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Summary Final year MD notes - neurology
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A collection suite of final medicine MD notes to ace your penultimate and final year exams! Look no further and save the stress of accessing multiple resources as this PDF collates and summarises information from several resources including but not limited to: -Talley and O’Connor clinical ...

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  • December 4, 2023
  • 27
  • 2023/2024
  • Summary

Subjects

  • neurology
  • nerves
  • final
  • year
  • medicine
  • australia
  • sydney
  • md
  • notes

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  • Macquarie University (MQ )
  • Unknown

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NEUROLOGY Hx
Headache, [SOCRATES] ® type/severity • Disturbed gait, sensation and weakness
• Time course (esp. SAH vs IIH) a. Dysesthesia (unpleasant feel)
a. Acute (secs) = SAH, stroke, focal/generalised seizure b. Paraesthesia (pins & needles) & numb
b. Subacute (hrs-days) = infection, inflammatory disorder (Guillain–Barré • Disturbances of vision, hearing, smell, speech &
syndrome) swallowing
c. Insidious (wks – mths) = IIH, tumour, neurodegenerative
• Triggers? ® auras, hormone changes? Consider pattern of symptoms:
• Assoc. (photo/phono-phobia, cold, mental clouding, rhinorrhoea, flushed head) • Unilateral vs bilateral
History of Fits, faints or funny turns [Seizures/Strokes] • Sensory vs motor vs sensori-motor
presenting • Pre-event [LAD] • Distal vs proximal weakness
complaint a. LOC o Cranial vs Long tract (UL vs LL)
b. auras • PNS vs ANS (bladder, ED, irregular BP)
c. DIZZY (vertigo, lightheaded), • Dermatomal/myotomal distribution or not
d. vision issue, speech,
e. trauma è extra-dural, sub-dural heam.
• During event (what happened? , duration – hrs, days?)
• After event [WILD] (weakness incontinence, Lateral Tongue biting, drowsiness)
• Previous episodes / scans (MRI, CT)
• Underlying CV cause (i.e. palpitation, SOB)

• Risk of Cerebrovascular disease: epilepsy/convulsions | HT | DM | Dyslipidaemia
Current Conditions o Previous stokes / STEMIs
o Previous accidents (e.g. head/spinal injuries) or Infection (meningitis, STIs)

• Anticonvulsants, anti-Parkinsonian drugs, COCP [­ stroke risk]
Medications
• Steroids, stains & Opiates
Past MHx
Surgeries/ • Chemotherapy for malignancy (leukaemia, myeloma or lymphoma)
Treatments • Splenectomy ( thrombocytopenia or lymphoma)

Tests Results of CT or MRI brain scan

Other Allergies? + Vaccinations [strep. Pneumoniae, FluVax]

Occupation • exposure to toxins (e.g. heavy metals)

Smoking • cerebrovascular disease [­ vascular risk]
Social Hx
Alcohol • blackouts, alcoholic dementia, myopathy

Drugs • Marijuana + cocaine induced headache

• Family Hx of migraine, stroke, Alzheimer’s, epilepsy
Family Hx
• X-LINKED: Colour blindness, DMD | Autosomal dominant (neurodegenerative disease): Huntington’s chorea, MS

• CVS – CAD SPIFE, RESP – SCSC FAWIF, GIT – BLIND CRAP, GU – FUNDWISE | PORN HAWC | Menstrual Cycle
SR
General: Fever | weight loss/gain | Speech | Smell | Hearing | Sight




Red flags on history Red flags on Examination

• Fever, photophobia or neck stiffness (meningitis or encephalitis) • Abnormal vitals

• New neurological symptoms (haemorrhage, malignancy or stroke) • Neurological abnormalities

• Dizziness (stroke) • Decreased LOC è other cause [CV, metabolic, psychogenic]:

• Visual disturbance (temporal arteritis or glaucoma) o Arrhythmias = assoc. with palpitations
o Aortic stenosis = LOC with heavy exercise
• Sudden onset occipital headache (subarachnoid haemorrhage)
o Transient ischaemic attacks = ‘drop attacks’ means the patient falls but NO LOC.
• Worse on coughing or straining (raised intracranial pressure)
o Vasovagal syncope = LOC due to abrupt drop in HR, BP (due to stress)
• Postural, worse on standing, lying or bending over or Pemberton’s sign
(raised intracranial pressure) o Micturition syncope = LOC due to urination
• Severe enough to wake the patient from sleep o Hypoglycaemia (diabetics on insulin) = sweating, weakness and confusion
BEFORE LOC.
• Vomiting (raised intracranial pressure or carbon monoxide poisoning)
o Psychogenic non-epileptic seizures (PNES) ® LOC [no response to
• History of trauma (intracranial haemorrhage) anticonvulsants] ® need psychotherapy to Rx anxiety and depression
• Pregnancy (pre-eclampsia) • Meningismus (similar to meningitis without inflammation of meninges ® i.e. stiff neck,
• Recent hed trauma within 3/12 = ?SDH\ photophobia)
• Headaches with use of medications/illicit drugs (e.g. anticoagulants, • Papilledema è Idiopathic intracranial hypertension (IIH), Raised ICP
sympathomimetic agents)




Examination Indication Purpose
Mental state Mental health • “A routine assessment to check your brain function that I do on all my patients of similar age”
examination (MSE) disorder • provides snapshot of a patient's emotions, thoughts, and behaviour at the time of observation
• helps identify the presence and severity of a variety of mental health conditions and the risk a patient
poses to him- or herself, or to others
Mini-Mental State Exam Elderly • tests cognitive function among the elderly è
(MMSE) • measures of orientation, registration (immediate memory), short-term memory (but not long-term
memory) as well as language functioning
• Orientation è registration è registration è attention + calc è recall è language
• Score out of 30 (> 25 - normal, 21-24 = mild cognitive impairment, <20 = dementia)

, Cranial Nerve Examination (upper CN – I, II, III, IV, VI)
• Today I have been asked to check your cranial nerves. These are the nerves that supply your face and neck
• Responsiveness + Orientated [“tell me how you got here today?”]
• Ptosis (drooping one/both eyelids = old age, 7th nerve palsy, Horner’s (ptosis + anhidrosis, myosis, anophthalmos)
GI
• Proptosis / strabismus (misalignment/deviation of one/both eye)
• Facial asymmetry & facial drooping (salivation)
• Obvious muscle wasting (Temporal)
• Alcohol wipe smell (test each nostril separately
o “Close eyes + cover one nose” “Describe to me what you smell”
CN I
o DDx (anosmia): Kallman URTI, smoking, ethmoid tumours, basal skull/frontal fracture, post pituitary surgery, congenital (eg. Kallmans syndrome),
meningioma of olfactory groove, infectious (meningitis)
• ENSURE YOU POSITION PATIENT AT EYE LEVEL!!
Acuity
• Cover one eye and read the smallest line you can
[snellan chart]
o If unable: ® “How many fingers” [CF] ® Hand movement [HM] ® Perception of Light (PL] ® NPL
• “Cover your own eye with one hand and then the other!”
• Cover your left eye with your left hand ® “look into my eye and say ‘yes’ when you see my finger moving”
• Repeat with coloured object (NARROWER visual field – cones located centrally in macula, rods peripheral)
• Repeat for other eye




Visual
Fields




CN 2
AFRO
CAP


Ishihara Plates:
Colour vision • optic neuritis (loss of red),
• Colour blindness: vit A deficiency / X-linked chromosome loss
• “Stare at point on the wall behind me ® now look at the red ball”
Accommodation
o Should see convergence of eyes
“Stare at a point behind me” ® Pen light from side and into eye slowly
• Check pupil size
Pupil light reflex • Repeat x2 (see constriction in blinded eye (direct) and then the other (consensual))
Reflexes (PEARL) Swing torch test
[Take glasses off] [Check size, • If light shone on damaged eye (NO consensual response)
shape of pupil] • If light shone on bad eye ® good eye ® bad eye (appears to dilate)
• Bad eye = Marcus Gunn pupil is a relative afferent pupillary defect indicating a decreased pupillary
response to light in the affected eye
• Failure of accommodation ONLY è midbrain lesion or with cortical blindness.

Pathology • Absent light reflex ONLY è midbrain lesion (e.g. Argyll Robertson pupil of syphilis – accomodates but
does not react), a ciliary ganglion lesion (e.g. Adie’s pupil)
• Amsler grid è AMD
Definition Distribution vision Light reflex
Optic Disc Optic disc swelling due to None
Papilloedema Bilateral Huge blind spot
(Fundoscopy) raised ICP DDx: retinoblastoma,
*Say would do Inflammed or infarcted optic Scotoma ®
Optic neuritis Unilateral Reduced
nerve head blindness
• Do you have any double vision (diplopia) ?
• Pursuit Movements (tracking) ® smooth conjugate movement
CN 3 • Saccades “Look left then right” “up and down”
Eye movements
[Draw large H ] o hypometric OR hypermetric/overshoot saccades
• Horizontal Nystagmus (MS or vascular lesion) 3 D’s -CN3 palsy:
Dilated pupils
Reflex types: o Vestibular lesion = nystagmus away from side of lesion Diplopia (down and out)
1) pursuit Divergent squint
o Cerebellar lesion = nystagmus to side of lesion
2) saccades
3) convergence • Vertical Nystagmus
CN 4
4)VOR o Midbrain lesion, floor of 4th ventricle
o EtOH, phenytoin
LR6 = abduction
Conjugate Gaze Palsy
SO4 = depressor
in eye adduction • PSP = Loss of vertical ® then horizontal gaze ® bilateral
(head tilt away fixed unequal eyes but reflex eye movements intact
from lesion • Parinaud’s syndrome = Involuntary upward dev of the eyes +
CN 6 loss of vertical agaze = pinealoma, MS, vascular
• One and a half syndrome = horizontal gaze palsy + impaired To exclude a CNIV lesion in context of 3rd nerve palsy, tilt head
adduction to same side as the lesion à the affected eye will intort if
CNIV intact)

, Cranial Nerve Examination (Lower CN – 5, 7-12)
“This is what the cotton wool/pin feels like” [Both sides of Head ® cheek ® jaw]
• Is it cold/hot or sharp/dull AND
• did it feel the same on both sides of the face?



Examine
Sensory division facial
of trigeminal sensation
V1 = ophthalmic [close
(sup. orbital) patients’
V2 = mandibular eyes]
(foramen
rotundum)


Dermatomes of the head and Facial sensation V, test all three Herpes zoster distribution of
neck divisions on each side the maxillary nerve
*Corneal Lightly touch cornea (not the conjunctiva) with cottonwool brought to the eye from side
reflex [Not
done] • No sensation = corneal ulceration / ACOUSTIC NERUOMA ( NO CN7 TO BLINK)

• (clench your teeth for me + relax): Feel for temporalis and masseter muscle wasting?
CN 5
Muscles of • (ask patient to bite down on wooden tongue depressor with molars): muscle strength
Motor division of mastication
trigeminal • (open your mouth – don’t let me close it): pterygoid muscle
V2 = maxillary • Jaw deviates to affected side
(foramen ovale)
Jaw Jerk Or • “Relax your jaw down slightly for me ® just going to tap tip of your chin/jaw lightly”
Masseter o è exaggerated jaw jerk = UMN lesion above pons [pseudobulbar palsy]
Reflex




NB: schwannoma from CNVIII can compress adjacent CNV and CNVII nerves, brainstem and cerebellum


• Frontalis (temporal) = “Raise your eyebrows and don’t me push them down “è NO wrinkle (UMN lesion –
FOREHEAD SPARING)
• OBICULARIS OCULI (ZYGOMATIC) “Close eyes TIGHTLY as you can and don’t let me open them” è Bell’s LMN
Facial movements palsy: upward movement of the eyeball and incomplete closure of the eyelid
• BUCCINATOR (BUCCAL) “Puff cheeks and don’t let me push them in” è asymmetry (LMN lesion)
• ZYGOMATIC MUSCLE (ZYG + BUCCAL) “Smile and show me your teeth” è facial paralysis (cortical lesion)
• CERVICAL Platysma + occipitalis

Q “Any change in • CNVII (chorda tympani) has sensory fibres for taste from anterior 2/3 of tongue ® fibres reach brain via CNV
taste” • Unilateral loss of taste: middle-ear lesions involving the chorda tympani (CN7) or lingual nerve (CNV)

Q “Any change in • Stapedius supplied by VII è controls stapes è hyperacusis when damaged
hearing”



Central causes (pons, medulla, upper
cervical cord) = FOREHEAD SPARING
Ø vascular lesion,
CN 7 Ø tumour,
Ø syringobulbia.


Peripheral causes
Ø aneurysm, tumour,
Ø chronic meningitis.
Ø Trigeminal ganglion causes include
trigeminal neuroma, meningioma
fracture

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