Neurology

Question 1

Bells palsy

Answer 1

Idiopathic facial nerve palsy
LMN
Mx - steroids
Most recover within 3 weeks but can be permanent

Question 2

Causes of facial nerve palsy

Answer 2

Herpes zoster infection (Ramsey-Hunt syndrome)
Otitis media 
Lyme disease
Guillain-barre syndrome
HIV
Sarcoidosis 
Sjogren syndrome
Tumour 
Stroke (UMN) 
Melkersson-Rosenthal syndrome

Question 3

Melkersson-Rosenthal syndrome

Answer 3

Characterized by recurrent episodes of facial paralysis, episodic facial swelling, and a fissured tongue

Question 4

Benign paroxysmal positional vertigo (BPPV)

Answer 4

Most common form of positional vertigo, accounting for nearly one-half of patients with peripheral vestibular dysfunction. It is most commonly attributed to calcium debris within the posterior semicircular canal, known as canalithiasis

Question 5

BPPV symptoms

Answer 5

Recurrant episodes of vertigo ~ 1 min
Provoked by certain types f movement
N+V can be associated
No hearing loss

Question 6

BPPV management

Answer 6

Dix-halpike maneuvre (diagnositic)
Epley maneuvre or Sermont maneuvre
(curative)

Question 7

Common causes of dementia

Answer 7

Vascular
Alzheimers
Lewy-body dementia
Fronto-temporal dementia

Question 8

Rarer causes of dementia

Answer 8

corticobasal degeneration (CBD)
Creutzfeldt-Jakob disease (CJD)
HIV-associated neurocognitive disorder (HAND)
Huntington's disease
multiple sclerosis (MS)
Niemann-Pick disease type C
normal pressure hydrocephalus (NPH)
Parkinson's disease dementia (PDD)
posterior cortical atrophy (PCA)
progressive supranuclear palsy (PSP)

Question 9

Management of dementia

Answer 9

Conservative/social:
Carers

Medical:
Antcholinesterase inhibitor (?)

Question 10

Management of dementia

Answer 10

Conservative/social:
Carers

Medical:
Antcholinesterase inhibitor (?)

Question 11

Encephalitis symptoms

Answer 11

Focal neurology
Altered mental status, motor or sensory deficits, altered behavior and personality changes, and speech or movement disorders.
Hemiparesis, flaccid paralysis, and paresthesias

Question 12

Encephalitis causes

Answer 12

Infective

Autoimmune

Question 13

Myotonic Dystrophy

Answer 13

Tri-nucleotide repeats, Autosomal dominant + anticipation
Type 1 – DMPK gene
Type 2 – ZNF9 gene
Features: Muscle weakness/pain, myotonia
Extra: Cardiac abnormalities, cataracts, hypersomnia, hypogonadism, DM
Exam: frontal balding + expressionless face, Wasting of hand muscle, grip myotonia + percussion myotonia
Ix: Urine dip, EMG “dive bomber” potentials, Genetic
Mx: Optimised Cardiac + resp RF, Phenytoin for myotonia

Question 14

Ptosis Causes

Answer 14

Unilateral
•	3rd nerve palsy (complete)
•	Horner’s Syndrome (partial)
Bilateral
•	Myotonic dystrophy 
•	Myasthenia gravis
•	Congenital

Question 15

Cerebellar Examination

Answer 15

Intro – scanning dysarthria
Eyes – Nystagmus (Fast phase towards lesion)
Outstretched arms – rebound phenomenon
UL – Reduced Tone & reflexes, Finger-nose incoordination, DDK
LL – Heel to shin, Foot tapping
Walking – wide based gait, ataxia

Question 16

Cerebellar Causes

Answer 16

Alcohol
Stroke
Sclerosis (MS)
Tumour – Posterior fossa
Paraneoplastic cerebellar syndrome
Iatrogenic – phenytoin  
Endocrine – hypothyroidism 
Rare (Friedrich’s ataxia + Ataxia telangiectasia)

Question 17

Friedreich’s ataxia

Answer 17

Autosomal recessive, trinucleotide repeat
Signs: young adults, pes cavus, bilateral cerebellar signs, leg wasting (absent reflexes + bilateral upgoing plantars) & posterior column loss
Other: kyphoscoliosis, optic atrophy 30%, High arched palate, sensorineural deafness, HOCUM murmur, urine dip (diabetes)
Ix: genetic testing
Mx: Specialist referral, patient education, RF mod., symptomatic treatment.

Question 18

Huntington’s Disease

Answer 18

AD, Trinucleotide repeats, Anticipation
Chorea - rapid, involuntary, non-repetitive + arrhythmic
Eye signs
Psychiatric – Depression, irritability, dementia
Ix: FH, genetic testing, MRI (caudate atrophy)

Question 19

Tuberous Sclerosis

Answer 19

Signs: “ASH LEAF”
Skin: Ash leaf macules, Shagreen patch, periungal fibromas, facial adeoma sebaceum
Resp: Cystic lung disease
Abdo: Renal enlargement (polycystic +/- angiomyolipomas)
Renal transplant +/- AV fistulae
Eyes: Retinal phakomas
CNS: mental retardation, seizures. (anti-epileptic drug signs)
Ix: Skull films, CT/MRI head, Echo + abdo US

Question 20

Lateral medullary syndrome

Answer 20

Occulusion of Posterior Inferior cerebellar artery
Features:
Cerebellar signs (inferior cerebella peduncle)
Nystagmus (vestibular nucleus)
Horner syndrome (desc. Sympathetic tract)
Palatal paralysis (nucleus ambiguous – CN IX, X)
Loss of CN V pain + temp sensation
Contralateral loss of pain + temp sensation (Spino-T tract)

Question 21

Facial Nerve palsy

Answer 21

Idiopathic: Bells Palsy 
Trauma
Infection: Herpes Zoster
Malignancy 
MS
Stroke
Mononeuropathy: diabetes, Sarcoidosis, lyme disease
Bilateral: Myasthenia + Guillain-Barre

Question 22

Hereditary sensory motor polyneuropathy

Answer 22

Signs:
Wasting of distal lower limb + preservation of thigh
Pes cavus
Weakness of ankle dorsi-flexion + toe extension
Variable stocking distribution of sensory loss
High stepping gait and stamping
Wasting of hand muscles
Palpable lateral popliteal nerve

Question 23

MS Mx

Answer 23

Mx: MDT (physio, OT, Social worker + dr)
Acute – IV methylprednisolone 5 days
DMD – Interferon Beta, Glatiramer
Monoclonals – Alemtuzumab (anti-CD-52), Natalizumab (Anti-α4 integrin)
Symptomatic – Baclofen (anti-spasmodic)
Carbamazepine (Neuropathic pain)
Laxatives +/- catheterisation/oxybutynin for GI disturbance

Question 24

Parkinson’s disease Mx

Answer 24

Conservative: Care + education + physio 
Medical:
L-Dopa
Dopamine agonists – Bromocriptine, Pergolide
MAO-B antagonists - Selegiline
COMT Antagonists - Entacapone
Anticholinergics – Can reduce tremor
Amantadine – Increases dopamine relase 
Surgical: Deep brain stimulaiton

Question 25

Ulnar nerve palsy

Answer 25

Inspection: partial claw hand (ring and little fingers)
Wasting (hypothenar eminence and dorsal interossei)
Sensation: lost ulnar distribution
Power: weak abduction and adduction of fingers
Special: Froment’s and Elbow flex test
Causes:
Anatomical compression (cubital tunnel syn, Guyon’s cannal syn.)
Trauma (supra-chondylar # humorous + elbow dislocation)

Question 26

Radial nerve palsy

Answer 26

Inspection: wrist drop (hand out and palms down)
Sensation: lost over 1st dorsal interosseous +/- dorsal forearm
Power: Loss of MCP extension +/- wrist weakness +/- triceps weakness
Causes:
High: (wrist + finger) mid-shaft humerus#, Saturday night palsy
Low (finger) @elbow – local wounds, # and dislocation

Question 27

Median nerve palsy

Answer 27

Inspection: wasting if thenar eminence 
Sensation: thumb and lateral 2.5 fingers 
Power: thumb abduction 
Causes:
Carpal Tunnel syndrome 
Pronator syndrome 
Anterior interroseous syndrome

Question 28

Carpal Tunnel Syndrome

Answer 28

Inspection: wasting of thenar eminence + scars over flexor retinaculum
Sensation: check over finger pulps and thenar eminence
Move: Opponens pollicis + abductor pollicis brevis
Special: thenl’s + Phalen’s
Ix: nerve conduction + US (RARELY NEEDED)
Mx: Conservative wrist splints
Medical: steroid injections
Surgical: Carpal tunnel decompression

Question 29

Myasthenia Gravis Examination

Answer 29

Intro: Nasal speech (+ “count to 50”) 
Inspection: Sternotomy scars (Thymoma) 
Cranial:
Bilateral ptosis – worse on upward gaze
Bilateral complex extra-ocular palsies 
“myasthenic snarl” – on smiling 
Peripheral:
Demonstrate fatigability + normal reflexes 
Extra: Ice pack test + FVC
Ix: Tensilon test

Question 30

Lambert-Eaton Myasthenic syndrome

Answer 30

Signs:
Diminished reflexes that become brisker after exercise
Lower limb girdle weakness
Association: Malignancy eg small cell lung cancer
Antibodies to pre-synaptic calcium channels
EMG: “second wind” phenomenon

Question 31

Holmes-Adie pupil

Answer 31

Dilated pupil with no response to light and sluggish response to accommodation

Decreased or absent ankle and knee reflexes

Mx: Benign condition (woop!) therefore reassure

Question 32

Argyll-Robertson pupil

Answer 32

Small irregular pupil
Accommodates but doesn’t react to light 
Atrophied + depigmented iris 
Exam: peripheral sensation (tabes dorsalis)
Causes: Quaternary syphilis 
Ix: FTA, TPHA 
Mx: penicillin

Question 33

Marcus Gunn Pupil

RAPD

Answer 33

Minor constriction to direct light
Dilation on moving light from normal to abnormal eye (swinging test)
Other features of optic atrophy:
↓Visual acuity + colour vision (red), central scotoma, pale optic disc + RAPD
Causes: CAC VISION

Question 34

Causes of RAPD

Answer 34

Commonest - MS + glaucoma
Congenital – Lebers hereditary optic neuropathy, CMT/HMSN, Friedrichs ataxia
Alcohol + toxins – ethambutol, lead, B12 def
Compressive – neoplasm, glaucoma + pagets
Vascular – DM, GCA, thromboembolic
Inflam – optic neuritis (MS, DM, Devic’s)
Sarcoid
Infection – Herpes zoster, TB, syphilis
Oedema – papilloedema
Neoplastic infiltration (lymphoma + leukaemia)

Question 35

Diabetic Retinopathy

Answer 35

Background – micro-aneurysms, blot haemorrhages, flame haemorrhages, hard exudates, macular oedema

Pre-proliferative – Cotton wool spots, venous changes

Proliferative – angiogenesis

Complications – Rebeosis iridis, vitreous haemorrhage, tractional retina detachment

Question 36

Retinitis Pigmentosa

Answer 36

Signs: White stick + braille book
Begins with loss of night vision
Tunnel vision
Fundoscopy: ‘bone spicule pigmentation’ 
Optic atrophy
Association: cataracts (absent red reflex) 
Causes: genetic AR, Acquired post retinitis 
Prog: Most registered blind by 40 years

Question 37

Age related macular degeneration

Answer 37

Wet: Neovascular + exudative - worse
Dry: non-neovascular, atrophic and non-exudative
Macular changes: Drusen spots, geographic atrophy, fibrosis, neovascularization
Features: reduced visual acuity, blurred vision, scotomas
RF: age, female, caucasian, FH, smoking
Mx: Ophthalmology referral + wet AMD anti-VEGF

Question 38

Cataracts

Answer 38

PC: difficulty night driving, reading road signs, cant read fine print
Painless, bilateral, asymmetrical process
Causes/RF:Age related, UV light
Systemic: Steroids, Infection (congenital rubella), Metabolic (hypocalcaemia, galactosaemia), Congenital (down’s syndrome, myotonic dystrophy)
Mx: surgery

Question 39

Hearing loss ddx

Answer 39

Conductive: Canal obstruction (wax, FB), TM perforation (trauma, infection), Ossicle defects (otosclerosis, infection)
SNHL: defects of cochlear, CN VIII & brain
Congenital: Alports (+haematura) & Jewell-lange-Nielsen (+long QT)
Acquired:
Presbyacussis
Drugs: gentamicin + vancomycin
Infection: meningitis + measles
Tumour: Vestibular schwannoma (A. neuroma)