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DPD interactive cases > Neurology (4) > Flashcards

Neurology (4) Flashcards

1
Q

What is Frank’s sign? What is it a sign of?

A

Diagonal earlobe crease from tragus to rear auricle – it is a sign of diabetes mellitus and cardiovascular disease (IHD)

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2
Q

What are the two main questions you must consider with any neurological condition?

A

What is the problem?
Where is the problem?
- Brain (BS, cerebellum), SC, nerve roots, peripheral nerves, NMJ, muscle

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3
Q

List a surgical sieve that you can use to consider different types of causes of neurological symptoms.

A 
Vascular 
Infection (subacute Hx)
Inflammation/Autoimmune
Toxic/Metabolic
Tumour/Malignancy

Hereditary/Congenital (Pes Cavus)

NOTE: INVITED MD can also be used (infection, neoplasia, vascular, inflammatory/autoimmune, trauma, endocrine, degenerative - Parkinson’s, metabolic, drugs)

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4
Q

List the order in which different optic nerve functions are tested in a neurological examination.

A

Visual acuity (count fingers, hand movements, light perception)
Visual fields
Pupillary reflexes
Fundoscopy

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5
Q

Main features of upper motor neurone lesions

A

Hyperreflexia
Hypertonia (spasticity)
Upgoing plantars
Reduced power

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6
Q

Main features of lower motor neurone lesions

A 
Hyporeflexia
Hypotonia (flaccid)
Wasting 
Reduced power 
Fasciculations
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7
Q

Where is the lesion likely to be in a patient with widespread bilateral derangement of motor function?

A

Neuromuscular junction

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8
Q

Name an important condition that causes loss of motor function in which the lesion is at the level of the neuromuscular junction.

A

Myasthenia gravis – autoantibodies against nicotinic acetylcholine receptors

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9
Q

What is Lambert-Eaton syndrome caused by?

A

Defect in the calcium channel on the presynaptic membrane involved in vesicular exocytosis
Similar symptoms to myasthenia gravis

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10
Q

What is a major risk factor for botulism?

A

IV drug use (expecially under the skin - skin popping –> skin abscess)
Botox inhibits ACh release so affects a wider range

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11
Q

Describe the test used to confirm a diagnosis of botulism.

A

Bioassay – two mice are injected with a serum sample from the patient, and one of the mice is given the botulinum antitoxin. If the mouse without the antitoxin dies, it is botulism

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12
Q

Describe the neurological signs seen in the examination of a patient with botulism.

A

LMN lesion signs:
Hyporeflexia
Hypotonia
Reduced power

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13
Q

What are the six main features of cerebellar disease?

DANISH

A 
Dysdiadochokinesia
Ataxia
Nystagmus
Intention tremor (Dysmetria, pass-pointing)
Scanning speech (+ slurred)
Hypotonia
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14
Q

Using the surgical sieve mentioned previously, list some causes of cerebellar disease.

A

Vascular – bleed in the cerebellar fossa
Infection – TB, varicella zoster, cerebellitis
Inflammation – MS
Tumour – primary or metastases
Toxic/Metabolic – alcohol, phenytoin

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15
Q

Describe how the anatomical level of a sensory lesion affects the area of which the abnormal sensation experienced.

A 
Brain – hemisensory
Spinal cord – at spinal cord level (e.g. T10 = umbilicus)
Nerve root (radiculopathy) – dermatomal 
Mononeuropathy – specific area of skin 
Polyneuropathy – gloves and stockings
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16
Q

What is the most common cause of polyneuropathy?

A

Diabetes mellitus

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17
Q

What is duloxetine and what can it be used to treat?

A

Anti-depressant (SNRI)

It can be used to treat peripheral neuropathy and premature ejaculation

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18
Q

Which other drug may be used to treat neuropathic pain?

A

Pregabalin

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19
Q

List the main toxic/metabolic causes of peripheral neuropathy.

A 
Drugs
Alcohol 
B12 deficiency 
Hypothyroidism
Uraemia 
Amyloidosis 
Diabetes mellitus
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20
Q

Suggest investigations that may reveal clues about each of the causes listed above.

A

Drugs – history
Alcohol – history + high GGT + high MCV
B12 deficiency – low Hb + high MCV
Hypothyroidism – TFTs
Uraemia – U&Es
Amyloidosis – history of multiple myeloma or chronic infection/inflammation
Diabetes mellitus – history + blood glucose + HbA1c

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21
Q

Explain why myeloma is associated with amyloidosis.

A

Myeloma causes increased production of immunoglobulins, which have light chains
The light chains are a precursor to amyloid fibrils
Deposition of abnormal protein in various organs

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22
Q

Explain why chronic inflammation/infection is associated with amyloidosis.

A

Inflammation leads to high levels of serum amyloid protein A (an acute phase protein)

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23
Q

List some associated symptoms to ask patients presenting with neurological symptoms.

A 
Impaired vision 
Impaired hearing 
Headache 
Speech disturbance
Weakness 
Sensory disturbance 
Bowel continence 
Urinary continence
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24
Q

List some inflammatory/autoimmune causes of peripheral neuropathy.

A

Vasculitis
Connective tissue diseases
Demyelinating polyneuropathy (e.g. Guillain-Barre syndrome)

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25
Q

Define ‘paraprotein’.

A

Monoclonal immunoglobulin or light chain present in the blood or urine

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26
Q

Describe the appearance of the feet in patients with long-term peripheral neuropathy.

A

High-arched foot (pes cavus)

Clawed toes

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27
Q

What is amaurosis fugax?

A

Painless temporary loss of vision in one or both eyes; descending curtain

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28
Q

List two causes of blurring of the optic disc margin and explain how you would differentiate between them.

A

Papilloedema – NO pain and NO blurring of vision

Papillitis – pain and blurring of vision

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29
Q

What is papillitis? What is it associated with?

A

Inflammation of the head of the optic nerve, associated with dymyelination (MS)

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30
Q

In which part of the spinal cord do you find the descending inhibitory tracts? What happens if there is a lesion?

A

Corticospinal tract - results in brisk reflexes and upgoing plantars. In Descending motor pathway: weakness

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31
Q

What happens if the spinothalamic tract is compressed at a particular level?

A

Impaired/loss of sensation up until the level of the lesion

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32
Q

Define paraparesis.

A

Partial paralysis of the lower limbs

Spastic paraparesis - increased tone, weak legs

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33
Q

State a vascular cause of spastic paraparesis.

A

Obstruction of the anterior or posterior spinal arteries

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34
Q

State an infective cause of spastic paraparesis.

A

TB of the spine (Pott’s disease)

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35
Q

State an inflammatory (demyelinating) cause of spastic paraparesis.

A

Transver myelitis (may be associated with infections e.g. chest infections caused by Mycoplasma pneumonia)

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36
Q

What features of the history are necessary for a diagnosis of multiple sclerosis?

A

Two lesions separated in time and space

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37
Q

Which condition causes pain and paraesthesia on the anterolateral thigh? (Reduced pinprick sensation)

A

Meralgia paraesthetica

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38
Q

What is this meralgia paraesthetica caused by?

A

Compression of the lateral femoral cutaneous nerve

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39
Q

Outline the treatment of this condition.

A

Reassure the patient that it isn’t something serious
Avoid tight garments
Lose weight

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40
Q

Which pharmaceutical options might you consider if the treatments persist despite these measures?

A

Carbamazepine

Gabapentin

41
Q

Describe the sensory innervation of the hand, and signs if the nerves are affected

A

Front:
Ulnar – medial 1.5 fingers
Median – lateral 3.5 fingers

Back:
Ulnar – medial 1.5 fingers
Radial – rest of the back of the hand
Median – finger tips of 1st, 2nd and 3rd digits

Ulnar claw
Radial - wrist drop; check base of hand
Median: Opposition affected, thumb abduction - point to the ceiling affected

42
Q

What is a radiculopathy?

A

Disease of the nerve roots

43
Q

What is sciatica?

A

Pain in the buttock, radiating down the leg below the knee

It is caused by compression of the lumbosacral nerve roots

44
Q

What can cause compression of nerve roots?

A

Disc herniation

Spinal canal stenosis (degen)

45
Q

Describe the main features of Parkinson’s disease.

A 
Rigidity 
Bradykinesia
Resting tremor (Pill Rolling, unilateral)
Gait instability 
(Dysphagia, amnesia, micrographia)
46
Q

List some other diseases that cause symptoms that are similar to Parkinson’s disease.

A

Progressive supranuclear palsy (Parkinsons + limited upgaze)

Lewy body dementia

47
Q

What is the key feature of progressive supranuclear palsy that helps distinguish it from Parkinson’s disease?

A

Limited up-gaze

48
Q

What is the underlying pathological process that causes Parkinson’s disease?

A

Depletion of dopaminergic neurons in the subtantia nigra

49
Q

What is cogwheel rigidity caused by?

A

A tremor superimposed on increased tone

50
Q

What is another name for progressive supranuclear palsy?

A

Steele-Richardson syndrome

51
Q

What are the key features of Lewy body dementia?

A

Vivid Hallucinations
Alzheimer’s
Parkinsonism

52
Q

If there are no abnormalities seen on examination and imaging of a patient presenting with confusion, what is the likely cause?

A

Toxic/metabolic

53
Q

What dangerous state can cause confusion and chest pain?

A

Carbon monoxide poisoning

54
Q

List four causes of confusion with reduced AMTS.

A

Post-ictal
Dysphasia - not true confusion
Dementia
Depressive pseudodementia - withdrawn, poor eye contact, precipitating factor (death)

55
Q

List 5 causes of dementia.

A 
Alzheimer’s disease 
Vascular dementia 
Lewy body dementia 
Alcoholism
Inherited (e.g. Huntingdon’s disease)
56
Q

Given the causes of dementia listed above, what are some important features of the history that you should check?

A

History of ischaemic heart disease/peripheral vascular disease
History/signs of alcohol abuse
Other symptoms (e.g. Huntingdon’s chorea)

57
Q

List a differential diagnosis for confusion and reduced consciousness.

A 
Hypoglycaemia 
Vascular (i.e. bleed)
Infection
Inflammation - cerebral vasculitis (rash)
Malignancy
Toxic/metabolic
58
Q

What are some distinguishing features of a subdural haematoma?

A

Falls and fluctuating consciousness

59
Q

What are the main symptoms of intracranial infection?

A

Headache
Neck stiffness
Changed behaviour
Fever

60
Q

State an inflammatory cause of confusion with reduced consciousness.

A

Cerebral vasculitis

61
Q

List some investigations you would perform to look for a toxic/metabolic cause of confusion with reduced AMTS.

A 
Drug history 
U&Es
LFTs 
Vitamin deficiencies 
Endocrinopathies (Cushing's psychosis)
62
Q

Which endocrine disease may present with confusion?

A

Cushing’s disease

63
Q

What is the motor criteria of the GCS?

A

6 (obeys commands > localises pain > withdrawal from pain > flexion to pain (decorticate) > extension to pain (decerebate) > no motor response)

64
Q

What is the verbal criteria of the GCS?

A

5 (oriented > confused > inappropriate words > incomprehensible sounds > no verbal response)

65
Q

What is the eye criteria of the GCS?

A

4 (spontaneous eye opening > eye opening in response to speech > eye opening in response to pain > no eye opening)

66
Q

In the AMTS, patients are asked to count backwards from 20 to 1. Why is this done?

A

To check for any deficits in attention/concentration

67
Q

What are the four main diseases that you need to think about when a patient presents in the emergency department with a headache?

A

Meningitis
Giant cell arteritis
Subarachnoid haemorrhage
Migraine

68
Q

List the main symptoms of meningitis.

A 
Headache 
Neck stiffness 
Fever 
Photophobia 
Kernig’s sign
69
Q

What is Kernig’s sign?

A

When the hip is flexed and the knee is at 90 degree, extension of the knee causes pain

70
Q

Describe the presentation of subarachnoid haemorrhage.

A

Sudden-onset worst headache ever

71
Q

What is the first investigation that is performed in suspected SAH?

A

CT Head

72
Q

What would you look for when doing a lumbar puncture of a patient with SAH?

A

Xanthochromia (yellow discolouration of the CSF due to the break down of haemoglobin)

73
Q

List the main symptoms of giant cell arteritis.

A

Headache
Loss of vision
Jaw claudication
Scalp tenderness

74
Q

Which disease is giant cell arteritis associated with?

A

Polymyalgia rheumatica (Shoulder girdle pain, systemic upset)

75
Q

How do you treat giant cell arteritis?

A

High-dose prednisolone - blindness risk

76
Q

List two investigations that you would perform in a patient with giant cell arteritis.

A

ESR

Temporal artery biopsy

77
Q

Describe the features of migraine.

A

Unilateral, throbbing pain around the eye, vomiting, photo/phono phobia, FHx

78
Q

List examples of negative and positive auras.

A

Negative – dark, black holes

Positive – flashing lights

79
Q

What is the window for thrombolysis in a patient with stroke?

A

Within 4.5 hours of onset of symptoms

80
Q

Which investigation must you perform in stroke patients before giving any treatment?

A

CT Head – exclude haemorrhage

81
Q

Describe the management of a stroke patient who presents > 4.5 hours after the onset of symptoms.

A

CT head to exclude haemorrhage
Aspirin (300 mg)
Swallow assessment
Maintain hydration, oxygenation and monitor glucose

82
Q

At what point do you worry about the blood pressure of a patient with a TIA?

A

If the blood pressure rises > 220/120 mm Hg

Otherwise don’t treat acutely

83
Q

Describe the management of a patient with TIA.

A

Aspirin

Risk factor modification

84
Q

List some investigations that you would perform in a patient with a TIA.

A

ECG (AF)
Echocardiogram
Carotid artery Doppler (CA Stenosis)

85
Q

Why is it important to monitor FVC in a patient with Guillain-Barre syndrome?

A

It can cause respiratory muscle weakness and reduce ventilation

86
Q

How is FVC monitored?

A

Spirometry

87
Q

What must you do if the FVC begins to drop?

A

Ventilate

88
Q

Why is it important to set up a cardiac monitor for patients with Guillain-Barre syndrome?

A

Guillain-Barre syndrome is associated with autonomic neuropathy

89
Q

How is Guillain-Barre syndrome treated?

A

IVIg

90
Q

Construct a simple list of causes of collapse.

A

Hypoglycaemia
Cardiac – vasovagal, arrhythmia, outflow obstruction, postural hypotension
Neurological – seizure

91
Q

Give another 2 causes of blurred vision

A

Anterior uveitis, vitreous haemorrhage

92
Q

Other causes of spastic parasthesia

A

Toxic/metabolic: subacute combined demyelination of the spinal cord; tumour malig/mets

93
Q

How do you test bradykinesia?

A

Fingers 2-5 to touch thumb

94
Q

Proximal Myopathy - name 4 causes

A

Cushings
Thyrotoxicosis
Osteomalacia
Vit D deficiency

95
Q

Name infections and inflammatory causes of peripheral neuropathy

A

Infection – HIV
Inflammation – Guillain-Barre syndrome, ConTis Disease, Vasculitis, CIDP (Chronia inflammatory demyelinating polyneuropathy)

96
Q

Name toxic causes of peripheral neuropathy

A

Alcohol, cisplatin, amiodarone, metronidazole, phenytoin, isoniazid, nitrofurantoin, gold

97
Q

Name Metabolic causes of peripheral neuropathy

A

Diabetes, amyloidosis, CKD, B12 Deficiency

98
Q

Name Hereditary causes of peripheral neuropathy

A

Hereditary - CMT disease, Dejerine-Sottas Disease, Refsum disease

99
Q

Name malignant causes of peripheral neuropathy

A

Paraneoplastic syndromes

Paraproteinaemia

DPD interactive cases (8 decks)

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