Question 7

College comments

Syllabus topic/section: 2.1.8 Neurological Intensive Care 

Discussion: 

Candidates who performed well in this section demonstrated a clear and structured answer, with knowledge of the neurological examination and specific deficits that were related back to the anatomical location of the lesion.

Answers that scored less well were vague and lacked structure. The marking Examiners commented that having a clearer structure and including all elements of the neurological exam in a logical sequence (eg motor: tone/power/reflexes, the various sensory examination components, autonomic features) would have led to more comprehensive and better scoring answers.
 

Interpretation

The comments sound like the examiners wanted the findings presented in a certain way; or rather, that candidates who presented their answer laid out in logical manner scored higher. This may be partly die to the fact that it is easier to mark a logically presented answer, and partly because a logical structure prevents you from forgetting various details. In this scenario, the question is asking about neurological findings, so the usual power/tone/reflexes/sensation structure is probably the most effective:

Basal ganglia stroke

• Power: contralateral weakness (including face)
• Tone: Contralateral upper motor neuron signs, increased tone and clonus
  (initially, flaccid)
• Reflexes: contralateral hyperreflexia
• Sensation:  contralateral loss of sensation (including face)
• Autonomic function: usually preserved

• Subtypes exist:

  • A pure motor variant (internal capsule and pons only)
  • A pure sensory variant (thalamus and corona radiata)
  • Ataxic hemiparesis (thalamus and internal capsule)

C5 spinal cord injury:

• Power: quadriparesis; shoulder shrug and elbow flexion is preserved
• Tone: Flaccid initially (spinal shock), later spasticity and contractures
• Reflexes: areflexic initiallyu, later hyperreflexic
• Sensation:  bilateral loss of sensation below the root of the neck
• Autonomic function: autonomic dysreflexia, neurogenic bladder and bowel

Critical illness myopathy

• Power: proximal muscle weakness
• Tone: decreased, flaccid
• Reflexes: would be normal if the muscles were not so weak
• Sensation: preserved
• Autonomic function: preserved