Summary
Summary Key conditions in neurology
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An overview of key conditions in neurology that you need to know for medical finals, with links to clinical neuroscience.
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1Neurology
Neurological history ............................................................................................................................... 3
Neurological examination ....................................................................................................................... 3
Cranial nerve exam ........................................................................................................................................... 3
Upper limb neurological examination ............................................................................................................... 8
Nervous system overview ..................................................................................................................... 10
Neuromuscular junction ................................................................................................................................. 11
Neuronal pathways - overview ....................................................................................................................... 11
Somatosensory system ............................................................................................................................................................. 12
Motor system ........................................................................................................................................................................... 16
Neurological presentations ................................................................................................................... 17
Focal or generalised weakness ........................................................................................................................ 17
Gait disturbance ............................................................................................................................................. 19
Dizziness and impaired balance ...................................................................................................................... 21
Involuntary movements (dyskinesias) ............................................................................................................. 22
Urinary or faecal incontinence ....................................................................................................................... 23
Visual symptoms ............................................................................................................................................ 28
Speech and language disturbances .................................................................................................................. 30
Bulbar symptoms ................................................................................................... Error! Bookmark not defined.
Cognitive problems ........................................................................................................................................ 30
Headache ....................................................................................................................................................... 31
Tremor ........................................................................................................................................................... 34
Neuropathic pain syndromes .......................................................................................................................... 35
Diabetic neuropathy ................................................................................................................................................................. 35
Complex regional pain syndrome ............................................................................................................................................. 36
Phantom limb pain ................................................................................................................................................................... 36
Trigeminal neuralgia ................................................................................................................................................................. 36
Post-herpetic neuralgia ............................................................................................................................................................ 36
Sensory disturbances ...................................................................................................................................... 37
Transient motor or sensory disturbances ........................................................................................................ 37
Cerebellar disorders ....................................................................................................................................... 37
Loss of consciousness ..................................................................................................................................... 37
Neurological emergencies ..................................................................................................................... 39
Raised ICP ...................................................................................................................................................... 39
Subarachnoid haemorrhage ............................................................................................................................ 42
Spinal epidural abscess ................................................................................................................................... 43
Meningitis ...................................................................................................................................................... 43
Encephalitis .................................................................................................................................................... 45
Status epilepticus ........................................................................................................................................... 46
Stroke ............................................................................................................................................................ 46
, 2
Spinal cord or cauda equina compression........................................................................................................ 61
Head trauma .................................................................................................................................................. 62
Acute respiratory distress ............................................................................................................................... 63
Temporal arteritis........................................................................................................................................... 64
Acute bulbar palsy .......................................................................................................................................... 66
Neurological conditions ........................................................................................................................ 66
Space occupying lesions .................................................................................................................................. 66
Idiopathic intracranial hypertension ............................................................................................................... 71
Epilepsy ......................................................................................................................................................... 71
Parkinson’s disease ........................................................................................................................................ 73
Huntington’s disease ...................................................................................................................................... 77
Motor neurone disease .................................................................................................................................. 78
Guillain-Barré syndrome ................................................................................................................................. 79
Myasthenia gravis .......................................................................................................................................... 80
Muscular dystrophies ..................................................................................................................................... 82
Multiple sclerosis ........................................................................................................................................... 83
Dementia ....................................................................................................................................................... 86
Polyneuropathy – diabetic and GBS ................................................................................................................ 91
Lumbar and cervical degeneration .................................................................................................................. 92
Facial nerve palsy ........................................................................................................................................... 93
Mononeuropathies......................................................................................................................................... 94
Carpal tunnel syndrome ........................................................................................................................................................... 95
Ulnar nerve palsy ...................................................................................................................................................................... 97
Thoracic outlet syndrome ......................................................................................................................................................... 97
Radial nerve compression ........................................................................................................................................................ 99
Lateral femoral cutaneous nerve compression (meralgia paraesthetica) .............................................................................. 100
Sciatic nerve damage .............................................................................................................................................................. 100
Common peroneal nerve damage .......................................................................................................................................... 101
Tibial nerve damage ............................................................................................................................................................... 102
Superficial peroneal (fibular) nerve injury .............................................................................................................................. 102
Deep peroneal nerve injury .................................................................................................................................................... 102
Saphenous nerve injury .......................................................................................................................................................... 103
Sural nerve injury.................................................................................................................................................................... 103
Superior gluteal nerve ............................................................................................................................................................ 104
Femoral nerve......................................................................................................................................................................... 104
Radiculopathies............................................................................................................................................ 104
Essential tremor ........................................................................................................................................... 106
Cerebellopontine angle lesions ..................................................................................................................... 107
Subacute combined degeneration of the spinal cord ..................................................................................... 107
Cavernous sinus syndromes .......................................................................................................................... 108
Pituitary tumours ......................................................................................................................................... 108
Wernicke-Korsakoff syndrome ...................................................................................................................... 108
Argyll Robertson pupil .................................................................................................................................. 109
Creutzfeldt-Jakob disease ............................................................................................................................. 109
, 3
Syringomyelia .............................................................................................................................................. 109
Charcot-Marie-Tooth Disease ....................................................................................................................... 110
Tuberous sclerosis ........................................................................................................................................ 110
Neurofibromatosis ....................................................................................................................................... 111
Neurological history
Presenting complaints
Stroke/TIA
• Exact time of onset (NB if patient woke up with Sx, the onset of time is assumed to be when they went to sleep)
• Severity of sx
o Weakness – subtle, moderate, complete paralysis
o Sensory disturbance – paraesthesia or complete loss of sensation
o Visual disturbance – how much of the visual field is affected
o Expressive dysphasia – can the patient speak at all
o Receptive dysphasia – can the patient understand any communication
o Dysarthria – mildly slurred speech or incomprehensible
• How have the Sx evolved since onset?
• Obvious trigger? What were they doing at the time that Sx developed?
Cranial nerve and cerebellar Sx – lesion is in the brainstem.
Nerve roots – myotomal problems at level of lesion, and dermatomal issues
Peripheral nerve – glove and stocking, LMN signs
NMj – weakness, no sensory problems
Neurological examination
Cranial nerve exam
Introduction:
• Wash hands
• Introduce self
• Confirm patients name and DOB
• Explain the examination “today I’ve been asked to perform a cranial nerve examination on you. This involves me
testing the nerves in your face and neck – to do this, I need to have a look at your eyes, assess the sensation and
function of muscles in your face, assess your hearing, and have a look in your mouth.”
• Gain consent
• Ask patient to sit on a chair, one arm’s length away
• Ask the patient if they’re in any pain at all before starting
General inspection:
• Facial asymmetry – CN VII palsy
• Eyelid abnormalities – ptosis could indicate CN III pathology
• Limb abnormalities
• Equipment/objects around the bed – walking aids, hearing aids, visual aids, prescriptions
CN I – OLFACTORY:
• Ask patient if they’ve noticed any recent changes in sense of smell
, 4
CN II – OPTIC: Recording visual acuity:
• Inspect pupils Recorded as chart distance (numerator) over the
a. Assess size number of the lowest line read (denominator). If
b. Assess pupil shape patient reads the 6/6 line but gets 2 letters
c. Assess pupil symmetry incorrect, record it as 6/6 (-2). If patient gets
• Visual acuity – Snellen chart. If patient normally wears glasses, more than 2 letters wrong, the previous line
ensure they wear them for the assessment. Stand patient 6m should be recorded as their acuity (+ the number
from Snellen chart. Ask the patient to cover one eye and read of letters they read from the line below)
the lowest line they can. Record lowest line patient was able to
read. Repeat steps for the other eye. If patient can’t read top line of chart at 6m, reduce distance to 3m.
• Pupillary reflexes – direct and consensual pupillary reflexes
• Accommodation reflex – ask patient to focus on a distant object. Place your finger 20-30cm in front of their eyes.
Ask the patient to switch from looking at the distant object to the nearby finger. Pupils should constrict and
converge bilaterally.
• Colour vision assessment (Ishihara plates) – if patient wears glasses ensure these are worn. Ask patient to cover
one of their eyes. Ask patient to read the numbers on the plates (first plate usually tests contrast sensitivity –
need to document if patient can’t read this). Document the number of plates they can identify correctly.
• Visual fields – sit opposite pt at 1m. Ask patient to cover one eye. Mirror patient and cover your eye. Ask patient
to focus on part of you face and not move their head/eyes.
a. Ask patient if any part of your face is missing
b. Place your finger at equal distance between you and the patient. Start from the periphery and slowly
move finger towards the centre and ask pt to report when they first see your finger moving. if you can
see your finger but the pt can’t = visual field defect. Repeat process for each visual quadrant
c. Repeat on the other eye
• Blind spot – sit opposite pt as 1m. Ask pt to cover one eye with their hand. Mirror patient and cover your eye. As
patient to focus on your face and not move their head/eyes. Use a red haptin to identify blind spot and size of it
by moving it laterally (normally found temporal to central vision at eye level). The red haptin should disappear
and re-appear at a similar point to you.
• Fundoscopy – assess optic disc
CN III (OCCULOMOTOR), IV (TROCHLEAR), VI (ABDUCENS):
• Inspect eyelids for ptosis
• Eye movements – hold your finger 30cm in front of
patient’s eyes. Ask patient to keep head still whilst
following your finger with their eyes. Ask them to let
you know if they get any double vision/pain. Move
your finger in H pattern and observe for any
restriction of eye movement or nystagmus
• Light reflex – ask patient to focus on target half a
metre away, shine a torch towards both eyes. Inspect
corneal reflex (should be positioned centrally and symmetrically)
• Cover test
CN V (TRIGEMINAL):
• Sensory assessment – assess light touch and pinprick sensation
o V1 (ophthalmic) = forehead
o V2 (maxillary) = cheek
o V3 (mandibular) = lower jaw
• Motor assessment
o Inspect temporalis and masseter for evidence of wasting
o Palpate masseter muscle bilaterally whilst asking patient to clench their teeth
o Ask patient to open their mouth whilst you apply resistance underneath jaw to assess lateral pterygoid
muscles.
• jaw jerk reflex (offer to test it in OSCE and explain purpose) – need explain procedure and ask consent to
proceed. Ask patient to open their mouth, place finger horizontally across the patient’s chin, tap your finger
gently with the tendon hammer → triggers a slight closure of the mouth.
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