Medical Clinical Notes

■Hypoglossal (CN XII) ▪︎Physical Exams -Inspect tongue for signs of atrophy, fasciculations, asymmetry of movement and strength, lateral deviation with protrusion ▪︎Signs/Symptoms of Defcit -Wasting of ipsilateral tongue muscles and deviation to ipsilateral side on protrusion

■Hypoglossal (CN XII) ▪︎Physical Exams -Inspect tongue for signs of atrophy, fasciculations, asymmetry of movement and strength, lateral deviation with protrusion ▪︎Signs/Symptoms of Defcit -Wasting of ipsilateral tongue muscles and deviation to ipsilateral side on protrusion

Cranial Nerve Examination and Associated Defcits ■Olfactory (CN I) ▪︎Physical Exams -Odour sensation: test each nostril separately ▪︎Signs/Symptoms of Defcit -Anosmia(can be associated with loss of taste) ■Optic (CN II) ▪︎Physical Exams -Visual acuity: test each eye individually; best corrected vision -Test visual felds: peripheral visual felds (counting fngers, white pin), central visual feld, and blind spot (red pin) -Assess pupils: direct and consensual pupillary reaction (aferent component), swinging fashlight test (for RAPD) -Fundoscopy: optic disc edema and pallor, venous pulsations, hemorrhages -Colour vision testing (Ishihara plates) ▪︎Signs/Symptoms of Defcit -Central vision loss, peripheral vision loss, absence of light refexes, RAPD, enlarged blind spot, colour desaturation (especially red) ■Oculomotor (CN III) ▪︎Physical Exams -Assess extraocular movements and nystagmus -Assess pupils: direct and consensual pupillary reaction (efferent component), size and shape -Accommodation refex and saccadic eye movements -Test for ptosis (levator palpebrae superioris) ▪︎Signs/Symptoms of Defcit -Eye deviation (e.g. one eye deviated down and out), ophthalmoparesis, ptosis, can demonstrate mydriasis ■Trochlear (CN IV) ▪︎Physical Exams -Test movement of superior oblique muscle ▪︎Signs/Symptoms of Defcit -Vertical diplopia, may tilt head towards unafected side (Bielschowsky head tilt test), afected eye cannot turn inward and downward ■Trigeminal (CN V) ▪︎Physical Exams -Test sensation above supraorbital ridge (V1), maxilla or cheeks (V2), mandible (V3) -Test corneal refex (aferent limb) -Assess motor function: temporalis, masseter, pterygoids, jaw jerk reflex ▪︎Signs/Symptoms of Defcit -Ipsilateral facial sensory abnormality and absent corneal refex on stimulation ipsilaterally,weakness and wasting of muscles of mastication, deviation of open jaw to ipsilateral side, trigeminal neuralgia ■Abducens (CN VI) ▪︎Physical Exams -Test movement of lateral rectus muscle ▪︎Signs/Symptoms of Defcit Horizontal diplopia, esotropia (convergent strabismus), and abductor paralysis of ipsilateral eye,leading to difculty looking laterally with diplopia ■Facial (CN VII) ▪︎Physical Exams -Test muscles of facial expression -Test corneal refex (eferent limb) -Visceral sensory nerve function to anterior 2/3 of the tongue -Visceral motor nerve function to salivary and lacrimal glands ▪︎Signs/Symptoms of Defcit -LMN lesion = ipsilateral facial weakness, involving forehead -UMN lesion = contralateral facial weakness, sparing the forehead -Loss of lacrimation, decreased salivation, dry mouth,loss of taste to anterior 2/3 of the tongue ipsilaterally, hyperacusis ■Vestibulocochlear (CN VIII) ▪︎Physical Exams -Vestibular function: nystagmus, caloric refexes -Cochlear function: whisper test, Rinne test, Weber test ▪︎Signs/Symptoms of Defcit -Vertigo, disequilibrium, nystagmus, sensorineural hearing loss ■Glossopharyngeal (CN IX) ▪︎Physical Exams -Assess vocal cord function (phonation) and gag refex (aferent limb) -Assess taste to posterior third of the tongue (bitter and sour taste) ▪︎Signs/Symptoms of Defcit -Dysarthria, dysphonia -Loss of taste in posterior third of ipsilateral tongue, loss of gag refex, dysphagia -Unilateral lesion is rare ■Vagus (CN X) ▪︎Physical Exams -Assess vocal cord function: guttural (“ga”) and palatal (“ka”) articulation -Assess gag refex (eferent limb) -Observe uvula deviation and palatal elevation -Assess swallowing ▪︎Signs/Symptoms of Defcit -Loss of gag refex, dysphagia, hoarse voice, paralysis of soft palate (failed elevation), deviation of uvula to contralateral side of lesion, anesthesia of pharynx and larynx ipsilaterally ■Accessory (CN XI) ▪︎Physical Exams -Assess strength of trapezius (shoulder shrug) and sternocleidomastoid muscles (head turn) ▪︎Signs/Symptoms of Defcit -Ipsilateral shoulder shrug weakness and turning head to opposite side

Predicting the pre-test probability of deep vein thrombosis (DVT) using the Wells score ■Previous documented DVT >>1 ■Active cancer (patient receiving treatment for cancer within previous 6 months or currently receiving palliative treatment)>> 1 ■Paralysis, paresis or recent plaster immobilisation of lower extremities >> 1 ■Recently bedridden for ≥ 3 days, or major surgery within previous 12 weeks >> 1 ■Localised tenderness along distribution of deep venous system >> 1 ■Entire leg swollen >>1 ■Calf swelling at least 3 cm larger than that on asymptomatic side (measured 10 cm below tibial tuberosity)>> 1 ■ Pitting oedema confined to symptomatic leg >> 1 ■ Collateral superficial veins (non-varicose) >>1 ■ Alternative diagnosis at least as likely as DVT>> –2 ●DVT low probability if Total score <1 ●DVT moderate probability if Total score 1–2 ●DVT high probability if Total score > 2

The 4 “A’s” of Guillain-Barré syndrome— Acute inflammatory demyelinating polyradiculopathy Ascending paralysis Autonomic neuropathy Albuminocytologic dissociation (increased albumin in CSF)

The classic triad (Charcot triad) in MS is scanning speech, intranuclear ophthalmoplegia, and nystagmus. Pregnancy may be associated with a↓in MS symptoms.

Myasthenia gravis ■Clinical presentation :- Fluctuating & fatigable proximal muscle weakness :- •Ocular (eg, diplopia, ptosis) •Bulbar (eg, dysphagia, dysarthnia) •Respiratory (myasthenic crisis) ■Causes ofexacerbations • Medications:- antibiotics (eg, fluoroquinolones,aminoglycosides), neuromuscular blocking agents, cardiac medications (eg, BBs), MgS04, penicillamine • Physiologic stress pregnancy/childbirth, surgery (especially thymectomy), infection ■ Diagnosis :- • Ice pack test (bedside), • AChRR-Ab (highly Diagnosis specific) • CT scan of chest (thymoma) ■ Treatment :- • AChE inhibitors (eg, pynidostigmine) ±immunotherapy (eg, corticosteroids, azathioprine) • Thymectomy

Petit mal seizures may be described with the classic EEG finding of 3-per-second spike-and-wave discharges.

■Seizure Triggers :- • Lack of sleep • Flashing hight • Emotional stress • Alcohol withdrawal • Idiopathic ■Vasovagal syncope Triggers :- • Prolonged standing • Physical/emotional stress • Heat

Both simple partial and complex partial seizures may evolve into 2° generalized seizures.