Week 5 Neurology

Question 1

How does the gait of someone with a functional leg weakness present differently to a structural?

Answer 1

It is often a dragging gait rather than a swinging one

Question 2

What is the telltail sign of a functional tremor?

Answer 2

Can be eased by distracting the patient

Question 3

How does a functional seizure present differently to an epileptic seizure?

Answer 3

Question 4

Do you get changes in the brain in NFD?

Answer 4

Yes

Question 5

How to treat FND?

Answer 5

An explaination fo the illness plus PT/OT

Question 6

What is Anhedonia

Answer 6

Finding little pleasure in doing things or little motivation to do things

Question 7

Which chemicals are commenly diminished in patients with depression?

Answer 7

Question 8

Common antidepressant and how it works?

Answer 8

Sertraline

It is an SSRI which stands for selective seritonin reuptake inhibitor.

It prevents your synapse from taking seritonin back up thus there is more available in the synapse

Question 9

What is the timeframe for when pain moves from acute to chronic?

Answer 9

Acute: 0-3 months
Chronic: 3-6 months

Question 10

What is the difference between primary and secondary chronic pain?

Answer 10

Primary: No known cause
Secondary: Due to an underlying condition

Question 11

Where is the perception of pain modulated?

Answer 11

In the thalamus.

Pain signal travel up the spinothalamic tract. Once they reach the thalamus they are combined with other sensory inputs, cognitive and emotional signals into the perception of pain.

Question 12

Under normal conditions how is pain downregulated?

What stimulates this pathway?

Answer 12

In an area called the periaqueductal grey mater serotonin is released and travels down where it triggers the release of endogenous opioids in the dorsal horn spinal cord interneurons.

This pathway can be stimulated by the anticipation of pain relief e.g. placebo pain medication or by emotionally supportive efforts by the clinition

Question 13

What is the periaqueductal grey mater?

Answer 13

This is grey meter surround the cerebral aquaduct in the midbrain.

It releases serotonin triggering the downregulation of pain signals.

Question 14

Where is periaqueductal grey mater?

Answer 14

Surrounding the cerebral aquaduct in the midbrain.

Question 15

What is the part of the brain that releases serotonin beginning the process of downregulation of pain?

Answer 15

Periaquaductal grey meter.

Hint: to be around rivers and streams in soothing

Question 16

What is the area of the spinal chord that recieves seroronin from the periaquaductal grey mater and in responses releases endogenous opiods?

Answer 16

dorsal horn spinal cord interneurons

Question 17

When it comes to the peripheral nervous system what does the term sensitization mean?

Answer 17

It refers to how strong a signal is produced by the same noxous stimuli.

For example in infected tissue a reduced acidic pH results in the stimulation threshold being decreased, thus pressure on an infected area causes more pain than pressure on an unaffected area.

Question 18

What are the three steps to pain management.

What does this tell you about reviewing?

Answer 18

There is a fine balance between suffering and addiction risks.

Regular reviews are necessary in order to establish which level a person is it.

Question 19

What are these features of?

Constricted pupils
Reduced respiratory effort
Hypotension
Low GCS

Answer 19

opioid overdose

Question 20

Which opioid receptors are responsible for respiritory depression?

Answer 20

μ-opioid receptors

When excited these are responsible for respiratory rate, inspiratory volume, CO2 chemoreception and pharyngeal function

Question 21

WHat is the mechanism of naloxone?

Answer 21

It has a higher affinity for opioid recptors but doesn’t depress them in the same way.

Question 22

WHat is the definition of neuropathic pain?

Answer 22

Pain caused by damage to a nerve through degregation, inflamation, compression etc.

Question 23

What is the mechanism of amitriptyline and what drug class is it?

Answer 23

Tricyclic antidepressant.

It is a serotonin reuptake inhibito like SSRIs however it also affects the reuptake of norepinephrine.

Question 24

What is the mechanism of gabapentin and pregabalin?

Answer 24

Gabapentin and pregabalin act on calcium channels pre-synaptically to reduce release of pro-nociceptive neurotransmitters. They decrease excitability, especially in the spinal cord.

Question 25

What is the mechanism by which opioids decrease pain?

Answer 25

The bind to opioid receptors blocking dopamine inhitory neurons. This encourages the reslease of dopamine between the secondary and tertiary neuron where the tertiary neurons releive pain. HInt: opioids are dope

Question 26

Where do pain patchs work?

Answer 26

At the skin nociceptors.

Question 27

What does a benzo overdose look like?

Answer 27

Similar to an opioid overdose but without the contricted pupils. Use flumazenil if you are sure of drug and dose and airway is threatened

Question 28

Presentation and treatment of an SSRI overdose

Answer 28

Presents as serotonin syndrome. "Serotonin syndrome" N&V, agitation, tremor, nystagmus, dilated pupils, tachycardia, neuromuscular hyperactivity, hyperthermia. Monitoring & Supportive treatment

Question 29

Treatment of an amitryptaline overdose?

Answer 29

Amitriptyline (Antidepressant / Neuropathic analgesia) Inihibits serotonin & noradrenaline reuptake, blocks Na+ channels but non-specific & broad symptoms. Arrhthymia, seizure, coma. Sodium bicarb to correct acidosis.

Question 30

What is the everyday purpose of stretch reflexs?

Answer 30

Contraction of a muscle in response to sudden stretch in order to maintain balance

Question 31

Which parts of the labarynth are responsible for hearing and which parts balance?

Answer 31

* Vestible & Semicircular canals (balance) * Cochlea (hearing)

Question 32

Which forms of awareness are the vestible and semicircular canal responsible for?

Answer 32

Vestibule Oval structure at the centre of the labyrinth Utricle and saccule detect linear acceleration - head position with respect to gravity Semicircular Canals 3 ‘loops’: anterior, posterior and lateral Detect angular (rotational) acceleration

Question 33

Which spacial planes do the different semicircular canals occupy?

Answer 33

Anterior and posterior in vertical plane Lateral in horizontal plane

Question 34

How do the cells of the vestibular system recieve movement information?

Answer 34

Cells of the vestibular system detect movement of fluid in the labyrinth using mechanosensitive hair cells Apical surface covered by cilia, membrane-bound hair like projections. The cells are covered by the otolithic membrane, a jelly like structure containing many small crystals called otoliths. Movement results in the otolithic membrane lagging behind the layer of hair cells due to inertia Hair cells act as transducers, converting kinetic energy into nervous impulses.

Question 35

Three different types of dizzyness and what they mean for the causes

Answer 35

Question 36

What is benign paroxysmal positional vertigo (BPPV) Pathophysiology, prognosis, diagnoses and treatment?

Answer 36

Presence of otolithic debris affecting free flow of endolymph in semicircular canals Typically spontaneous, may follow after minor head injury Transient (seconds) precipitated by movement Self-limiting after weeks or months Dix-Hallpike manoeuvre is diagnostic, Epley manoeuvre helps move debris to utricle and saccule

Question 37

What is the Dix-Hallpike manoeuvre?

Answer 37

You rotate the patients head by 90 degrees. Then ask them to lie down radidly while supporting the head. If this makes the dizzyness worse and you observe nystigmus then it is a dianogses of BPPV

Question 38

What is Nystagmus?

Answer 38

Nystagmus is a rhythmical, repetitive and involuntary movement of the eyes. It is usually from side to side, but sometimes up and down or in a circular motion.

Question 39

What does BPPV stand for?

Answer 39

Benign paroxysmal positional vertigo (BPPV)

Question 40

What is the Epley manoeuvre?

Answer 40

Patient turns their head to the affected side and performs dix-hallpike. They then wait and turn their head to the other side. Then also rotate the body and sit up. This should help move the debris to the vestible

Question 41

What manouvre would you use to treat BPPV?

Answer 41

Epley manouvre

Question 42

What manouvre would you use to diagnose BPPV?

Answer 42

Dix-hallpike manouvre

Question 43

What could it be if a patient presents with vertigo combined with tinitis, increasing deafness and feeling of fullness in the ear?

Answer 43

Ménière disease

Question 44

Examples of vestibular sedatives?

Answer 44

Drugs that decrease vertigo. * Antihistamines: Cinnarizine, dimenhydrinate, and meclizine * Dopamine receptor antagonists: Prochlorperazine * Anticholinergics: Scopolamine * Benzodiazepines: Diazepam (Valium), clonazepam, lorazepam, and alprazolam Short answer: ines

Question 45

Prevelence of delirium?

Answer 45

Very common, affecting ~25% of all hospital in-patients The top clinical presentation for a junior doctor to be familiar with

Question 46

What is the screening tool for dilerium called?

Answer 46

4AT Hint: The 4 legged ATATs fell over due to dilerium

Question 47

What do each of these labels say? And decribe the pathways of visual information

Answer 47

Light enters form the visual field, is focussed, crosses over then lands on the temporal or nasal regions of the retina. It then travels up the optic nerve. Information from the nasal portion of the optic nerve (temporal visual field) then crosses over at the optic chiasm. Information from each visual field then travels up the optic tract and to the lateral geniculate body. Fibres from the lower and upper visual fields separate with lower travelling through the temporal lobe and upper travelling through the anterior parietal. They then reach the occipital cortical areas in the optic radiation.

Question 48

What are the names for the following visual field defects?

Answer 48

Question 49

Decribe the experience of the following visual field defects

Answer 49

Question 50

What visual field defects would you get from lesions at the following sites?

Answer 50

Question 51

When there is a lesion in the visual cortex why do you get macular sparing?

Answer 51

Macular sparing occurs because the visual cortex has a dual blood supply from the middle cerebral artery (MCA) and the posterior cerebral artery (PCA). If one vascular pathway is damaged, the macular regions of the visual cortex can still rely on the other blood supply

Question 52

What is pappilodema a sign of?

Answer 52

Increased ICP

Question 53

Which part of the retina is responsible sensing red/green light?

Answer 53

Cones 2 major layers: * Neurosensory retina * Retinal pigment epithelium Neurosensory retina * Photoreceptors – specialised neurons for phototransduction * Rods - ↑sensitive, ↓acuity, no colour * Cones - ↓sensitive , ↑acuity, red/green * Ganglion – new (2007), blue, circadian rhythm Retinal pigment epithelium: * Maintain overlying neurosensory layer * Absorbing scattered light * Blood/eye barrier Hint: Traffic cones are red

Question 54

Which part of the retina is responsible sensing blue light and circadian rythm?

Answer 54

Ganglion 2 major layers: * Neurosensory retina * Retinal pigment epithelium Neurosensory retina * Photoreceptors – specialised neurons for phototransduction * Rods - ↑sensitive, ↓acuity, no colour * Cones - ↓sensitive , ↑acuity, red/green * Ganglion – new (2007), blue, circadian rhythm Retinal pigment epithelium: * Maintain overlying neurosensory layer * Absorbing scattered light * Blood/eye barrier

Question 55

What does the primary visual cortex do?

Answer 55

**Primary Visual Cortex Occipital lobe Receives direct visual signal input originating from the contralateral side (e.g. left visual field to right PVC)** Higher Visual Centres (ventral-dorsal model) Dorsal Stream Posterior parietal cortex ‘where/how’ pathway Integrates vision with motor/sensation Ventral Stream Inferior temporal cortex ‘what’ pathway Form recognition, object representation, visual memory

Question 56

What does the dorsal stream do and where is it?

Answer 56

Primary Visual Cortex Occipital lobe Receives direct visual signal input originating from the contralateral side (e.g. left visual field to right PVC) Higher Visual Centres (ventral-dorsal model) **Dorsal Stream Posterior parietal cortex ‘where/how’ pathway Integrates vision with motor/sensation** Ventral Stream Inferior temporal cortex ‘what’ pathway Form recognition, object representation, visual memory

Question 57

What does the ventral stream do and where is it?

Answer 57

Primary Visual Cortex Occipital lobe Receives direct visual signal input originating from the contralateral side (e.g. left visual field to right PVC) Higher Visual Centres (ventral-dorsal model) Dorsal Stream Posterior parietal cortex ‘where/how’ pathway Integrates vision with motor/sensation **Ventral Stream Inferior temporal cortex ‘what’ pathway Form recognition, object representation, visual memory**

Question 58

What is visual agnosia? Which part of the brain is likely affected?

Answer 58

Visual Agnosia * Inability to visually recognise objects * Lesions of ventral stream - occipital and/or temporal lobes

Question 59

What is the part of the brain that communicates information about coordination of eye's movements from the midbrain and pons to the cranial nerves responsible for eye movement?

Answer 59

Medial longitudinal fasciculus (MLF)

Question 60

What does a lesion in the MLF result in?

Answer 60

Disconjugate eye movements Also known as Internuclear Ophthalmoplegia

Question 61

What is an ocularvestibular response?

Answer 61

A reaction where you look towards an irritation in the ear

Question 62

When might you test for an ocularvestibular response?

Answer 62

To look for MLF lesions in comatose patients (you can't ask them to move eyes)

Question 63

How does Internuclear Ophthalmoplegia present and what does it signify?

Answer 63

Inability to adduct. Dysconjugste eye movements. Signifies a lesions in the medial longitudinal facsiculus This is different to an occulomotor nerve palsy as the resting gaze will be normal. And diplopia will only be present when looking horizontally.

Question 64

Where are visual movements cordinated?

Answer 64

In the midbrain and pons

Question 65

What is the difference between wernicke's area and broca's area?

Answer 65

Wernicke’s Area (Sensory) * Location: posterior temporal lobe * Inputs: 1. Sounds of words sent from auditory pathways 2. Visual representation of words from visual pathways * Function: temporal speech/language comprehension Broca’s Area (Motor Programming) * Location: dominant inferior frontal gyrus * Inputs: Temporal and parietal lobes via the arcuate fasciculus * Outputs: cranial nerve nuclei in pons, medulla controlling bulbar muscles

Question 66

Describe the differences between expressive dysphasia, receptive disphasia and conduction dysphasia. Which parts of the brain are affected?

Answer 66

Expressive Dysphasia (Broca’s area) Effortful and broken speech (telegraphic) Comprehension may be intact Receptive Dysphasia (Wernicke’s area) Difficulty understanding language Fluent and effortless speech, but may lack meaning Conduction Dysphasia (arcuate fasciculus) Intact comprehension and fluent speech, but poor speech repetition

Question 67

What is the arcuate fasciculus?

Answer 67

Connects Wernicke's to Broca's. Disruption of this area causes conduction dysphasia where articulation and understanding are fluent however you can't repeat words when instructed as communication between reception and expression is broken therefore the two aren't linked.

Question 68

Difference between dysarthria, dysphonia and anathria?

Answer 68

Dysarthria – Impairment of speech production due to neurological damage to the motor component of speech. Sounds slurring Anarthria – Total loss of speech production Dysphonia – Impairment of speech production due to changes in the vocal apparatus. Sounds hoarse, raspy

Question 69

WHat is it called when speech is impaired due to Impairment of speech production due to neurological damage to the motor component of speech and it sounds slurring?

Answer 69

Dysarthria

Question 70

What is it called when speech is impaired due to changes in the vocal apparatus and it sounds hoarse, raspy

Answer 70

Dysphonia

Question 71

What is 5-hydroxytryptamine known as?

Answer 71

Serotonin