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General Neurology (Q. 1-37)

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General Neurology (Q. 1-37) GENERAL NEUROLOGY (Q. 1-37) 1) Reflexes – classification, reflex arc, examination of normal reflexes. AA reflex is an involuntary and nearly instantaneous movement in response to a stimulus. A true reflex is a behavior which is mediated via the reflex arc. AA reflex arc is a neural pathway that controls an action reflex. Most sensory neurons do not pass directly into the brain, but synapse in the spinal cord. This characteristic allows reflex actions to occur relatively quickly by activating spinal motor neurons without the delay of routing signals through the brain, although the brain will receive sensory input while the reflex action occurs. There are two types of reflex arc - autonomic reflex arc (affecting inner organs) and somatic reflex arc (affecting muscles). Monosynaptic refers to the presence of a single chemical synapse. In polysynaptic reflex pathways involve one or more interneurons connect afferent (sensory) and efferent (motor) signals. The most important reflexes in clinical diagnosis are the biceps (C5 – –C6), brachioradialis (C5 – –C6), triceps (C7 – –C8), adductor (L2 – –L4), quadriceps (L2/3 – –L4), posterior tibial (L5), and Achilles (S1 – – S2) reflexes. Some clinically important extrinsic reflexes are the abdbdominal (T6 – T12), cremasteric (L1 –L2), bulbocavernosus (S3 – S4), and anal wink (S3 –S5) reflexes. 2) Reflexes – quantitative changes, pathological reflexes. AA reflex action is an involuntary and nearly instantaneous movement in response to aa stimulus. A true reflex is a behavior which is mediated via the reflex arc. Abnormal reflexes:: --Babinski sign: the plantar reflex is a reflex elicited when the sole of the foot is stimulated with a blunt instrument. In normal adults the plantar reflex causes a downward response of the hallux (flexion). An upward response (extension) of the hallux is known as Babinski response. The Babinski sign can indicate upper motor neuron lesion constituting damage to the corticospinal tract. --Clonus is a series of involuntary muscular contractions and relaxations. Clonus is a sign of certain neurological conditions and it is particularly associated with upper motor neuron lesions such as in stroke, multiple sclerosis, spinal cord damage and hepatic encephalopathy.Spontaneous twitching known as fasciculations usually caused by lower motor neuron pathology, clonus causes large motions that are usually initiated by a reflex. Clonus is most common in the ankles, where it is tested by rapidly flexing the foot upward. It can also be tested in the knees by rapidly pushing the patella towards the toes. --Hyperreflexia is defined as overactive or overresponsive reflexes. Examples of this can include spastic tendencies, which are indicative of upper motor neuron disease as well as the lessening or loss of control ordinarily exerted by higher brain centers of lower neural pathways. The most common cause of hyperreflexia is spinal cord injury. --Hyporeflexia is the condition of below normal or absent reflexes. Hyporeflexia is generally associated with a lower motor neuron deficit at the alpha motor neurons from the spinal cord to muscle. 3) Sensation – anatomy, physiology of the superficial and deep sensibility. Sensation: The somatosensory system is a diverse sensory system composed of the receptors and processing centres to produce the sensory modalities such as touch, temperature, proprioception (body position), and nociception (pain). The sensory receptors cover the skin and epithelia, skeletal muscles, bones and joints, internal organs, and the cardiovascular system. The system reacts to diverse stimuli using different receptors: thermoreceptors,, nociceptors,, mechanoreceptors and chemoreceptors.. Transmission of information from the receptors passes via sensory nerves through tracts in the spinal cord and into the brain. Processing primarily occurs in the primary somatosensory area in the parietal lobe of the cerebral cortex. The point-to-point mapping of the body surfaces in the brain is called a homunculus and is essential in the creation of a body image. This brain-surface ("cortical") map is not immutable. Dramatic shifts can occur in response to stroke or injury. Superficial sensation: the awareness or perception of feelings in the superficial layers of the skin in response to touch, pressure, temperature, and pain. Such sensations are conveyed to the brain via the spinothalamic system. Deep sensation: the awareness or perception of pain, pressure, or tension in the deep layers of the skin, muscles, tendons, or joints. Such sensations are conveyed to the brain via the spinal column. General somatosensory pathway: a somatosensory pathway will typically have three long neurons: The first neuron always has its cell body in the dorsal root ganglion of the spinal nerve (if sensation is in head or neck, it will be the trigeminal nerve ganglia or the ganglia of other sensory cranial nerves).. The second neuron has its cell body either in the spinal cord or in the brainstem. This neuron's ascending axons will cross to the opposite side either in the spinal cord or in the brainstem. The axons of many of these neurones terminate in the thalamus, others terminate in the reticular system or the cerebellum. In the case of touch and certain types of pain, the third neuron has its cell body in the thalamus and ends in the postcentral gyrus of the parietal lobe. In the periphery, the somatosensory system detects various stimuli by sensory receptors (ex. byby mechanoreceptors for tactile sensation and nociceptors for pain sensation). In the spinal cord, the somatosensory system includes ascending pathways from the body to the brain. Some ascending pathways, particularly those involved with control of posture are projected to the cerebellum. In the brain, the primary somatosensory area in the human cortex is located in the postcentral gyrus of the parietal lobe. 4) Sensation – study of common sensation, sensory symptoms, sensory syndromes. Human sensory system: consists of the following sub-systems: Visual system consists of the photoreceptor cells, optic nerve, and V1. Auditory system Somatosensory system consists of the receptors, transmitters (pathways) leading to S1, and S1 that experiences the sensations as touch oror pressure, temperature (warm or cold), pain (including itch and tickle), and the sensations of muscle movement and joint position including posture, movement, and facial expression. Gustatory system Olfactory system Sensory Symptoms: Positive symptoms: •• Pain •• Hyperalgesia: when threshold to pain appears lowered. •• Hyperpathia: pain threshold elevated, but once reached, the painful stimulus is excessively felt. •• Hyperaesthesia •• Paraesthesia: “burning feeling”.. •• Dysaesthesia/allodynia: when touching is painful. •• Neuralgia •• Causalgia: spontaneous burning sensation with increased sensitivity to painful stimuli. •• Phantom limb pain Negative symptoms: •• Hypaesthesia: decreased sensation. •• Anaesthesia: loss of feeling. Sensory Syndromes: Peripheral Syndromes Sensory Polyneuropathy, Diabetic Neuropathies, Acquired Immunodeficiency Syndrome – – Associated Neuropathies, Toxic Neuropathies, Amyloid Neuropathy, Proximal Sensory Loss, Temperature-Dependent Sensory Loss, Mononeuropathy. Spinal Syndromes Myelopathy, Syringomyelia, Spinal Hemisection. Brain Syndromes Thalamic Infarction and Hemorrhage, Thalamic Pain Syndrome, Trigeminal Neuralgia, Cortical Infarction. 5) Pyramidal system. Examination of muscle strength. Lesion syndromes of the central and peripheral motor neuron. Pyramidal system: any of the important motor nerves on each side of the central nervous system that run from the sensory motor areas of the cortex through the brainstem to motor neurons of the cranial nerve nuclei and the ventral root of the spinal cord. Muscle strength: the amount of force a muscle can produce with a single maximal effort. Size of muscle cells and the ability of nerves to activate them are related to muscle strength. Upper Extremity Strength Testing: Finger extension, Finger abduction, Thumb abduction in plane ofof palm, Thumb abduction perpendicular to plane of palm, Thumb opposition, Wrist flexion and hand abduction, Wrist extension and hand abduction, Elbow flexion, Elbow exte nsion. Lower Extremity Strength Testing: Hip flexion, Knee extension, Knee flexion, Leg abduction, Leg adduction, Toe dorsiflexion, Foot dorsiflexion, Foot plantar flexion. Upper motor neurons are motor neurons that originate in the motor region of the cerebral cortex or the brain stem and carry motor information down to the final common pathway, that is any motor neurons and they are not directly responsible for stimulating the target muscle. The pyramidal tract is a collection of axons that travel between the cerebral cortex ofof the brain and the spinal cord and mostly contains motor axons. It actually consists of two separate tracts in the spinal cord: the lateral corticospinal tract and the anterior corticospinal tract. The neurons of the corticospinal tracts are sometimes referred to as pyramidal tract neurons (PTN), because their axons form part of the pyramidal tracts leading to the spinal cord. Injuries to the motor pathways result in paralysis. Damage to the motor neurons in the frontal cortex or their tracts result in upper motor neuron syndromes. For example, if the left lateral corticospinal tract is damaged at the second cervical vertebra, control of the left upper and lower limbs is lost. Upper motor neuron syndrome is characterized by spastic paralysis where
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