Neurology Week 4 Flashcards
4 core presentations of neurology
headaches
confusion/disorientation
weakness
loss of consciousness
10 cardinal neurological symptoms
memory and cognition tLOC headache vision hearing speech and swallowing limb weakness limb numbness bladder/bowel disturbance gait and balance
differences between UMN and LMN lesions (AFTR)
UMN VS LMN
atrophy: minimal VS yes
fasciculations: no vs yes
Tone: spastic vs reduced
reflexes: brisk vs diminished
what kind of rigidity does parkinson’s disease have?
cogwheeling rigidity AKA lead pipe
what level does the spinal cord end?
L1, thereafter is cauda equina
what is the highest level a lesion can be in if there are no upper limb symptoms?
T2
definition of syncope
transient loss of consciousness due to hypo-perfusion of the brain
what are some cardiac causes of syncope
heart block, VT, VF, outflow obstructions
what are some neurogenic causes of syncope?
vasovagal, cough syncope, carotid sinus sensitivity
definition of seizure
clinical manifestation of abnormal cortical synchronised neuronal discharge
things to ask about when clarifying syncope VS syncope
situation trigger warning symptoms witness account aftermath predisposing factors
common situation for seizures to happen?
random
what commonly triggers a cardiac syncope?
exercise
common aftermatch of seizures
muscle aches
lateral tongue bitting
injury
common witness account of syncopes
pallor
intermittent jerking
common witness account of sizures
cry, stiffened limbs, convulsions, central cyanosis, noisy breathing
questions to ask for ear issues
hearing loss? otalgia discharge noises (tinnitus) dizziness (vertigo) phx fmhx
hearing loss clarifications
duration, uni or bilateral, sudden or gradual, constant or variable, trauma? other hx
hx of dizziness
precipitating factors? standing/lying/sitting
worse with movement?
vision?
how long, is it constant or episodic
what is the reflex that stabilises our vision when he move our heads
vestibulo-ocular reflex
what is vertigo often described as
hallucination of movement
room spinning sensation
what does rinnes test +ve and -ve suggest?
+ve means air conduction better. can suggest normal hearing, or sensorineural hearing loss
-ve suggest conductive hearing loss
how is webbers test result interpreted
equal if normal or bilateral sensorineural loss
lateralises to damaged side in conductive loss
lateralises to normal side in sensorineural loss
what nerve roots do each of the following areas represent
deltoids thumb middle finger nipple umbilicus symphysis pubis medial leg between 1st and 2nd toe lateral foot
C5 - deltoids C6 - thumb C7 - middle finger T5 - nipple T10 - umbilicus T12 - symphysis pubis L4 - medial leg L5 - between 1st and 2nd toe S1 - lateral foot
what blood supply supplies the dorsal columns
posterior spinal artery
what does the MRC power scale 0 - 5 mean
0 means no movement at all 1 means slight twitching 2 can lift up without gravity effect 3 can lift up against gravity 4 can lift up and push back slightly 5 can lift up and push back on examiner (normal)
what is delirium defined as
acute state of confusion
what neurotransmitter plays a key role in delirium
acetylcholine
what are the clinical features of delirium
impaired consciousness impaired cognitive function perceptual d/o (hallucinations) paranoid delusions psychomotor abnormalities sleep/mood disturbances
what are some precipitating factors of delirium
infection injury malnutrition dehydration iatrogenic immobility forced restraint
what are some risk factors of delirium
underlying brain diseases old age visiual/hearing impairment polypharmacy renal impairment sleep deprivation
what are some iatrogenic causes of delirium
GA, surgery, drugs, urinary catheter
what kind of drugs can cause delirium
opioids, steroids, sedatives.
what bloods are important to take in delirium, and why?
FBC - infection/anaemia CRP - infection U+E - electrolyte imbalance (Ca, K, Na) TFTs bone profile B12/folate coagulation
how to treat delirium?
find underlying cause and fix it
maintain hydration
restore patients eyesight if impaired
how to tranquilize dangerous delirious patient?
500mcg haloperidol PO or 1mg IM
lorazepam otherwise
most common dementia cause
alzheimer’s disease
key feature of AD?
gradual decline, memory decline
key feature of vascular dementia?
step wise deterioration
key feature of frontotemporal dementia?
personality and behaviour change.
what medication to avoid for lewy body dementia
antipsychotics
key feature in lewy body dementia?
visual hallucinations come before Parkinson symptoms
fluctuation in cognition, alertness and attention
PD features as well
difference between speech and language
speech is how you say things
language is what you say
what is receptive aphasia?
it is when understanding is affected, person hears language but cannot comprehend.
describe the 4 types of expressive aphasia
word finding difficulty - know words in head but cannot get it out
semantic error - mixing up word meanings, using words wrongly
phonemic error - mixing up sounds in the words
jargon - gobelrdy gurr, not making any sense with what they say, just sounds
define dysarthria
disturbance in speech that results from muscle weakness, paralysis or poor coordination
describe flaccid dysarthria and what is it also known as. is it UMN or LMN?
AKA bulbar palsy - LMN cause
imprecise articulation, hypernasality, reduced breath control, nasal emission audible
describe spastic dysarthria and what is it also known as. is it UMN or LMN?
UMN, AKA pseudobulbar palsy
slow/laboured speech
low monotonous pitch
slow and slurred
what kind of dysarthria do huntington’s patients have
hyperkinetic dysarthria
what patients get hypokinetic dysarthria?
parkinsons
describe ataxic dysarthria? cause?
cerebellar system
irregular pitch and loudness
altered prosody
disjointed ups and downs
describe apraxia
motor control difficulty, effortful and groping for words
agrammatical
describe dysphonia
disorder of voice or phonation, roughness, hoarseness, strain
3 D’s of elderly patient care
delirium, dementia, depression
what is assessed in an MMSE?
a bee stung molly then peter caught it
appearance behaviour speech mood thought flow/content perceptions cognition insight
difference between mood and affect?
mood is what the patient thinks and feels in their words
affect is what the assessor sees
what is required for TACS diagnosis
unilateral weakness of face, arm and leg (or sensory deficit)
homonymous hemianopia
high cerebral dysfunction (dysphasia, visuospatial disorder e.g. inattention)
what is required for PACS diagnosis
2 of the following
unilateral weakness of face, arm and leg (or sensory deficit)
homonymous hemianopia
high cerebral dysfunction (dysphasia, visuospatial disorder e.g. inattention)
what is required for POCS diagnosis
one of
cerebellar brainstem syndromes
loss of consciousness
isolated homonymous hemianopia
what is required for LACS diagnosis
one of
unilateral weakness (or sensory deficit) of face and arm, arm and leg or all three
pure sensory stroke
ataxic hemiparesis
what are the red flags in back pain?
sphincter or gait disturbance
saddle anaesthesia
progressive motor loss
non-mechanical pain fever or weight loss age <20 or >55 thoracic pain previous Ca Hx HIV
what is the most common acute neuropathy
Guillain Barre syndrome
what viruses can trigger GBS
campylobacter jejuni
EBV, CMV
what are the clinical features of GBS
progressive bilateral limb weakness and numbness (paraesthesia)
absent reflexes
can progress to respiratory failure
what is myaesthenia gravis caused by
autoimmune destruction of acetylcholine receptors
what are the clinical features of myaesthenia gravis
fatiguiability of muscle on sustained or repeated activity that improves after rest
ptosis that improves after sleep or with an ice pack
weakness progresses from eyes and down leading to difficulty talking, chewing, swallowing and breathing.
what is ramsay-hunt syndrome
reactivation of herpes zoster virus in the geniculate ganglion, affecting the 7th CN
what are the clinical features of ramsay-hunt syndrome
LMN palsy, herpetic vesicles in external auditory meatus. loss of taste in the front of tongue, and possibly hearing loss and tinnitus.
what are some options to intervene when there is airway obstruction
head tilt chin lift recovery position nasopharyngeal tube oropharyngeal tube intubation
what is to be assessed when evaluating breathing?
RR, sats, auscultation
what else can be assessed for quick neurological status
pupillary reflex
what blood should be quickly assessed in unconscious patient
glucose
how to assess GCS and the different values
Eye
- nothing
- responds to pain
- responds to voice
- spontaneous
Verbal
- nothing
- groans
- inappropriate speech
- confused
- normal
Movement
- nothing
- extensor reflex to pain
- flexion reflex to pain
- withdraws from pain
- localises to pain
- can follow instructions
what is the classical triad of meningitis
fever, headache, neck stiffness
other symptoms of meningitis
N&V
photophobia
seizures
rash (non-blanching)
what is kernigs sign
neck pain on flexion of knee
what is brudzinski’s sign
involuntary hip flexion when neck is flexed
how to investigate for meningitis
bloods
LP
what do the different LP values indicate
protein
glucose
WBC/lymphocytes
color
viral - normal protein, normal glucose (compared to blood), elevated lymphocytes, low neutrophls
bacterial - high protein, low glucose, high neutrophils and lymphocytes
fungal/TB - low glucose, high proteins, high lymphocytes and neutrophils
contraindications of an LP
raised ICP trauma immunocompromised coagulopathy status injury at needle site
complications of menigitis
death seizures brain damage blindness and deafness peripheral gangrene
additional tasks in meningitis case
reporting to authorities, contact tracing
common causes of subarachnoid haemorrhage
70% by berry aneurysms
10% congenital
most common site of a berry aneurysm
anterior communicating artery
clinical presentation of SAH
worst ever headache with no prior hx, came on suddenly and reaches max intensity within a minute.
photophobia, vomiting, 3rd nerve palsy
SOCRATES of SAH
S - diffuse O - rapid onset, less than 1 min C - constant/throbbing R - sometimes to the neck A - photophobia, nausea, neck stiffness Think meningitis also T - lasts for more than an hour E - nil S - 10/10
complications of an SAH
raised ICP, stroke, hydrocephalus
investigations for suspected SAH
CT, LP
how to circumvent a traumatic LP?
look for bilirubin as signs of hx of RBC in CSF
clinical features of temporal arteritis
few week hx of constant moderate headache on temples.
weight loss, malaise
jaw claudication
scalp tenderness, blurred vision, diplopia, ocular muscle symptoms
how to investigate temporal arteritis?
look for inflammatory markers in blood - CRP, ESR
temporal artery biopsy
clinical features of migraine
episodic severe unilateral throbbing headache. can be associated with visual auras or scotomas. somes vomitting and photo and phonophobia.
what is a TIA?
acute loss of focal cerebral function OR acute monocular visual loss, <24hrs, symptoms worst at onset and get better
what symptoms are common with middle cerebral artery strokes?
UMN facial weakness hemiplegia hemianopia aphasia visiospatial problems (non-dominant hemisphere)
what symptoms are common in vertebral and basilar artery strokes
diplopia nystagmus dysarthria dysphagia bulbar weakness ipsilateral LMN facial weakness respiratory failure/coma contralateral hemiparesis, quadriparesis
what is the definition of shock?
in adequate organ perfusion due to hypotension or acute circulatory failure resulting in generalised cellular hypoxia
how do patients in shock present?
pale, clammy
tachypneac
talking in short sentences
rash in septic shock
what symptoms does brain failure cause in shock?
decreased GCS
confusion
dizziness
what symptoms does respi failure cause in shock?
tachypnea
agonal breathing
cyanosis
respi arrest
what symptoms does cardiovascular failure cause in shock?
clammy skin
cold
edema
tachy/bradycardia
4 types of shock?
hypovolaemic (low blood volume)
cardiogenic (heart failure)
distributive (vasodilation)
obstructive (low SV)
example causes of hypovolaemic shock?
massive bleeding
diarrhea
example causes of cardiogenic shock?
MI
dysrhythmia
example causes of distributive shock?
sepsis
anaphylaxis
what kind of shock would a PE cause?
obstructive shock
what blood traces would indicate cardiogenic shock?
increased troponin
what ECG signs would indicate cardiogenic shock?
inverted T wave
5 common types of movement disorders
tremors chorea tics myoclonus dystonia
describe the 5 main types of movement disorders
tremors are rhythmical repeated movements usually in the hands. can be resting or action tremor
describe the 3 types of action tremors
postural tremor (hands stuck out) intention tremor (amplitude increases over course of action kinetic tremor
how to differentiate a true intention tremor?
tremors come on during action and amplitude increases over course of action
how to describe a tremor?
distribution
resting/postural
frequency
amplitude
describe a parkinsonian tremor
asymmetrical onset
predominantly resting tremor
often coarse pill rolling tremor
chin rolling tremor common
what is an essential tremor
mainly postural tremor, bilateral onset in upper limbs
often tremor of head
what are the 3 main symptoms of parkinsonism
resting tremor
rigidity
bradykinesia
what kind of drugs can cause parkinsonism
antipsychotics
sodium valproate
metoclopramide
dopamine blocking drugs
describe chorea
slow moving smooth involuntary body movement often flowing from one body part to another
describe hemibalism
abrubt amplitude involuntary movement of limbs often described as “ballistic”
describe dystonia
repetitive movements with sustained contractions
often bilateral and associated with a stiff neck
abnormal postures
difference between generalised and focal dystonia
generalised dystonia usually childhood onset, start in lower limb and progresses to whole body - genetic cause
focal dystonia usually middle age onset can affect different body parts commonly
cervical, blephorospasms(eyelid), jaw opening, spasmodic dystonia and task specific dystonia
describe tics
involuntary sudden rapid repetitive non rhythmic stereotyped movements or vocalisation
can be suppressed at great psychological tension
usually in children but goes away
becomes tourettes sd if persists
describe myoclonus
burst shock like muscular contractions
What does VIVID stand for in headache presentation differentials
Vascular Infective Visual threatening Intracranial pressure (space occupying lesion) Dissection
What would a headache worse when lying down, together with early morning nausea indicate?
Raised intracranial pressure
What can cause a space occupying lesion
Bleed/clot, tumor, cyst, abscess,
What is the nature of headaches of someone with a growing tumor or abscess
Progressive constant headache
What sign will a carotid artery dissection give?
Horners syndrome and neck pain
What eye sign will indicate a cavernous sinus thrombosis in someone with a headache
Exopthalmos
What type of head ache is severe unilateral and focused over 1 eye?
Cluster headache
