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Neurology and Special Senses > Neurology Presentations > Flashcards

Neurology Presentations Flashcards

1
Q

How would a patient describe a tension headache?

What can trigger tension headaches?

A 
Band distribution - frontal-occipital
Associated with neck pain
Mild to moderate pressure pain
No N&V or aura 
Last a few hours

stress, poor posture, depression and anxiety

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2
Q

How are tension headaches managed?

A

Reassure
Aspirin, paracetamol or NSAIDs all first line
Acupuncture

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3
Q

What is the diagnostic criteria for migraine?

A

At least 5 headaches that:

  • Last 4-72 hours
  • Are severe, unilateral, pulsating and interrupt daily activity
  • Are associated with N&V or photo/phonophobia
  • Are not due to a secondary cause
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4
Q

What are some migraine triggers?

A 
Oestrogen (COCP and menstruation)
Foods (cheese, red wine, citrus fruits)
Stress
Bright lights 
Alcohol
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5
Q

How are migraines managed?

a) Acute
b) prophylaxis + when is prophylaxis offered?
c) menstrual induced

A

ACUTE:

  1. oral triptan + NSAID or paracetamol
  2. prochlorperazine + nasal triptan

PROPHYLAXIS if >2/month:

  1. propranolol (preferred in women) or topiramate (teratogenic)
  2. acupuncture

MENSTRUAL MIGRAINE
frovatriptan

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6
Q

Describe the aura associated with some migraines

A
  • transient hemianopic disturbance

- spreading scintillating scotoma

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7
Q

Describe the signs and symptoms of a cluster headache and the timing/ frequency of attacks

A

Severe, sudden onset, unilateral pain around the eye

Ipsilateral autonomic features - rhinorrhoea, sweating, partial horner’s, lacrimation, lid swelling

Typically occur at night
1-2 hour bouts daily over 6-12 weeks

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8
Q

What can trigger cluster headaches?

A

Triggers - alcohol, histamine, heat, exercise

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9
Q

How are cluster headaches managed?

A

Acute - subcutaneous sumatriptan, 100% O2

Prophylaxis - verapamil (some evidence for prednisolone)

Surgery - trigeminal nerve blockade

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10
Q

How would you investigate headaches?

A

BP
Optic fundi
Temporal artery palpation if >50

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11
Q

What are the red flags for headaches?

A 
Systemic symptoms: fever, vomiting, LOC
Thunderclap 
Immunocompromised 
Precipitated by Valsalva
Focal neurological deficit 
Positional 
Personality change 
Cognition change 
Malignancy known to give brain mets
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12
Q

What are the features of medication induced headache?

A

> 15 headaches a month

History of opioid or triptan use

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13
Q

What secondary causes of headaches would you consider?

A 
V: temporal arteritis 
I: meningitis, sinusitis, malaria, HIV
T: head injury, SAH
A: 
M: hypothyroid 
I:
N: brain metastasis, primary tumour 
D: medication induced, CO poisoning

Other: dental/ jaw

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14
Q

What would you ask about in a history for loss of consciousness?

A

Before - triggers? prodromes - visual, auditory, palpitations? change of colour?

During - Duration? convulsions? continence? tongue biting?

After - time for recovery

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15
Q

What are the 5P’s and 5C’s of loss of consciousness

A 
Precipitant
Prodrome
Palpitations
Position
Post event
Colour
Convulsions
Continence
Cardiac hx
FH of sudden cardiac death
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16
Q

What investigations would you request for a patient who has come in with loss of consciousness?

A 
FBC, U&E, Blood glucose
BP - lying and standing
EEG
ECG - 24hr
Imaging with MRI
Carotid sinus massage
Table tilt test
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17
Q

What 3 things characterise syncope?

A

Loss of consciousness
Transient - recover by themselves
Global cerebral hypoperfusion

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18
Q

What are your differentials for LOC?

A

NEURO: RICP, epilepsy, Parkinson’s, Lewy Body dementia

CARDIAC: arrhythmias, HOCM, aortic stenosis

METABOLIC: diabetic autonomic failure, uraemia, hypoglycaemia

DRUGS: diuretics, antihypertensive

OTHER: hyperventilation induced, carotid hypersensitivity

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19
Q

What is vertigo? and what causes it?

A

Spinning

Rotatory

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20
Q

What are the central causes for vertigo?

A 
vertebrobasilar ischaemia 
posterior circulation stroke 
Acoustic neuroma 
MS
Alcohol
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21
Q

What are the peripheral causes for vertigo?

A 
Viral labyrinthitis 
Vestibular neuronitis 
BPPV
Meniere's 
Ototoxic drugs
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22
Q

Nystagmus that is what? likely indicates a central cause of vertigo?

A
  • Bidirectional

- Purely horizontal or vertical or torsional

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23
Q

What are some bedside examinations you’d want to do in a patient presenting with vertigo? Describe the results in terms of where the lesion is

A

Rombergs

  • proprioception or vestibular system issue
  • they fall towards the side of the lesion
  • normal if cerebellar cause

Uttunberg

  • march on spot with eyes shut
  • rotate towards the side of a labyrinthine lesion

Head impulse

  • patient fixes eyes and examiner moves head
  • catch up saccade will occur when head rotated to side of lesion if peripheral lesion

Skew deviation
- cover eyes and if central lesion then vertical correction will occur when eye uncovered

Dix-hallpike - BPPV

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24
Q

What is ataxia?

Describe an ataxic gait

A

Disorder of co-ordination, balance and speech

Wide based, appear drunk, can’t stand with feet together

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25
Q

Where can a lesion be to cause ataxia?

What type of ataxia would you get at these locations?

A

Cerebellar vermis = gait ataxia
Cerebellar hemisphere = peripheral ataxia (finger-nose test)

Can also be due to poor proprioception:

  • peripheral sensory neuropathy
  • DCML
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26
Q

What can cause a bilateral ataxia? What would you seen on examination of ataxia was bilateral?

A
  • Alcohol (cerebellar degeneration)
  • B1 and B12 deficiency
  • MS
  • CJD and other intracranial infections
  • Drugs

Patient veers from side to side

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27
Q

What can cause a unilateral ataxia? What would you seen on examination of ataxia was bilateral?

A
  • Cerebellar or brainstem stroke
  • SOL

Patients veers to the side of the lesion

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28
Q

What is friedreich’s ataxia? What pattern of inheritance does it show?

A

AR trinucleotide repeat disorder that does not exhibit anticipation

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29
Q

What are the signs, symptoms and associated diseases of Friedreich’s ataxia?

A

At age 10-15:

  • cerebellar ataxia
  • kyphoscoliosis
  • absent ankle jerks but extensor plantars
  • optic atrophy

Associated with HOCM and diabetes

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30
Q

What is ataxic telangiectasia and what are the signs, symptoms and associated diseases?

A

AR inherited combined immunodeficiency disorder:

  • cerebellar ataxia
  • telangiectasia (including ocular)
  • recurrent chest infections

Associated with lymphoma and leukaemia

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31
Q

What is athetosis? What can cause it?

A

Slow involuntary writhing movements affecting the extremities

Asphyxia, neonatal jaundice, Huntington’s and cerebrovascular disease

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32
Q

What is dystonia?

A

Sustained muscle contraction frequently causing twisting movements or abnormal postures because of con-contraction of antagonistic muscles

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33
Q

How is dystonia managed?

A

Focal - botulinum injections

Generalised - L Dopa if <40, Anticholinergics, tetrabenazine, deep brain stimulation

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34
Q

What is chorea?

A

Continuous, irregular, jerky movements occurring at random locations

35
Q

What can cause chorea?

A

Hereditary - Huntington’s, benign hereditary, Wilson’s
Infection - syndenham’s , HIV, meningitis/encephalitis
Vascular - infarct, polycythaemia
Metabolic - glucose, hyperthyroid, hypocalcaemia
Immune - SLE, anti-phospholipid, pregnancy
Drugs - Dopamine antagonist, oral contraceptive, amphetamines and cocaine

36
Q

What is spasmodic torticollis?

A

Shortened sternocleidomastoid means the head is tilted and chin tilted the opposite way

37
Q

What is myoclonus?

A

Sudden shock like muscle jerks that are frequently repetitive

38
Q

What are tics?

A

Rapid repetitive stereotyped movements

Can be voluntarily suppressed - lead to internal tension

Triggered by stress or boredom

39
Q

What are the types of tics?

A

Motor - eye blinking, head jerk, nose twitch, shoulder shrug, facial grimace

Vocal - throat clear, grunting, coughing, sniffing

Other - vulgar words, repeating words, vulgar gestures

40
Q

What is a tremor? What are the types and what could cause them?

A

Rhythmical oscillatory movement of body part

Resting: Parkinson’s
Postural: anxiety, alcohol, thyroid, essential, Wilsons
Action: cerebellar disease

41
Q

What is an essential tremor? Describe the tremor seen in this disorder

A

Autosomal dominant postural tremor

  • Symmetrical
  • affects UL (+/- head)
  • Low amplitude
  • High frequency
  • Not present in sleep
  • Improve with alcohol
42
Q

How are essential tremors managed?

A

Propranolol and Primidone

43
Q

What would you investigate when determining the cause for a tremor?

A 
Neurological exam
Type of tremor
Medication history
Thyroid function
LFT
Copper levels 
Imaging
44
Q

What is characteristic of polyneuropathies?

A

Motor and/or sensory disorder of multiple peripheral or cranial nerves

Symmetrical
Widespread
Worse distally

45
Q

What would be a typical history of someone with a sensory peripheral neuropathy?

A
  • glove and stocking distribution of paraesthesia
  • problem with small objects like buttons
  • burning their fingers
46
Q

What would be a typical history of someone with a motor peripheral neuropathy?

A
  • becoming clumsy handed
  • falling more
  • wasting hand muscles
  • high stepping gait
47
Q

What are the autonomic signs of polyneuropathy?

A

Postural hypo
Reduced sweating
Ejaculatory failure
Horner’s

Constipation
Nocturnal diarrhoea
Urine retention
Erectile dysfunction
Holmes-adie pupil
48
Q

What can cause primarily sensory polyneuropathy?

A 
Diabetes
Uraemia (renal failure) 
Alcohol
Reduced B1
Reduced B12/folate
Leprosy
49
Q

What can cause primarily motor polyneuropathy?

A
  • Guillain-Barre
  • Chronic inflammatory demyelinating polyradiculoneuropathy
  • Charcot-marie tooth
  • Lead poisoning
  • Diptheria
50
Q

What causes mixed polyneuropathy i.e. sensory and motor?

A

Hypothyroid/glycaemia
Malignancy - paraneoplastic (SCLC), polycythaemia vera
Autoimmune: polyarteritis nodosa, RA, sjogrens, sarcoid
Infection - lyme, HIV
Drugs: isoniazid, phenyotin, metronidazole

51
Q

What are your differentials for motor weakness?

A 
V: stroke
I: GBC, sepsis, encephalopathy 
T: cord injury, RICP
A: MS, myasthenia, poly/dermatomyositis, cushings, thyroid dysfunction, SLE, Duchenne 
M: hypoglycaemia, hypokalaemia, hypercalcaemia 
I: 
N: MSCC, hypercalcaemia 
D: statins, alcohol, steroids
52
Q

What is the neurological disturbance in fibular neuropathy?

A

Lateral leg and dorsal foot sensation loss

Foot drop

53
Q

What causes meralgia paraesthetica? In whom and how does it present?

A

Compression of the lateral femoral cutaneous nerve anywhere along its course (L2/L3 and around ASIS)

RF: obesity, pregnancy, tense ascites

  • Tingling/burning in upper antero-lateral thigh
  • Worse on standing
54
Q

Which body parts are most affected by diabetic sensory neuropathy?

A

Feet > hands

55
Q

How would a polyneuropathy as a result of B1 deficiency present?

A

Feet > Hands
Burning and shooting pains
Reduced reflexes
Muscle weakness

56
Q

What is the sensory disturbance in B6 excess/deficiency?

A

PATCHY sensory loss of extremities

57
Q

What is the sensory disturbance in B12 deficiency?

A

Transient and MIGRATORY

Loss of proprioception and vibration

58
Q

What drugs can cause sensory disturbance?

A 
Chemotherapy agents
Antiretrovirals
Phenytoin
Metronidazole and nitrofurantoin
Isoniazid
59
Q

What is the sensory disturbance in migraine with aura?

A

Acute spreading loss
Typically from hand up ipsilateral arm to face and tongue
Last <1hr

60
Q

What primary care investigations would you want to do for someone presenting with a polyneuropathy?

A 
HBA1C
TFTs
LFTs (alcohol abuse)
Vitamin levels 
CRP, WCC (infection?)
61
Q

Which side of the brain are the speech centres found?

A

Dominant hemisphere

Left (most of the time even if left handed people)

62
Q

Where is Broca’s area?
Which artery supplies it?
What is the function?

A

Next to motor cortex in frontal lobe
Superior MCA
Production of speech

63
Q

Where is Wernicke’s area?
Which artery supplies it?
What is the function?

A

Next to auditory cortex in superior temporal lobe
Inferior MCA
Interpretation of language

64
Q

What connects Broca’s and Wernicke’s areas? Where is this found?

A

Arcuate fasciculus

Supramarginal gyrus of parietal lobe

65
Q

What is the difference between dysarthria and dysphasia?

A

Dysarthria is a MOTOR disorder of speech - articulation and pronunciation

Dysphasia is a disorder of language - problem in thoughts becoming spoken

66
Q

What can cause dysarthria?

A

UMN lesions of the brainstem or hemisphere

LMN of the brainstem affecting bulbar muscles

67
Q

What can cause dysarthria?

Briefly, how would they classically present?

A

Pseudobulbar palsy
- slurred speech with weak voice

MS
- can be slurred, staccato etc depending on lesion location

Parkinson’s
- quiet and monotonous

MND
- indistinct and nasal

68
Q

Compare the presentation of Brocas, Wernkicks and conductive aphasia

A

BROCA
- non-fluent slow and halting, comprehension intact, insight

WERNICKE
- fluent, no comprehension, no insight, neologisms, may of may not be able to repeat

CONDUCTIVE
- fluent, insight, unable to repeat strings of words

69
Q

What is cognition?

A

Process of acquiring knowledge and understanding through thought, experience and senses

70
Q

What can affect cognition?

A

Demenia, Parkinson’s, Huntington’s
Metabolic - hypoglycaemia, toxins, hypothyroid
CVS - Stroke, hypo perfusion, decreased folate, B6 or 12
Other - infections, drugs, trauma, menopause, tumour

71
Q

What is neuropathic pain?

How does it present?

A

Pain due to a dysfunctional nervous system

Shooting, electrical burning pain
Can be continuous or intermittent
Spontaneous

72
Q

What are some causes of neuropathic pain?

A

Peripheral:
- diabetes, alcohol, herpes, radiculopathy, tumour infiltration, trigeminal neuralgia

Central:
- MS, post-stroke, chemotherapy

73
Q

How is neuropathic pain managed?

A
  1. amitriptyline, duloxetine, gabapentin, pregabalin
  2. switch drugs don’t add
Flare: tramadol 
Localised area (e.g. herpes): capsaicin cream
74
Q

What are the CI’s and ADR’s associated with neuropathic pain meds?

A

Amitriptyline

  • CI in arrhythmia, heart block, post MI
  • ADR - Anticholinergic syndrome, drowsiness, long QT

Duloxetine ADR - GI upset, drowsy, dry mouth

Gabapentin

  • Caution in diabetes
  • ADR - dizzy, drowsy, unsteady

Pregablin ADR - headache, dizzy, drowsy

75
Q

What is first line management for trigeminal neuralgia?

A

Carbamazepine

76
Q

Where can lesions be to affect bladder control?

What conditions would typically affect bladder control at each of these levels?

A

CENTRAL:
- Stroke, MS, head injury, dementia, parkinsons

SUPRASACRAL (often about T12)
- spinal cord injury, MS, spina bifida, cervical spondylosis

SACRAL (S2,3,4) and PERIPHERAL
- spinal cord injury, spina bifida, cauda equina, peripheral neuropathy eg diabetes

77
Q

Describe the bladder and sphincter dysfunction in someone with a lesion above T12

A
  • overactive/spastic bladder so that bladder volume is low and there are involuntary contractions
  • the sphincter control is uncoordinated with bladder contraction
  • patient gets urge incontinence
78
Q

Describe the bladder and sphincter dysfunction in someone with a lesion at S2,3,4 or peripheral

A
  • flaccid and underactive bladder so that bladder volume is high
  • underactive sphincter control
  • patients get urinary retention
79
Q

Describe a hemiplegic gait and state what would cause it

A

Knee is extended and the foot dropped
Circumduct the leg to compensate

Cause: contralateral brain lesion

80
Q

Describe a diplegic/ paraplegic gait and state would would cause it

A

Legs adducted giving a scissoring movement
Circumduct legs to compensate

Cause: bilateral brain lesion (CP), spinal cord lesion, MND

81
Q

Describe a neuropathic gait (due to peripheral neuropathy)

A

High steppage and then slam the foot down in order to sense when it’s on the floor

82
Q

Describe a myopathic gait and state what would cause it

A

Waddling - laterally flex torso away and circumduct the leg

Cause: polymyalgia rheumatica, muscular dystrophy

83
Q

Describe an antalgic gait

A

Shortened stance phase on affected leg

84
Q

Describe a frontal gait and state what would cause it

A

Wide based and a normal arm swing are what differentiate it from Parkinonism gait as everything else is the same i.e. shuffling, hesitation to start, en bloc turning

Cause: frontal lobe pathology

Neurology and Special Senses (28 decks)

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