20220813 prog b neuro workshop 2

Case 1
Stem: hearing loss, examine CN
DX: cp angle lesion post surgery. also has some cerebellar and contralateral hemiparesis.
Approach -
Inspect for face CN7 and limb posture/wasting
CN 2 to 12 or by groups as below
7 8 5. 8 check whisper and asymmetry, Weber, rinne. Simultaneously check back of head/ear for
scar, radiotherapy.
eyes screen and nystagmus
lower CN screen.
Pronator drift (contralateral) and cerebellar UL (ipsilateral)
Otoscopy
Offer visual fields
 
Cn 5 use pinprick compare normal side.
CN 8.
Visual fields demonstrate 1 arm length. Look into my eye. Central scotoma put in middle.
 
 
Case 2
Stem: frequent falls. Examine
DX: parkinsonism
Approach
 Inspect for face, resting tremor, limb posture
History tripping and falling in elderly.
BP. Face
Hand dance
Walk
 
Finger tap - Bradykinesia if amplitude drops when trying to move fast.
Cogwheel is more common. Distract by asking to move contralateral arm
 
If predominantly lower limb symptoms, suspect vascular parkinsonism
 
Invx. Look for previous brain scans - periventricular white matter, NPH
 
Hx for Parkinson plus x 5.
Psp. early falls within 1st year due to axial rigidity (idiopathic PD 3 yr), vertical gaze palsy falls going
downstairs and cannot read bottom of newspaper
Lbd. Hallucinations, fluctuating sensorium, sleep disturbance. Check memory and ADLs.
MSA p and c. Postural hypo (preceding giddiness). If cerebellar signs then c.
Cbgd. Alien limb.
 
Vascular parkinsonism.
NPH. Difficulty walking , urinary, memory problems
 
Screen other intrinsic causes - vision
Screen extrinsic causes
 
 
Mx
Idiopathic PD don't need to refer. Screen bloods for multiple myeloma etc. Start madopar 62.5mg
TDS. Golden period 10yr. Madopar HBS long acting for night.
Other options - selegiline, entacapone, amantadine. Benhexol for tremors. Dbs.
 
Case 3
Stem. An episode of loss of vision. Hx and pe. (SP)
DX
 
Approach
 
Ddx vision loss
Localization
Eye - retinal detachment
Optic nerve - amaurosis fugax, optic neuritis ms,
Brain - cortical blindness
 
 
 
 
 
Hx
Screen PMH and drugs
HOPC
site/character - unilateral bilat? Whole visual field or one part?
Onset, time course, progression - acute or gradual
 
 
ICE what do you think could be cause? Anything you are especially worried about?
 
PE
BMI, hr Pulse bp
Snellen
Pupils, rapd, eom
Visual fields including central scotomata
Crao. Fundoscopy for cherry red spot. Papilloedema
CN 5 sensation CN 7
UL. Pronator drift, dysmetria, power kiv reflexes.
Gait.
CV – pulse, Carotid bruit

 
Invx
Capillary glucose
Ecg
 
 
 
 
Drive. Emphasize legal aspect.
 
 
 
Amaurosis fugax. Young stroke/hypt
Don't use abcd2 not applicable for Amaurosis fugax. Send to a&e for CT brain and young stroke
workup. young female - MS eye pain numbness before. Ocps.
Check allergy for aspirin
my car how - I will help call NOK.
Ddx monocular blindness
 
Stroke posterior circulation dysarthrua, dysphagia, giddiness, hearing
Amaurosis fugax
Temporal arteritis jaw claudication, headache
Migraine aura

Case 4
Stem: fainting spell. Hx and pe
DX: juvenile myoclonic epilepsy
 
 
Approach to fainting spell
 
Ddx
Syncope
Seizure
Sheldon score tongue biting incontinence post ictal confusion
 
Epileptic syndromes. Jme Hx of myoclonus. cornflakes flying syndrome?? Learning disabilities.
 
 
Brain stroke bleed or ischemia
Drugs, alcohol
Heart. Postural change exertion.
Metabolic hypoglycemia, electrolyte
 
 
 
Approach
 
screen PMH and dhx
HOPC
new or recurrent
Pre, during, post. Witness
Start postural BP at 5min
 
PE
BMI
Temp, postural BP, pulse hr.
Standing
Skin for neurofibromas sturge Weber portwine and tuberous sclerosis
check eyes, CN 7. Mouth for tongue bite and head for injuries.
Walk to couch
Lie down 45deg screen UL in Pronator drift, cerebellar, screen power
Auscultate heart for AS, carotids, lungs
 
Stat invx
Capillary glucose, fbc, na k cr, ECG
 
Mx
Seizure first presentation. Neuro fast track. Eeg mri.
Driving. Epilepsy i.e. recurrent including scar epilepsy no driving end of story legally. Seizures on aed
got special stuff.
pregnancy. Highest teratogenic risk to foetus is valproate. Give folate also. Safest keppra
lamotrkfine and carbamazepine 3%. Poorly controlled seizures worse for baby will cause iugr.
Monitor thrombocytopenia and lft.
Safety advice swimming/heights
 
Rapd - swing fast, hold to count of 3.
 
Case 5
Stem - difficulty walking. Examine lower limbs. Weakness since teenage years.
 
DX: CMT? Hsmn? Cidp?
 
 
Pe
Foot of bed Inspect walking aids/splint, face, UL ll posture wasting, skin changes
Pes cavus - since childhood. Wasting - lmn chronic. Contracture - chronic umn.
Tone leg lift passive slow moving first for rigidity, then lift up no need to be too violent.
Clonus technically should be after AJ but never mind.
Babinski - must touch 1st mtpj. S1 reflex to l4/5 count to 3000. Go back and check child before age 2
Power
Sensory pinprick - l3 medial knee l5 lateral leg SPN webpage dPN S1 lateral heel. Proprioception
don't confuse pt! up down or don't know. small movement. 2 of 3.
Heel shin - up in air, knee, slide, up.
 
 
gait high steppage bilat lmn dorsiflexor weakness or circumduction umn weakness of hip flexors.
 
 
 
 
Findings - flaccid tetraparesis distal predominant, accompanying sensory deficits. Chronic.
Functionally impaired.
DX -
 
Ahc and peripheral neuropathy affect distal - sensory or not. nmj muscle affect proximal.