neurology loc ii-common cases

7/25/2019 Neurology Loc II-common Cases

1/64

Neurology-localisation

CommonNeurologyCases


2/64

Bilateral lower limb weakness

The key features to discern are:Upper and lower motor neurone pattern ofweaknessIs sensation normal?What is the pattern of sensory decits?


3/64


4/64

Proximal weakness-distinguishing features

Myasthenia gravis- fatiguability, bulbar,ocular and respiratory involvement

MND-fasciculations and wasting; bulbar,and respiratory involvement; ocularsparing. Mixture of UMN and LMN signs


5/64

Myopathy-additional pointsCauses:

Acquired ; inammatory (PM, DM), endocrine(hyperthyroidism, Cushings syndrome), toxic (statins,brates, colchicine, AZT, chloroquine),

Inherited : dystrophy (Myo Dystrophy, FSH, Beckers,LGMD, rare-distal myopathy)Investigations:

CK, EMG and muscle biopsy.


6/64


7/64

Peripheral Neuropathy-additional points

Causes Diffuse polyneuropathy: DM, CRF, B12 def,

hypothyroidism, GBS/CIDP, Sjogrens syndrome , CMT, Drugs ( cisplatin, v incristine, taxol ( S>M ),thalidomide, pyridoxine, ddI, ddC, d4T, , INH ( S>M ), ,chloroquine ), HIV, toxins (alcohol, lead and n-hexane), Paraneoplastic.

Multiple mononeuropathy: Vasculitic n europathy,Leprosy, multiple entrapment neuropathy, MMN

(Those in bright red font cause sensory n europathy )

Investigations : NCS, EMG, spinal tap


8/64


9/64


10/64

Wasted hands


11/64MMN: multifocal motor neuropathy


13/64


15/64


16/64


17/64


19/64


21/64


22/64


23/64


24/64


25/64


26/64

One wasted hand-key p ointers

Wasted thenar:consider distal median Tinels, split IV nger numbness -CTSBenedictan sign and loss of O sign- proximal median

Wasted hypothenar-intrinsics:Consider ulnar- split IV nger numbness, Froments s ign.Usually c ompression is a t elbow, but know how to differentiate wrist

vs e lbow ulnar palsy

All muscles w asted-segmental vs co mbined median and ulnarnerve palsy.


27/64

Bilateral wasted hand

Bilateral thenar wasting: Consider bilateral median-CTS

Bilateral hypothenar-intrinsic wasting: Bilateral ulnar-usually c ompression at elbow, often in thebackground of polyneuropathy.

Both muscle groups wasted-see overleaf


28/64

Other mononeuropathies


29/64


30/64


31/64

Cranial neuropathy


32/64


33/64


34/64

ptosis


35/64


36/64

Difficulty with speech


37/64

Speaking difficulty

Dys/a phoniaDys/an arthria

Dys/a phasia


38/64

Dys/aphoniaLocal: vocal cords/larynx

Neuromuscular junction:MGNerves: IX-X, recurrent laryngeal.Think- base of skull (NPC)/, jugular foramen

(mass lesions), neck-thorax (recurrent laryngeal

nerve) and GBS/MFSBrainstem: medulla


39/64

DysarthriaFlaccid

Neuromuscular junction :MGNerve:IX-X--think base of skull,jugular foramen

-neck (mass l esions); GBS/MFSBrainstem: medulla

SpasticBilateral subcortical/cortical- pseudobulbar palsy

CerebellarExtrapyramidal : PD


40/64

Dysphasia1. Is n aming affected?2. Assess uency: speech ca dence-rhythm,

grammar and frustration from inability toexpress.

3. Comprehension- test 1-2-3 step commands4. Conrm if the associated signs a re

consistent with dysphasia localizationOptional step:Repetition

Type naming fluency comprehension Other clues repetition


41/64

Global poor poor poor Drowsy, eye deviation,dense BF weakness

Brocas poor poor good Dysarthria, dysphagia brachiofacial weakness

ernickes poor good poor !o weakness" #Fdeficit

$onduction%not important&

poor !ot bad good #F deficit"'arietal lobe signs ()*

Transcortical +Broca poor poor good -igns of subcorticalstroke

Transcortical+ ernickes

poor good poor -igns of subcorticalstroke

poor

poor

poor

Fluency when repeatingis .. worse than duringspontaneous speech

good

good


42/64

Poor vision


43/64


44/64


45/64

Gait analysis-important points

Do not over-commit.Keep a second or third choice up your

sleeveFurther examination is necessary


46/64

Gait-unsteady, ataxic

CerebellarSensory a taxia-either dorsal column or

sensory ne uronopathy

Romberg's s ign may be useful

Beware of mimic: severe spasticity (e.g.from Cx myelopathy) or gait apraxia


47/64

Gait-extrapyramidal

Parkinsonism

Beware of gait apraxia


48/64

Gait-spastic

Hemi or bilateralBeware of mimic from apraxic g ait


49/64

Gait- apraxic gaitIgnition failureSmall short, magnetic st eps w ith poor ground clearanceTurning in numbers

Causes: NPH, Binswangers d isease, Frontal lobedysquilibrium

Beware of ataxic a nd spastic g ait mimicking apraxia


50/64

Gait patterns- High steppingUni/bilateral foot drop

Beware not all patients with foot drops have highsteppage!Severe sensory loss

Causes:Severe non-length dependent sensory neuropathy

or sensory neuronopathy. Reexes sh ould besignicantly reduced.Dorsal column dysfunction including that from

high cervical myelopathy


51/64

Gait- Waddling

Proximal myopathy

Beware hip pathology


52/64

Hemiplegia

Basic limb examinationBS signs

Right hemisphere: VF, sensory a nd visualneglect, constructional apraxiaLeft hemisphere: Language, VF, sensory

and visual neglectCauses; stroke, pri/sec. tumours, CVT


53/64

Visual eld- patterns..knowcauses

BitemporalHomonymous- hemi/

quadrantanopiaCentral scotomaAltitudinal


54/64

Cerebellar- exam. steps

Eyes-nystagmus, poor pursuit, saccadicdysmetria

Speech-staccatoUpper limbs-dysmetria, dysdiadokinesiaLower Limbs-abnormal heel shin test

Gait-ataxic gait


55/64


56/64

Parkinsonism-signsRest tremor, pin-rolling high amplitude, lowfrequencyRigidity-lead pipeRigidity- cog-wheelBradykinesiaPostural instability

Typical gait: Stooped posture, poor arm swing, small short shuffling steps, festination, turning innumbers a nd retropulsion.


57/64

Parkinsonism-plus: elicit;AsymmetryVertical saccadic eye movementsCerebellar signs

Postural hypotension, urinary incontinence,impotenceAsk:

Drug history, family history, liver diseaseFalls, Autonomic sym ptomsHx of hypoxic cerebral injury/ encephalitisMental state examination for cognitive impairment

Pkii


58/64

Parkinsonism-severity/complications

Assess severity when walking the patientNote any dyskinesia that may be present

Ask a mount/types o f medications h e is o nAsk for complications s uch as falls, pneumonia.


59/64

Other movement disorders

Choreoathetosis: dance like irregular,semi-purposeful, non-stereotypic

movements of the limbs, often bilateral;patient looks restless.If proximal and large amplitude: Ballismus


60/64


61/64

Choreoathetosis-RxTetrabenazine, dopamine a ntagonist

Benzhexol for tardive dyskinesia secondary toneuroleptics

For PD dopa-dyskinesia: reduce L-dopa anduse long acting dopa antagonist


62/64


63/64


64/64

neurology loc ii-common cases

Documents