Neurology

cases
 NEUROLOGY CASES

Diagnosis: Stroke – affecting the right side

GENERAL APPEARANCE: May have contractures on affected side, may have
obvious facial droop
TONE: Usually increased
(unless acute) on HELP!
affected side S roke is the commonest neuro--
St
POWER: Reduced on affected l gy case in finals, so knowing itt
lo
side well is important. Common ques--
tions are: what types of strokess
REFLEXES: Hyper-reflexia on
are there? how do you clinicallyy
affected side d stinguish between infarct andd
di
SENSATION: Usually intact, but haemorrhage (headache, losss
may have sensory of consciousness, coma)? whatt
is the treatment for an infarctt
inattention
( spirin, risk factor management,,
(a
COORDINATION: Normal (but may be multidisciplinary care, carotidd
impossible to assess D ppler if good recovery)?
Do
due to decreased Practise talking about the sitee
power) o a lesion and causes and sitess
of
of visual defects.
of
OTHER: Patient may have
dysphasia and
homonymous hemianopia
CAUSES: Infarct or haemorrhage
MARKERS OF SEVERITY: Inattention, absent power, contractures
NOTES: Strokes affecting the right side are caused by left
sided cerebral lesions. As a consequence, Broca’s
and/or Wernicke’s areas may be affected. This
may result in an expressive and/or receptive
dysphasia. Reception can be tested by one, two
and three stage commands. The patient may have a
homonymous hemianopia on the same side as the
clinical findings.

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 4 WEEKS TO FINALS

Diagnosis: Stroke – affecting the left side

GENERAL APPEARANCE: May have contractures on affected side. May have
facial droop
TONE: Increased on affected
side HELP!
POWER: Decreased on affected The commonest questions forr
side stroke are detailed on the previ--
REFLEXES: Hyper-reflexia on o s page. It is essential to know
ou w
a out the multi disciplinaryy
ab
affected side
care of stroke. Early physio--
SENSATION: Usually normal (but t erapy for early mobilisationn
th
check for inattention) a d prevention of contractures..
an
COORDINATION: Normal (but may be O assessment to ascertain
OT n
level of independence and to o
hard to assess)
attempt discharge home withh
OTHER: Look for contractures t e necessary aids. Appropriatee
th
and homonymous n rsing care on a dedicatedd
nu
hemianopia stroke ward is also part of thee
CAUSES: Infarct or n tional guidelines. Speechh
na
t erapy including swallowing
th g
haemorrhage a s sessment and assistancee
MARKERS OF SEVERITY: Contractures, w i th speech deficits is alsoo
inattention, e sential.
es
immobility
NOTES: Left sided strokes are
usually caused by a lesion in the right hemisphere.
As a consequence Broca’s area and Wernicke’s
area are preserved. Lesions of the right hemisphere
can cause apraxia or neglect. A lesion in the
right hemisphere can cause a left homonymous
hemianopia.

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 NEUROLOGY CASES

Diagnosis: Cerebellar Signs

GENERAL APPEARANCE: May be in wheelchair if patient has multiple
sclerosis (MS)
TONE: Reduced on affected
side (although some HELP!
cerebellar syndromes R member DANISH
Re
may be bilateral) Dysdiadochokinesia
POWER: Normal Ataxia
Nystagmus
REFLEXES: Normal
Intention tremor
SENSATION: Normal Slurred speech
COORDINATION: Impaired with Hypotonia
past pointing and
These are the main signs in a
intention tremor
c rebellar syndrome. Make sure
ce e
OTHER: Nystagmus, y u know the more common
yo n
dysdiadochokinesia, c uses as this is the most com--
ca
ataxia, slurred mon question to come up.
speech You may get asked to assesss
t e speech. Ask the patient to
th o
CAUSES: Commonest say ‘British Constitution’ or ‘bib--
causes are stroke, liica
call cr
c ititic
ic
cissm’
m.
MS, alcohol,
anticonvulsant
therapy and paraneoplastic syndromes (lung
cancer)
NOTES: The commonest cause of bilateral cerebellar signs
is MS. Check for an internuclear ophthalmoplegia
when you look for nystagmus. If the diagnosis is
MS, ophthalmoscopy may reveal optic disc pallor.
Is the patient in a wheelchair? Are they relatively
young? All these will point to MS. Strokes will
tend to cause a unilateral cerebellar syndrome.

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 4 WEEKS TO FINALS

Diagnosis: Parkinson’s Disease

GENERAL APPEARANCE: Mask-like face and resting ‘pill-rolling’ tremor
TONE: Increased, with ‘cog-wheeling’ or ‘lead-piping’ if
severe
POWER: Normal HELP!
REFLEXES: Hyper-reflexia This is very common in finals andd
SENSATION: Normal a diagnosis that you should be e
COORDINATION: Normal a le to make from the end of thee
ab
b d.
be
OTHER: Shuffling gait,
Common questions relate to o
difficulty initiating t e causes, and the treatment.
th
movement Ensure that you test thee
CAUSES: Parkinson’s p tient’s gait and functions suchh
pa
a doing up buttons and writing,,
as
disease is caused
a this shows your awarenesss
as
by degeneration o the practical problems thatt
of
of the cells in the p tients face.
pa
substantia nigra Also try and mention multi--
and pigmented d sciplinary care with OT andd
di
p h ysiotherapy to maintainn
neurones. This i dependence for as long ass
in
leads to a reduced possible.
po
level of dopamine.
Other causes
of a Parkinsonian syndrome are antipsychotic
medications.
NOTES: Parkinson’s disease is a syndrome of bradykinesia,
tremor and rigidity. It is commonly unilateral.
Treatment should be withheld for as long as
possible as the medications used either wear off
or can cause unwanted side effects with long-term
use (dyskinesia). Medications available are L-dopa
with a dopa-decarboxylase inhibitor, dopa agonists
or COMT antagonists.

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 NEUROLOGY CASES

Diagnosis: Old Polio

GENERAL APPEARANCE: Shortened wasted limb
TONE: Reduced
POWER: Reduced/absent
REFLEXES: Absent HELP!
SENSATION: Normal P lio can be distinguished from
Po m
COORDINATION: Normal (if able) Guillain–Barré by its asymmet--
CAUSES: Poliomyelitis r cal nature. In an exam, the keyy
ri
i the shortened wasted limb.
is
NOTES: Polio affects the
Old polio is uncommon inn
anterior horn cells fifinals and more common in post--
and motor neurones ggrraduate exams.
of cranial nerves. It
may start with a GI
infection. It can then progress to an asymmetrical
paralysis. In children, it will result in failure of
growth of the limb resulting in a shortened wasted
limb with lower motor neurone signs. Treatment is
supportive and patients may require ventilation.

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 4 WEEKS TO FINALS

Diagnosis: Median Nerve Palsy

GENERAL APPEARANCE: Usually normal
TONE: Reduced in thenar muscles
POWER: Reduced power of
flexion, abduction HELP!
and opposition of The commonest question about thiss
the thumb c ndition is the cause.
co
REFLEXES: Normal Ensure you look at the patient!
Does the patient have rheumatoidd
SENSATION: Reduced over
h nds? Do they look acromegalic?
ha
palmar aspect of Also ensure that you test forr
the first three and Tinel’s sign.
a half fingers The median nerve palsy mayy
not be complete. There may just bee
COORDINATION: Normal
sseenssor
oryy loss
s .
ss
OTHER: Wasting of the
thenar eminence
CAUSES: Compression of the median nerve as it runs
through the carpal tunnel is the most common.
NOTES: Carpal tunnel syndrome is caused by pregnancy,
rheumatoid arthritis, acromegaly, oral
contraceptive pill use, gout, TB and amyloid.
Mononeuritis multiplex may also cause a median
nerve palsy (diabetes, SLE, sarcoid and other
inflammatory conditions). Diabetes may cause
a median nerve palsy without mononeuritis
multiplex.

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 NEUROLOGY CASES

Diagnosis: Radial Nerve Palsy

GENERAL APPEARANCE: Wrist drop
TONE: Decreased in wrist and finger extensors
POWER: Reduced in wrist
and finger extensors HELP!
REFLEXES: Normal You may not spot the wrist dropp
SENSATION: May be some straight away, as the patient’ss
reduced sensation h nds may be in the resting posi--
ha
tion. Look for a splint nearby and
d
over thumb/dorsal
when you examine the arm, lookk
area between thumb f r scars that suggest ortho--
fo
and 1st finger paedic surgery for fracture.
COORDINATION: Normal If you ensure that you test alll
the muscle groups, you will nott
CAUSES: Most common
miss the diagnosis.
cause is trauma to The commonest questions aree
the radial nerve as r garding cause and treatment.
re
it winds around the
spiral groove of the
humerus. Humeral fracture is therefore a common
cause.
NOTES: These patients present with wrist drop after
humeral fracture or repair of a fracture. A gradual
return of function may occur. Swift repair of
the fracture may improve functional outcome.
Splinting of the wrist allows improvement of
function as the small muscles of the hand work
better with the wrist in the neutral position.

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 4 WEEKS TO FINALS

Diagnosis: Ulnar Nerve Palsy

GENERAL APPEARANCE: Claw hand, wasting of the small muscles of the
hand
TONE: Decreased in small
muscles of the hand HELP!
POWER: Reduced/absent E sure you look for the cause..
En
power in the small L ok for deformation at the elbow
Lo w
muscles of the hand j int as this is the commonestt
jo
c use. Also look for evidencee
ca
other than the
of diabetes (finger prick marks),,
thenar muscles rheumatoid changes (nodules) orr
REFLEXES: Normal SLE (butterfly rash).
SENSATION: Decreased sensation Treatment can involve reliev--
ing any pressure on the nervee
in the little finger
( urgery), treatment of underly--
(s
and medial half of i g condition, or simple methodss
in
the ring finger s chh as sp
su spliliinnttin
ng.
g
COORDINATION: Normal
OTHER: Hyperextended
MCP joints and flexed IPJs
CAUSES: Commonest is injury at the elbow (fracture,
lengthy surgery with pressure on nerve). Other
causes include mononeuritis multiplex (e.g.
diabetes, rheumatoid, SLE and others).
NOTES: Ulnar nerve injuries are obvious from the end of
the bed. Muscles affected are the small muscles of
the hand (other than the thenar eminence muscles),
flexor carpi ulnaris and the ulnar half of flexor
digitorum profundus.

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 NEUROLOGY CASES

Diagnosis: Motor Neurone Disease 1

GENERAL APPEARANCE: May have contractures of both legs and visible
fasciculation
TONE: Increased
POWER: Reduced HELP!
REFLEXES: Increased The key to diagnosis in an exam m
SENSATION: Normal i the mixture of upper and lowerr
is
COORDINATION: Normal m tor neurone signs and youu
mo
s ould mention them. Questionss
sh
OTHER: There may be ankle
you may get asked are around d
clonus and up-going diagnosis (clinical plus EMG),,
plantars a d management (see
an e below).
CAUSES: Motor neurone The symptoms and signss
a e very variable depending onn
ar
disease is a
whether upper or lower motorr
degenerative neurone signs predominate.
neurological Overleaf is an alternative clin--
disorder of unknown i al picture.
ic
aetiology. There
is degeneration of
upper and lower motor neurones as well as cranial
nerve nuclei. This results in upper and lower motor
neurone signs.
NOTES: Onset is usually after the age of 50. Men are
affected more than women. Most patients
die within 5 years. Prognosis is poor when
there are bulbar symptoms. Management is a
multidisciplinary approach with OT, physiotherapy
and speech therapy all being vital to maintaining
independence.

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 4 WEEKS TO FINALS

Diagnosis: Motor Neurone Disease 2

GENERAL APPEARANCE: Cachexia
TONE: Reduced
POWER: Reduced (arms
and shoulders) HELP!
REFLEXES: Increased As can be seen, the presentation and d
SENSATION: Normal c inical findings are very variable, butt
cl
COORDINATION: Normal d agnosis is easy when you divide thee
di
fifindings into upper and lower motorr
OTHER: Wasting and
neurone.
fasciculation seen The questions you need to askk
CAUSES: See previous page y urself when you examine anyy
yo
NOTES: The alternative p tient neurologically are:
pa
● Is this unilateral or bilateral?
presentation
(unilateral suggests brain lesion)
is with bulbar ● If bilateral, is there a sensory
symptoms level? (spinal cord)
– wasted, ● If no sensory loss, is it upper or

fasciculating lower motor neurone, or both?

(polio, MND)
tongue, palatal ● If purely sensory, what tracts
paralysis, and are affected and are there
indistinct nasal any pointers to the cause of a
speech. This neuropathy? (finger prick marks)
has the worst
prognosis of all
presentations.

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 NEUROLOGY CASES

Diagnosis: Multiple Sclerosis

GENERAL APPEARANCE: Very variable, usually a young patient, may be in a
wheelchair, may have contractures
TONE: Increased
(especially in legs) HELP!
POWER: Reduced The key in talking about MS in ann
REFLEXES: Increased e am is to emphasise the needd
ex
(especially in legs) for multidisciplinary management..
S me drugs can help reduce spas--
So
SENSATION: Reduced
ticity (baclofen or botulinum toxin),,
COORDINATION: Impaired, with b t physiotherapy is essential ass
bu
past pointing and w ll. OT assessment to improve
we e
intention tremor. functionality in the home is alsoo
very important to talk about.
OTHER: Other cerebellar
Mentioning the MS Societyy
signs may well and self-help groups always goess
be present, optic d wn
do n wel
elwwiith exa
xami
mine
minerss.
ne
ners
atrophy on
ophthalmoscopy,
possibly internuclear ophthalmoplegia
CAUSES: Plaques of inflammatory demyelination occur
anywhere within the CNS. The exact aetiology is
unclear.
NOTES: The disease is diagnosed clinically by identifying
two or more neurological symptoms that are
separated in space and time. MRI demonstrates
plaques, and CSF analysis may show oligoclonal
bands. Assessment of visual evoked potentials can
aid diagnosis.
The condition is very variable in its course.
The variants are: relapsing remitting (majority
of patients), primary progressive, secondary
progressive, and fulminant. The commonest
presentation is with optic neuritis or sensory
symptoms.
Treatment with high dose steroids during a
relapse may help shorten the relapse, but they
do not affect long-term functional prognosis.
Few drugs have any effect in preventing relapses
although interferon beta may help in certain
groups (see NICE guidelines).3

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 4 WEEKS TO FINALS

Diagnosis: 3rd Nerve Palsy

GENERAL APPEARANCE: Unilateral ptosis
EYE POSITION: Affected eye is pointed down and laterally
MOVEMENTS: Unable to adduct the
eye past the midline HELP!
PUPIL: Dilated As soon as you see the eye point--
OTHER: Patient almost i g down and out, you should
in d
certainly complains k ow the diagnosis. If there iss
kn
a ptosis, ensure that you lift thee
of double vision
eyelid to check the position off
when eyelid is t e eye.
th
elevated You will get asked about caus--
CAUSES: Commonest cause es and possibly investigations.
is microvascular
pathology, mostly
diabetes. This doesn’t always result in the patient
having a ptosis or pupillary dilatation. Other
causes of a 3rd nerve palsy are cavernous sinus
lesions, superior orbital fissure lesions, vasculitis,
posterior communicating artery aneurysms (is the
palsy painful?). Mononeuritis multiplex may cause
this (for which there are various causes).
NOTES: The patient should be investigated with a CT
scan of the head to look for structural lesions. A
vasculitis screen should be performed and a CXR
for sarcoid. Angiography for cerebral aneurysms
should be considered if the clinical picture suggests
this is likely.

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 NEUROLOGY CASES

Diagnosis: 6th Nerve Palsy

GENERAL APPEARANCE: Affected eye adducted
EYE POSITION: Inward pointing in the primary position
MOVEMENTS: No/limited
abduction of the eye HELP!
PUPIL: Normal As with the 3rd nerve palsy, thee
OTHER: Patient complains of k y is the eye position. If thee
ke
double vision when e e is adducted and unable too
ey
a duct, you have the diagnosis..
ab
attempting to abduct
If ophthalmoscopy reveals pale e
the eye optic discs, the diagnosis is mostt
CAUSES: Raised intracranial lilkely to be MS. Papilloedemaa
pressure, MS, would suggest raised ICP.
cavernous sinus
and superior orbital
fissure lesions, vascular lesions in the brainstem
NOTES: The 6th nerve has a long course. It is therefore
susceptible to damage from raised intracranial
pressure.

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 4 WEEKS TO FINALS

Diagnosis: Diabetic Neuropathy

GENERAL APPEARANCE: May have Charcot joint, or ulcers
TONE: Normal
POWER: Usually normal
REFLEXES: Reduced ankle and HELP!
knee reflexes The most likely diagnosis of a
SENSATION: Stocking (and glove) s nsory neuropathy in finals iss
se
distribution sensory d abetes. The giveaway is fingerr
di
p ick marks (if you get to see thee
pr
loss – vibration sense
fifingers!).
is the first modality Ensure that you test all thee
to go s nsory modalities.
se
COORDINATION: Normal, but gait Questions would includee
m nagement of the neuropathy,,
ma
may be wide based
a d management and monitor--
an
or stamping i g of diabetes and its otherr
in
OTHER: Ulcers/callus c mplications.
co
formation over
pressure areas
CAUSES: Diabetic neuropathy is relatively common and is
related to the degree of diabetic control as well as
duration of the disease.
NOTES: Patients with diabetes should have their sensory
function tested yearly. They may complain of pain
(especially at night) in the feet and legs. Patients
should be advised to look after their feet and wear
well-fitting shoes.
A rarer form of diabetic neuropathy is
amyotrophy, which involves wasting and weakness
of the proximal muscles.
Complications of diabetic neuropathy include
neuropathic ulcers and Charcot joints.

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