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Neurology for finals

Neurology for finals. Gowri Sri Paranthaman FY1 Manchester Royal Infirmary. Collapse/ LOC Hx Temporal Arteritis + Rx + steroids advice Cerebellar ataxia Parkinson’s Epilepsy MND Confusion Myasthenia Gravis. Headache Hx Vertigo + nystagmus Acute Mx head injury Neuro exam

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Neurology for finals

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  1. Neurology for finals Gowri Sri Paranthaman FY1 Manchester Royal Infirmary

  2. Collapse/ LOC Hx Temporal Arteritis + Rx + steroids advice Cerebellar ataxia Parkinson’s Epilepsy MND Confusion Myasthenia Gravis Headache Hx Vertigo + nystagmus Acute Mx head injury Neuro exam Cranial nerves Higher cortical function SAH Neurofibromatosis Dementia Common past year OSCEs

  3. Cranial nerves I • Not tested much unless a frontal lobe tumor (usually unilateral anosmia) is suspected • “Has there been any change in your sense of smell?” • Test by asking if patients can smell orange, coffee, vanilla or cinnamon in each nostril. • Anosmia – blocked nasal passage, trauma, relative loss with ageing, Parkinsons, MS

  4. Cranial nerve II,III,IV and VI • Inspection - ptosis (partial-Horner’s/complete-3rd nerve palsy) • pupils (size, regular, accommodation and light reflex) • Visual Acuity • Color Vision • Visual Fields • Visual neglect • Fundoscopic Examination

  5. Eye movement - nystagmus/ disconjugate gaze • oculocephalic reflex - brainstem eye movement pathways are intact. (doll’s eye reflex) • horizontal and vertical and convergence

  6. Cranial nerve V • facial sensation - double simultaneous stimulation, test all 3 divisions • corneal reflex (CN 5 and CN 7) • Temporalis, masseter, pterygoid muscles (wasting, clench teeth, push mouth against hand) • jaw jerk reflex

  7. Cranial nerve VII • asymmetry in facial shape/ depth of furrows in nasolabial fold. • blink, smile, puff out cheeks, clench eyes tight, wrinkle brow etc • UMN lesion (stroke/tumour) - contralateral face weakness sparing the forehead • LMN lesion (facial nerve injury/ Bell’s) - weakness involving the whole ipsilateral face.

  8. Cranial nerve VIII • fingers rubbed together or words whispered • Rinne’s test (516 Hz) • Sensorineural deafness = louder at pinna (AC>BC) • Conductive deafness = louder at mastoid (BC>AC) • Weber’s Test • Normal = equally loud in both ears • Sensorineural deafness = louder in normal ear • Conductive deafness = louder in deaf ear

  9. Cranial nerve IX, X and XII • Ask patient to cough – hypophonia/bovine (uni/ bilat vocal cord weakness) • Speech • Swallowing- smooth/ delay • Say aah- elevation of palate – uvula deviation (contra lesion) • Gag reflex • Atrophy or fasciculations / deviation of tongue • Move tongue from side to side and push it forcefully against the inside of each cheek

  10. Cranial nerve XI • Sternocleidomastoid and trapezius • Shrug shoulders • Turn head against resistance

  11. Motor examination • Inspection • Tone • Power • Reflexes • Coordination

  12. Upper limb examination • Inspection: Muscle wasting, Fasciculation, Involuntary movements, Scars • Tone • Power -Shoulder abduction (C5) /adduction (C6,C7) -Elbow flexion (C5,C6) /extension (C7) -Wrist flexion (C6,C7) / extension (C6,C7) -Finger flexion (C8) / extension (C7,C8) -Finger abduction + thumb opposition (T1) • Reflexes -Biceps jerk + Supinator jerk(C5,C6) / Triceps jerk (C7,C8) Co-ordination -Finger to nose, ensuring patient can reach, only moves finger position as patient moves finger to nose -Dysdiadochokinesis -Finger-thumb opposition - one at a time

  13. Lower Limb examination • Inspection - scars, abnormal movements, abnormal posture, muscle wasting, fasciculations, hypertrophy, tremors • Tone • hip (rolling the leg at the knee) • knee (abrupt flexing of the knee) • clonus • Power -hip flexion (L1-3) and extension (L5,S1) -knee flexion (L5,S1) and extension (L3,L4)

  14. Power continued… -ankle plantar flexion (S1,S2) and dorsiflexion (L4,L5) -toes (curl them up and don’t let me open them) Compares power on each side, with isolation of muscle groups to prevent cheating • Reflexes -Knee jerk (L3/4) -Ankle jerk (S1/2) -Plantar reflex (L5,S1,S2) • Coordination -heel-shin test -foot tapping test

  15. Sensory examination • Light touch sensation with cotton wool with patient’s eyes closed - Compares dermatome on each side, any difference • Pain sensation with neurotip • Temperature • Vibration sense with a 128Hz tuning fork (eg on sternum) • start on distal joint • When does the vibrating stop? • Joint position sense on both sides

  16. Power Grading (Medical Research Council Scale) 0 No movement Flicker of movement Movement but not against gravity Movement against gravity but not resistance Weak movement against resistance Normal

  17. Gait • walking aids. safe to walk? Needs help? • straight line from one side of the room to the other and then walk back • Rhythm- antalgic gait, circumductive (hemiplegic), scissoring gait (spastic paraparesis with both legs adducted), waddling gait (weak hip abductors • Parkinsons - Slow to initiate movement, shuffling, festinant, loss of arm swing • Unilateral cerebellar disease - deviating towards side lesion.

  18. Cerebellar ataxia - walk heel to toe, broad based • High stepping gait - subacute combined, unilat- common peroneal nerve palsy, bilat - hereditary neuropathies - Charcot Marie Tooth • Walk on heels - foot drop, walk on toes - weakness of the S1 nerve root • Romberg’s test - more unsteady with eyes closed (proprioception loss)

  19. Parkinsonsism • Triad - Resting tremor, bradykinesia and rigidity • Face - Mask like, expressionless, little blinking, glabellar tap • Gait - Flexed posture, reduced arm swing, festinant, slow to initiate and stop movement • Tone – increased. Cog wheel/ lead pipe rigidity • Tremor- pill rolling • Speech – extrapyramidal dysarthria (slow, quiet and hesitant ) • Micrographia

  20. Upper motor neuron lesion • Stroke (hemiplegia), cerebral palsy, MS (spastic paraplegia) • No muscle wasting • Pyramidal weakness • Upper limb – weak abductors and extensors (flexed) • Lower limb – weak adductors and flexors (extension) • Increases tone (spasticity/ clasp knife) • Hyperreflexia and clonus. Upgoing plantar. • Circumductive gait

  21. Cerebellar lesions • Nystagmus (downbeat) • Slow, slurred , staccato/ scanning speech (British constitution) • Decreased tone, drift and tremor in limbs (usually upper) • Finger nose testing – Intention tremor and past pointing • Dysdiadokokinesis - • Rebound – oscillate above intended position • Ataxic gait DANISH

  22. Peripheral neuropathy • Usually generalised (diabetic), mononeuropathy (medicn nerve) or radiculopathy • Distal sensory or motor and sensory loss • Inspection - Pes cavus, wasting, fasciculation,clawing • Tone – decreased • Power – distal weakness • Reflexes – Reduced/ absent • Sensory – glove and stocking loss / paraesthesia • Disease affecting pathology of the peripheral nerves may be perfectly normal/ proximal weakness (Guillain- Barre syndrome) • Eg Charcot- Marie-Tooth,

  23. Myasthenia gravis • Opthalmoplegia, diplopia and ptosis • Proximal weakness and fatiguability (look to ceiling – look for ptosis or get up from chair from sitting – increased weakness on repetition) • Bulbar palsy –swallowing, aspiration, neck down • Diaphragm/intercostal weakness

  24. Charcot Marie Tooth • Foot drop - early presentation. Can cause hammer toe. • Wasting in distal lower limb - "stork leg" or "inverted bottle" appearance. • Weakness in the hands and forearms – later in life • Scoliosis is common. Hip can be malformed. • As vocal cords atrophy, problems with chewing, swallowing and speaking

  25. Higher cognitive function (MMSE) • Attention- rpt numbers + backwards and orientation- time, place, person • Memory – immediate, short and long term • Calculation – serial sevens • Abstract thought – explain proverbs/ diff between objects/ estimate (frontal) • Spatial perception – draw clock, time, 5 pt star • Visual and body perception – facial recog, hemineglect (parietal +occipital) • Apraxia – perform imaginary task, copy hand movements

  26. Collapse/ LOC • Witness testimony • Aura/ funny smell • Before/ during/ after incident • Timing • Previous history of collapse • PMH- esp cardiac/ vascular

  27. Headache • Location • Radiation • Mode of onset • Severity • Nature • Aggravating factors • Relieving factors • Duration • Periodicity • Associated features

  28. Remember… • To finish , I would like to examine upper/lower/CN • Cause – at least 3 • Investigations – Bloods, Antibodies, CSF, EMG, nerve biopsy, CT, MRI • Treatment – conservative, medical and surgical

  29. Thank you. • Any Q?

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