Neurological examination for psychiatrists

Report
Neurological examination
for psychiatrists
Dr T M Jenkins MBChB MRCP PhD
Clinical Lecturer in Neurology
June 2014
Neurophobia (n) fear of neurology
amongst medical students ( and
professionals)
What are the reasons for
neurophobia?
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High interest
Difficult
Basic science
Neuroanatomy
Multiplicity of diagnoses
…and…
Causes of neurophobia
 Poor or inadequate teaching
Why is it necessary
(objectives)?
 Syllabus
 Relevant in real life differentials
 Relevant to part 1 exams- 10 neurology
MCQs/EMIs
Syllabus
 Be aware of the equipment required in the full
neurological examination
 Overview of examination of the nervous
system
 Understand how to examine each pair of
cranial nerves with reference to common
abnormalities and how to elicit them
 Understand how to examine the CNS and PNS
with reference to common abnormalities and
how to elicit them
Equipment used
“The
neurologist”
Jose Perez
Oil on canvas
Neurologists love to observe and measure. Historically, their tools have been the percussion hammer for knee jerks, the
vibrating fork for bone conduction, and the pins for determining whether the patient is numb or faking it. Today,
neurologists use electroencephalograms to tell when we're brain dead.
Medical students can spot a neurology professor a ward away. They're almost invariably serious-minded, academically
oriented males with a penchant for raising the possibility of an extremely rare and always incurable malady named after
some seventeenth-century Frenchman. Polyneuropathy, neuropraxia, amyotrophy, and encephalopathy are just some of
the hard-to-pronounce words neurologists typically love to let casually roll from their tongues. No doubt the doctor peering
into the centaur's skull is about to pronounce the poor fool as suffering from anencephaly.
Neurological examinationan approach
 Make an anatomical diagnosis (where is
the lesion?)
 Make a pathological diagnosis (what is
the lesion?)- go back to history
Question
 An 86yo man is referred to the psychiatry
clinic with progressive confusion, visual
and auditory hallucinations over 6
months and is struggling to cope at
home.
Neurological examination
 Cranial nerves are normal.
 There is bilateral limb rigidity and resting
tremor, but normal power, reflexes,
coordination and sensation.
 Movements are slow and show a
decrement on repetitive testing.
 He is confused and scores 59/100 on
Addenbrooke’s cognitive examination.
What is the likely
pathophysiology?
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A: Neurofibrillary tangles
B: Tauopathy
C: Lewy bodies
D: Prion protein
E: Dopamine excess
Technique
• What does the neurological examination tell
us?
COGNITIVE IMPAIRMENT, PARKINSONISM
• What does the history tell us?
DEMENTIA
• Which type of dementia is associated with
hallucinations and Parkinsonism? (AD/ FTD/
LBD/ prion/ vascular)
LEWY BODY DISEASE
What is the likely
pathophysiology
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A: Neurofibrillary tangles
B: Tauopathy
C: Lewy bodies
D: Prion protein
E: Dopamine excess
Overview of examination
of the CNS
 Cranial nerves
 Arms
 Legs
 T/P/R/C/S
 Cognitive, lobar
Anatomical localisation:
common patterns
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Cortical- brain
UMN- brain (consider cranial nerves)
UMN- cord
Cauda equina
LMN- anterior horn cell to muscle, often
neuropathy
 NMJ- MG
 Myopathy
Localisation: cranial
nerves- rule of four
 1,2,3,4 above pons
 5,6,7,8 pons
 9,10,11,12 medulla
 Factors of 12: 3,4,6,12 in midline
Rule of four
 M- midline
 Motor pathway
 Motor nerves/nuclei
(3,4,6,12)
 MLF
 Medial lemniscus
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S- side
Spinothalamic tract
Spinocerebellar
Sympathetic
Sensory nucleus of V
The cranial nerves
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12 pairs
Origin
Sensation
Motor
Autonomic
III, VII, IX, X
Remembering names
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On
Old
Olympus'
Towering
Top
A
Fine
Vested
German
Viewed
A
Hop
Question
 A 50yo man presents with behavioural
change over the previous year.
Previously he was very neat and tidy, but
now his wife says “he has become a
slob”. He appears apathetic. On
examination, he has lost his sense of
smell and has a pout reflex.
What is the likeliest
diagnosis?
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A: Depression
B: Parkinson’s disease
C: Olfactory groove meningioma
D: Glioblastome multiforme
E: Fronto-temporal dementia
Which of these tests is most
likely to provide the
diagnosis?
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A: HADS assessment
B: Clinical examination of limbs
C: CT brain
D: SPECT scan
E: Addenbrooke’s cognitive assessment
1. Olfactory
 Sense of smell
Olfactory nerve
meningioma
History and examination
 Frontal
 Olfactory nerve
 Slow growing
What is the likely
diagnosis?
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A: Depression
B: Parkinson’s disease
C: Olfactory groove meningioma
D: Glioblastome multiforme
E: Fronto-temporal dementia
Which of these tests is most
likely to provide the
diagnosis?




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A: HADS assessment
B: Clinical examination of limbs
C: CT brain
D: SPECT scan
E: Addenbrooke’s cognitive assessment
II. Optic nerve
 Vision
Eyes: 5 things (minimum)
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Acuity
Fields
Pupils
Fundi
Eye movements
(colour vision)
(near vision)
(accommodation
and convergence)
(etc)
II: optic nerve
Visual fields
Pupil reactions to light and
near (accommodation)
Visual acuity
Fundoscopy
Visual fields
3, 4 and 6: the nerves
controlling eye movements
Left eye
6. Abducens
The rest: 3.
Oculomotor
4. Trochlear
Convergence
3, 4 and 6
3. Oculomotor palsy
4. Trochlear palsy
E.g. Trauma
E.g. Coning
6. Abducens palsy
E.g. Multiple sclerosis
Question: Which of the following eye
signs is thought to be pathognomic
of multiple sclerosis?
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A: Argyll-Robertson pupil
B: Bilateral internuclear ophthalmoplegia
C: Holmes-Adie pupil
D: Horner’s syndrome
E: Kayser-Fleischer ring
Argyll-Robertson pupils
Bilateral, light-near dissociation, normal acuity
Internuclear
ophthalmoplegia
Nystagmus
Look to right
Look straight ahead
Pons level
Convergence usually normal
Look to left
MLF
Modified from Notz et al, Consultant, 2009 and Gray’s anatomy
Holmes-Adie pupil
Left pupil relatively
dilated, poor reaction to
light
Tonic reaction to
accommodation
Usually unilateral, can be bilateral, test AJs
Modified from neurology.org
Horner’s syndrome
Anisocoria more noticeable in dark,
reacts normally
Modified from mrcpopth.com
Kayser-Fleischer ring
KF ring
Modified from Hepatitis Monthly, 2009
Question: Which of the following eye
signs is thought to be pathognomic
of multiple sclerosis?
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A: Argyll-Robertson pupil
B: Bilateral internuclear ophthalmoplegia
C: Holmes-Adie pupil
D: Horner’s syndrome
E: Kayser-Fleischer ring
Question: Which of the following lesions
is most likely to cause bitemporal
hemianopia?
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A: Parietal lobe tumour
B: Occipital lobe tumour
C: Pituitary tumour
D: Cerebrovascular disease
E: Frontal lobe tumour
Visual fields
Question: Which of the following lesions
is most likely to cause bitemporal
hemianopia?
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A: Parietal lobe tumour
B: Occipital lobe tumour
C: Pituitary tumour
D: Cerebrovascular disease
E: Frontal lobe tumour
Question: Which of the
following is associated with
ptosis and depression?
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A: Third nerve palsy
B: Myasthenia gravis
C: Horner’s syndrome
D: Levator dehiscence
E: Sixth nerve palsy
Question: Which of the
following is associated with
ptosis and depression?
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A: Third nerve palsy
B: Myasthenia gravis
C: Horner’s syndrome
D: Levator dehiscence
E: Sixth nerve palsy
5. Trigeminal
 Sensation to face
 Muscles of jaw
Reflexes
corneal
“Open your mouth”
“Clench your teeth”
jaw jerk
5. Trigeminal
Trigeminal neuralgia
Question: what neurological
condition did George Clooney
suffer from?
7. Facial nerve
Upper motor
neurone e.g. stroke
Lower motor
neurone e.g Bell’s
“Raise your eyebrows”
“Close your eyes”
“Blow out your cheeks”
“Show me your teeth”
Question
 You notice a tonic spasm on a woman
who cannot resist closing her right eye
while talking to you. She is able to carry
out most of her daily activities including
watching TV normally. This is best
described as:
Question
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A: Blepharospasm
B: Tonic seizures
C: Multiple sclerosis
D: Normal phenomenon
E: Catatonic posturing
What it is not:
Catatonia
Tonic seizures
Multiple sclerosis
Possibilities
Blepharospasm
Motor tics
??Bell’s with aberrant
reinnervation
Usually bilateral
Common in children
Involuntary
Can be suppressed
May be triggered by
flickering lights
Can be situationspecific
Question
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A: Blepharospasm
B: Tonic seizures
C: Multiple sclerosis
D: Normal phenomenon
E: Catatonic posturing
8. Vestibulo-cochlear
Hearing
Balance
Testing hearing
 Rinne’s test
Normal air > bone
 Weber’s test
Quieter in affected ear:
sensorineural
Louder in affected ear:
conductive
Modified from: drdavidson.ucsd.edu
Same: no help
Question: A nurse noticed that she has to
raise her voice considerably when talking
to an elderly patient whose threshold to
voices has increased. This is:
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A: Hyperaesthesia
B: Paraesthesia
C: Hypoesthesia
D: Hypoalgesia
E: Hyperalgesia
Question: A nurse noticed that she has to
raise her voice considerably when talking
to an elderly patient whose threshold to
voices has increased. This is:
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A: Hyperaesthesia
B: Paraesthesia
C: Hypoesthesia
D: Hypoalgesia
E: Hyperalgesia
aisthesis
“sensation”
algos
“pain”
9. Glossopharyngeal and
10. Vagus
 Palate movement
 Gag
 Cough
NB Speech “puh” “kah” “tah”
Say “aaah”
Question: link the speech defect to
the anatomical cause
 1: Hypophonia
 2: Expressive dysphasia
 3: Pseudobulbar
dysarthria
 4: Phonation on
inhalation
 5: Scanning dysarthria
 6: Nasal dysarthria
 7: Receptive dysphasia
 8: High pitched and
variable
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A: Cerebellum
B: Wernicke’s area
C: Extrapyramidal lesion
D: Hysterical
E: Broca’s area
F: Myasthenia gravis
G: Upper motor neurone
lesion
 H: Vocal cord paralysis
Question: link the speech defect to
the anatomical cause
 1: Hypophonia
 2: Expressive dysphasia
 3: Pseudobulbar
dysarthria
 4: Phonation on
inhalation
 5: Scanning dysarthria
 6: Nasal dysarthria
 7: Receptive dysphasia
 8: High pitched and
variable
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A: Cerebellum
B: Wernicke’s area
C: Extrapyramidal lesion
D: Hysterical
E: Broca’s area
F: Myasthenia gravis
G: Upper motor neurone
lesion
 H: Vocal cord paralysis
XI. Accessory
“Turn your head against my hand”
“Shrug your shoulders”
12. Hypoglossal
“Stick your tongue out”
“Waggle it side to side”
Question
 An 80 year old man presents with a 6
month history of progressive weakness,
swallowing problems, slurred speech and
weight loss. On examination of his
tongue, there is bilateral wasting and
fasciculations. The jaw jerk is normal.
Question: what is the
likeliest abnormality of his
speech?
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A: Hypophonia
B: Flaccid dysarthria
C: Scanning dysarthria
D: Expressive dysphasia
E: Spastic dysarthria
Question: what is the
likeliest abnormality of his
speech?
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A: Hypophonia
B: Flaccid dysarthria
C: Scanning dysarthria
D: Expressive dysphasia
E: Spastic dysarthria
Summary: cranial nerves
POTTER
 On
 On
 On
 They
 Travelled
 And
 Found
 Voldermort
 Guarding
 Very
 Ancient
 Horcruxes
CRANIALS
 Olfactory
 Optic
 Oculomotor
 Trochlear
 Trigeminal
 Abducens
 Facial
 Vestibulocochlear
 Glossopharyngeal
 Vagus
 Accessory
 Hypoglossal
Questions?
Arms and legs
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Tone
Power
Reflexes
Coordination
Sensation
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Gait
GCS
Cognitive exam
Lobar signs
Tone
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Normal
Reduced
Rigid/cogwheel
Clasp-knife
Power
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Normal
Proximal
Distal
Pyramidal
Hemiparesis/Paraparesis
Fatiguable
NB Bradykinesia
Reflexes
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Normal
Absent
Brisk
Plantars
Coordination
 Cerebellar ataxia
 Sensory ataxia
Sensation
 Glove and stocking
 Sensory level
 Dissociated sensory loss (eg syrinx,
anterior cord infarct, subacute combined
degeneration)
Which gaits are associated
with which disorders?
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A: High-stepping
B: Festinant
C: Waddling
D: Circumducting
E: Broad-based
F: Trendelenburg
G: Pigeon
H: Marche a petit pas
I: Stamping
J: Magnetic
K: Scissoring
 1: Spastic paraparesis
 2: Diffuse cerebrovascular
disease
 3: Stroke
 4: Myopathy
 5: Normal pressure
hydrocephalus
 6: Bilateral foot drop
 7: Sup. gluteal nerve lesion
 8: Musculoskeletal disorders
of childhood
 9: Sensory ataxia
 10: Parkinson’s disease
 11. Cerebellar ataxia
Which gaits are associated
with which disorders?
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A: High-stepping
B: Festinant
C: Waddling
D: Circumducting
E: Broad-based
F: Trendelenburg
G: Pigeon
H: Marche a petit pas
I: Stamping
J: Magnetic
K: Scissoring
 1: Spastic paraparesis
 2: Diffuse cerebrovascular
disease
 3: Stroke
 4: Myopathy
 5: Normal pressure
hydrocephalus
 6: Bilateral foot drop
 7: Sup. gluteal nerve lesion
 8: Musculoskeletal disorders
of childhood
 9: Sensory ataxia
 10: Parkinson’s disease
 11. Cerebellar ataxia
A Glasgow coma score
between 9 and 12 indicates:
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A: Severe head injury
B: Mild head injury
C: Moderate head injury
D: No head injury involved
E: Alert and orientated
A Glasgow coma score
between 9 and 12 indicates:
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A: Severe head injury
B: Mild head injury
C: Moderate head injury
D: No head injury involved
E: Alert and orientated
Glasgow coma scale
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Best eye response (E)
1. No eye opening
2. Eye opening in response to pain
3. Eye opening to speech
4. Eyes opening spontaneously
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Best verbal response (V)
1. No verbal response
2. Incomprehensible sounds
3. Inappropriate words
4. Confused
5. Orientated
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Best motor response (M)
1. No motor response
2. Extension to pain (abduction of arm, external rotation of shoulder, supination of forearm,
extension of wrist, decerebrate response)
3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of
forearm, flexion of wrist, decorticate response)
4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when
supra-orbital pressure applied ; pulls part of body away when nailbed pinched)
5. Localizes to pain (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line
and gets above clavicle when supra-orbital pressure applied.)
6. Obeys commands
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Grading severity of head
injury
GCS
Mild
13-15
Moderate
9-12
Severe
8 or less
Addenbrooke’s cognitive
examination
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Attention and orientation
Memory
Fluency
Language
Visuospatial
Cutoff <88/100
18
26
14
26
16
Cognitive examinationprofile?
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Attention and orientation
Memory
Fluency
Language
Visuospatial
Total 54/100
12/18
2/26
11/14
24/26
6/16
Alzheimer’s disease
 Classic presentation is amnestic for dayto-day events
 Visuospatial deficits
Adapted from Pick’s disease support group
Cognitive examination
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Attention and orientation
Memory
Fluency
Language
Visuospatial
Total 54/100
12/18
22/26
2/14
4/26
14/16
Front-temporal dementia
 Behavioural and language variants
Adapted from Pick’s disease support group
Question: The part of the
brain involved in working
memory is:
A: Thalamus
B: Hypothalamus
C: Prefrontal cortex
D: Hippocampus
E: Basal ganglia
Question: The part of the
brain involved in working
memory is:
A: Thalamus
B: Hypothalamus
C: Prefrontal cortex
D: Hippocampus
E: Basal ganglia
Memory
memory
Working memory
prefrontal cortex
Long term memory
Explicit memory
(declarative)
episodic
semantic
Implicit memory
Skills/ habits
cerebellum,
basal
ganglia
Conditioned
reflexes
cerebellum,
others
Emotional amygdala
Cortical lobar examination
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Frontal
Parietal
Temporal
Occipital
NB Seizures
Dysphasia
Neglect
Hemianopia
The most common type of
seizure with an aura is:
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A: Grand mal
B: Petit mal
C: Complex partial seizure
D: Absence seizure
E: Pseudoseizure
The most common type of
seizure with an aura is:
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A: Grand mal
B: Petit mal
C: Complex partial seizure
D: Absence seizure
E: Pseudoseizure
Miscellaneous questions
Which EEG waveform typically has a
frequency of 4-7.5 Hz?
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A: Theta
B: Gamma
C: Alpha
D: Delta
E: Beta
Miscellaneous questions
Which EEG waveform typically has a
frequency of 4-7.5 Hz?
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A: Theta
B: Gamma
C: Alpha
D: Delta
E: Beta
Which of the following is
not dyskinesia?
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A: Chorea
B: Athetosis
C: Hemiballism
D: Oculogyric crisis
E: Akathisia
Which of the following is
not a dyskinesia?
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A: Chorea
B: Athetosis
C: Hemiballism
D: Oculogyric crisis
E: Akathisia
“Abnormal involuntary movements”
Question
 A 23yo woman presents with hallucinations
and delusions. She has become paranoid that
people were trying to kill her, afraid of going
out. She had heard voices telling her she was
going to die and seen people coming to get her
in her house. Her mother said that in the
previous week, sometimes she did not seem to
be listening to her, was “tuned out”, fiddling
with things and not appearing to listen. Her
concentration was poor.
Examination
 On examination, she appeared confused
and agitated and pyrexial with writhing
movements evident in her face and
limbs.
Question: what is the
likeliest diagnosis?
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A: Schizophrenia
B: Drug-induced psychosis
C: Anti-NMDA receptor encephalitis
D: Viral encephalitis
E: Bacterial meningitis
Question: what is the
likeliest diagnosis?

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A: Schizophrenia
B: Drug-induced psychosis
C: Anti-NMDA receptor encephalitis
D: Viral encephalitis
E: Bacterial meningitis
Question: A 40 year old man
presents with a 4 week
history of confusion. His MRI
scan is shown below
What is the likely cause of
his confusion?



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A: Viral encephalopathy
B: Delirium
C: Prion dementia
D: Bacterial sepsis
E: Huntington’s disease
What is the likely cause of
his confusion?

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


A: Viral encephalopathy
B: Delirium
C: Prion dementia
D: Bacterial sepsis
E: Huntington’s disease
Huntington’s
A 28 year old man with a history of
alcohol excess is admitted in a confused,
hallucinating and combative state. On
examination, his gaze is directed to the
right. What is the likeliest diagnosis?
•
•
•
•
•
A: Left-sided subdural haematoma
B: Bacterial meningitis
C: Hyponatraemia
D: Hepatic encephalopathy
E: Wernicke’s encephalopathy
A 28 year old man with a history of
alcohol excess is admitted in a confused,
hallucinating and combative state. On
examination, he is unable to look to the
left. What is the likeliest diagnosis?
•
•
•
•
•
A: Left-sided subdural haematoma
B: Bacterial meningitis
C: Hyponatraemia
D: Hepatic encephalopathy
E: Wernicke’s encephalopathy
Question
A 28yo lady with a history of
personality disorder collapses during
an argument with her boyfriend, who
witnesses her shaking violently for 20
minutes before recovering.
Immediately afterwards, she told the
paramedics she had no memory of the
event. She tells you she felt dizzy
beforehand.
What is the likeliest diagnosis?
 A: Episode of grand mal status
epilepticus
 B: Absence seizure
 C: Non-epileptic attack
 D: Vaso-vagal syncope
 E: Complex partial seizure
What is the likeliest diagnosis?
 A: Episode of grand mal status
epilepticus
 B: Absence seizure
 C: Non-epileptic attack
 D: Vaso-vagal syncope
 E: Complex partial seizure
Where neurology and
psychiatry collide
 Seizures and NEAD
 Encephalitis and psychosis
 Depression and long-term neurological
illness
 Confusional states
Summary
 Be aware of the equipment required in the full
neurological examination
 Overview of examination of the nervous
system
 Understand how to examine each pair of
cranial nerves with reference to common
abnormalities and how to elicit them
 Understand how to examine the CNS and PNS
with reference to common abnormalities and
how to elicit them
Neurophilia effect
Cognitive
neuroscience
students were
shown complex
data and received
2 explanations with
and without
neurological
terminology
Grey graphs shows satisfaction to a
meaningless explanation without and with
neurological terminology
Good luck!

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