1
Q
General inspection of Parkinson’s disease
A
Hypomimia
Resting tremor - exacerbated by counting backwards
Stooped posture
2
Q
Eye exam in parkinson’s disease
A
Nystagmus –> MSA?
Vertical gaze palsy –> PSP?
3
Q
Gait in parkinson’s disease
A
Stooped
Shuffling
ABSENT ARM SWING
Slow initiation
4
Q
Extras to an examination of PD patient
A
- Assess for micrographia
- Assess gait
- BP lying + standing
- MMSE
- Drug chart
- Abdominal examination
- Abdo exam (Wilson’s disease = liver failure)
5
Q
Causes of parkinsonism
A
- Idiopathic
- Parkinson + (MSA, PSP, Lewy body)
- Multiple SNigra infarcts
- Wilson’s disease
- Antipsychotics
6
Q
What parts of the Hx may point you towards a cause for parkinsonism?
A
- Lewy body: visual hallucinations, memory problems
- Infarcts in SN: sudden onset
- MSA: postural hypotension, bladder/bowel problems
- Antipsychotics: drug Hx
7
Q
Ix in ?PD?
A
It’s a clinical dx!
but must do CT/MRI to exclude a vascular cause
- DaTscan (iodine isotope injection which binds to DAergic neutrons in SNigra)
8
Q
Medical Tx of Parkinsons
A
L-DOPA + DDCinhibitors
- DA agonists (ropinirole)
- MAO-B inhibitors (Selegiline)
- COMT inhibitors (entacapone)
9
Q
Unwanted side effects of L-DOPA?
A
- Dyskinesias (occur in peak therapeutic effect)
- On-off effect
- Psychosis
- Nausea/GI upset
- Hypotension
10
Q
Features of parkinsonism
A
- Bradykinesia
- Rigidity
- Tremor
Gait: slow to start, festinating, absent arm swing, shuffling
- Tremor
- Hypomimia
- Micrographia
- SLEEP disorder
- Depression
11
Q
Sleep disorder in PD patients
A
- Insomnia + frequent waking
- Restless legs + early morning dystonia
- Nocturia (from auto- dysfunction)
- Violent enactment of dreams
12
Q
Features of PSP?
A
Postural instability –> falls
Vertical gaze palsy
Speech + swallow problems (pseudo bulbar palsy)
Tremor is unusual
13
Q
Features of Lewy body dementia
A
Parkinsonism precede memory loss
Visual hallucinations!
14
Q
Ddx for tremor
A
Intention tremor = cerebellar
Resting tremor = parkinsonism
Postural (i.e. worse w arms outstretched)=
- Thyroid
- EtOH withdrawal
- SABA/LABA use
- Anxiety
15
Q
Features of multi system atrophy
A
Autonomic dysfunction: postural hypo, bladder/bowel dysfunction
Cerebellar syndrome!!!
- nystagmus
16
Q
how many cervical nerves and cervical vertebrae
A
Cervical nerves: C1-8
Cervical vertebrae: C1-7
All cervical nerves arise from ABOVE their corresponding vertebrae BUT C8 nerve arises from between C7 and T1 vertebrae
17
Q
symmetrical + distal LMN signs = where is the lesion?
What are the differential
A
Peripheral motor polyneuropathy
- Charcot Marie Tooth
- Paraneoplastic
- Guillain-Barré syndrome
18
Q
Findings on examination in Charcot Marie Tooth?
A
- Champagne bottle legs
- Highs stepping gait w foot drop
- High- arched foot
- Sensory loss in stocking distribution
19
Q
Investigations in Charcot Marie Tooth
A
Nerve conduction studies
Genetic testing
20
Q
Mx of Charcot Marie tooth
A
Supportive
MDT: GP, physio, neurologist, specialist nurse OT
- foot care + special shoe choice
- ankle braces
21
Q
Define GBS
A
autoimmune demyelinating polyneuropathy
22
Q
Features of GBS
A
preceding infection (campylobacter)
- ascending hypotonia + weakness
- paraesthesia
- breathing + swallowing probs
- Autonomic probs: labile BP, urinary retention
23
Q
Pathophysiology of GBS
A
cross-reactivity of antibodies to infection –> attacks gangliosides
24
Q
Ix for diagnosis of GBS
A
- Look for infection eg stool culture
- Anti-ganglioside antibodies
- Nerve conduction studies (low conduction velocity due to demyelination)
- LP: high CSF protein levels!
25
Mx of GBS
Supportive:
AIRWAY: ITU if FVC<1.5L
ANALGESIA
AUTONOMIC: catheter +/- inotropes
Definitive:
IVIG, plasma exchange
Physio
26
Ddx for bilateral + symmetrical proximal muscle weakness
Proximal myopathy
Endocrine:
DM, hyperthyroidism, cushings, acromegaly
EtOH, statins, steroids
Paraneoplastic
Inherited: MD
Inflammatory: Dermato/polymyositis
27
Ddx for Hand wasting
Muscle atrophy - think LMN
AHC: MND, old polio, Charcot Marie Tooth
Nerve root (C8T1): Spondylosis
Plexus: cervical rib compression
Neuropathy: Charcot, DM
Muscle: RA (disuse), myotonic dystrophy
28
Ix for proximal myopathy
```
Glucose/HbA1c
TSH
9am cortisol
LFTs - alcohol
CK (statins)
Anti-jo1
CXR
EMG
Genetic analysis
```
29
CN7 palsy - forehead involvement = ? causes?
Forehead involvement = LMN lesion
```
Cerebellopontine angle tumour
Bells palsy
Otitis media, RH syndrome
Parotid malignant tumour
Trauma
```
Systemic = DM, HIV, sarcoid
30
CN7 palsy - forehead sparing = ? causes?
UMN lesion
CVA
MS
SOL
31
Features of cerebellopontine angle tumour
CN 5678 involvement:
- DANISH
- loss of corneal reflex
- facial muscle weakness
- vertigo, tinnitus, sensorineural deafness
32
Mx of Bells palsy
```
Conservative:
Protect eye - dark glasses, artificial tears, tape eye @ night
Medical:
PREDNISOLONE w/i 72 hours
(if ?VZV give valaciclovir)
```
(Surgery: plastics if no recovery)
33
Prognosis of Bells Palsy
Full recovery = 80%
Remainder: delayed recovery or permanent neuro/cosmetic changes
34
Myasthenia Gravis - Ix?
- Tensilon test (improvement w anticholinesterase)
- anti-cholinesterase antibodies
- EMG
- CT thorax (thymoma!!!)
- TFTs (graves is common)
- Spirometry - esp FVC
35
Findings on inspection of myasthenia gravis
Thymectomy scar
Bilateral ptosis
Snarl
36
3 ways to assess fatiguability in myasthenia gravis
1. Repeatedly flap arm
2. Ask to count down from 50
3. Ask them to look up --> bilateral ptosis
37
Management of myasthenia gravis
Acute: IVIG/plasmapharesis
Chronic: PYRIDOSTIGMINE
Thymectomy - of benefit even if no thymoma
38
Important investigation in bilateral proximal muscle weakness that improves on testing
Anti-VGCC
| CT thorax: usually a paraneoplastic syndrome due to SCLC!!!
39
In any patient with CN3 palsy, what investigation would u do in all patients
CT angiogram = a sign of a PCA aneurysm
40
Dangerous differentials for Horners syndrome
Apical lung tumour
| Carotid artery dissection/aneurysm
41
secondary prevention for stroke/TIA
Optimise RFs (smoking, wt loss, HTN, DM)
STATIN (everyone)
Clopidogrel 75mg OD for everyone unless on anticoagulation
Warfarin/NOAC: if cardioembolic stroke/AFib/venous sinus thrombosis/dissection
42
Causes of foot drop?
| Associated sensory features
Fibular head trauma
Sitting cross legged
Loss of sensation along lateral lower leg
43
What nerve is at risk of damage in distal humerus fracture?
| Presentation?
Ulnar nerve
Weakness of finger abduction
Ulnar claw - flexed 4th and 5th finger - ONLY if lesion is close to rist
Can't do 'good luck' sign
Loss of sensation in ulnar 1.5 fingers
44
Weak elbow extension
| wrist drop
Radial nerve damage at the axilla
45
Wrist drop + finger drop
Lesion is of radial nerve, at the humerus
46
Waiters tip - where is the lesion? cause?
C56 i.e. higher brachial plexus
| - shoulder dystocia
47
Ulnar paradox
Ulnar claw is worse the more distal the lesion is:
close to wrist: medial lumbricals weakened -- > 4+5th fingers flexed
More proximal: Flexor dig prof weakened --> 4+5th fingers less flexed!
48
Wasting of dorsal muscles of hand
Claw hand
Lesion? Cause?
Lower brachial plexus injury (C8T1)
Cause: trauma from suddenly arm is pulled superiorly (tree)
OR Apical lung tumour --> T1 involvement
49
Causes of a raised hemidiaphragm - where is the lesion? what causes it?
Phrenic nerve palsy (C3-5)
```
Neoplasm:
- lung, thymoma, myeloma
Mechanical:
- Cervical spondylosis
Infective:
- Zoster, HIV, TB, Lyme
```
50
2 or more peripheral nerve palsies - what is this phenomenon called?
And what can cause it?
Mononeuritis multiplex
```
WARDS PLC (most common = DM)
Wegeners, Amyloid, RA, DM, Sarcoid, PAN, Leprosy, Cancer
```
51
Ddx for vertigo
IMBALANCE
- Infection: Ramsay Hunt, labrynthitis (post URTI)
- Meniere's (tinnitus, SNHL, N+V)
- BBPV (positional)
- Amino glycosides (gent)
- Arterial: Stroke, migraine
- Nerve: Acoustic Neuroma
- Central: MS, SOL
- Epilepsy
52
TACS criteria for stroke - what is it for? what are the criteria?
Anterior circulation stroke
- Homonymous hemianopia
- Hemparesis OR sensory deficit
- Higher cortical dysfunction: dysphasia or hemispatial neglect
53
Define a posterior circulation stroke
Haemorrhage or infarct of the vertebral arteries or basilar artery or its branches
54
Presentations of posterior circulation stroke
Cerebellar syndrome
Brainstem syndrome
Homonymous hemianopia (occipital lobe involvement)
55
Define lacunar stroke (i.e. what structures are affected
Small infarcts in blood supply to internal capsule, basal ganglia, thalamus
absence of brainstem signs/higher cortical dysfunction/drowsiness/homonymous hemianopia
56
Absent corneal reflex in R eye
+ Loss of pain sensation in L arm and leg
diagnosis? other features?
R sided lateral medullary syndrome
i.e. infarct in post inf cerebellar artery or vertebral artery
Other features: dysphagia, dysarthria, ataxia, nystagmus, Horners syndrome
57
Pupil - constricted
+ doesn't react to light
+ DOES accommodate
Argyll Robertson pupil
DM or neurosyphilis
58
Pupil - fixed and dilated + doesn't respond to light or accomodation
Holmes Adie
Often viral cause
59
Features of temporal lobe- focal seizure
Automatisms (lip smacking)
Hallucinations (olfactory)
Emotional disturbance
Deja vu/jamais vu
60
ITP - platelet count? clotting times?
Low platelets
| Normal APTT and PT
61
Common long term complication o meningitis
SN hearing loss
62
Pt takes metoclopramide for post-op nausea
- retracted eyelids, fixed upward gaze, neck writhing --> dx? mx?
Oculogyric crisis
| Mx = procyclidine
63
Why be careful of rapid correction of hyponatremia
Central pontine myelinolysis
| -
64
Ring enhancing lesions on CT
toxoplasmosis
65
ROmbergs test - what does it tell you?!
+ve = sensory ataxia
defect w vision/vestibular system/proprioception
-ve = ataxia is likely due to cerebellar syndreom
66
Bilateral cerebellar signs - likely cause?
global cause
- EtOH
- MS
- phenytoin
67
Causes of cerebellar syndrome
```
Vascular: posterior circulation stroke
MS
EtOH
SOL: CPA tumour
Wilsons
Phenytoin
MSA
```
68
Nystagmus in cerebellar syndrome
Nystagmus is worse when looking towards the same side as lesion
69
Differentials for conductive deafness
Outer ear: FB, wax
TM perforation: trauma, infection
Middle ear: effusion
70
Differentials for SN hearing loss
- Presbycusis (age related)
- Drugs: gentamicin, vancomycin
- Infection: meningitis, measles
- Menieres
- Malignancy: CPA lesion
- Paget's (CN8 invasion)
71
Fx of CN4 palsy
Failure to depress the eye on adduction
Diplopia is v bad on looking down + in
72
Failure to depress the eye on adduction
| Dx? what else may be seen on inspection
CN4 palsy
Ocular torticollis
73
Intranuclear ophthalmoplegia = explain
Lesion in MLF (v myelinated)
Ipsilateral eye fails to adduct, contralateral eye has nystagmus on abduction
MLF connects CN3 + CN6 nuclei - on lateral gaze, output to CN3 and CN6 is initiated via MLF
74
Causes of CN3 palsy
PCA aneurysm
MS
SOL
DM, compression
75
Ix in simple palsies --> opthalmoplegia
FBC (infection)
Glucose, HbA1c (DM)
MRI head (aneurysm)
CT head (haemorrhage)
76
Type of imaging for MS?
gadolinium enhancing MRI
77
Presentation of MS
Paraesthesia
Optic neuritis (loss of central and colour vision + painful eye)
Ataxia + cerebellar signs
Motor: spastic paraparesis
78
Features of MS
```
Paraesthesia
Spastic paraparesis
Transverse myelitis --> bilateral sensory, motor + autonomic Sx
Urinary retention, constipation
Optic neuritis, INO
CEREBELLAR: falls, ataxia, tremor
```
79
Ix in MS
Bloods: autoantibodies MOB and MBP
Imaging: Gadolinium enhancing MRI
LP: IgG oligoclonal bands
Evoked potentials
80
Mx of MS
Acute attack: methylprednisolone
Preventing attacks:
- IFNbeta + mAbs = alemtezumab
Symptomatic:
- Amitryptiline (pain)
- Clonazepam (tremor)
- Self catheterisation/oxybutynin
- Physio + baclofen (spasticity)
81
Glucose levels in CSF: normal? Bacterial meningitis? TB meningitis?
Protein levels in CSF>?
Normal = 60-70% plasma glucose. Protein <1
Bacterial <50% of plasma glucose. protein >1
TB <50% of plasma glucose. protein 1-5!!!
82
LP in encephalitis
LP in viral meningitis
Encephalitis:
moderately low glucose
high protein + lymphocytes
Viral meningitis:
Normal glucose (>50% plasma)
Protein <1
high WCC
83
Surgical Mx of subdural
Burr Hole Craniostomy
84
Surgical mx of extradural
Craniectomy
85
Mx of SAH
1) urgent neurosurgical referral
2) monitor Obs + repeat CT head if deteriorating
3) aim for SBP >160
4) NIMODIPINE 60mg/4 hrs for 3 weeks
5) CT angio --> Surgical CLIPPING or COIL EMBOLISATION
6) STOOL SOFTENERS, analgesia, antitussives
86
RFs for intracranial venous thrombosis
```
Young
Malignancy
Thrombophilia
Pregnancy, OCP
Local infection - otitis, sinusitis, meningitis
```
87
Why does cerebral venous thrombosis --> increased ICP?
Why does CVT present like a stroke?
Cerebral veins lie in the subarachnoid space. therefore when they thrombose + occlude --> reduced CSF drainage --> raised ICP
When cerebral veins thrombus --> increased pressure in veins + blood stasis --> less oxygen to brain tissue and cerebral edema
88
clinical features of Cerebral venous thrombosis
- Raised ICP: headache, visual changes, papilloedema
- Focal deficits: hemiparesis (reduced oxygenation of brain tissue)
- Seizures
- Encephalopathy
89
Ix for ?cerebral venous thrombosis
CT head
MRI head - T2 weighted
CT venography
LP
Yr 6 PACES knowledge COPY RJ Challenger
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