Neurology + Psychiatry Flashcards
Stroke management:
- 1st line (1)
- 2nd line (1)
- what to do with blood pressure?
- what else to give? (1)
- within 4.5 hr = THROMBOLYSIS
- within 6 hr = THROMBECTOMY
- BP should NOT be lowered in acute phase unless complications eg hypertensive encephalopathy or thombolysis
- give aspirin ASAP once haemorrhagic excluded
Stroke:
- what do do RE anticoagulation for AF? (1)
usually start 14 days post ischaemic stroke (and obviously stop in hemorrhagic)
what to do RE blood pressure and thrombolysis
lower to < 185/110
Absolute contraindications to thrombolysis?
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
- Lumbar puncture in preceding 7 days
- Gastrointestinal haemorrhage in preceding 3 weeks
- Active bleeding
- Oesophageal varices
- Uncontrolled hypertension >200/120mmHg
Relative contraindications thrombolysis?
- Pregnancy
- Concurrent anticoagulation (INR >1.7)
- Haemorrhagic diathesis
- Active diabetic haemorrhagic retinopathy
- Suspected intracardiac thrombus
- Major surgery / trauma in the preceding 2 weeks
Stroke:
- who gets thrombolysis AND thrombectomy? (1)
within 6 hours of symptom onset
AND
occlusion of the proximal anterior circulation
Stroke:
- secondary prevention drug? (1)
- who gets carotid endarterectomy? (1)
clopidogrel (aspirin if contraindicated)
> 50% occasion
TIA mimics (2)
hypoglycaemia
intracranial haemorrhage (–> IMAGING)
TIA:
- medication for resolved TIA awaiting specialist review within 24hr (1) reviewed bt specialist within initial 21 days (1) and long term after the 21 days (1)
- what to give alongside? (1)
- aspirin first
- then DAPT first 21 days
- then clopidogrel after 21 days
clopidogrel (initial dose 300 mg followed by 75 mg od) + aspirin (initial dose 300 mg followed by 75 mg od for 21 days) followed by monotherapy with clopidogrel 75 mg od
if not appropriate for DAPT, just clopidogrel
give PPI
Stroke:
when to consider carotid artery endartectomy?
Carotid artery endarterectomy can be considered if there is a stroke or TIA in the carotid territory, and the patient is not severely disabled.
(if stenos >50%)
MS:
diagnosis?
MRI with contrast
MRI
high signal T2 lesions
periventricular plaques
Dawson fingers: often seen on FLAIR images - hyperintense lesions penpendicular to the corpus callosum
CSF
- oligoclonal bands (and not in serum)
increased intrathecal synthesis of IgG
Visual evoked potentials
- delayed, but well preserved waveform
Uhthoff’s phenomenon
Uhthoff’s phenomenon occurs when you get “Uhthoff” the bath.
(worsening of vision following rise in body temperature)
MS
- diagnosis?
2+ relapses (clinical objective or 2+ lesions)
Lhermitte’s syndrome
paraesthesiae in limbs on neck flexion
Epilepsy:
when yo start treatment after 1 seizure? (4)
the patient has a neurological deficit
brain imaging shows a structural abnormality
the EEG shows unequivocal epileptic activity
the patient or their family or carers consider the risk of having a further seizure unacceptable
Epilepsy treatment:
- generalised tonic clinic? men/women (2)
- focal seizure (2)
- absence (1)
- myoclonic (1)
- tonic/ atonic seizure (1)
- men: SV
- women: lamotrigine or levetiracetam (DUE TO PREGNANCY ISSUES of SV)
- lamotrigine or levetiracetam
- ethosuximide
- men: SV
- women: levetiracetam
- men: SV
- women: lamotrigine
antiplatelet regimens is recommended following an acute ischaemic stroke?
aspirin 300mg for 2 weeks then clopidogrel 75mg
Brocas dysphaisa:
- what is it? (1)
- what lobe? (1)
- how different to Wernickes? (1)
Broca’s dysphasia: speech non-fluent, comprehension normal, repetition impaired
FRONTAL lobe
Spoken word is heard at the ear. This passes to Wernicke’s area in the temporal lobe (near the ear) to comprehend what was said. Once understood, the signal passes along the arcuate fasciculus, before reaching Broca’s area. The Broca’s area in the frontal lobe (near the mouth) then generates a signal to coordinate the mouth to speak what is thought (fluent speech).
Conduction aphasia
Classically due to a stroke affecting the arcuate fasiculus - the connection between Wernicke’s and Broca’s area
Speech is fluent but repetition is poor. Aware of the errors they are making
Comprehension is normal
Herpes simplex encephalitis:
- which lobe? (1)
- features? (1)
- which organism? (1)
temporal lobe
fever, headache, psychiatric symptoms, seizures, vomiting
focal features e.g. aphasia
peripheral lesions (e.g. cold sores) have no relation to the presence of HSV encephalitis
HSV-1
Herpes simplex encephalitis:
- investigations? (4)
- management? (1)
CSF: lymphocytosis, elevated protein
PCR for HSV
CT: medial temporal and inferior frontal changes (e.g. petechial haemorrhages) - normal in one-third of patients
MRI is better
EEG pattern: lateralised periodic discharges at 2 Hz
IV aciclovir
third nerve palsy signs
ptosis, down and out deviation of eye, mydriasis
Raised ICP causes herniation of which cranial nerve
3rd nerve
Horners syndrome
Miosis, ptosis, anhidrosis, and enophthalmos
neuropathic pain meds adjustment - how to do it
Drugs for neuropathic pain are typically used as monotherapy, i.e. if not working then drugs should be switched, not added
first-line treatment*: amitriptyline, duloxetine, gabapentin or pregabalin
neuropathic pain- what is used as ‘rescue therapy’ for exacerbations?
tramadol
migrane prophlyaxis
propranolol OR topiramate
(avoid -ol in asthma, avoid topiramate in pregnancy)
migraine acute management
triptan, NSAID
Campylobacter jejuni - what syndrome
Guillain-Barre syndrome
CYP450 inhibitors
The mnemonic SICKFACES.COM can be used to easily remember common CYP450 inhibitors.
Sodium valproate
Isoniazid
Cimetidine
Ketoconazole
Fluconazole
Alcohol & Grapefruit juice
Chloramphenicol
Erythromycin
Sulfonamides
Ciprofloxacin
Omeprazole
Metronidazole
CYP450 inducers
The mnemonic CRAP GPs can be used to easily remember common CYP450 inducers.
Carbemazepines
Rifampicin
Alcohol
Phenytoin
Griseofulvin
Phenobarbitone
Sulphonylureas
umbilicus dermatome
T10
knee cap dermatom
down on all fours - L4
big toe dermatome
L5 - largest of the 5 toes
what vitamins In pabrinex
vitamins B and C
thiamine (B1) is essential to prevent Wernikes
Wernikes encephalopathy triad
nystagmus
ompthalmoplegia
ataxia
Korsakoffs symptoms (2)
addition of retrograde and anterograde amnesia AND confabulation
eye movement cranial nerves
LR6, SO4
Common peroneal nerve lesion
where does injury occur?
symptoms?
neck of the fibula
foot drop
weakness of foot dorsiflexion
weakness of foot eversion
weakness of extensor hallucis longus
sensory loss over the dorsum of the foot and the lower lateral part of the leg
wasting of the anterior tibial and peroneal muscles
bells palsy management
prednisolone
seizure territories
occipital –> flashers/floaters
parietal –> paraesthesia
frontal –> Jacksonian march
temporal–>
triceps reflex nerves
C7-C8
A 23-year-old man wakes up on a Sunday morning unable to extend his wrist
radial nerve palsy
huntingdons chromosome
chromosome 4
Adhesive capsulitis
frozen shoulder
A 60-year-old gentleman with a background of lumbar spondylosis and chronic back pain presents with gradually worsening bilateral upper limb paraesthesias and leg stiffness.
degenerative cervical myelopathy
peak incidence of seizures alcohol withdrawal
36hr
delirium tremens
48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
triptan + SSRI
serotonin syndrome
SSRI discontinuation syndrome: what symptom most common? (1)
gastrointestinal effects common
Cyanopsia: what does it mean? (1)
blue-tinted vision, is not known to occur with SSRI discontinuation. It is a recognised side effect of some drugs, including sildenafil.
Paroxetine use in pregnancy
SSRIs:
Use during the first trimester gives a small increased risk of congenital heart defects
Use during the third trimester can result in persistent pulmonary hypertension of the newborn
Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
best atypical antipyshciotic for side effects
Aripiprazole has the most tolerable side effect profile of the atypical antispsychotics, particularly for prolactin elevation
ssri for anxiety
Sertraline is the first-line drug for generalised anxiety disorder
lithium
nausea/vomiting, diarrhoea
fine tremor
nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion
weight gain
idiopathic intracranial hypertension
leucocytosis
hyperparathyroidism and resultant hypercalcaemia
coroner and mental health act
always must be referred
What is Hoover sign - what is it used for?
Hoover’s sign is a quick and useful clinical tool to differentiate organic from non-organic leg paresis. In non-organic paresis, pressure is felt under the paretic leg when lifting the non-paretic leg against pressure, this is due to involuntary contralateral hip extension
PHQ-9 score: what is a moderate/severe score (1)
‘less severe’ depression: encompasses what was previously termed subthreshold and mild depression
a PHQ-9 score of < 16
‘more severe’ depression: encompasses what was previously termed moderate and severe depression
a PHQ-9 score of ≥ 16
what type of medication is imipramine
TCA
Risperidone -typical or atypical antispcyhotic
ATYPICAL
1st line SSRI for GAD
sertraline
Which one of the following is a side effect of excess vitamin B6 (pyridoxine) ingestion?
peripheral neuropathy
Myasthenia gravis - what drugs exacerbate an attack?
penicillamine
quinidine, procainamide
beta-blockers
lithium
phenytoin
antibiotics: gentamicin, macrolides, quinolones, tetracyclines
BB = slow sympathetic nervous Sx
Myasthenia gravis: main Sx
worsening fatigue later in day
essential tremor inheritance? (1)
Treatment (1)
Autosomal dominant
Features
postural tremor: worse if arms outstretched
improved by alcohol and rest
most common cause of titubation (head tremor)
Management
propranolol is first-line
primidone is sometimes used
Lacunar stroked features (5)
purely motor
most common lacunar syndrome
purely sensory
sensorimotor stroke
ataxic hemiparesis
ipsilateral weakness and limb ataxia that is out of proportion to the motor deficit
dysarthria-clumsy hand syndrome
three nerve palsy - MIOSIS or MYDRIASIS
Mydriasis
what causes Internuclear ophthalmoplegia
multiple sclerosis
vascular disease
what is Titubation
a bobbing or rhythmic swaying of the head and trunk, can be seen in essential tremor and hence makes this option incorrect too. However, it’s more commonly associated with cerebellar disorders.
Hearing change in Bells palsy
Hyperacusis
Triptans and ischaemic heart disease
sumatriptan, are serotonin agonists used in the acute treatment of migraines. They cause vasoconstriction of cranial blood vessels and inhibit the release of vasoactive peptides. However, they can also cause coronary artery vasospasm and are therefore contraindicated in patients with a history of ischaemic heart disease due to the increased risk of myocardial infarction.
when to take triptans if you have a migrane
should be taken as soon as possible after the onset of headache, rather than at onset of aura
posterior stroke - what vessel
verterbrobasilar arteries
Abnormal nerve conduction studies
Guillian Barre syndrome (campylobacter jejuni)
TIA + DOAC / risk of bleed
–> A&E for maging
Other patients should be given 300mg of aspirin immediately then assessed by a specialist within 24 hours. First-line secondary prevention is clopidogrel 75mg once daily.
Obese, young female with headaches / blurred vision
idiopathic intracranial hypertension
RF: idiopathic intracranial hypertension
Risk factors
obesity
female sex
pregnancy
drugs
combined oral contraceptive pill
steroids
tetracyclines
retinoids (isotretinoin, tretinoin) / vitamin A
lithium
idiopathic intracranial hypertension:
treatment
weight loss
carbonic anhydrase inhibitors e.g. acetazolamide
topiramate
?repeated lumbar puncture may be used as a temporary measure but is not suitable for longer-term management
surgery: optic nerve sheath decompression and fenestration may be needed to prevent damage to the optic nerve. A lumboperitoneal or ventriculoperitoneal shunt may also be performed to reduce intracranial pressure
Ulnar nerve: areas
C8 - T1
palmar and dorsal aspects of 1 and 1/2 fingers medially
damage to ulnar nerve at wrist
xDamage at wrist
‘claw hand’ - hyperextension of the metacarpophalangeal joints and flexion at the distal and proximal interphalangeal joints of the 4th and 5th digits
wasting and paralysis of intrinsic hand muscles (except lateral two lumbricals)
wasting and paralysis of hypothenar muscles
sensory loss to the medial 1 1/2 fingers (palmar and dorsal aspects)
Good antiemetic for Parkinson’s / which to avoid
Prochlorperazine, like metoclopramide and haloperidol, blocks dopamine receptors. Thus, it may exacerbate Parkinsonian symptoms due to its ability to penetrate the central nervous system (CNS).
–> domperidone (doesn’t cross blood brain barrier)
Trigeminal neuralgia management (1)
What to do if doesn’t work? (1)
carbamazepine
failure to respond to treatment or atypical features (e.g. < 50 years old) should prompt referral to neurology
red flags trigeminal neuralgia
Sensory changes
Deafness or other ear problems
History of skin or oral lesions that could spread perineurally
Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally
Optic neuritis
A family history of multiple sclerosis
Age of onset before 40 years
Bells palsy - UMN/ LMN and which side?
Bell’s palsy is a lower motor neuron condition. Unlike UMN conditions of the face, in LMN conditions the entire side of the patients face is affected
SAME Side + LMN
Bell’s palsy is a lower motor neuron condition. Unlike UMN conditions of the face, in LMN conditions the entire side of the patients face is affected
Migrane:
propanalol
topiramate
ASTHMA
and PREGNANCY
Propranolol is the most appropriate option here in a woman of childbearing age, with no history of asthma, requiring migraine prophylaxis.
Sciatic nerve:
which nerves?
paralysis causes … (2)
Basics
sciatic nerve is supplied by L4-5, S1-3
divides into tibial and common peroneal nerves
Supplies
hamstring muscles
adductor muscles
Features of sciatic nerve lesion
motor: paralysis of knee flexion and all movements below knee
sensory: loss below knee
reflexes: ankle + plantar lost, knee jerk intact
what causes sciatic nerve paralysis (3)
1 feature of neck of femur
2 posterior hip dislocation
3 trauma
what does pabrinex contain
Pabrinex, a yellow coloured fluid which you might have seen on the wards, contains vitamins B and C. It does not vitamin D.
wernickes encephalopathy what investigations
Investigations
decreased red cell transketolase
MRI
which antiepleptic causes numbness
phenytoin
Phenytoin because it feels funny in your toes
Phenytoin and p450
Phenytoin is also an inducer of the P450 system.
Side effects phenytoin:
acute (2)
chronic (5)
idiosyncratic (5)
teratogenic (1)
Acute
initially: dizziness, diplopia, nystagmus, slurred speech, ataxia
later: confusion, seizures
Chronic
common: gingival hyperplasia (secondary to increased expression of platelet derived growth factor, PDGF), hirsutism, coarsening of facial features, drowsiness
megaloblastic anaemia (secondary to altered folate metabolism)
peripheral neuropathy
enhanced vitamin D metabolism causing osteomalacia
lymphadenopathy
dyskinesia
Idiosyncratic
fever
rashes, including severe reactions such as toxic epidermal necrolysis
hepatitis
Dupuytren’s contracture*
aplastic anaemia
drug-induced lupus
Teratogenic
associated with cleft palate and congenital heart disease
when should you check phenytoin levels
Phenytoin levels do not need to be monitored routinely but trough levels, immediately before dose should be checked if:
adjustment of phenytoin dose
suspected toxicity
detection of non-adherence to the prescribed medication
Phenytoin and anaemia
causes megaloblastic anaemia
first-line for spasticity in multiple sclerosis
Baclofen and gabapentin
MS treatment:
acute relapse (1)
High-dose steroids (e.g. oral or IV methylprednisolone) may be given for 5 days to shorten the length of an acute relapse. It should be noted that steroids shorten the duration of a relapse and do not alter the degree of recovery (i.e. whether a patient returns to baseline function)
Drug options for reducing the risk of relapse in MS
natalizumab
ocrelizumab
fingolimod
bet-interferon
glatiramer acetate
MS treatment specific problems:
1- fatigue
2- spacicity
3- bladdy dysfunction
4- oscillopsia (visual feilds oscillation)
1- sort underlying problem, + mindfullness/CBT
2- baclofen/ gabapentin + physio (cannabis+botox under investigation)
3- guidelines stress the importance of getting an ultrasound first to assess bladder emptying - anticholinergics may worsen symptoms in some patients
if significant residual volume → intermittent self-catheterisation
if no significant residual volume → anticholinergics may improve urinary frequency
4- gabapentin
Tuberous sclerosis
what is it? what does it cause
genetic disorder –> benign tumours
can cause epilepsy or sebaceous on nose
depigmented ‘ash-leaf’ spots which fluoresce under UV light
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum (angiofibromas): butterfly distribution over nose
fibromata beneath nails (subungual fibromata)
cafe-au-lait spots* may be seen
Tuberous sclerosis
- cutaneous features
- neurological features
- other features
Cutaneous features
depigmented ‘ash-leaf’ spots which fluoresce under UV light
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum (angiofibromas): butterfly distribution over nose
fibromata beneath nails (subungual fibromata)
cafe-au-lait spots* may be seen
Neurological features
developmental delay
epilepsy (infantile spasms or partial)
intellectual impairment
Also
retinal hamartomas: dense white areas on retina (phakomata)
rhabdomyomas of the heart
gliomatous changes can occur in the brain lesions
polycystic kidneys, renal angiomyolipomata
lymphangioleiomyomatosis: multiple lung cysts
Neurofibromatotosis VS tuberous sclerosis:
similarities (3)
Autosomal dominant
ocular hamartoma
neurocutaneous disorder
refers to a transient loss of consciousness due to decreased blood flow to the brain caused by a heart block. usually accompanied by symptoms such as dizziness, palpitations or chest pain. In this case, the patient’s symptoms are not suggestive of a cardiac origin.
Stokes-Adams attack
a sudden and transient episode of muscle weakness, typically triggered by strong emotions such as laughter, anger or surprise. It is often associated with narcolepsy, a sleep disorder that causes excessive daytime sleepiness and fragmented night-time sleep. The patient’s symptoms of leg weakness following bouts of laughter and brief collapse are characteristic.
cataplexy
Neurological problems - UMN vs LMN in:
MS
progressive muscle atrophy
ALS (amyotrophic lateral sclerosis)
progressive bulbar palsy
MS - only UMN
Progressive muscular atrophy - only LMN
ALS - both UMN and LMN
Progressive bulbar palsy- loss of brain stem motor nuclei therefore palsy of tongue, muscles of chewing and swallowing and facial nerve
most common motor neuron disease
typical of amyotrophic lateral sclerosis (ALS)
Feeding in motor neuron disease
Percutaneous gastrostomy tube (PEG) is the preferred way to support nutrition in patents with motor neuron disease
Motor neuron disease: management
Riluzole
prevents stimulation of glutamate receptors
used mainly in amyotrophic lateral sclerosis
prolongs life by about 3 months
Respiratory care
non-invasive ventilation (usually BIPAP) is used at night
studies have shown a survival benefit of around 7 months
Nutrition
percutaneous gastrostomy tube (PEG) is the preferred way to support nutrition and has been associated with prolonged survival
triceps reflex
C7-C8
ankle
S1-2k
knee reflex
L3-4
biceps reflex
C5-6
way to remember all reflexes
S1-S2 (1-2 buckle my shoe) - Ankle
L3-L4 (3 -4 kick the door) - Knee
C5-C6 (5-6 pick up the stick) - biceps
C7-C8 (7-8 close the gate) - tricep
Lacunar infarct
involves perforating arteries around the internal capsule, thalamus and basal ganglia
presents with 1 of the following:
1. unilateral weakness (and/or sensory deficit) of face and arm, arm and leg or all three.
2. pure sensory stroke.
3. ataxic hemiparesis
Anterior stroke
The following criteria should be assessed:
1. unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
2. homonymous hemianopia
3. higher cognitive dysfunction e.g. dysphasia
Total anterior circulation infarcts (TACI, c. 15%)
involves middle and anterior cerebral arteries
all 3 of the above criteria are present
Partial anterior circulation infarcts (PACI, c. 25%)
involves smaller arteries of anterior circulation e.g. upper or lower division of middle cerebral artery
2 of the above criteria are present
posterior circulation in fact (25%)
involves vertebrobasilar arteries
presents with 1 of the following:
1. cerebellar or brainstem syndromes
2. loss of consciousness
3. isolated homonymous hemianopia
Webers syndrome stroke pattern
ipsilateral III palsy
contralateral weakness
Lateral medullary syndrome
aka Wallenberg’s syndrome
ipsilateral: ataxia, nystagmus, dysphagia, facial numbness, cranial nerve palsy e.g. Horner’s
contralateral: limb sensory loss
HUNTINGDONS chromosome
chromosome 4
causes of flapping tremor
encephalopathies
phenytoin
CO2 retention
Wilson’s disease
degenerative cervical myelopathy treatemnt
spinal surgery
epilepsy rectal medication
diazepam 10mg
First-line antiepileptic for a boy who presents with absence seizures.
Ethosuximide
Epilepsy meds:
1st line for all generalised seizures (except absence) = sodium valproate if male, lamotrigine/levetiracetam if female.
1st line for focal seizures: lamotrigine / levetiracetam
1st line for absence: ethosuxamide
Carbamazepine only given 2nd line for focal seizures: carbs + fo’CALories
CT head showing temporal lobe changes
herpes simplex encephalitis
what parkinons drugs cause hallucinations?
Dopamine receptor agonists
e.g. bromocriptine, ropinirole, cabergoline, apomorphine
Sodium valorate side effects
Sodium (hyponatraemia)
V - vomiting
A - Alopecia
L - Liver toxicity
P - Pancreatitis / Pancytopaenia
R - Ravenous / round / retention of fat (increased appetite/weight gain)
O - Oedema
A - Ataxia
T - Teratogenic (neural tube defects)
E - Enzyme Inhibitor (Inhibites seizures)
xCubital tunnel syndrome
ulnar nerve
homonymous quadrantanopias
homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior)
left homonymous hemianopia means visual field defect to the left, i.e. lesion of right optic tract
homonymous quadrantanopias: PITS (Parietal-Inferior, Temporal-Superior)
incongruous defects = optic tract lesion; congruous defects= optic radiation lesion or occipital cortex
Jacksonian movement (clonic movements travelling proximally) i
frontal lobe seizure
ulnar (e.g. cubital tunnel syndrome) vs C8/T1 radiculopathy
C8/T1 radiculopathy can mimic ulnar nerve neuropathy. In this case, the preserved sensation of the forearm favours a diagnosis of cubital tunnel syndrome. The ulnar nerve does not provide sensation to the medial forearm, which is innervated by the medial antebrachial cutaneous nerve (C8 and T1).
Cubital tunnel syndrome is correct. This is a classical description of ulnar nerve neuropathy. The ulnar nerve supplies sensory innervation to the palmar and dorsal aspects of 1.5 fingers medially. It has a motor component which can result in wasting and paralysis of intrinsic hand muscles (except lateral two lumbricals) and the hypothenar muscles. Froment’s test can be used to test the function of the adductor pollicis muscle which is often weak in ulnar neuropathy.
axillary nerve neuropathy
The axillary nerve has both a motor and a sensory distribution of innervation. It has motor fibres that innervate the deltoid muscle, acting as an abductor, flexor and extensor at the shoulder joint, as well as the teres minor muscle, allowing lateral rotation of the glenohumeral joint. Its sensory function is from the superior lateral cutaneous nerve of arm, which sweeps around the posterior border of the deltoid and supplies the skin over the lower two-thirds of the posterior part of this muscle, as well as that covering the long head of the triceps brachii.
carpal tunnel syndrome
Median nerve dysfunction results in carpal tunnel syndrome characterised by sensory loss over the lateral 3.5 digits, and loss of motor function to the flexor muscles of the forearm and hand as well as those muscles responsible for flexion, abduction, opposition, and extension of the thumb.
This presents with ipsilateral facial pain and temperature loss. Along with contralateral limb/ torso pain, ataxia and nystagmus.
Wallenburg syndrome (lateral medullary syndrome)
wallen’burg’ / ice’burg’ - loss of temperature + facial pain
a form of midbrain stroke characterised by the an ipsilateral CN III palsy and contralateral hemiparesis
Webers syndrome
a sign of upper motor neuron dysfunction and points to a disease of the central nervous system - in this case from the history degenerative cervical myelopathy [DCM] affecting the cervical spinal cord is most likely. To elicit it, the examiner should flick the patients distal phalanx (usually of the middle finger) to cause momentary flexion. A positive sign is exaggerated flexion of the thumb.
Hoffmans sign
Carpal tunnel syndrome Sx
thenar muscle wasting
unilateral weakness of pincer
positive phalens test
positive tinnels
Useful for managing tremor in drug-induced parkinsonism
proccyclidine
GCS: motor response
Motor response 6. Obeys commands
5. Localises to pain
4. Withdraws from pain
3. Abnormal flexion to pain (decorticate posture)
2. Extending to pain
1. None
Verbal response 5. Orientated
4. Confused
3. Words
2. Sounds
1. None
Eye opening 4. Spontaneous
3. To speech
2. To pain
1. None
Driving post TIA
after 1 month if Sx free- don’t inform DVLA
Pituitary tumor visual changes
Bitemporal hemianopia, upper quadrant defect
Visual defect: Patient who has had an extensive stroke with right-sided hemiplegia
R homonymous hemianopia
A 72-year-old man develops visual problems. He is noted to have a left homonymous hemianopia with some macula sparing.
occipital cortex
A 54-year-old man complains of sweating, headaches and ‘tunnel vision’.
optic chism
This patient has a pituitary tumour causing compression of the optic chiasm and bitemporal hemianopia. The sweating and headaches are consistent with acromegaly.
Status epilepticus treatment
2x IV lorazepam 5-10 mins apart
(or PR diazepam or buccal midazolam)
THEN
levetiracetam, phenytoin or sodium valproate
THEN
GA
Patient who has had an extensive stroke with right-sided hemiplegia
- what visual defect will the have?
RIGHT homonymous meianopia (SAME SIDED)
huntingdons- what is it
Progressive, autosomal dominant disease
trinucleotide repeat disorder: CAG
(anticipation)
Features typical develop after 35 years of age
chorea
personality changes (e.g. irritability, apathy, depression) and intellectual impairment
dystonia
saccadic eye movements
