle pain Antalgic

33
Q

What is vertigo?

A

The illusion of movement, a sensation of rotation or tipping.
(The patient feels the surroundings are spinning or moving)

34
Q

What are some medical risk factors for falls in the elderly?

A
  • Cognitive impairment (dementia and delirium)
  • Arthritis, muscle weakness
  • Disorders of balance and gait (parkinsonism, ataxia, stroke)
  • Visual impairment
  • Postural hypotension and syncope
  • Vestibular disorders
  • Polypharmacy esp. with sedative drugs, neuroleptics, antihypertensives, and anticonvulsants
  • Alcohol excess
  • Peripheral neuropathy
  • Use of walking aid
35
Q

What does a ten-part neurological examination include?

A
  1. State of consciousness, arousal, appearance
  2. Mental state, attitude, insight
  3. Cognitive function - orientation, recall, level of intellect, language, other cortical problems e.g. apraxia
  4. Gait and balance tests, including tandem walking and Romberg’s test
  5. Neck - stiffness, palpation and auscultation of carotids
  6. Cranial nerve examination
  7. Motor system - Upper limbs, thorax and abdomen, lower limbs
  8. Coordination and fine movements
  9. Sensory system
  10. Specialised tests as required e.g. Hallpike for vertigo, Phalen’s test etc.
36
Q

Describe the muscle power assessment (MRC Scale)

A

Grade 5: Normal power

Grade 4: Active movement against gravity and resistance

Grade 3: Active movement against gravity only

Grade 2: Active movement with gravity eliminated

Grade 1: Flicker of contraction

Grade 0: No contraction

37
Q

How can you assess the level of consciousness in a patient?

A
  • ACVPU scale
  • GCS score
38
Q

What is the ACVPU scale?

A

An assessment of conscious level and response to stimuli. (A quicker and easier assessment than the GCS score). Stands for:

Alert: The patient is fully awake and at their baseline level of cognition.

Confusion: Awake but confused. New or worsening confusion (delirium). Assess the patient’s orientation to time, place, and person.

Voice: Patient responds when you talk to them. This includes opening their eyes, making sounds, and moving.

Pain: Responds to a painful stimulus (e.g. supraorbital pressure)

Unresponsive: No response to voice or a painful stimulus.

39
Q
A

Clinical medicine (9 decks)

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