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Questions and Answers
A patient presents with sensory loss affecting vibration and proprioception on the left side of their body, but normal pinprick sensation bilaterally. Where is the most likely location of the lesion?
A patient presents with sensory loss affecting vibration and proprioception on the left side of their body, but normal pinprick sensation bilaterally. Where is the most likely location of the lesion?
- Left cerebral cortex
- Right cerebral cortex
- Right spinal cord (dorsal column)
- Left spinal cord (dorsal column) (correct)
Which neurological finding is most indicative of cerebellar dysfunction?
Which neurological finding is most indicative of cerebellar dysfunction?
- Loss of sensation in the right hand
- Intention tremor and dysmetria (correct)
- Muscle weakness in a dermatomal pattern
- Hyperreflexia and spasticity
A patient exhibits a positive Romberg's test, with increased sway when standing with feet together and eyes closed, but minimal sway with eyes open. This finding primarily suggests dysfunction in which system?
A patient exhibits a positive Romberg's test, with increased sway when standing with feet together and eyes closed, but minimal sway with eyes open. This finding primarily suggests dysfunction in which system?
- Vestibular system
- Corticospinal tract
- Extrapyramidal system
- Dorsal column pathway (correct)
Uhthoff's phenomenon, characterized by worsening of neurological symptoms with heat exposure, is commonly associated with which condition?
Uhthoff's phenomenon, characterized by worsening of neurological symptoms with heat exposure, is commonly associated with which condition?
A patient presents with impaired pinprick and touch sensation on the right side of the face. Which cranial nerve is most likely affected?
A patient presents with impaired pinprick and touch sensation on the right side of the face. Which cranial nerve is most likely affected?
A patient exhibits dysmetria, dysdiadochokinesia, and an intention tremor in the left upper limb. Which part of the cerebellum is most likely involved?
A patient exhibits dysmetria, dysdiadochokinesia, and an intention tremor in the left upper limb. Which part of the cerebellum is most likely involved?
Which of the following cranial nerves is primarily responsible for abduction of the eye?
Which of the following cranial nerves is primarily responsible for abduction of the eye?
In the context of motor control, what is the primary role of the basal nuclei?
In the context of motor control, what is the primary role of the basal nuclei?
A lesion in the primary motor cortex would most likely result in:
A lesion in the primary motor cortex would most likely result in:
Which of the following is a characteristic feature of upper motor neuron lesions but not lower motor neuron lesions?
Which of the following is a characteristic feature of upper motor neuron lesions but not lower motor neuron lesions?
The corticospinal tract is primarily responsible for:
The corticospinal tract is primarily responsible for:
Saltatory conduction, which increases the speed of action potential propagation, is primarily due to:
Saltatory conduction, which increases the speed of action potential propagation, is primarily due to:
Which part of the cerebral cortex is primarily involved in processing somatic sensations like touch, pain, and temperature?
Which part of the cerebral cortex is primarily involved in processing somatic sensations like touch, pain, and temperature?
A central scotoma, as described in the patient presentation, refers to:
A central scotoma, as described in the patient presentation, refers to:
Based on the patient's initial presentation of numbness and pins and needles sensation on the left side of the body, which anatomical location is least likely to be the site of lesion?
Based on the patient's initial presentation of numbness and pins and needles sensation on the left side of the body, which anatomical location is least likely to be the site of lesion?
The presence of oligoclonal bands in cerebrospinal fluid (CSF) is suggestive of:
The presence of oligoclonal bands in cerebrospinal fluid (CSF) is suggestive of:
In the context of cranial nerve examination, asking a patient to shrug their shoulders tests the function of which cranial nerve?
In the context of cranial nerve examination, asking a patient to shrug their shoulders tests the function of which cranial nerve?
Dysarthria and dysphagia would most likely indicate dysfunction in which cranial nerves?
Dysarthria and dysphagia would most likely indicate dysfunction in which cranial nerves?
What is the primary function of the premotor cortex in motor control?
What is the primary function of the premotor cortex in motor control?
The medial lemniscus pathway is primarily responsible for transmitting which type of sensory information?
The medial lemniscus pathway is primarily responsible for transmitting which type of sensory information?
What is the likely explanation for the patient's 'electric shock' sensation down her spine when bending her neck?
What is the likely explanation for the patient's 'electric shock' sensation down her spine when bending her neck?
In a patient with suspected multiple sclerosis, which of the following CSF findings would be most supportive of the diagnosis?
In a patient with suspected multiple sclerosis, which of the following CSF findings would be most supportive of the diagnosis?
A patient presents with diplopia (double vision) and is found to have impaired adduction of the right eye and impaired vertical movements of the right eye. Which cranial nerve is most likely affected?
A patient presents with diplopia (double vision) and is found to have impaired adduction of the right eye and impaired vertical movements of the right eye. Which cranial nerve is most likely affected?
What does 'dysdiadochokinesia' refer to in a neurological examination?
What does 'dysdiadochokinesia' refer to in a neurological examination?
Which of the following is NOT a typical symptom reported in the patient's initial presentation?
Which of the following is NOT a typical symptom reported in the patient's initial presentation?
The confrontation test is used to assess which neurological function?
The confrontation test is used to assess which neurological function?
What is the significance of a reduced visual acuity of 4/6 in the right eye, while the left eye is 6/6?
What is the significance of a reduced visual acuity of 4/6 in the right eye, while the left eye is 6/6?
The Ishihara plates are used to assess:
The Ishihara plates are used to assess:
Based on the examination findings, which area of the cerebellum is most likely involved in the patient's gait and coordination issues?
Based on the examination findings, which area of the cerebellum is most likely involved in the patient's gait and coordination issues?
In the context of myelin's role in the nervous system, what is 'conduction velocity'?
In the context of myelin's role in the nervous system, what is 'conduction velocity'?
Flashcards
Basic organization of the CNS?
Basic organization of the CNS?
Includes cerebral hemispheres, cerebellum, brainstem (midbrain, pons, medulla), and ventricles.
Cerebral cortex regional functions?
Cerebral cortex regional functions?
Primary areas process raw sensory data. Unimodal areas refine one type of data. Multimodal areas integrate different senses.
Function of the cerebellum?
Function of the cerebellum?
Coordinates movement and posture. Damage can lead to ataxia or uncoordinated movement.
Neurological examination?
Neurological examination?
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Impaired vibration/proprioception?
Impaired vibration/proprioception?
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Positive Romberg's test
Positive Romberg's test
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Finger to nose test
Finger to nose test
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Dysdiadochokinesia?
Dysdiadochokinesia?
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Uhthoff's phenomenon
Uhthoff's phenomenon
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Optic neuritis
Optic neuritis
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Trigeminal nerve impairment?
Trigeminal nerve impairment?
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CSF analysis in MS?
CSF analysis in MS?
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MRI findings in MS?
MRI findings in MS?
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Myelin's role in nervous system?
Myelin's role in nervous system?
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Study Notes
Medicine 3 – Week 1-3: Learning Goals
- Briefly describe the development of the nervous system
- Describe the basic organization of the CNS, focus on cerebral hemispheres, cerebellum, midbrain, pons, medulla, and ventricles
- Identify and describe the functions of the regions (primary, unimodal, and multimodal association areas) of the cerebral cortex associated with voluntary movements, somatic sensations, and language
- Describe the anatomy of the cerebellum including the different functional regions, interpret clinical findings from cerebral cortical and cerebellar lesions
- Describe and demonstrate testing for cortical dysfunction and cerebellar dysfunction
- Describe the neural pathways involved in the control of voluntary movements mentioning the key anatomic landmarks related to these pathways
- Briefly explain the control of movements including the role of the primary motor cortex, supplementary and premotor cortex, basal nuclei and cerebellum
- Describe spinal and supraspinal control of muscle tone, interpret effects of upper/lower motor neuron lesions on muscle tone and tendon reflexes
- Compare UMN and LMN lesion characteristics
- Describe main somato-sensory pathways, mentioning key anatomic landmarks related to these pathways
- Describe basis of examination of motor function, reflexes, coordination, and sensory functions which overlaps with clinical practice
- Name cranial nerves and categorize them by function
- Describe anatomy (origin, pathway, important relations) of the cranial nerves
- Describe specific function and structures supplied by each cranial nerve
- Describe clinically important cranial nerve-related reflexes
- Solve clinical problems by analyzing signs/symptoms of cranial nerve lesions
- Describe and demonstrate how to clinically test the cranial nerves
- Describe the structure of myelin and its role in the nervous system like action potential propagation, conduction velocity, and saltatory conduction
Case Scenario: Patient presentation
- Jenny Wilson, a 47-year-old dressmaker from rural Queensland, presented to her GP with numbness and pins and needles sensation on her left side, including her left upper and lower limbs, and trunk
- She noticed these symptoms in her left foot about a week prior
- Three days prior, she began experiencing pins and needles sensations in her trunk and left upper limb
- Wilson reports no weakness but acknowledges a sense of instability, observed at night
- Bending her neck causes "an electric shock or a brief, tingling sensation" from her neck/upper back down spine into her arms/legs
- Wilson received a winter flu vaccine two weeks prior and developed dysuria, prescribed antibiotics after a urine test
- Wilson denies neck pain, back pain, fever, headache, visual, or hearing disturbances, with no similar episodes, neurological deficits, or significant medical/family history
Application exercise 1
- Discuss the patient presentation and note key findings
- Determine most likely location of the lesion, possibilities include:
- Cerebral cortex: False, not ataxia, very unlikely, need to exclude the face
- Internal capsule: False, some motor involvement, not an isolated deficit
- Brainstem: Cranial nerve palsies
- Cervical spinal cord: Plausible
- Thoracic spinal cord: Unlikely, need upper lesion for upper signs
- Peripheral nerves: Much more focal
Examination - Initial Presentation
- Temp – 37.7 °C, PR – 72/min regular, BP – 122/70
- CVS/RS - Normal, Abdomen - Mild suprapubic tenderness on deep palpation, Dysuria
Neurological Examination:
- Cranial nerves: Normal
- Sensory Examination:
- Loss of vibration sense at toes, ankles, knees, knuckles, and lateral malleolus on the left side
- Loss of proprioception sensation on left big toe and thumb
- Pin prick sensation is normal
- Motor Examination: Normal tone/power/reflexes in upper/lower limbs
- Coordination: Positive Romberg's test, near-normal FTN (finger-to-nose) and HTS (heel-to-shin) on the left (Dysmetria worse when eyes are closed.) Normal on the right side
Application Exercise 2
- Discuss the neurological examination findings in groups.
- Determine most likely lesion location and diagram it
- Consider differential diagnoses indicating most likely and possible conditions to exclude
Patient Presentation - Subsequent
- Patient was referred to a neurologist
- She became completely symptom-free within a few days and did not see the neurologist
Patient Presentation - Relapse
- For the next 3 years, she remained symptom-free
- She began to notice waxing and waning impaired sharpness of vision in her right eye and left-sided clumsiness
- One morning upon waking up, she noticed double images next to each other due to strained eyes preparing dresses for a preschool
- She has blurry vision, eye pain in the right eye, particularly when moving it
- Momentary glittering or flickering lights occur when she shifts her gaze
- Center of the visual field is either missing or distorted (central scotoma), forcing gaze shifts to read text
- The patient decides to see her GP
Application Exercise 3
- Analyze key information to formulate potential explanation for the clinical presentation
- Based on symptoms, determine expected findings in extraocular muscle examination
- Complete the table indicating appropriate movement to test each extraocular muscle and nerve involved
- Abduct, Lateral Rectus, CN VI
- Adduct, Medial Rectus, CN III
- Depress/Adduct, Superior Oblique, CN IV
Patient Examination - Relapse
- Normal general examination
- Temperature: 37.6 °C
- Regular pulse: 78/min
- BP: 128/74
- Normal cardiovascular, respiratory, and abdominal systems
- Cranial nerves:
- Olfactory: Normal
- Optic nerve findings
- Reduced visual acuity in right eye: 4/6
- Left eye acuity 6/6
- Confrontation test results: Central scotoma present
- Ishihara plates: Left - 22/22, Right - 16/22 (requires 6m distance to see what's visible at 22m)
- Symmetrical pupils, reactive to light
- Normal fundoscopic examination
Application Exercise 4
- Analyze key observations and explain the findings
Examination Continued
- Trigeminal nerve: Impaired pin prick and touch sensations on the right side of the face
- Facial nerve: Normal
- Vestibulocochlear nerve: Normal
- Glossopharyngeal nerve: Normal, uvula central
- Vagus nerve: Normal, gag reflex
- Accessory nerve: Normal, shrug and head turn intact
- Hypoglossal nerve: Normal, tongue protrusion midline
Application Exercise 5
- Examine video and comment on findings
Application Exercise 6
- Consider what the new findings indicate
Examination Contd - Additional Findings
- Gait was unsteady at arrival
- Patient notes unsteadiness started a few weeks prior after hot showers, and recurred subsequently
- Uhthoff sign
- Motor System Exam: Normal
- No atrophy/fasciculations
- No pronator drift
- Tone: Normal bilaterally in upper and lower limbs, but increased in left lower limb
- Reflexes: Normal
- Power: Full strength (grade 5) in upper and lower limbs bilaterally
Examination Contd - Sensory and Coordination
- Sensory Exam: Largely intact
- Gait/Coordination Exam:
- Feet close together elicits increased sway bilaterally with difficulty balancing eyes open
- Unable to tandem walk without losing balance (vermis) which means truncal ataxia with wide base and unsteady pattern of walking
- Difficulty maintaining heading on straight-line trajectory, often veering
- Finger to nose irregular with overshoot/undershoot using the left hand (paravermis)
- Heel-to-shin, unable to do it smoothly and accurately when using left leg Dysdiadochokinesia
- Rapid alternating movements show some difficulty in performing rapid alternating movements using her left hand (Paravermis)
Application Exercise 7
- Analyze the key observations and formulate a diagnosis
- Delineate the location(s) of lesion leading to these findings
Application Exercise 8
- Map lesions to diagram representing patients signs up to this point
- What condition(s) might this patient have?
- Stroke
- Motor neuron disease
- NMSOD?
- Multiple sclerosis
Application Exercise 8 - Answer
- Lesions
- Cerebellar vermis and left paravermis region
- Left medial longitudinal fasciculus
- Right trigeminal nerve
- Left dorsal column
Patient Presentation - Diagnosis
- Patient referred to neurology clinic
- MS diagnosis suspected
Patient Investigations
- CSF Parameter:
- Opening Pressure - 140 mmH2O
- Appearance - Clear
- Protein - 60 mg/dL
- Glucose - 60 mg/dL
- CSF Glucose/Blood Glucose Ratio - 0.8
- IgG - 150mg/L
- IgG/Protein Ratio - 0.25
- Oligoclonal Bands - Present
- White Cell Counts - 5 cells/mm³
- Blood Parameter:
- Random Blood Sugar - 110 mg/dL
- Erythrocyte Sedimentation Rate (ESR) - 24 mm/hour
- High sensitivity C-Reactive Protein (hs-CRP) - 0.4 mg/dL
- WBC count - 6,000 cells/mm³
- Electrolytes (Sodium) - 142 mEq/L
- Electrolytes (Potassium) - 4.0 mEq/L
- Vitamin D - 40 ng/mL
- Vitamin B12 - 350 pg/mL
- Aquaporin-4 Antibodies (NMSOD) - Negative
- MOG Antibodies (MOGAD) - Negative
- Venereal Disease Research Lab (VDRL) Test (Syphilis) - Non-reactive
- Anti-Nuclear Antibodies (ANA), Rheumatoid factor, DS DNA, ANCA, Lupus anticoagulant, Anticardiolipin antibody - Negative
Application exercise 9 & 10
- Interpret CSF and blood investigation results
- Go through the MRI images and locate any evidence to support a diagnosis of multiple sclerosis
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