Neurology Flashcards
Tests to do if query myasthenia gravis
Short acting anticholinesterase agent in MG would transiently improve symptoms.
Do chest imaging to rule out thymoma
Do CT brain
Blood as,pale for anti acetylcholinesterase antibodies
Problems with MG
Progressive fatiguable weakness
They also have problems with mastication, talking, drinking, swallowing. Aspiration pneumonia and resp failure can result as unable to clear secretions
Neuro systems review
Headaches Altered vision Fits, faints, funny turns Hearing difficulties Memory problems Speech and swallowing difficulties Weakness Numbness or tingling Incontince or retention Erectile dysfunction Balance or coordination difficulties How is it affecting ADLs FH
Progressive weakness without sensory loss. Arm twitching. Legs giving way. Change in speech. Father died when in 30s.
Amyotrophic lateral sclerosis- UMN AND LMN lesions. Some genetic component but sporadic mutations more common
Severe painful unilateral headaches. No warning. Eye watering, nasal stuffiness. No symptoms between headaches. Usually at night.
Cluster headache
Tight band like headache precipitated by stress
Tension headache
Brief stabbing pain when chewing or brushing teeth
Trigeminal neuralgia
Photophobia, neck stiffness, fever, headache
Meningitis
Sudden onset excruciating headache. Reaches climax within minutes
Subarachnoid haemorrhage
Unilateral landing headshcem multiple triggers, lasts for hours, aversion to bright lights, can be preceded by aura
Migraine
20 minute unilateral debilitating headache p. Retro orbital pain with red eye and watering
Cluster headache
Headache triggered by changes in position or exertion. Changes in vision or headache with leaning forward, coughing, sneezing
Raised Icp- SOL- tumour, abscess. Hydrocephalus
Pain around eyes with blurred vision and halos around lights
Acute angle closure glaucoma
Scalp tenderness, unilateral. Jaw claudication .
Temporal arteritis
Red flags for headaches
Sudden onset High severity Fever New onset neurological deficit New onset cognitive dysfunction Change in personality Impaired GCS recent head trauma Headache triggered by cough, sneeze, exercise or change in posture Headache with halls around lights Headache with jaw claudication
LOC triggered you vigorous exercise in a young person
Hypertrophic cardiomyopathy or cardiogenic syncope
Triggered by pain, fear, prolonged standing. Preceded by pallor, nausea, sweating, no confusion afterwards
Vaso vagal
Triggered when standing up
Postural hypotension
Collapse on shaving or turning head
Carotid sinus sensitivity
Crying out, falling to floor, period of stiffness followed by rhythmic jerking that gradually decreases in amplitude and frequency, period of confusion after
Generalised tonic clinic seizure
LOC, pale and sweaty beforehand, jerking of limbs, eye rolled back short duration, no confusion
Vaso vagal
Violent shaking, head moving side to side , arching back, episodes of stillness before starting again, forced eye closure
Psychogenic non epileptic struck
Facial weakness on right side, motor weakness on left
Right side brainstem lesion
Left weakness and sensory changes
Right hemisphere lesion
Lower motor neurone weakness in all four limbs and loss of sensation
Peripheral neuropathy
UMN signs in all four limbs and loss of sensation
Spinal cord lesion
Loss of vision and pain in eye. Incontinence. Leg weakness
Think MS
Do MRI brain and spine
Elderly patient, head trauma, worsening lethargy, confusion
Subdural haematoma
Do CT
Progressive weakness, cannot walk unaided, started off at numbness and tingling in hands and feet. Now SOB. Had food poisoning three weeks ago
Absent reflexes , glove and sticking sensory loss
GBS
Differential of transverse myelitis
Do LP and MRI
Treatment of GBS
Iv immunoglobulin
Or plasma exchange
DVT prophylaxis, lots of obs
LP with high protein but normal white cells
GBS
Key features of GBS
Peak disability in four weeks Antecedent trigger Areflexia CSF- high protein, normal cell count Generally spontaneous recovery occurs
Differentials of GBS
Acute myelopathies Botulism Diphtheria Lyme disease Vasculitis neuropathy
Oligoclonal bands in CSF and not in blood
Think MS
Four limb symptoms and urinary disturbance
Cervical spine
Right sided facial weakness. Whole face, no sparing. Sensation normal
Right LMN lesion. Bell’s palsy
Treatment of Bell’s palsy
Steroids
aciclovir
Tape eye closed at night
Can initially worsen before getting better
Painful vesicles affecting external ear, palate. Facial weakness. Ear and face pain
Ramsay hunt syndrome
Treat with aciclovir within 3 days of onset and steroids
Young female with foot slapping when walking after a weekend kneeling
Common peroneal nerve palsy. Get nerve conduction studies
Ask about back pain as the palsy could be due to prolapsed disc.
Wrist drop
Radial nerve palsy. Often due to compression on mid shaft of humerus. Get neurophysiology assessment. Give splint to help with function
Young man, blurring in right eye, discomfort and pain in movement of eye. Reduction in vision in right eye. Left eye normal
Optic nerve problem. Eg optic neuritis
Blood tests following RAPD
Serum b12 as deficiency can mimic optic neuropathy
Look for evidence of multi system inflammation
No pun specific inflammatory markers eg CRP, ESR
Specific immunological markers- ANA, ANCA, serum ACE,
Infectious triggers eg HIV, syphillis, hep B and C
Rarer antibodies eg Devics
MRI scan would show high signal in optic nerve
Causes of an unsteady gait
Cerebellum problems leading to cerebellar ataxia
Dorsal column problem leading to sensory ataxia
Peripheral nerve problems leading to sensory ataxia
Vestibular problems
Features of cerebellar disease
Vertigo and nausea
Voice changes- staccato
Poor coordination in arms and legs
One side of body affected- ipsilateral lesion
Vestibular problems
Nausea
Vertigo
Room spinning
Can lead to hearing loss and tinnitus
Unsteady gait and sensory loss. Pins and needles. Balance worse in dark. Fall over when eyes closed
Sensory ataxia
Unsteady gait and bladder disturbance
Spinal cord lesion
How to treat MS relapse
High dose steroids, give PPI alongside this
Try to treat symptoms of the relapse
Medications used in MS
Steroids to treat relapse
Disease modifying agents eg beta interferons
Baclofen- reduce muscle spasticity. Can be very sedative through
Gabapentin- reduce neuropathic pain
Sertraline- depression often common with chronic disease
Oxybutinin- if urge incontinence a problem but can lead to bladder retention
How to treat neuropathic pain
Pregablin
Gabapentin
Tricyclic antidepressant eg amitriptylline
Carbamazepine (useful in trigeminal neuralgia)
Side effects of beta interferons
Injection site reaction or rash
Flu like symptoms for a few days
Reduced immune system
Conditions that can mimic MS
Devics syndrome- neuromyelitis optics, affects spinal cord and optic nerve. Test for NMO antibodies
Anticsediolipin antibody syndrome
Neurosarcoidosis
Sjogrens
Side effects of steroids
Acne Blurred vision Cataracts Glaucoma Easy bruising Difficulty sleeping High blood pressure Increased appetite and weight gain Increased Body hair Ulcers Diabetes Osteoporosis Impaired wound healing
