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PACES - Limbs Flashcards

1
Q

How would you test power of shoulder abduction?

A

‘Lift your arms into a chicken position, don’t let me push down’

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2
Q

How would you test power of arm flexion?

A

Put your arms in front of you like a boxer
Stop me from pulling you arms out

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3
Q

How would you test power of arm extension?

A

‘Put your arms in front of you like a boxer, push against my hand’

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4
Q

How would you test power of wrist flexion?

A

How you arms straight out and make a fist.
Hand under fist, push my hand down towards the ground

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5
Q

How would you test power of wrist extension?

A

Now cock your wrists back
Hold forearm, stop me from pushing your fist down

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6
Q

How would you test power of finger abduction?

A

Spread your fingers
Stop me from pushing your fingers together

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7
Q

How would you test power of thumb abduction?

A

Turn hand palm up, bring the thumb towards the ceiling. Stop me from pushing your thumb down

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8
Q

How would you test power of hip flexion?

A

‘Keeping your knee straight, lift your leg off the bed’
Hold their thigh, ‘stop me from pushing your leg down’

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9
Q

How would you test power of hip extension?

A

Push your leg down, hold underneath their thigh. ‘Push your leg into the bed’

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10
Q

How would you test power of knee flexion?

A

“Bend your leg at the knee and rest your foot flat on the bed.”
Hold their leg around the back of the calf. “Don’t let me straighten your leg/Pull your heel in towards your bottom”

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11
Q

How would you test power of knee extension?

A

Holding their leg on the shin.
“Try to straighten you leg, push against my hand away with your leg”

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12
Q

How would you test power of dorsiflexion?

A

Place leg straight again: point toes toward face. Place your hand on the dorsum of foot.
“Stop me from pulling your foot down”

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13
Q

How would you test plantar flexion?

A

Place your hand on the sole of the foot. “Push down against my hand”

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14
Q

Which anatomy are you testing with hip flexion?

A

1: Psoas
2: L2
3: Femoral

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15
Q

Which anatomy are you testing with hip extension?

A

1: Gluteus Maximus
2: L5/S1
3: Inf. gluteal nerve

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16
Q

Which anatomy are you testing with knee flexion?

A

1: Hamstrings
2: L5
3: Sciatic

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17
Q

Which anatomy are you testing with knee extension?

A

1: Quads
2: L3/4
3: Femoral

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18
Q

Which anatomy are you testing with dorsiflexion?

A

1: Tibialis anterior (and others)
2: L4/5
3: Deep Peroneal

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19
Q

Which anatomy are you testing with plantar flexion?

A

1: Gastronemeus (and others)
2: S1/2
3: Tibial nerve

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20
Q

How would you test for arm fasciculations?

A

Gently flick the deltoid if clinical suspicion

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21
Q

How do spasticity and rigidity differ?

A

Spasticity = velocity dependent (fast = more resistance)

Rigidity = constant resistance

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22
Q

Describe the muscle power grading system

A

0 = Absent contraction
1= Feeble (ie. twitching)
2 = Can move with gravity eliminated (ie. can move leg horizontally when lying on a bed)
3 = Move against gravity (Can lift heel off bed)
4 = Movement against partial resistance
5 = Full strength

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23
Q

What is Jendrassik’s Manoeuvre?

A

Reinforces reflexes

Ask them to clench their teeth or grasp their hands together and pull apart

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24
Q

What does a positive Romberg’s test mean and how would you carry it out?

A

Sensory ataxia (Peripheral neuropathy)
Tabes Dorsalis (Sensory pathways of spinal cord)

Ask them to stand with their feet close together and stretch out their arms.

Ask to close their eyes. If they fall, lack of proprioceptive input.
If cerebellar, unsteady when eyes are pen and closed.

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25
Q

how would a hemiparesis present?

A

UMN signs (Increase tone, brisk reflexes, upgoing plantars, Clonus)

Hemiparetic Gait

Sensory Loss

Visual Field defect?

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26
Q

What would your differential be in a pt presenting with hemiparesis?

A

Anterior circulation stroke

SOL

Cerebral Palsy

Stroke Mimic (Sepsis, Hypoglycaemia, Demyelination)

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27
Q

How would you manage a patient with a stroke?

A

A-E approach

Thrombolysis if <4.5h
Thrombectomy if <6h

Admit to Hyperacute stroke unit

Regular neuro obs,
CT Head
Aspirin, Statin
SALT, Rehab, Physiotherapy, OH assessment

Lifestyle advice
DVLA advice (4weeks)
Chadvasc/Hasbled anticoag advice

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28
Q

how would a spastic paraparesis present?

A

Bilateral increased tone
Pyramidal Weakness bilaterally
Increased reflexes
Upgoing plantars/clonus
Spastic scissoring gait

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29
Q

What are the main causes of a spastic paraparesis?

A

MS
Cord Compression
Trauma
Anterior horn cell MND
Cerebral Palsy

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30
Q

What is the likely cause if a patient presents with a spastic paraparesis and a clear sensory level?

A

Cord compression
Cord Infarction
Transverse Myelitis

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31
Q

What is the likely cause if a patient presents with a spastic paraparesis and UMN signs in the upper limbs?

A

cervical Myelopathy above C5

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32
Q

What is pyramidal weakness?

A

Weakness in upper limb extensors and lower limb flexors

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33
Q

What are the key signs of dorsal column pathology?

A

Loss of vibration
Loss of joint position sense

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34
Q

What are the key signs of a cerebellar syndrome?

A

Ataxic wide-based gait
Inability to walk heel to toe
Rhomberg Negative
Dysdiadokinesis, past pointing, intention tremor,
Nystagmus
Ataxid Dysarthria

Should be reduced tone,

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35
Q

What can cause a bilateral cerebellar syndrome?

A

MS
Paraneoplastic Syndromes
Stroke/SOL of Posterior Circulation

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36
Q

How might a peripheral neuropathy present?

A

Loss of sensation
Loss of proprioception
Charcot Joint?

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37
Q

What can cause a peripheral neuropathy?

A

B12 def
Diabetes
Alcohol
GBS
CMT
Amyloidosis

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38
Q

How is B12 def managed?

A

IM Hydroxycobalamin.
3/wk for 2 wks. then 3 monthly

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39
Q

What is charcot marie Tooth syndrome?

A

Peripheral Motor and sensory neuropathy

Distal wasting of legs and hands
Weakness, mild sensory loss
Arreflexia
Bilateral foot drop
high stepping gait

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40
Q

How common is CMT?

A

Fairly
1 in 2500

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41
Q

How does friedrich’s ataxia present?

A

Spastic Paraparesis
Absent lower limb reflexes
Cerebellar Signs

Has spinocerebellar signs, corticospinal tract signs, dorsal column signs

42
Q

How is friedrich’s ataxia inherited?

A

Autosomal Recessive

43
Q

Which investigations should you ask for in most neuro stations?

A

Bedside:

Bloods: B12/Folate, BMs, Syphylis

Nerve Conduction Studies

MRI/CT Head/Spine

AMTS?

Full CN screen

Gene check if ?inherited

44
Q

How would you manage complex neuro cases?

A

MDT Approach
Involve specialist, SALT, OT, physio, geneticist etc
Screen family
Manage complications (Cardiac, Ortho, Endo)

45
Q

How does a flacid paraparesis present?

A

Reduced tone bilaterally
Wasting and weakness
Reduced/absent reflexes
Downgoing plantars

46
Q

What can cause a flaccid paraparesis?

A

Anterior horn -> Nerve Root -> Plexus -> Peripheral Nerve -> NMJ -> Muscle

AH - MND, Polio

NR - Compression (disc herniation, abscess, mets)

Plexus -> Lumbosacral Plexopathy

Nerve - GBS, Infection, CMT, Amyloid etc (Lots for this)

NMJ - MG, LE, Botulism

Myopathy - Poly/Dermatomyositis
Connective tissue disorders
Cancer
Drugs (Statins)
Lots others (Surgical sieve)

47
Q

Pt presents with high stepping gait?

A

Common peroneal nerve palsy
L5 Radiculopathy
CMT

48
Q

What can cause a mix of umn and lmn signs?

A

MND
Friedrich’s ataxia
Subacute combined degeneration of the cord
Taboparesis
Syringeomyelia

49
Q

Which spinal cord tracts are motor in function?

A

Pyramidal = voluntary movement (corticospinal)

Extrapyradimal = Involuntary movements (reflexes, tics, posture)

50
Q

Which spinal tracts are sensory in function?

A

Dorsal Column - Fine touch, proprioception, (crosses at medulla)

Spinocerebellar - proprioception

Spinothalamic - pain and temperature, crosses at level

51
Q

Where would you test C5

52
Q

Where would you test c6?

53
Q

Where would you test c7?

A

Middle finger

54
Q

Where would you test c8?

A

Little finger

55
Q

Where would you test T1?

A

Ulnar side of forearm

56
Q
A

Carpal tunnel scar

57
Q

What is clasp-knife spasticity?

A

Initial resistance to movement followed by sudden drop in tone (velocity dependent)

UMN lesions

Either flexors or extensors

58
Q

What is lead pipe rigidity?

A

Hypertonicity which persists through range of movement (PD)

59
Q

What is cogwheeling?

A

Start and stop movements (PD if has tremor)

60
Q

What might cause an ataxic gait?

A

Cerebellar lesion (Veer to one side)
Sensory Ataxia (Watch feet, no proprioception)

61
Q

What might cause a waddling gait?

A

Proximal lower limb weakness (myopathy)

62
Q

How might someone with a unilateral/bilateral spastic paraparesis walk?

A

Bi - Scissoring, inverted feet, internal rotation of hips

Uni - Circumdating, one leg stiff and swings round in an arc with each stride

63
Q

What is brown-sequard syndrome?

A

Hemisection of spinal cord

Complete sensory loss at level
Impaired pain and temperature ipsilaterally
Impaired fine touch, vibration contralaterally

64
Q

What would be your differential for UMN signs?

A

Stroke

SOL

MS

65
Q

What can cause a unilateral lower limb hemiparesis (One side completely spastic, the other side effectively normal)?

A

Hemisphere - Stroke, MS, SOL, Cerebral Palsy

Hemicord - MS, Cord Compression

66
Q

What can cause a spastic paraparesis?

A

Common = MS, Corc compression (LMN at level, UMN below level), Cervical Myelopathy, Cord trauma, Cerebral Palsy

67
Q

How do you perform Romberg’s test

A

30s with eyes together. Eyes closed
Positive = loss of balance = sensory ataxia (proprioceptive deficit)

68
Q

Investigations for UMN lesion?

A

MRI cord and brain

Lumbar Puncture for MS (oligoclonal bands)
FBC for infection, CXR for malignancy
B12/Folate for subacute combined degeneration

69
Q

What is the supportive management for UMN lesions?

A

MDT = gpm radiologist, neurosurgeon, physio, OT
Motility aids,
Catheterisation
Baclofen for spasticity

70
Q

What can cause a stroke in a young person?

A

SLE/APLS/Vasculitis/Carotid artery dissection/SCA

71
Q

What would your ddx for someone with stroke symptoms?

A

head injury, hypo/hyperglycaemia, Infection

72
Q

Stroke rehab?

A

MENDS

MDT
Eating
neurorehab
DVT Prophylaxis
Sore avoidance

73
Q

Most common symptoms of MS?

A

TEAM
Tingling
Eye (Optic neuritis)
Ataxia (+ Cerebellar signs)
Motor (Spastic Paraparesis)
Lhermitte’s Sign (electric shock down neck)

74
Q

What is the diagnosis criteria for MS called?

A

McDonald’s Sign

75
Q

MS management?

A

MDTapproach

Acute = steroids

Disease modifying = IFN-B

Biologics = Natalizumab

Symptomatic (pain - amitryptiline, spasticity baclofen

76
Q

What can cause bilateral distal symmetrical LMN signs?

A

Motor peripheral Polyneuropathy - CMT, lead poisoning, paraneoplastic

77
Q

What might cause bilateral symmetrical proximal LMN signs?

A

Muscular dystrophy
Poly/Dermatomyositis
Cushing’s Thyrotoxicosis
Steroids, Statins
Paraneoplastic

78
Q

What might cause unilateral LMN signs?

A

Group of muscles with same supply = Peripheral mononeuropathy or nerve root damage

79
Q

What can cause hand wasting

A

Anterior Horn: Syringeomyelia, MND, Polio
Roots: Spondylosis (C8,T1)
Brachial Plexus: Cervical Rib
Neuropathy: CMT, Mononeuritis Multiplex
Muscle: Myotonic Dystrophy, RA

80
Q

How does a peripheral neuropathy (sensory) present?

A

DM, Alcohol, B12

bilateral, symmetrical, glove and stocking distribution. Loss of tendon reflexes. Signs of trauma/deformity. Loss of proprioception

81
Q

How does a peripheral neuropathy (motor) present?

A

CMT, Paraneoplastic, GBS

Bilateral, symmetrical LMN weakness
Low tone, hyporefllexia

82
Q

How would you investigate peripheral neuropathy?

A

urine dip
FBC (Infection), LFTs with GGT (Alcohol), U&E (CKD), Glucose and HBA1c, TFTs, B12, Folate
CXR (Paraneoplastic)
Nerve conduction studies
Nerve Biopsy
MRI if in doubt about location of lesion

85
Q

Pt has:
peripheral muscle wasting
Stepping Gait
Weak dorsiflexion
Absent ankle jerk
Variable sensory loss

A

CMT

MDT, foot care, orthoses

86
Q

Parkinson’s presentation

A

Inspection: asymmetric resting tremor, mask-like facies, dysphonia

Gait: Shuffling, absent arm swing

Arms: Cogwheeling/lead pipe rigidity, normal power/reflexes, tremor, bradykinesia, coordination

Eyes: Vertical gaze palsy if PSP, nystagmus if MSA

Function: Struggles with buttons/tying shoes

87
Q
A

Mask-Like facies

88
Q
A

Vertical gaze palsy - PSP

89
Q

Parkinson’s Ix

A

Full history

LL/CN Exam - look for PSP/MSA

Lying Standing BP

MMSE

Test for micrographia

Drug Chart (Iatrogenic)

Bloods - FBC, U&Es, LFTs, Lipids, HBA1c, Copper studies

CT/MRI

90
Q

Parkinson’s Mx

A

MDT
L-dopa + Carbidopa
Dopamine agonists
MAO-B Inhibitors

91
Q

Parkinsonism syndrome causes

A

PD

PSP, MSA, LBD

Vascular
Metoclopramide, Prochlorperazine

92
Q

PSP

A

PD plus postural instability, vertical gaze palsy

93
Q

MSA

A

PD plus autonomic failure (cerebellar signs, postural hypotension)

94
Q

Side effects of L-Dopa?

A

Dyskinesia
On/Off
Insomnia

95
Q

Cerebellar signs

A

DANISH
Dysdiadochokinesia
Ataxia
Nystagmus
Intention tremor
Scanning dysarthria
Hypotonia

96
Q

Causes of cerebellar syndrome

A

DAISIES
Demyelination
Alcohol
Infarct
SOL
Inherited (ataxia telangiectasia, Friedrich’s)
Epilepsy meds
System Atrophy

97
Q

CN 5,6,7,8 + cerebellar signs

A

Vestibular Schwannoma

98
Q

Pt presents with:
Pes cavus
Bilateral Cerebellar Ataxia
Leg wasting
Arreflexia
Loss of vibration and proprioception

A

Friedrich’s Ataxia

AR mitochondrial disorder

Degeneration of dorsal column, spinocerebellar tracts and corticospinal tracts

99
Q

Cerebellar exam

A

Inspection

Gait

Romberg

Arms

Coordination

Eyes

Speech

100
Q

What might cause bilateral ptosis?

A

MG
Myotonic Dystrophy

Finals (12 decks)

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