Neurology shorts. Flashcards

Question

NEUROLOGY EXAM: Gait. 1. Hemiplegic: cerebrovascular disease 2. Diplegic gait: cerebral palsy 3. Parkinsonian: extrapyramidal disorders 4. Ataxic gait: cerebellar 5. Stamping (sensory ataxic) gait: proprioceptive disorders 6. Neuropathic (high stepping) gait: foot drop pathologies. 7. Myopathic (waddling) gait: myopathic disorders 8. Antalgic: pain 9. Normal

Answer 1

1. Hemiplegic: cerebrovascular disease . UMN lesion = contralateral decorticate posturing (pyramidal weakness: UL extension weakness, LL flexion weakness). Arm flexed, leg extended. . Distal > proximal weakness (wrist/hand weakness + foot drop > shoulder/hip). . Contralesional lower limb circumduction during swing-phase . Contralesional upper limb flexed with reduced arm swing 2. Diplegic gait: cerebral palsy . as per hemiplegic . bilateral . hip ADDuction spasm = lower limbs crossing midline at end of swing-phase (scissoring) 3. Parkinsonian: extrapyramidal disorders . flexed posture . small steps/festinating gait with reduced arm swing . difficulty initiating/stopping gait . several steps to turn on the spot 4. Ataxic gait: cerebellar . broad-based, staggering gait . ipsilesional veering 5. Stamping (sensory ataxic) gait: proprioceptive disorders . swing-phase limb, high knee raise and foot slap on ground (inability to judge distance of foot to ground). . gait pattern exaggerated when visual stimulus removed (eyes closed or room darkened). . Romberg's test positive 6. Neuropathic (high stepping) gait: foot drop pathologies. . swing-phase limb, high knee raise (enables clearance of toes/foot from ground) and differentiating from "stamping gait" normal planting of foot on ground (proprioception in tact). 7. Myopathic (waddling) gait: myopathic disorders . trunk leans contralesional side at swing-phase initiation (compensation of inability of hip ABDuctors to raise pelvis on ipsilesional side to enable foot lift off) . trendelenburg positive 8. Antalgic: pain . minimal time on weight bearing during stance-phase on ipsilesional limb 9. Normal

Answer 2

1. Orientation to time/place/person 2. Dominant hand 3. Free speech: describe cookie jar picture IF DYSPHASIA -> consider other parietal features : limb strength and visual fields - if RECEPTION severely impaired, consider written commands - if FLUENT with paraphasic errors (phonemic, similar sounding words or semantic, similar category of word errors) nominal and receptive dysphasia. DYSPHASIA. 4. Comprehension: - close your eyes - touch your left hand to your right ear - touch your nose, then your chin, then your forehead - point to the ceiling after you point to the floor 5. Repetition: - blue sky - the orchestra played and the audience applauded - baby hippopotamus - no ifs, ands or buts 6. Naming function: thumb, watch, nose EXTRA- 7. Reading paragraph 8. Writing favourite food - if SLOW and NON-FLUENT (hesitant), expressive dysphasia -> hemiparesis - if GLOBAL (unable to comprehend or speak + hemiparesis), large lesion DYSARTHRIA. 9. Cerebellar function: baby hippopotamus 10. Muscular function- - Me me me = lip (CN 7) - la la la = tongue (CN 12) - ka ka ka = palate (CN9/10) - eeee = vocal cord (recurrent laryngeal nerve) 11. Cough (bovine = recurrent laryngeal nerve palsy) 12. fatigueability (count backwards from 20 = MG) IF DYSARTHRIA -> lower cranial nerves - jaw jerk - mouth insp: ulceration or local lesions - extrapyramidal disease and myopathies IF DYSPHONIA (husky voice) -> cough - laryngeal disorder - recurrent laryngeal nerve palsy - focal dystonia

Answer 3

GEN INSP: -diagnostic facies -cranial nerve or limb lesions 1. Dominant hand 2. Orientation TPP 3. SPEECH -naming -repetition -comprehension -reading -writing 4. Parietal lobes DOMINANT AALF or Gerstmanns syndome -Acalculia -Agraphia -Left right disorientation -Finger agnosia NON-DOMINANT -dressing apraxia BOTH -sensory inattention: tactile inattention/extinction -visual inattention: visual field testing CORTICAL SENSORY LOSS (NON-LOCALISING) - graphasthesia (draw number on hand) - two-point discrimination (0.6cm finger, 3cm hand/feet) - joint position sense - stereognosis - constructional apraxia: clock face 5. Temporal lobe (MEMORY) - Short term recall: 3 unrelated items (green, yacht, rose) - Long term memory: year world war 2 ended 6. Frontal lobe - frontal release signs (grasp reflex, glabella tap) - proverb interpretation: rolling stone gathers no moss - fundoscopy (foster kennedy syndrome: frontal lobe tumour causing ipsilateral papilloedema and contralateral optic atrophy) - smell 7. Other Further testing: speech / cranial nerve / peripheral neurological examination

Answer 4

Cerebellar lesion- up (hypotonia) UMN weakness - down (muscle weakness) Posterior column loss- any direction (loss of joint position sense)

Answer 5

- proximal muscle weakness + atrophy limb girdles - cardiomyopathy and arrythmias

Answer 6

SUMMARY: . myopathic facies- facial muscle wasting (no ptosis or frontotemporal balding) . facial weakness . arms- wasting upper limb girdle, scapula winging, tone (normal/reduced), power (weakness upper limb girdle/upper arm), coordination/sensation equivocal. . legs- bilateral foot drop (weak dorsiflexion), lower limb girdle muscles in tact . abdo muscle weakness (lower > upper) BEEOVERS SIGN DDX: 1. myotonic dystrophy 2. limb girdle muscular dystrophy (prox muscle weakness and wasting) 3. polymyositis (prox muscle weakness with tenderness) 4. inclusion body myositis (wrist/finger, anterior thigh and anterior tibialis NEURO EXAM: shoulder girdle Shoulder -shrug (traps, CN11, C3-4) -pull shoulder blades together (rhomboids, C4-5) -push against wall (serratus anterior, C5-7) -abduct from side (supraspinatus, C5-6) -abduct from 15 degrees from side (deltoid, C5-6 and circumflex n.) -abduct with internal rotation + adduct (pec major C6-T1) -external rotate (infraspinatus, C5-6) -internal rotate (teres major, C5-7) -cough with palpation of sides (latt dorsi, C7-8)

Answer 7

General: myopathic facies, pinprick from BSL testing, cognition. Face: bilateral ptosis, wasting facial muscles with hollow temples and cheeks, frontal balding, smooth forehead and cataracts. Speech: nasal, dysarthric ?dysphagia Neck: SCM atrophy with weak neck flexion Chest: gynecomastia, ?cardiac device, cardiomyopathy (AF, MVP) Resp: aspiration ?NIV Abdo: constipation, gallstones Hands/feet: wasting and fasciculation, generalised symmetrical distal-predominant weakness (DM1, becomes proximal later but DM2, neck/finger flexor and hip girdle early). -gait: high steppage, foot drop, trendelenberg positive -tone/reflexes/coordination/sensation preserved till late Key points: -grip myotonia -percussion myotonia Other complications: -cataracts -diabetes (and thyroid dysfunction) -dilated cardiomyopathy -AF and cardiac arrythmias -MVP -dysphagia -aspiration / NIV -constipation -gallstones -testicular atrophy and infertility SUMMARY: Steven is a gentleman who presents with difficulty using his arms. The most salient findings were that of generalized symmetrical distal-predominant muscle wasting and weakness, with evidence of myotonia and characteristic facial features in keeping with myotonic dystrophy. DDx: 1. Hereditary inclusion body myositis 2. Limb girdle muscular dystrophy Ix: CK EMG: dive-bomber effect, high frequency activity that varies (whining sound). Genetic test

Answer 8

1. Myotonic dystrophy 2. Myotonia congenita (myotonic tongue and thenar eminence, recessive more severe) 3. Paramyotonia congenita (episodic myotonia after cold exposure)

Answer 9

1. Myopathic -inflammatory myopathies . polymyositis (anti-synthetase, anti-Jo1, anti-MDA5) . dermatomyositis . inclusion body myositis (distal, asymmetric involvement hip flexors, quadriceps, tibialis anterior and weak ankle dorsiflexion and forearm flexors with grip weakness) = anti-cN1A . immune mediated necrotising myopathy (Anti-HMGCR) -acquired myopathies . inflammatory . paraneoplastic . endocrine - thyroid, cushings . drugs- steroids and alcohol -hereditary muscular dystrophies- Becker's / duchennes, myotonic dystrophy, limb girdle, fascioscapulohumeral 2. Neuromuscular junction disorder: myasthenia gravis 3. Neurogenic: -spinal muscular atrophy ie anterior horn cell damage (proximal muscle wasting and fasciculation, autosomal recessive Kugelberg-Welander disease) -motor neurone dx -polyradiculopathy -non-length dependent peripheral neuropathy

Answer 10

1. Hereditary muscular dystrophy 2. Congenital myopathies (rare) 3. Acquired (PACE PODS) P Polymyositis or dermatomyositis A Alcohol C Carcinoma E Endocrine (hypothyroidism, hyperthyroidism, cushing's syndrome, acromegaly, hypopituitarism) P Periodic paralysis (hyperkalaemia, hypokalaemic or normokalaemic) O Osteomalacia D Drugs (clofibrate, chloroquine, steroids) S Sarcoidosis

Answer 11

1. Alcohol 2. CTD 3. Paraneoplastic syndrome

Answer 12

Symmetrical proximal muscle weakness arms and legs - gait aids - wasting - tenderness Characteristic cutaneous features - hands: gottrons papules (fingers, knee extensor surfaces), mechanic hands, nailfold capillaries - eyes: heliotrope rash - back: shawl sign (poikiloderma = hyperpigment + telangiectasia in sun exposed and unexposed areas) OTHER- A. Hand exam - non-erosive polyarthrits and arthralgia (palpation and ROM, for active synovitis and deformity) - power (grip, pincer, opposition) - function (open lid, button) B. Bulbar dysfunction - cachectic, speech, CN 9, 10, 12 C. Respiratory exam - pulmonary fibrosis - pulmonary HTN] D. Steroid SE - cushingoid appearance - bruising - skin atrophy - cataract - proximal myopathy E. Aetiology- malignancy SUMMARY- pt presented with weakness/hand lesions asked to examine his upper limbs. Most salient findings were that of symmetrical bilateral proximal muscle weakness in upper and lower limbs associated with characteristic cutaneous features of gottrens papules, mechanic hands, heliotrope rash and shawl sign suggestive of dermatomyositis with no active synovitis in the small joints of the hands. This was complicated by evidence of pulmonary fibrosis and pulmonary HTN, bulbar dysfunction and features of corticosteroid excess. I was unable to identify underlying malignancy. DDX- proximal weakness ddx 1. myopathic 2. neuromuscular junction disorder 3. neurogenic Ix- CK Myositis Ab: anti-Jo1, anti-Mi2, anti-TIF1y, anti-MDA5 Muscle biopsy Assess complications -ILD: HRCT, RFT -Pulm HTN: TTE -Age appropriate malignancy screen -Steroid SE: BMD, HbA1c, Lipids

Answer 13

Polymyositis -anti-synthetase -anti-Jo1 Dermatomyositis -Anti-Jo1 -Anti Mi2 -anti-MDA5 (rapid lung disease) IBM -anti-cN1A Immune mediated necrotising myopathy -Anti-HMGCR

Answer 14

UPPER LIMB C1/2 neck flex/ext C3 neck lateral flexion C4 shoulder shrug C5 shoulder abduction C6 elbow flex, wrist ext C7 elbow ext, wrist flex C8 finger flexion T1 finger abduction LOWER LIMB L2 hip flexion L3 knee extension L4 ankle dorsiflexion L5 great toe-extension S1 ankle plantar flexion ankle eversion hip extension S2 knee flexion S3-4 anal wink

Answer 15

Achilles reflex = S1, S2 "buckle my shoe" Patellar reflex = L3, L4 "kick the door" Biceps and brachioradialis reflex = C5, C6 "pick up sticks" Triceps = C7, C8 "lay them straight" Cremasteric reflex = L1, L2 "Testicles move" Anal wink reflex = S3, S4 "winks galore"

Answer 16

See clinical exam document

Answer 17

DYSARTHRIA (patterns) - Cerebellar: staccato, irregular, scanning (jerky speech that is broken into separate syllables with syllable stress (explosive/loud)) - pseudo-bulbar (UMN CN 9-12): slow, hesitant, hollow sounding speech with harsh strained voice (squeezing words out from tight lips) - bulbar (LMN CN 9-12): nasal (air escaping into nasopharynx) with imprecise articulation - MND can have mixed pseudo-bulbar and bulbar palsy. - facial nerve/muscle weakness (UMN or LMN): slurred - extrapyramidal: monotonous. DYSPHASIA Fluent dysphasia (speech flows freely, prosody maintained, normal length and structure). Non-fluent dysphasia (effortful, no prosody, short sentences lacking filler words and prepositions. Paraphasic errors of speech: - Phonetic paraphasia: consonant subbed (fell v tell), similar sound - Semantic paraphasia: associated word subbed (cat v dog) - Neologism: non-existent word subbed (cookie v ratatat) Aphasia subtype: Expressive (broca's): non-fluent with impaired repetition and naming, comprehension preserved. Receptive (wernicke's): fluent, PARAPHASIC, impaired repetition, naming and comprehension Conductive (arcuate fasciculus): impaired repetition and naming. Anomic (angular gyrus, encephalopathy, left hemisphere brain): impaired naming. Global (left MCA): impaired.

Answer 18

Complete - LMN signs - sensory loss - Horner's syndrome Upper trunk (C5/C6) Erb-Duchenne - waiter tip - decreased movement: . shoulder . elbow flexion - sensory loss C5/C6 (lateral arm, forearm, thumb) Lower trunk (C8/T1) Klumpkes - claw hand (all lumbricals) - sensory loss C8/T1 ulnar - Horners

Answer 19

Wasting: small muscles of hand - hypothenar (thenar spared) - ulnar claw (medial 2 lumbricals, hand less clawed in higher lesions) - wasting medial forearm - weak finger ABD / ADD and thumb ADD - sensory loss: little + medial half ring finger - scars (fracture, dislocation) and OA at elbow DDX wasting small muscles of hand: -anterior horn cell disease (poliomyelitis) -radiculopathy (trauma, prolapse disc) -plexopathy (brachial plexus, pancoast tumour, cervical rib) -peripheral nerve lesion -myopathy -muscle disuse atrophy

Answer 20

PROXIMAL (humerus, pronator teres syndrome) - hand of benediction, unable to flex lateral 2 fingers on making fist - weak flexion / pronation forearm - sensory: palmar cutaneous br thenar. ANTERIOR INTEROSSEOUS SYNDROME: - pure motor - weak opposition - weak pronation with flexed elbow (pronator quadratus) DISTAL (carpal tunnel) - ape hand, thenar wasting - weak LOAF (lumbricals, OPP, ABD, FLEX) - hand of benediction on making fist - paraesthesia lateral 3 1/2 digits - phalens (wrist flex), or tinel (tapping tingling) - scar from carpal tunnel release, diabetes, hypothyroid, acromegaly, RA/ OA.

Answer 21

Wrist drop Weak wrist EXT Sparing intrinsic muscles of hand (if wrist passively EXT) Impaired grip strength Sensory loss first dorsal interossi Scars elbow (fracture, dislocation), note if using crutches. AXILLA - weak elb EXT, forearm SUP, wrist/finger EXT - sensory loss post-forearm, 1st dorsal interossi - decreased reflexes (triceps, brachioradialis) SPIRAL GROOVE - weak forearm SUP, wrist/finger EXT - sensory loss 1st dorsal interossi PROXIMAL FOREARM - weak wrist / finger EXT - no sensory loss WRIST -no weakness -sensory loss 1st dorsal interossi

Answer 22

Posterior interosseous nerve lesion - weak finger ext Peripheral neuropathy C7/8 nerve root or plexus (weak wrist extension, finger ext) - cervical spondylosis - brachial plexus injury Motor neuron disease (no sensory) Corticospinal tract (hemiparesis)

Answer 23

Gait: - high steppage gait - foot drop - unable to heel walk Power: - weak eversion / dorsiflexion Reflexes intact Sensory: - lateral calf / foot dorsum Other: -fibula scar / compression around fibular neck -wasting anterolateral compartment calf

Answer 24

Common peroneal nerve palsy Peripheral neuropathy (CMT) Sciatic nerve palsy: inversion and plantar flexion weak L5 nerve root lesion: inversion weak (disc prolapse) Lumbosacral plexopathy Motor neurone disease (no sensory deficit) Distal myopathy

Answer 25

Gait: - high steppage - foot drop - unable to heel walk Weak: - hip ABD - knee flexion - plantar flexion / dorsiflexion - ankle INV / EVER Sensory: dorsum of foot, lateral calf up to lateral thigh.

Answer 26

Gait: - high steppage gait - foot drop Weak: - knee flexion - plantar flexion / dorsiflexion - ankle INV / EVER Reflexes: - preserved knee jerk - loss of ankle jerk and plantar Sensory: - below knee, tibial (posterolateral leg, lateral foot, sole of foot) and common peroneal nerve (lateral leg, dorsum foot)

Answer 27

INSP: - gait aids, shoe/ankle supports - pes cavus - clawing toes - distal muscle atrophy: -anterolateral compartment with preserved thigh musculature "inverted champagne bottle" -peroneal muscle atrophy Gait: - ataxic - proprioception: broad based, stamping, rhombergs positive - peripheral neuropathy: foot drop, high stepping, heel walk impaired Weakness: symmetrical Reflexes: absent Sensation: symmetric stocking distribution (variable) - vibration - proprioception - pain/temp usually normal Other: thickened nerves, optic atrophy (argyll robertson pupil) SUMMARY: symmetrical distal predominant weakness with lower motor neuron signs, likely long standing given presence of pes cavus and severe atrophy of distal muscles suggesting hereditary neuropathy such as CMT.

Answer 28

Peripheral neuropathy Myotonic dystrophy Anterior horn cell disease (polio, SMA, PMA) Inclusion body myositis (no sensory changes) — NMJ (no wasting, reflexes preserved) Myopathy (usually proximal, reflexes and sensation preserved)

Answer 29

Metabolic - diabetes - uraemia (CKD) - thyroid - B12 deficiency - drugs - eTOH Immune mediated (more motor predominant, not length dependent ie prox = distal weakness) - gullain barre - CIDP Paraneoplastic - tumor - paraproteinemia CTD / vasculitis Idiopathic

Answer 30

GBS / CIDP CMT MULTIFOCAL MOTOR NEUROPATHY Malignancy Porphyria Lead poisoning Can consider diabetes and dapsone.

Answer 31

INSP: -scar -wasting -fasciculations Gait: - high stepping gait (foot drop, distal weakness) - waddling gait (proximal weakness) - ataxia, broad based and stamping (sensory) - rhombergs Tone: - decreased or equal Power: - symmetric motor deficit (non-length dependent distribution affecting prox = distal muscles) Reflexes: - decreased Sensory: - large fibre sensory loss - proprioception - vibration - worse distal - pain/temp loss less common SUMMARY: non-length dependent (distal predominant) sensorimotor neuropathy

Answer 32

CIDP Subacute combined degeneration of the cord (B12 level, holotranscobalamin, methylmalonic acid) Anterior horn cell disease NMJ Myopathy

Answer 33

Metabolic - diabetes - uraemia (CKD) - hypothyroid - eTOH - drugs Paraneoplastic Vasculitic Sjogrens syndrome Amyloidosis vit b12 def, vit b6 excess

Answer 34

Primary nerve disease - Spontaneous activity: increased fasciculation and fibrillation due to denervation - Voluntary activity: increased amplitude (surviving axons innervate more motor fibres each), decreased recruitment of motor units. Primary muscle disease - Spontaneous activity: myotonic discharges - Voluntary activity: decreased amplitude of motor unit action potentials, increased motor units activated (early recruitment)

Answer 35

GEN INSP - diagnostic facies CORNEA - arcus senilis - band keratopathy - kayser-fleischer rings SCLERA - jaundice - pallor - injection PTOSIS ?miosis / horners. EXOPTHALMOS EYELIDS - xanthelasma LID LAG ORBITS - palpate: tenderness, brow for anhidrosis (horner's) - auscultate bruit NEUROLOGICAL EXAM - ACUITY: eye chart - FIELDS: . red hatpin: desat = optic neuritis . red hatpin confrontation . central vision for blindspot - FUNDI: cornea, lens, humour, disc colour and state of cup, retina- vessels, exudates, haemorrhages, pigmentation - PUPILS: . shape, size, symmetry . light reflex (direct and consensual) . RAPD . accommodation - EYE MOVEMENTS: . III, IV, VI nerves- movement, diplopia + gaze palsies (e.g. supraneuclear lesion) + fatigueability (myasthenia) . Nystagmus + cerebellar (unilateral or bilateral, slow phase to centre, fast phase in direction of gaze) + peripheral vestibular (HINTS, corrective saccade if abnormal vestibular ocular reflex due to loss of vestibular apparatus or nerve) + monocular (weakness opposite eye, neuropathy - III, IV, VI, INO) + vertical (central) + congenital + multidirectional (cerebellar, drug toxocity e.g. anticonvulsants phenytoin) . Saccades (overshoot or undershoot = cerebellar) Corneal reflex (V) OTHER - other cranial nerves - long-tract signs - urine analysis (diabetes)

Answer 36

light touch lost- pontine pain temp lost - medullary, upper cervical jaw jerk (pseudobulbar palsy, increased)

Answer 37

Dorsal column degeneration Orthopaedic pain (Charcot joints) Reflexes decreased (deep tendon) Shooting pain Argyle-Robertson pupil (impaired light reflex, intact accommodation) Locomotor ataxia Impaired proprioception, high stepping gait Syphilis

Answer 38

1. Rinne (mastoid process): - Conductive deafness = Bone > Air - Sensorineural deafness = Air > Bone (normal) confirmed on Weber 2. Weber (forehead): - Conductive deafness = louder in abnormal ear - Sensorineural deafness = louder in normal ear Causes of conductive deafness: -wax -otitis media -otosclerosis -paget's disease of bone Causes of sensorineural deafness: -presbycusis -trauma -toxin (aspirin, alcohol, streptomycin) -infection (congenital rubella , syphilis) - tumour - brain stem lesion - vascular disease internal auditory artery

Answer 39

Cerebellar nystagmus: unilateral or bilateral. -drift, pursuit / saccades -associated with dysarthria and limb ataxia Peripheral vestibular nystagmus: unidirectional, horizontal, worse in direction of fast phase. -vestibulo-ocular reflex (eyes fix on bridge of nose when head moved) Monocular: weakness opposite eye, CN palsy or INO Vertical nystagmus: central disorder Congenital nystagmus: dramatic Multidirectional nystagmus: generalised cerebellar dysfunction or drug toxicity (anticonvulsants).

Answer 40

Location: abducens nucleus + MLF e.g. left sided lesion

Answer 41

Ipsilateral (face) -horners -diplopia -nystagmus -pain/temp -ataxia (limbs) Contralateral (limbs) -pain/temp

Answer 42

Infection: URTI / COVID-19, meningitis Tumour: Meningioma of olfactory groove, ethmoid tumours Trauma: Head trauma (cribiform plate fracture) Hydrocephalus Congenital - hypogonadotrophic hypogonadism

Answer 43

DDx absent light, intact accommodation - midbrain (argyll-robertson pupil) = syphilis - ciliary ganglion (adie's pupil, on eye bigger than the other)= viral or bacterial infection - parinauds syndrome - bilateral anterior visual pathway lesion (bilateral afferent pupil deficits) DDx absent convergence, intact light - cortical lesion - midbrain lesion (rare)

Answer 44

Constriction- - horner's syndrome - argyll robertson pupil - pontine lesion (bilateral, reactive to light) - narcotics (opiates) - pilocarpine drops - old age Dilation- - adies pupil - third nerve lesion - mydriatrics, atropine poisoning or cocaine - iridectomy, lens implant, iritis - post-trauma, deep coma, cerebral death - congenital

Answer 45

Lesion efferent parasympathetic pathway (CN 3 -> ciliary ganglion) Dilated pupil Decreased light response (direct and consensual) Slow or incomplete accommodation, slow dilation after Decreased tendon reflexes Impaired sweating Young women

Answer 46

Lesion of iridodilator fibres in midbrain 1. syphilis 2. diabetes 3. alcoholic midbrain degeneration 4. other midbrain lesions Signs -small, irregular, unequal pupil -no light response -accommodation response intact -decreased reflexes, if tabes associated

Answer 47

Space occupying lesion Hydrocephalus -obstructive -communicating (increased formation or decreased absorption) Idiopathic intracranial hypertension -idiopathic -OCP -addisons -drugs (nitrofurantoin, tetracycline, vitamin A, steroids) -lateral sinus thrombosis -head trauma HTN Central retinal vein thrombosis Cerebral venous sinus thrombosis High CSF protein (GBS)

Answer 48

Chronic papilloedema or optic neuritis Glaucoma Ischemia Familial - retinitis pigmentosa, Leber's disease (mitochondrial), Freidrich's ataxia

Answer 49

MS Toxic - ethambutol, chloroquine, nicotine, alcohol Metabolic - vit B12 Ischemia - DM, temporal arteritis, atheroma Familial- LHON (Lebers) Infective - infectious mono (glandular fever, EBV)

Answer 50

Age Endocrine - diabetes, steroids Hereditary or congenital- dystrophia myotonica Ocular disease - glaucoma Irradiation Trauma

Answer 51

Normal pupils- -age, fatigue, congenital -myotonic dystrophy -myasthenia gravis -FSH, ocular myopathy (mitochondrial) -thyrotoxic myopathy -botulism, snake bite Constricted pupils- -horner's syndrome -tabes dorsalis Dilated pupils- -third nerve lesion

Answer 52

Loss vertical and / or downward gaze Distinguished from CN palsy 3 , 4 , 6 - both eyes affected - pupils unequal - no diplopia - reflex eye movements in tact (flexing / extending neck)

Answer 53

Clinical features- 1. supranuclear gaze palsy 2. convergence-retraction nystagmus 3. lid retraction 4. light-near dissociation Causes- -central: pinealoma, MS, vascular lesions -peripheral: trauma, diabetes, vascular, idiopathic, raised ICP

Answer 54

Central: vascular, tumour, MS, syringobulbia . Pons = light touch . Medulla = pain Peripheral (posterior fossa): aneurysm, tumour, chronic meningitis Trigeminal ganglion (petrous temporal bone): meningioma, fracture of middle fossa . sensory loss all 3 divisions . post-ganglionic lesion if sensory loss 1 division Cavernous sinus (associated CN 3, 4, 6 palsy): aneurysm, thrombosis, tumour Other: sjogrens, SLE, toxins, idiopathic

Answer 55

UMN- vascular, tumour LMN- pontine (associated 5, 6): vascular, tumour, syringobulbia, MS -posterior fossa (acoustic neuroma, meningioma) -petrous temporal bone (bell's palsy, ramsay hunt syndrome, otitis media, fracture) -parotid (tumour, sarcoid) Bilateral LMN facial weakness- GBS, bilateral parotid disease (sarcoidosis), mononeuritis multiplex, myopathy and NMJ

Answer 56

Central: vascular (lateral medullary infarct - vertebral artery or PICA), tumour, syringobulbia, MND (vagus) Peripheral (posterior fossa): aneurysm, tumour, chronic meningitis, GBS (vagus)

Answer 57

FINDINGS: General: walking aids, orthotics, prosthesis, insulin pen Neurological: -bilateral symmetrical length dependent peripheral sensory and/or motor neuropathy in glove and stocking distribution -wasting, weakness, areflexia Extra: -finger-prick, cataracts, ulcers, charcot's joints, callus (diabetes mellitus) -clawing of toes, pes cavus (CMT) -amiodarone facies -anaemia (b12 deficiency) -eTOH abuse -arthritis / rash (vasculitis). DDX: Drugs and toxins - -amiodarone, gold, isoniazid, metronidazole, vincristine, phenytoin, nitrofurantoin, cisplatinum - Vit B6 excess, Vit B12 deficiency - alcohol (+/- thiamine deficiency) - heavy metals Metabolic - diabetes - CKD - hypothyroidism - porphyria Infiltration - amyloid Immune-mediated - GBS Tumour- lung ca Idiopathic CTD or vasculitis- SLE, PAN Hereditary

Answer 58

diabetes, alcohol vit b12 or b1 def carcinoma porphyria arsenic or thallium poisoning hereditary

Answer 59

Acromegaly Hereditary motor and sensory neuropathy (CMT) CIDP Infiltration - amyloidosis, leprosy, others (sarcoidosis, neurofibromatosis)

Answer 60

Benign idiopathic MND Motor root compression Malignant neuropathy Spinal muscular atrophy / bulbospinal muscular atrophy Any motor neuropathy (less commonly)

Answer 61

Idiopathic Arthropathy (RA) Endocrine (acromegaly, hypothyroidism) Pregnancy Trauma and overuse

Answer 62

Huntingtons disease Sydenham's chorea (rheumatic fever) Wilsons disease Drugs (OCP, L-dopa, phenytoin) Vasculitis or CTD (SLE) Thyrotoxicosis Polcythemia or hyperviscosity Viral encephalitis

Answer 63

0 no muscle contraction 1 flicker or trace 2 movement with gravity eliminated 3 movement against gravity but not resistance 4 movement against gravity and some resistance 5 movement against gravity with full resistance

Answer 64

MS Alcohol Space occupying lesion (posterior-fossa) Vascular lesion (brainstem) Inherited (freidrichs, SCA) Paraneoplastic syndrome Drugs (phenytoin, lithium, carbamazepine) MSA Metabolic: hypothyroid, b12 def, Wilson’s , coeliac?? Infection: HIV, toxoplasmosis Inflammation: GBS (Miller fisher)

Answer 65

Face: -nystagmus -saccades (overshoot, correction) -dysarthria (staccato) Truncal ataxia. UL: -hypotonia -dysmetria -dysdiadochokinesis Gait: -rhombergs negative -ataxic gait (heel-toe impaired) -veering to side of lesion LL: -hypotonia -dysmetria with heel-shin

Answer 66

Hemiparesis: pyramidal pattern of weakness with UMN features. Investigations: CT/MRI, BP, BSL, lipid profile, ECG, telemetry, echo, carotid artery doppler IF YOUNG- thrombophilia screen, echo with bubble study ?PFO. Management: A. ACUTE. -thrombolysis -DAPT with aspirin lifelong -NIHSS stroke scale B. Long-term. -rehab -psychology -nutrition -atrial fibrillation: anticoagulation

Answer 67

Weakness of downward movement Vertical diplopia SIN = Superior oblique INtorts the eye

Answer 68

Bilateral ptosis Fatigueability -eye -speech -chicken wing (arm) Thymectomy scar

Answer 69

1. ataxia 2. areflexia 3. opthalmoplegia

Answer 70

Wilsons disease: -wing beating tremor -stiffness -coordination deficit -kayser fleisher rings -mood changes -abdo pain, dark urine / light stool + jaundice.

Answer 71

Inheritance: : X-linked, AD and AR. Uncomplicated: hypertonic urinary bladder disturbance, and mild loss lower extremity vibration. Complicated: hypertonic urinary bladder, mild loss lower extremity vibration, and other system / neurologic finding (ataxia, seizures, intellectual disability/dementia, muscle atrophy, extrapyramidal disturbance, peripheral neuropathy). Tx: symptom mx. . improve fitness (cardiac-daily exercise regimen, muscle strength and gait) to reduce spasticity . occupational therapy, assisted walking devices, ankle-foot orthotics . drugs to tx spasticity (baclofen, tizanidine, dantrolene, botox injections) and urinary urgency (oxybutynin (anticholinergic/antimuscarinic), solifenacin (antimuscarinic), mirabegron (b3 adrenoreceptor agonist), or botox injections).

Answer 72

1. Optic nerve lesion: partial or complete visual loss on side of lesion 2. Optic chiasm lesion: bitemporal hemianopia (both temporal fields) 3. Optic tract: homonymous hemianopia 4. Optic radiation lesion: homonymous field defect - lobe dependent. -Temporal lobe lesion: superior homonymous quadrantanopia -Parietal lobe lesion: inferior homonymous quadrantanopia 5. Visual cortex or optic radiation: homonymous hemianopia Causes homonoymous hemianopia -vascular (stroke) -trauma -tumour -infection (encephalitis) -demyelination (MS) Causes optic nerve lesion -vascular (acute optic artery ischemia) -trauma -demyelination (MS, optic neuritis) -compression: raised intraocular or intracranial pressure -metabolic: VitB12 deficiency, diabetes, etOH -inherited conditions (Leber's optic neuropathy) Causes of bitemporal hemianopia -optic chiasm lesion -pituitary fossa tumour -craniopharyngioma -suprasellar meningioma

Answer 73

Muscle NMJ Peripheral nerve Plexus Nerve root Anterior horn cell

Answer 74

MMNCB (LMN only) UMN + LMN -mixed pathology (cervical myelopathy + peripheral neuropathy) -cauda equina -freidrichs ataxia -subacute combined degeneration of the cord

Answer 75

Duchenne muscular dystrophy - no dystrophin Becket muscular dystrophy - misshapen dystrophin - mild age 10-20 Clinical features: symmetric proximal lower limb weakness more than distal. Gait. -waddle (wheelchair) - calf hypertrophy - gowers sign (leaning forward) Other: weak diaphragm (resp failure), scoliosis, dilated cardiomyopathy and arrhythmias. High CK. Mx: steroids slow progression.