Pathologies in which cranial nerves could cause diploplia?
- CN III, IV, VI (oculomotor, trochlear, abducens)
1) What is a classic UMN lesion pattern on examination?
2) What is a classic LMN lesion pattern on examination?
1)
- ↑ Tone (spasticity) - due to reduced central descending inhibition
- ↓ Power
- ↑ Reflexes (hyperreflexia) - upgoing plantars
2)
- ↓ Tone (flaccid)
- ↓ Power
- ↓ Reflexes
What are the cerebllar signs?
Problems with coordination
- Ataxia
- Nystagmus
- Dysdiadochokinesia
- Intention tremor - dysmetria, pass-pointing
- Speech
What are the causes of cerebellar lesion?
- Vascular - bleed
- Infection - TB, VZV cerebellitis
- Inflammation - MS
- Tumour - primary, secondary metastases
- Toxins - alcohol, phenytoin
What is the distribution of sensory loss based upon the location of the lesions
1) Cerebral cortex?
2) Spinal cord?
3) Nerve roots (radiculopathy)?
4) Polyneuropathy (multiple peripheral nerves)?
5) Mononeuropathy (single peripheral nerve)?
1)
- Hemisensory loss
2)
- Level e.g. umbilicus
3)
- Dermatomal distribution
4)
- Glove and stockings distribution
5)
- Specific area
Give an example of a cause of polyneuropathy and a cause of mononeuropathy
- Polyneuropathy - diabetic neuropathy
- Mononeuropathy - mendian nerve in carpal tunnel syndrome
Which drug would you use in someone with diabetic neuropathy?
- Duloxetine
List some possible causes of peripheral neuropathy
- Vascular - none
- Infection - HIV
- Inflammation / autoimmune
- Guillan-Barre (acute inflammatory demyelinating polyneuropathy)
- Chronic inflammatory demyelinating polyneuropathy
- Connective tissue disease
- Vasculitis
- Tumour
- Paraneoplastic manifestation
- Paraproteinaemia
- Toxin
- Alcohol
- Cisplatin
- Amiodarone
- Metronidazole
- Phenytoin
- Isoniazid
- Nitrofurantoin
- Gold
- Metabolism
- Diabetes
- B12 deficiency
- Amyloidosis
- Chronic kidney disease
- Hereditary
- Hereditary sensory motor neuropathy
- Long-standing peripheral neurpathy causes pes cavus (high arch, clawing of toes)
- E.g. Charcot-Marie-Tooth, Dejerine-Sottas disease, Refsum disease
1) In one sentence, what happens in amyloidosis?
2) What are the different types of amyloidosis?
1)
- Deposition of abnormal protein in various organs, affecting function
2)
- Amyloidosis with myeloma
- Myeloma - increased production of immunoglobulin with light chain, these light chains become the precursors of amyloid fibrils
- Chronic infection / inflammation - serum amyloid A inflammatory protein
What sign do you see on fundoscopy in papilloedema and what does papilloedema suggest and how does this present clinically?
- Ill-defined optic disc margins
- Papilloedema suggests raised ICP
- Blurred vision, painless
What sign do you see on fundoscopy in papillitis and what does papillitis suggest - what conditions. How does papillitis present clinically?
- Ill-defined optic disc margin (like in papilloedema)
- Papillitis = Optic neuritis (inflammation of the head of the optic nerve) often in demyelination disorders such as MS
- Blurred vision, painful eye movements
List the different pathologies of the spinal cord you can get
- Vascular - e.g. anterior spinal infarct
- Infection - e.g. Pott’s disease (TB of spine)
- Inflammation - e.g. MS, Transverse myelitis (associated with mycoplasma pneumonia)
- Tumour - primary spinal cord tumour or secondary metastasis
- Toxin -
- Metabolic - e.g. B12 deficiency
What type of disorder is MS and how does it characteristically present?
- Demyelinating disorder
- Multiple lesions evident separated in time and space
- E.g. Optic neuritis shown by papillitis - optic nerve lesion
- E.g. Spinal cord lesion - causing paresis
Question about meralgia paraesthetica - see DPD notes page 39
1) What is the distribution of sensory loss in radiculopathy (nerve root pathology)?
2) List the causes of radiculopathy (nerve root pathology)
1)
- Dermatomal
2)
Compression by:
- Disc herniation
- Spinal canal stenosis
- Osteoarthritis - osteophyte compression on nerve roots
1) Recall the sensory innervation of the hand
2) If there is a pathology of the median nerve, what muscle and movement is affected?
3) If there is a pathology of the ulnar nerve, what muscle and movement is affected?
4) If there is a pathology of the radial nerve, what muscle and movement is affected?
1)
- See diagrams
2)
- Abductor pollicis brevis - opposition
3)
- Incomplete answer
4)
- Incomplete answer
1)
What is the basic principle of the pathophysiology of Parkinson’s disease?
2)
What are the characteristic signs of parkinson’s disease?
1)
- Loss of dopaminergic neurones in substantia nigra
2)
Triad of…
- Pill rolling tremor
- Rigidity (↑ tone, cogwheel rigidity)
- Bradykinesia
What are the features of lewy body dementia?
- Features of alzheimer’s disease
- Parkinson’s
- Hallucinations
List the possible causes of confusion - differential diagnoses
- Hypoglycaemia
- Vascular - subdural haematoma (fall, fluctuating consciousness), other bleeds
- Infection - temp? intracranial infection - headache and neck stiffness in meningitis and behaviour change in encephalitis, extracranial infection? In pneumonia, sepsis
- Inflammation - cerebral vasculitis?
- Tumour
- Toxins / Metabolic
- Drugs
- U&Es
- LFTs
- Vitamin deficiencies
- Endocrinopathies (Cushing’s may appear psychotic)
Outline the different aspects of the GCS and how to assess / score them
- Eyes (4)
- Spontaneously open
- Open to command
- Opens to pain
- Not open
- Verbal (5)
- Talking
- Confused
- Words
- Sounds
- None
- Motor (6)
- Obeys commands
- Localise pain
- Withdrawals to painful stimuli
- Abnormal flexion
- Extension
- Nothing
What is the AMTS used to assess and how is it carried out?
- Used to assess confusion
- Recall - tell patient to remember a phrase e.g. ‘West Register Street’
- DOB
- Age
- Time
- Year
- Place
- Recall (West register street) - ask patient to recall the phrase you asked them to remember
- Recognise doctor / nurse
- Prime minister
- Second World War
- Count backwards from 20 to 1
What signs and symptoms are there on examination in meningitis?
- Headache
- Fever
- Neck stiffness
- Photophobia
- Kernig’s sign (pain when leg raised and knee straightened)
What are characteristic features of subarachnoid haemorrhage?
- THUNDERCLAP HEADACHE (sudden onset, very severe)
- Meningism
- Headache
- Neck stiffness
- Photophobia
1) What are the characteristic presentations of giant cell arteritis (temporal arteritis), who is it most common in and what is it highly associated with?
2) What is the investigation for giant cell arteritis?
3) What is the treatment for giant cell arteritis?
1)
- Jaw claudication
- Scalp tenderness
- Most common in >50yr olds
- Highly associated with polymyalgia rheumatica (shoulder girdle pain, stiffness, constitutional upset- fever, malaise)
2)
- ↑ ESR
- Biopsy
3)
- Prednisolone (reduce risk of blindness)
