Pp2 Tutorial 4

Front 1

Kylie presents to you with numbness of the fingers in her left hand. Assuming that it is a neurological problem, list the pathologies (5) and specific areas that a lesion/compression/other problem could be occurring in order to give her that problem.

Back 1

1. Carpal Tunnel Syndrome
- A compression of the median nerve by the transverse carpal ligament
- Pre-disposing factors: pregnancy (fluid retention), rheumatoid arthritis (inflammation of that area), hyperthyroidism (causes a little bit of oedema), anything that causes oedema, repetitive strain injury (overuse)

2. Thoracic Outlet Syndrome
- Positional, intermittent compression of the brachial plexures and/or subclavian artery and nerve
- Predisposing factors: ankylosing spondylitis (causes a hunch), pendulous breasts, osteoarthritis, bad posture, any degenerative disorder causing stooping

3. Multiple Sclerosis
- Degeneration of the CNS occurring in the brain, spinal cord, or optic nerve
- Familial predisposition or can be an autoimmune disease

4. Diabetic Neuropathy
- Affects the discriminative pathway for sensing vibrations
- Damage occurs due to hyperglycaemia

5. Tumour
- Occurring in the brain at the primary sensory cortex (right hemisphere)
- Can cause compression of the optic nerve causing visual disturbances and headaches

Front 2

Kylie presents to you with numbness in her left hand. Assuming that it is a neurological problem, for the selected disorders (3), what signs would you attempt to elicit in diagnosing her?

Back 2

*Diabetic neuropathy
- If she says she is not a diabetic - do a urine test. If the test is (++) or (+++) for glucose in the urine then she is a diabetic. If there is a lot of glucose in the urine she may have had uncontrolled diabetes for a while.
- Take a tuning fork, have her close her eyes, get her to touch the end of the vibrating tuning fork with her fingers.
- Two point discrimination test - to see if she can determine that difference in distance between points, or if she just feels it as one point.

*Carpal tunnel syndrome
- Tinel's sign - the health practitioner will elicit a positive response by tapping two fingers on the median nerve as it transverses the carpal ligament - she will have tingling in the thumb and first two and a half fingers
- Phalen's sign - exaggerated prayer position, or reverse prayer - she will have tingling in the thumb and first two and a half fingers
- later on test for muscle wasting and decreased motor pathway

*Thoracic outlet syndrome
- Lifting her arm to a horizontal and pushing it back slightly - if pain and tingling is elicited she may have thoracic outlet syndrome
- test her pulse - if her pulse is decreased in pressure (not speed) and when she lifts her hand up the pulse is stronger and more bounding

Front 3

Kylie presents to you with numbness of the fingers in her left hand. Assuming that it is a neurological problem, why do you test for vibration sensation, fine touch and temperature while doing the physical exam?

Back 3

We test for vibration sensation, fine touch, and temperature in the physical exam as each of these travels via different pathway, hence we are testing three different pathways.
Vibration sensation travels by the discriminative pathways in the dorsal white column; in the early stages of a disorder only the dorsal white column will be affected, therefore testing for vibration sensation, fine touch, and temp allows you to determine how far the neuropathy has progressed.
Fine touch travels by the neospinothalamic tract which is a faster tract, and temperature travels by the paleospinothalamic tract, a slower tract.
Essentially the neospinothalamic and the paleospinothalamic tract carry the same information therefore is often regarded as one pathway called the anterior-lateral spinothalamic tract.

Front 4

You are doing a neurological exam and you elicit a deep tendon reflex on your patient's knee. Why? What information do you learn from this portion of the physical exam.

Back 4

In the physical exam you elicit a deep tendon reflex to determine where the neurological problem is occurring. The deep tendon reflex tells us a lot of information as it involves the afferent nerve, the cell bodies of the afferent nerve, the interneurons and the connections in the grey matter of the spinal cord, the efferent nerve, the neuromuscular junction, and the muscle itself. We test both knees and at different locations to see at what level the pathway is functioning. Also, we test positions that have a proper connection with the brain so we can see how well it is working. Normally, descending neurons from the brain provide some inhibition of spinal reflexes, however if there was a problem this inhibition would not occur, resulting in hyper- or hypo-flexion. If there is an upper motor neuron lesion, hyper-reflexia would occur and if there was a lower motor neuron lesion, hypo-reflexia or no reflex would occur.

Front 5

John R. is presenting to you with a loss of strength in his left arm. Assuming that this is a neural problem, what pathologies would you be interested in investigating? For each pathology (5), give two symptoms or risk factors for that disorder.

Back 5

1. Multiple sclerosis (brain) - unilateral visual disturbances (blurring in one eye, double vision), genetic risk factor
2. Stroke (brain) - smoking, hypertension
3. Guillian-Barre syndrome (spinal cord) - muscle weakness, genetic predisposition
4. Severe nerve compression - pain in arm, tingling
5. Myasthenia gravis (peripheral neuromuscular disorder) - decreased ability of eye muscle, genetic risk factor

Front 6

When conducting the physical exam, you will test for muscle tone, tendon reflexes, atrophy of muscles, and the Babinski sign. What will you expect to find in (1) an upper motor lesion, and (2) a lower motor lesion?

Back 6

Upper motor lesion:
- Tendon reflex: hyper-flexia
- Muscle tone: hypertonia
- Atrophy of muscles: yes
- Babinski sign: absent

Lower motor lesion:
- Tendon reflex: hypo-flexia or no reflex
- Muscle tone: hypotonia
- Atrophy of muscles: yes
- Babinski sign: clenching of toes together in a protective fashion

Front 7

K.V. is a 32 y/o female complaining of an extremely bad headache and you think it may be meningitis. What are the signs and symptoms of meningitis?

Back 7

Signs:
- Photophobia
- Sonophobia
- Phonophobia
- Fever
- Petechial rash
- Papilledema
- Kernig's sign
- Brudzinski's neck sign

Symptoms:
- Extreme and severe headaches (migraines)
- Previous complaint of flu, sinisitis, or upper respiratory tract infection
- Rash

Front 8

Mr T.Y. is 59 y/o today (he thinks). He explains that his wife died 3 years ago and he just cannot remember things the way that he had. He wonders whether you have a realignment technique for his spine that may help give him greater blood flow to his brain, thereby helping to improve his memory. What are some likely causes of his memory loss? Very briefly describe each. (9)

Back 8

1. Alzheimer's disease - aetiology not confirmed; affects mainly short term memory; degeneration of the areas of the brain involved in language and memory; most prevalent type of dementia.
2. Parkinson's disease - affects mostly the basal ganglia; approx. 20% of people with Parkinson's get dementia; is a long-term dementia which affects the actual memory and distant effects.
3. Huntington's disease - a genetic degenerative disorder (autosomal dominant); involves repeating trinucleotides on one of our genes (more than 40); occurs later in life - usually passes on to children before they know they have it; degeneration of cognitive and physical function.
4. Depression - most common reversible/curable type/cause of dementia.
5. Vascular dementia - a kind of closing of the arteries; causes hypoxia to the brain which eventually causes damage to the brain; decrease in cortical mass.
6. Multi-infarct dementia - patients predisposed to the development of thrombi in the ascending aorta that break off and travel to the brain; patient has a 'turn' from a tiny infarct causing damage/distress to the brain; patient feels 'fuzzy' or feels sick; over time multiple infarcts cause damage to the tiny interneurons associated with cognitive function.
7. Temporal dementia - second most prevalent type of dementia; degeneration of the temporal lobes and frontal lobe; at least 5 distinctly different mechanisms by which it could occur; multiple aetiologies.
8. Creutzfeldt-Jakob disease - caused by the consumption of a prion (abnormal protein); prion crosses the BBB and changes similar proteins to proteins like itself - causes degeneration of the neurons nearby; universally fatal; can be linked back to someone who has consumed dead/decaying infected animal/human neural tissue.
9. Wernike-Korsakoff syndrome - degeneration of the brain due to a thiamin deficiency; most prevalent in patients who are alcoholics; 3 different mechanisms by which alcohol decreases thiamin levels or doesn't allow its conversion to its active form.

Front 9

You suspect cerebellar dysfunction in one of your patients. How would you test to support your hypothesis?

Back 9

- Assess for cerebellar tremor - look at the way they pick something up; as they get closer and closer to the object their hand will drift off to one side and then overcompensate their movement to the other side; they learn to do things in a quick manner as they are able to decrease the tremor (need to slow them down so you can see how they approach the object)
- Walk in a straight line - heel to toe in a straight line
- The back of the foot of one leg, slide up the shin of the other leg
- Rapidly differing movements e.g. patients palm up then palm down quite fast; if they can't do this they may have a cerebellar dysfunction; testing their ability to perform rapid and co-ordinated movements
- Patient - touch her finger to his moving finger - try to co-ordinate that movement; person with a cerebellar problem/tremor will exhibit an overcorrection