Presentations/introduction to neurology Flashcards
What is ptosis, bulbar symptoms, diplopia characteristic of?
Myaesthenia gravis!
What is bulbar palsy?
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.
What is hemiplegic gait?
Abduction and circumduction of the affected limb in patients with UMN lesion affecting the leg
What is spastic gait?
Scissoring gait found in spastic paraplegia
What is steppage gait?
Patients with footdrop the high stepping gait lifts the foot to avoid catching the toes, can be bilateral
What is ataxic gait?
Road bases, uncoordinated, unsteady gait characteristic of cerebellar syndromes or where is loss of proprioception
What is waddling gait?
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
What is a stamping gait?
Loss of proprioception the gait is ataxic with the advancing leg lifted too high and brought down with a solid stamp
What is parkinsonian gait?
Forward flexed, shuffling gait with reduced arm swing
What is antalgic gait?
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
What does suddenly usually mean in neurology?
Vascular
What would a hemiparesis/hemisensory problems point to?
They would point to problems with the brain (left or right)
What would visual disturbances point to?
Point to the brain
What sits in the brainstem?
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
What would you expect in a spinal cord lesion?
Para or quadripesis in terms of distribution
What would you expect with problems with the motor pathway?
You would expect upper and lower motor neurone signs
What would you expect with damage to nerve roots?
They are characteristically very painful if you squash or inflame them
Dermatomal sensory loss
Myotomal weakness
Loss of reflexes at the appropriate levels
What is the buzzword for myaesthenia gravis, and what points to neuromusclar junctions being affected?
Fatigue ability
No sensory impact
What would you expect if there was a problem with muscle?
Proximal weakness
Dont expect sensory involvement
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…
Cervical cord lesion vs peripheral neuropathy
Cervical cord lesion- UMN and a sensory level
Peripheral neuropathy- LMN and glove/stocking distribution of sensory loss
What would an up-going plantar reflex indicate?
UMN lesion
What would a horners syndrome indicate?
It indicates a sympathetic problem on the same side
What should you assess when assessing motor symptoms?
Observation Tone Clonus Power- pyramidal, long tract, UMN Reflexes- root values- best mnemonic Plantars Hoffmans(reflexes)
What is bulbar palsy?
Refers to speech and swallowing difficulties
What can movement disorders involve?
They can be hyperkinetic with additional involuntary movements
Hypokinetic with stiffness and slowness (seen in parkinsons)
What is the frontal lobe responsible for?
Personality Exucative activity (more comolex actions- zipping coat/ driving)
What does the temporal lobe do?
It has the primary auditory cortex
What is the role of the occipital lobe?
Has the primary visual pathways
What does the parietal lobe?
Has a role in interpretating input from frontal, temporal, occipital
What is the cerebellum responsible for?
Fine motor control
What is the brainstem responsible for?
Breathing, heart rate, temperature control
Recieves input from the hypothalamus
What is the basal ganglia responsible for?
Plays a big role in movement, really important when you start thinking about parkinsons disease and huntingtons disorder.
What would an infarct to the middle cerebral artery present with?
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
What would an infarct to the anterior cerebral artery affect?
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.
What is the corpus callosum?
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
What are the two arteries which take blood up to the brain?
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!
What is the role of the cerebellum?
Tone
Posture
Balance
For example: if somebody was helping move house
What reflexes are important at the brainstem?
The cough reflex
The vomiting reflex
The blink reflex
The jaw jerk reflex
What is the role of the basal ganglia and what happens when it is damaged?
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)
What do you get when the cerebellum is damaged?
Ataxia and incoordination of limbs and gait
Vertigo
Nystagmus
What do you get if there is damage to the brainstem?
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
What are the signs of spinal cord damage?
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
What do you get if nerve roots are damaged?
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
What do you get if a peripheral nerve is affected?
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
What signs do you get if the neuromuscular junction is affected?
Fatigue (especially with chewing and proximal limb muscles)
Weakness without any sensory loss
Ptosis with changing diplopia
No muscle atrophy
What are the signs of the muscle being affected?
Weakness without sensory loss
Proximal muscles will be more weak than distal
Weakness that is often slowly progressive
Muscle atrophy or pseudo hypertrophy
What would a patient present with if they had problems with the meninges/CSF?
Diffuse headache
Meningismus (neck stiffness, photophobia, headache)
Cranial nerve abnormalities
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
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
What is meant by delirium?
An acute onset of abnormal mental state, with disturbed consciousness, disorientation, severe motor restlessness, fear, irritability, visual hallcuinations.
What is aphasia?
An impairment of language, affecting the production or comprehension of speech and the ability to read or write
What is the difference between brocas and wernicks aphasia?
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
Where is the brocas and wernickes area located?
Brocas area is located in the left hemisphere of the frontal lobe
Wernickes area is located in the posterior superior temporal lobe
How do you test the olfactory nerve?
Has the patient had a change in sense of smell
Use of smelling substances
What is anosmia caused by?
Blocked nasal passages
Common cold
Trauma
Relative loss occurs with ageing and parkinsons disease
How do you test the optic nerve?
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
What nerves do the pupillary light reflex and accomadation reflex involve?
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
What are two abnormalities related to pupil reactivity?
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)
What is RAPD?
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
What does papilloedema mean and what is it a result of?
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
How do you test cranial nerves 3,4,6?
Test them by doing eye movements (in all 9 planes)
Check for nystagmus
What are the causes of nystagmus?
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.
What does the trigeminal nerve do?
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
How do you test the motor function of the jaw?
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
What is the role of the facial nerve?
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
What is bells phenomenon?
The normal upward gaze of eyes however you can see it in bells palsy because the eye doesn’t close.
How do you test the eight cranial nerve?
Rinnes and webers
Test balance
What is the ninth nerve and what does it do?
The glossopharyngeal nerve
Sensory- posterior 1/3rd of togue, pharynx, middle ear
Motor- stylopharyngeus
Autonomic- salivary glands (parotid)
What are tremors?
Rhythmic symmetric movements of a body part, may be coarse or fine
What is a resting tremor and what does this indicate?
A tremor which is worse with rest and eases with activity- pillrolling tremor
Parkinsons disease
What is postural tremor and what would this indicate?
When the tremor becomes worse with posture, for example if you out your arms out
Causes…
- salbutamol
- hyperthyroid
- encephalopathy
What is an intention tremor?
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
What is an essential tremor?
A type of postural tremor which happens with age
Theres no underlying cause
They tend to be referred to neurology
Treatment= beta blockers
What does parkinsonian gait look like?
Shuffling with difficulty turning around
Arm swinging in early stages
What is antalgic gait?
This is common and is a short stance phase due to pain on walking
Common causes,,
OA, fractures
What is waddling gait and what is it caused by?
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…
What is trendelenburg gait? What is it caused by?
See USMLE pass video
This is an unstable pelvis due to contralateral gluteal muscle weakness
Pelvis tilts on walking (hip drop)
What are extrapyradimal symptoms?
Symptoms caused by antipsychotics
1) dystonia
- stiffness/muscle rigidity/spams/ eye movements (deviations)
Treated with anticholinergics- benztropine
2) akathisia
Restlessness
Canada q bank
