Neurology Long Case

Question 1

Multiple sclerosis

Answer 1

1. Diagnosis
   - relapsing remitting or primary progressive or secondary progressive
2. Risk factors
   - female, age
   - family history
   - medications (anti-TNF)
3. Presentation
   - optic neuritis
   - transverse myelitis
   - cerebellar
   - spastic paraparesis
   - pseudo-relapse (Uhthoff’s phenomenon)
   - flares (frequency)
4. Investigations
   - Macdonald’s criteria
   - MRI Gad +
   - LP - oligoclonal bands
   - visual evoked responses
5. Management
   - follow-up
   - supportive care
   - treatment of flares - steroids/IVIG
   - oral/injectable/monoclonal antibodies (disease modifying therapy) - natalizumab/fingolimod/teriflunomide/ alemtuzumab
6. Complications
   - complications of disease - spasticity/incontinence
   - complications of treatment
7. Outlook/Current status
   - impact/work/relationships
   - depression
   - functional status/aids
   - mobility/falls
   - sexual dysfunction
   - future plans

Question 2

Myasthenia gravis

Answer 2

1. Diagnosis
2. Risk factors
   - thymoma
   - paraneoplastic Lambert Eaton dx
   - family history
3. Presentation
   - triggers (anaesthetics, antibiotics)
   - myasthenic crisis
   - bulbar symptoms
   - ocular symptoms
   - proximal fatiguable weakness
4. Investigations
   - ice-pack test
   - antibodies - MUSK, Acetylcholine Receptor Ab, LRP-4
   - EMG with RNS
   - CT chest for thymoma
   - associated autoimmune dx
   - PFTs
5. Management
   - trigger avoidance
   - pyridostigmine
   - steroids + sparing agents
   - PLEX/IVIG
   - thymectomy
6. Complications
   - respiratory failure
   - dysphagia
   - complications of therapy
7. Outlook
   - impact on work/function
   - future planning

Question 3

Myasthenia Gravis examination

Answer 3

1. Fatiguability
   - ptosis
   - occulomotor
   - facial
   - bulbar
   - speech
   - neck flexion
   - proximal limb girdle
2. Thymectomy scar
3. Preserved reflexes
4. No muscle atrophy
5. No sensory loss

Question 4

Guillain-Barre syndrome

Answer 4

1. Diagnosis
2. Risk factors
   - preceding infection
   - prior episodes
3. Presentation
   - ascending motor weakness
   - sensory symptoms
   - upper limb/facial/bulbar
   - autonomic sx
4. Investigations
   - LP - albuminocytologic dissociation
   - NCS
   - peak flow
   - anti GQ1b (Miller-Fisher)
   - anti GM1, GD-3 (AMAN)
5. Management
   - supportive care
   - steroids/immunosuppression
   - IVIG/PLEX
   - rehabilitation
6. Complications
   - complications of therapy
   - respiratory failure
7. Outlook
   - plateaus at 2-4 weeks
   - impact

Question 5

Differential diagnoses for acute ascending motor paralysis

Answer 5

1. Guillain Barre
2. Toxins - botulism, arsenic
3. Snake/tick bites
4. Polio
5. Polyarteritis nodosa
6. Acute intermittent porphyria

Question 6

Stroke

Answer 6

1. Diagnosis
2. Risk factors
   - AF
   - age, past/fam history
   - vascular risk factors
   - hypercoagulability
3. Presentation
   - stroke syndrome
   - residual deficits
4. Investigations
   - Carotid US
   - ECG, Holter, TTE
   - MRI Brain
5. Management
   - speech/PT/OT
   - anti platelet
   - anticoagulation
   - statin
   - CEA
6. Complications
   - seizures
   - aspiration/infections/VTE
7. Outlook
   - driving
   - fatigue
   - depression
   - function/ADLs/falls

Question 7

Syncope (aetiology)

Answer 7

1. Cardiac
   - arrhythmias
   - valvular heart disease
   - HCM
   - order TTE/Holter
2. Hypovolemia
   - review fluid status
3. Autonomic dysfunction
   - vasovagal
   - diabetes
   - Parkinson’s
   - review postural BP
4. Drugs
   - medication review
5. Hypoglycaemia
   - review glucometer
6. Addison’s
   - UEC, serum cortisol, ACTH, short synacthen

Question 8

Syncope (management)

Answer 8

1. Identify aetiology
2. Investigations
3. Non-pharmacological
   - education
4. Pharmacological
   - medication review
5. Minimize complications
   - falls
   - driving
   - impact on ADLs
   - impact on work

Question 9

Seizures

Answer 9

1. Diagnosis
2. Risk factors
   - structural
   - familial/genetic
3. Presentation
   - aura
   - focal vs generalized
   - witnessed
4. Investigations
   - MRI
   - EEG
5. Management
   - education
   - anti-convulsants
   - epilepsy surgery
6. Complications
   - side effects of therapy
   - status epilepticus
7. Outlook
   - impact on driving
   - mental health
   - falls

Question 10

Peripheral Neuropathy (approach)

Answer 10

1. Type and time course - Sensory/motor/mixed/autonomic?
2. Examine for length dependent LMN weakness/sensory
3. Causes
   - inherited - Charcot Marie Tooth
   - drug-induced
   - toxic (alcohol)
   - diabetic
   - B12 deficiency
   - hypothyroidism
   - myeloma
   - autoimmune (SLE, RA, vasculitis)
4. Investigation
   - NCS/EMG - axonal or demyelinating
   - screen for drugs/alcohol
   - FBE
   - UEC
   - HbA1c, fasting BSL
   - B12, folate
   - TSH
   - SPEP, UPEP
   - ANA, ENA, ANCA
5. Management
   - address cause
   - treat neuropathic pain
   - physiotherapy and OT assessment - walking aids, home assessment
6. Complications
   - avoid falls