Physical Examination

Question 1

RAPD

Answer 1

(Marcus-Gunn pupil)

Normal: light shone into either eye constricts both pupils equally

Afferent limb of optic nerve damaged: light shone into affected eye causes less constriction of that eye. Therefore pupil appears to relatively dilate when light swung from good eye to affected eye. (Relevant afferent pupillary defect).

Potential causes: retinal damage of affected eye e.g. CRAO, CRVO, large retinal detachment or due to significant optic neuropathy e.g. optic neuritis, unilateral advanced glaucoma, compression secondary to tumour or abscess

Question 2

Visual fields

Answer 2

Bitemporal hemianopia: loss of temporal visual field in both eyes (central tunnel vision). Causes: optic chasm compression by tumour e.g. pituitary adenoma

Homonymous field defect: affect same side of the visual field in both eyes. Causes: stroke, tumour, abscess (pathology affecting visual pathways posterior to optic chiasm). Hemianopia for half of the fields or quadrantanopia for quarter

Scotoma: area of absent/reduced vision surrounded by area of normal vision. Causes: demyelinating disease e.g. MS, diabetic maculopathy

Monocular vision loss: total loss of vision in one eye secondary to optic nerve pathology (e.g. anterior ischaemic optic neuropathy) or ocular disease (e.g. CRAO, total retinal detachment)

Question 3

Oculomotor nerve palsy (CNIII)

Answer 3

“down and out” appearance of eye

+ ptosis

+ mydriasis

Question 4

Trochlear nerve palsy (CN IV)

Answer 4

Vertical diplopia when looking inferiorly. Patients often tilt head forward and tuck chin in to compensate.

Question 5

Abducens nerve (CN VI)

Answer 5

convergent squint due to unopposed action of medial rectus muscle

horizontal diplopia worse when trying to look to affected side

Question 6

HINTS exam

Answer 6

Head Impulse

Nystagmus

Test of Skew

Head impulse:
Positive = consistent with peripheral vertigo
Positive when there is a significant lag with corrective saccades (in ONE direction, horizontally - BOTH or VERTICAL concerning for central)

Nystagmus:
Unidirectional horizontal nystagmus consistent with peripheral vertigo. Multidirectional/torsional/vertical concerning for central.

Skew:
deviation of eye once uncovered concerning for central vertigo

Question 7

Stroke mimics

Answer 7

migraine aura
hemiplegic migraine
Todd's paralysis
CNS tumour or abscess
functional/conversion reaction
hypertensive encephalopathy
head trauma
MS
PRES 
MELAS
syncope
subdural
systemic infection
toxic metabolic disturbance
transient global amnesia
carotid artery dissection
extending aortic dissection
bell's palsy
vestibular neuronitis
cerebral venous sinus thrombosis

Question 8

Medial medullary syndrome

–> anterior spinal artery or vertebral artery

Answer 8

contralateral weakness

contralateral vibration and proprioception loss

ipsilateral tongue weakness

Question 9

Lateral medullary syndrome

–> vertebral, basilar, anterior spinal artery, or PICA

Answer 9

Ipsilateral

• facial sensory loss
• nystagmus
• horner’s syndrome
• loss of gag reflex
• ataxia, with tendency to fall to ipsilateral side

Contralateral
- pain and temperature sensory loss in the extremeties

Generally

• vertigo
• nausea
• dysphagia

Question 10

Locked-in syndrome

–> basilar artery

Answer 10

bilateral whole body weakness
bilateral facial weakness
lateral gaze weakness
dysarthria

able to move eyelids and have vertical gaze

Question 11

ACA syndrome

Answer 11

contralateral hemiparesis of LL
contralateral sensory loss of UL

anosmia
frontal lobe dysfunction - altered judgement, insight, mentation

Question 12

PCA syndrome

Answer 12

PROXIMAL

• contralateral homonymous hemianopia (cortical blindness)
• contralateral hemiplegia
• chorea and hemibalismus
• oculomotor nerve palsy, loss of voluntary eye movements
• thalamic pain/hyperalgesia syndrome
• emesis centres
• crossed deficits - motor on one side, sensory on the other

DISTAL

• contralateral homonymous hemianopia
• visual agnosia

Question 13

Dominant MCA (Gerstmann syndrome)

Answer 13

agraphia
acalculia
finger agnosia
R-L disorientation

–> contralateral weakness, sensory loss, hemineglect (weakness usually worse in arm and face than in leg)

contralateral homonymous hemianopia
global aphasia (receptive and expressive)

Question 14

Expressive aphasia

Answer 14

Broca’s aphasia

can’t communicate verbally but understanding may be intact

Question 15

Receptive aphasia

Answer 15

Wernicke’s

unable to understand speech

Question 16

Non dominant MCA syndrome

Answer 16

contralateral weakness, sensory loss, hemineglect (as for dominant)

contralateral homonymous hemianopia (as for dominant)

apraxia and spacial disorientation

Question 17

FAST-ED stroke score

Answer 17

(F)acial palsy

(A)rm weakness (drift, effort against gravity)

(S)peech changes

(T) - no score for T

(E)ye deviation

(D)enial/neglect

Question 18

ROSIER

Answer 18

Recognition of Stroke in the Emergency Room (ROSIER)

(-1) loss of consciousness or syncope
(-1) seizure activity

rest = +1 each 
new, acute onset (or on awakening from sleep) finding of
- asymmetric facial weakness
- asymmetric arm weakness
- asymmetric leg weakness
- speech disturbance
- visual field defect

score of 1 or more = stroke possible

Question 19

Reflexes in acute stroke

Answer 19

may be decreased initially

progress to be increased

Question 20

Reflexes in spinal cord injury

Answer 20

may be decreased initially

progress to increased

Question 21

Reflexes in peripheral nerve injury

Answer 21

decreased

Question 22

Neurogenic shock

Answer 22

hypotension and relative bradycardia due to circulatory collapse from loss of sympathetic tone

Question 23

spinal shock

Answer 23

temporary loss of spinal cord function and reflex activity below the level of a spinal cord injury
characterised by
- flaccid areflexic paralysis
- bradycardia and hypotension
- absent bulbocavernosus reflex

usually resolves after 48 hours