Phase 3a (GP oxford handbook notes)

Question 1

what types of lesions are indicated by absent or decreased reflexes?

Answer 1

sensory nerve or root (e.g neuropathy, spondylosis)
anterior horn cell (MND, polio)
motor nerve or root (neuropathy, spondylosis)
nerve endin e.g myasthenia gravis
or muscle (myopathy)

Question 2

type of lesion indicated by increased reflexes

Answer 2

upper motor neurone lesion - lack of higher control e.g post stroke

Question 3

what does clonus normally indicate?

Answer 3

UMN lesion

Question 4

what rhyme can help to remind you which nerve roots innervate which reflexes?

give answers for ankle jerk, knee jerk, biceps and triceps

Answer 4

One, two– buckle my shoe (S)
Three, four– kick the door. (L)
Five, six– pick up sticks. (C)
Seven, eight– shut the gate. (C)

S1,2 = ankle jerk (plantar flexion)
L3,4 = knee jerk (knee extension) 
C5,6 = biceps and brachioradialis (elbow flexion)
C7,8 = triceps (elbow extension)

Question 5

what mneumonic is used to help name all the cranial nerves in order?

what is used to help remember if they are sensory, motor or both?

Answer 5

Oh - olfactory (sensory) 
Oh - optic  (sensory) 
Oh - oculomotor (motor)
to - trochlear (motor)
touch - trigeminal (both)
and - abducens (motor)
feel - facial (both)
virgin - vestibulochoclear (sensory) 
girls - glossopharyngeal (both)
vaginas  - vagus (both)
and - accessory (motor)
hymens - hypoglossal (motor)

some say money matter but my brother says big boobs matter more

Question 6

when testing the optic nerve three possible findings are

monocular blindness
bitemporal hemianopia
homonymous hemianopia

what are the common cause for these three presentations?

Answer 6

mono - MS, giant cell arteritis

bitemp hemi - pressure on optic chiasm (pituitary adenoma)

homonymous hemi - affects half the visual field on the side OPPOSITE to the lesion - stroke, abscess, tumour

Question 7

what nerve is effected if the eye is pointing ‘down and out’ and what are the possible causes?

Answer 7

3rd nerve = down and out (tramps palsy)
+/- pupil being large

DM, giant cell arteritis, syphilis, PCA aneurysm, idiopathic

if pupil is NORMAL size, DM or other vascular cause

Question 8

a lesion in the 7th nerve causes what presentation?

whats the difference between and upper motor neuron lesion or a lower motor neurone lesion in this nerve?

Answer 8

facial nerve: causes unilateral facial weakness and drooping

upper motor neuron - e.g from a stroke (or tumour). You get forehead sparing so only affects lower 2/3rd of the face

lower motor neurone - e.g Bell’s palsy, (also otitis media, polio, skull fracture, pontine angle tumour, parotid tumour, herpes zoster
affects whole side of face

Question 9

describe how bells palsy presents?

cause?

Answer 9

unilateral facial weakness and drooping, WITHOUT any other neurological signs, usually sudden onset

idiopathic, ?viral

Question 10

management of bells palsy

Answer 10

give prednisolone if <72 hours onset

self limiting normally, reassure.
85% should begin to improve within 3 weeks - refer if not, and most will be fully recovered by 3-4 months

conservative measures - eye drops to lubricate, tape eye shut at night if won’t close, avoid things which might irritate eye such as swimming.

Question 11

what is ramsay hunt syndrome?

Answer 11

basically bells palsy caused by herpes zoster virus, preceded by severe pain in ear and companied by zoster rash. if <24 hours after rash appears, can give antivirals (acyclovir)

Question 12

how does carpal tunnel present?

what nerves are involved?

Answer 12

loss of sensation over lateral 3 and 1/2 fingers and palm +/- wasting of thenar eminence and inability to flex thumb.

median nerve - roots C5-T1

Question 13

how does gillian barre polyneuritis present? and what is it?

Answer 13

ascending motor neuropathy - may advance fast. proximal worse than distal - so trunk, resp and cranial nerves can also be involved.

develops within few weeks of infection (campylobacter - GI, but also URTI, flu) or afters surgery or vaccination.

prognosis good - 85% make complete or near complete recovery

Question 14

what should you do if you suspect someone with gillian barre syndrome presents and why?

Answer 14

resp invovlement is the danger due to possible requirement of ventilation of ITU- admit to hosp immediately if suspected.

Question 15

whats the main cause of an antalgic gait?

Answer 15

gait adjusted to minimise pain in a joint - most often OA of the hip

Question 16

compare a drunken gait to a sensory ataxic gait and what causes them?

what test should you do to tell the difference?

how can you use it to localise the possible location of a lesion?

Answer 16

wide based gait with patient looking forwards and placing feet down carefully is drunken

wide based gait with patient watching their feet is sensory ataxic and stamping feet down clumsily

test rombergs - if romburg positive more suggestive of sensory ataxic

alcohol or cerebellar lesion –> they will fall to the side of the lesion for drunken gait

sensory ataxic = peripheral neuropathy pr spinal cord disease (cervical spondylsosis, MS, syphilis,

Question 17

how might foot drop present?

what test should you do to narrow down the cause?

Answer 17

patient tripping frequently or a high stepping gait. unable to walk on heels and cannot dorsiflex the foot

check the ankle reflex!

Question 18

what are the possible causes of foot drop? and how does the ankle jerk help to narrow this down?

Answer 18

common peroneal palsy - trauma, normal ankle jerk

sciatica - absent ankle jerk

L4,5, root lesion - ankle jerk may be absent

peripheral motor neuropathy - weak or absent

distal myopathy - weak or absent

MND - increased ankle jerk!

Question 19

describe hemiplegic gait and who it presents in?

Answer 19

arm adducted and internally rotates, elbow flexed +/- finger flexion with foot plantar flexes and leg swings around in a lateral arc

UMN lesions - stroke often

Question 20

describe a parkinsonian gait?

Answer 20

shuffling - short steps with feet barely leaving ground (audible)

turning ‘en bloc’ - multiple small steps required to turn

gait freezing - inability to move feet and may worsen in tight spaces (through a door) or when initiating walking (so hesitant to start/walk through door)

lack of normal arm swing (normally unilateral in parkinsons)

Question 21

describe a scissor gait and who it might present in ?

Answer 21

patient walks on tiptoe and knees rub together/cross during the walking cycle which may be accompanied by complex arm movements to assist walking

spastic paraplegia

Question 22

who do you classically see a waddling gait in?

Answer 22

proximal myopathy e.g MD

but other causes are pregnancy/congenital dislocation of the hip

Question 23

describe the two main types of tremor and what they are commonly assocaited with?

Answer 23

resting tremor - present at rest but stops when doing voluntary movement: PD (pill rolling, rhythmic)

intention tremour - irregular, large amplitude tremour, worse on movement particularly like pointing: cerebellar disease

Question 24

what is chorea and what conditions are assocaited with it?

Answer 24

non rhythmic, jerky, purposeless movements with volunarty movements possible in between.

dyskinetic cerebral palsy or huntingtons disease