Presentations/introduction to neurology

Question 1

What is ptosis, bulbar symptoms, diplopia characteristic of?

Answer 1

Myaesthenia gravis!

Question 2

What is bulbar palsy?

Answer 2

Bulbar palsy refers to a set of signs and symptoms linked to the impaired function of the lower cranial nerves, typically caused by damage to their lower motor neurons or to the lower cranial nerve itself. The impacted cranial nerves are a set of nerves that arise straight from the brainstem and include cranial nerves IX (9), X (10), XI (11), and XII (12). Lower motor neurons are the neurons that connect the central nervous system, such as the brain and spinal cord, to the muscles they innervate.

Question 3

What is hemiplegic gait?

Answer 3

Abduction and circumduction of the affected limb in patients with UMN lesion affecting the leg

Question 4

What is spastic gait?

Answer 4

Scissoring gait found in spastic paraplegia

Question 5

What is steppage gait?

Answer 5

Patients with footdrop the high stepping gait lifts the foot to avoid catching the toes, can be bilateral

Question 6

What is ataxic gait?

Answer 6

Road bases, uncoordinated, unsteady gait characteristic of cerebellar syndromes or where is loss of proprioception

Question 7

What is waddling gait?

Answer 7

In muscular dystrophy weakness of the trunk and pelvis result in an exaggerated lumbar lordosis and tilting of the pelvis toward the non weight bearing side with each step

Question 8

What is a stamping gait?

Answer 8

Loss of proprioception the gait is ataxic with the advancing leg lifted too high and brought down with a solid stamp

Question 9

What is parkinsonian gait?

Answer 9

Forward flexed, shuffling gait with reduced arm swing

Question 10

What is antalgic gait?

Answer 10

If there is pain on weight bearing in one leg the step on that side is short, the foot is brought down gingerly and the step completed as quickly as possible resulting in a limp

Question 11

What does suddenly usually mean in neurology?

Answer 11

Vascular

Question 12

What would a hemiparesis/hemisensory problems point to?

Answer 12

They would point to problems with the brain (left or right)

Question 13

What would visual disturbances point to?

Answer 13

Point to the brain

Question 14

What sits in the brainstem?

Answer 14

Cranial nerves
Motor pathways to the limbs
Sensory nerves from the limbs
Sympathetic pathway down the lateral pathway- horners syndrome

Combination of these symptoms point to a location of the brainstem

Question 15

What would you expect in a spinal cord lesion?

Answer 15

Para or quadripesis in terms of distribution

Question 16

What would you expect with problems with the motor pathway?

Answer 16

You would expect upper and lower motor neurone signs

Question 17

What would you expect with damage to nerve roots?

Answer 17

They are characteristically very painful if you squash or inflame them

Dermatomal sensory loss

Myotomal weakness

Loss of reflexes at the appropriate levels

Question 18

What is the buzzword for myaesthenia gravis, and what points to neuromusclar junctions being affected?

Answer 18

Fatigue ability

No sensory impact

Question 19

What would you expect if there was a problem with muscle?

Answer 19

Proximal weakness

Dont expect sensory involvement

Question 20

What would your differentials be if there was a motor and sensory disturbance in all four limbs and what would you expect to see in both…

Answer 20

Cervical cord lesion vs peripheral neuropathy

Cervical cord lesion- UMN and a sensory level

Peripheral neuropathy- LMN and glove/stocking distribution of sensory loss

Question 21

What would an up-going plantar reflex indicate?

Answer 21

UMN lesion

Question 22

What would a horners syndrome indicate?

Answer 22

It indicates a sympathetic problem on the same side

Question 23

What should you assess when assessing motor symptoms?

Answer 23

Observation
Tone
Clonus
Power- pyramidal, long tract, UMN
Reflexes- root values- best mnemonic
Plantars
Hoffmans(reflexes)

Question 24

What is bulbar palsy?

Answer 24

Refers to speech and swallowing difficulties

Question 25

What can movement disorders involve?

Answer 25

They can be hyperkinetic with additional involuntary movements Hypokinetic with stiffness and slowness (seen in parkinsons)

Question 26

What is the frontal lobe responsible for?

Answer 26

``` Personality Exucative activity (more comolex actions- zipping coat/ driving) ```

Question 27

What does the temporal lobe do?

Answer 27

It has the primary auditory cortex

Question 28

What is the role of the occipital lobe?

Answer 28

Has the primary visual pathways

Question 29

What does the parietal lobe?

Answer 29

Has a role in interpretating input from frontal, temporal, occipital

Question 30

What is the cerebellum responsible for?

Answer 30

Fine motor control

Question 31

What is the brainstem responsible for?

Answer 31

Breathing, heart rate, temperature control Recieves input from the hypothalamus

Question 32

What is the basal ganglia responsible for?

Answer 32

Plays a big role in movement, really important when you start thinking about parkinsons disease and huntingtons disorder.

Question 33

What would an infarct to the middle cerebral artery present with?

Answer 33

The middle cerebal artery supplies the lateral part of the motor cortex, when looking at the homonuculus this means that the face, fingers and hands will be affected

Question 34

What would an infarct to the anterior cerebral artery affect?

Answer 34

This would affect the lower extremities because the anterior cerebral artery supplies the middle motor cortex which when looking at the homonuculus is the lower extremities.

Question 35

What is the corpus callosum?

Answer 35

This is communication from one part of the brain to the other Responsible for the ability to integrate one side of the brain to the other

Question 36

What are the two arteries which take blood up to the brain?

Answer 36

Internal carotid and vertebral arteries Internal carotid- responsible for anterior circulation Vertebral arteries- responsible for posterior circulation There is communication between the anterior and posterior circulation, this is called the circle of willis!

Question 37

What is the role of the cerebellum?

Answer 37

Tone Posture Balance For example: if somebody was helping move house

Question 38

What reflexes are important at the brainstem?

Answer 38

The cough reflex The vomiting reflex The blink reflex The jaw jerk reflex

Question 39

What is the role of the basal ganglia and what happens when it is damaged?

Answer 39

Involved in the integration of motor and sensory input When damaged, You get.. - extrapyramidal signs (bradykinesia, shuffling gait, masked facies etc...) Movement disorder (chorea, athetosis, tremor which may be uni or bilateral)

Question 40

What do you get when the cerebellum is damaged?

Answer 40

Ataxia and incoordination of limbs and gait Vertigo Nystagmus

Question 41

What do you get if there is damage to the brainstem?

Answer 41

Cranial nerve involvement- facial weakness, facial sensory loss, dysphagia, dysarthria, hoarseness and diplopia Vertigo Tetra paresis Coma Changes in blood pressure, heart rate and resp rate

Question 42

What are the signs of spinal cord damage?

Answer 42

Sensory level is present Weakness that may involve both legs or all limbs Bowel and bladder signs Autonomic nervous system dysfunction Loss of reflexes At the level of cord involvement with hyperactivity below that level Babinski sign +ve Leg spasticity

Question 43

What do you get if nerve roots are damaged?

Answer 43

Dermatomal distribution of sensory loss Neck or back pain which may extend into the limb Loss of deep tendon reflexes associated with that root Weakness in muscles supplied by that root

Question 44

What do you get if a peripheral nerve is affected?

Answer 44

You get a mixture of motor and sensory findings Distribution of signs either in a single nerve or many nerves Distal limb signs Sensory loss Muscle atrophy Autonomic manifestation

Question 45

What signs do you get if the neuromuscular junction is affected?

Answer 45

Fatigue (especially with chewing and proximal limb muscles) Weakness without any sensory loss Ptosis with changing diplopia No muscle atrophy

Question 46

What are the signs of the muscle being affected?

Answer 46

Weakness without sensory loss Proximal muscles will be more weak than distal Weakness that is often slowly progressive Muscle atrophy or pseudo hypertrophy

Question 47

What would a patient present with if they had problems with the meninges/CSF?

Answer 47

Diffuse headache Meningismus (neck stiffness, photophobia, headache) Cranial nerve abnormalities

Question 48

The mode of onset is really important in neurology, what do the following indicate... A) sudden (over a few seconds or minutes) B) acute C) subacute D) gradual onset

Answer 48

A= embolic event, seizures, this is a few secs to minutes B= acute, over days but less than 2 weeks, indicate traumatic, acute inflammation, vascular or toxic exposure C= subacute onset (between 2 and 6 weeks) D= gradual onset (more than 6 weeks) pointing to chronic inflammation, degeneration, space occupying lesions or chronic intoxication

Question 49

What is meant by delirium?

Answer 49

An acute onset of abnormal mental state, with disturbed consciousness, disorientation, severe motor restlessness, fear, irritability, visual hallcuinations.

Question 50

What is aphasia?

Answer 50

An impairment of language, affecting the production or comprehension of speech and the ability to read or write

Question 51

What is the difference between brocas and wernicks aphasia?

Answer 51

Brocas is where the fluency is affected but the comprehension may be intact Wernickes is where the comprehension is affected but the fluency is intact

Question 52

Where is the brocas and wernickes area located?

Answer 52

Brocas area is located in the left hemisphere of the frontal lobe Wernickes area is located in the posterior superior temporal lobe

Question 53

How do you test the olfactory nerve?

Answer 53

Has the patient had a change in sense of smell | Use of smelling substances

Question 54

What is anosmia caused by?

Answer 54

Blocked nasal passages Common cold Trauma Relative loss occurs with ageing and parkinsons disease

Question 55

How do you test the optic nerve?

Answer 55

1) You have to test visual acuity This can be done by using a snellen chart Allow the patient to use their glasses or contact lenses if available Position the patient 6m away from snellen eye chart Have the patient cover one eye at a time using a card Record the smallest line the patient reads successfully and repeat with the other eye If there are no available charts then use counting finger method at 6m and if patient cant see advance till 30cm away from the patient If still cant see then use counting fingers, if still cant see use hand movements and if still cant see then use light perception 2) visual fields (Remove both yours and the patients glasses before field examination) 3) examination of the pupils The pupils should appear equal in size, perfectly round and react to light and accommodation, normal pupil size is 2-4mm Test the pupillary reflex and the accommodation reflex 4) fundus examination

Question 56

What nerves do the pupillary light reflex and accomadation reflex involve?

Answer 56

Pupillary light reaction ``` Afferent= optic nerve Efferent= parasympathetic component of the third nerve on both sides ``` Accommodation reaction ``` Afferent= arises in the frontal lobes Efferent= parasympathetic component of the oculomotor nerve on both siddd ```

Question 57

What are two abnormalities related to pupil reactivity?

Answer 57

1) Horners syndrome- this is where there is a disruption in the sympathetic innervation of the pupillary dilator muscle Complete syndrome is composed of- miosis, ptosis, apparent enopthalmos (posterior displacement of the eyeball within the orbit) anhydrosis 2) Argyll Robertson pupil (prostatute pupil) This is where the pupil responds to accommodation but not to light 3) myotonic pupil (holmes adie) This is when one pupil is larger than the other It fails to react to light but does accomadate 4) marcus gunn pupil, important in patients with demyelinating disease, Affected eye will dilate in the face of direct light (positive RAPD)

Question 58

What is RAPD?

Answer 58

This is where light is shone from one eye to another and the affected eye dilates in response to light It indicates a problem in the retina or optic disc Things which cause an RAPD.... - large retinal detachment - central retinal artery or ischaemic central retinal vein occlusion - optic nerve ischaemia, optic neuritis, compression, asymmetric glaucoma

Question 59

What does papilloedema mean and what is it a result of?

Answer 59

Blurred or elevated optic papilla (optic nerve head or optic disc) Results from transmission of increased ICP into the eye via. The subarachnoid space, which extends out along the optic nerve

Question 60

How do you test cranial nerves 3,4,6?

Answer 60

Test them by doing eye movements (in all 9 planes) | Check for nystagmus

Question 61

What are the causes of nystagmus?

Answer 61

Being passed down from your parents. Other eye issues, like cataracts or strabismus. Diseases like stroke, multiple sclerosis, or Meniere's disease. Head injuries. Albinism (lack of skin pigment) Inner ear problems. Certain medications, like lithium or drugs for seizures. Alcohol or drug use.

Question 62

What does the trigeminal nerve do?

Answer 62

The trigeminal nerve has three sensory divisions- opthalmic, maxillary, mandibular Also has a motor component- supplies the muscles of mastication It carries all modalities of sensation from the face, the anterior part of the scalp, the eye and the somatic sensation from the anterior 2/3rds of the tongue Also innervates the gym, teeth, mucous membranes of the cheeks, nasal passages, sinuses and the anterior components of the palate and nasopharynx

Question 63

How do you test the motor function of the jaw?

Answer 63

Ask the patient to open the mouth and note any deviation of the jaw, if one is weak the jaw deviates to the side of the weak muscle If the lesion is supranuclear the jaw will deviate to the opposite side Then test the mouth opening against resistance

Question 64

What is the role of the facial nerve?

Answer 64

Can be remembered as FACE, EAR, TASTE, TEAR ``` Face= muscles of facial expression and blinking Ear= stapedius Taste= anterior 2/3rds of the tongue Tear= parasympathetic supply to the lacrimal glands ``` With lower motor neurone facial weakness all muscles are affected whereas with upper motor neurone facial weakness the forehead is preserved

Question 65

What is bells phenomenon?

Answer 65

The normal upward gaze of eyes however you can see it in bells palsy because the eye doesn’t close.

Question 66

How do you test the eight cranial nerve?

Answer 66

Rinnes and webers | Test balance

Question 67

What is the ninth nerve and what does it do?

Answer 67

The glossopharyngeal nerve Sensory- posterior 1/3rd of togue, pharynx, middle ear Motor- stylopharyngeus Autonomic- salivary glands (parotid)

Question 68

What are tremors?

Answer 68

Rhythmic symmetric movements of a body part, may be coarse or fine

Question 69

What is a resting tremor and what does this indicate?

Answer 69

A tremor which is worse with rest and eases with activity- pillrolling tremor Parkinsons disease

Question 70

What is postural tremor and what would this indicate?

Answer 70

When the tremor becomes worse with posture, for example if you out your arms out Causes... - salbutamol - hyperthyroid - encephalopathy

Question 71

What is an intention tremor?

Answer 71

This is when the tremor is worse when you are intending to do something ie: touch your finger to nose, vice versa Usually due to a cerebellar cause

Question 72

What is an essential tremor?

Answer 72

A type of postural tremor which happens with age Theres no underlying cause They tend to be referred to neurology Treatment= beta blockers

Question 73

What does parkinsonian gait look like?

Answer 73

Shuffling with difficulty turning around | Arm swinging in early stages

Question 74

What is antalgic gait?

Answer 74

This is common and is a short stance phase due to pain on walking Common causes,, OA, fractures

Question 75

What is waddling gait and what is it caused by?

Answer 75

This is where the patient swings from side to side like a duck It is due to an unstable pelvis (due to bilateral gluteal muscle weakness) Common causes- pregnancy, muscular dystophies etc...

Question 76

What is trendelenburg gait? What is it caused by?

Answer 76

See USMLE pass video This is an unstable pelvis due to contralateral gluteal muscle weakness Pelvis tilts on walking (hip drop)

Question 77

What are extrapyradimal symptoms?

Answer 77

Symptoms caused by antipsychotics 1) dystonia - stiffness/muscle rigidity/spams/ eye movements (deviations) Treated with anticholinergics- benztropine 2) akathisia Restlessness Canada q bank