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How to decipher neurology: 5 easy steps
Learning neurology is challenging. Yet, it is a necessary hurdle for medical students, post-grad medical exams and some sub-specialties (e.g. psychiatry, ICU, general practice). Let's look at some...
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Keep calm and carry on: neurology
During our lifetime, data suggests that 1 in 3 of us will experience an anxiety disorder. This certainly matches day-to-day clinical practice. Our patients are often in the midst of an anxiety disorder...
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Parkinson's Law: does it apply to neurology?
In November 1955, The Economist published a fascinating article by Prof Cyril Northcote Parkinson. A naval historian, Dr Parkinson served as a professor of history in Singapore. The success of this...
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Erythema nodosum and neurology
A skin exam is often worthwhile in neurology. Many younger doctors with an interest in neurology would benefit from spending some time in a dermatology service. It can be quite eye-opening (e.g....
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Eastchester clapping sign: a novel screen for neglect
If you spend some time working in a stroke unit, you'll quickly notice that patients with left hemisphere strokes often display right hemiparesis and dysphasia. On the contrary, right hemispheric...
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TIA and stroke risk factors
Let's start with some terminology. Most would agree that a transient ischaemic attack (TIA) is a brief period of neurological dysfunction caused by focal brain, spinal cord or retinal ischaemia. TIAs...
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Pendular reflexes: rare but helpful
I learned the standard cerebellar signs in medical school. We all know these: gait ataxia, dysarthria, nystagmus, intention tremor, past pointing, rebound, dysdiadochokinesia and pendular reflexes....
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The Gordon reflex: an easy alternative to the Babinski reflex
The internet is a remarkable resource for those interested in medical history. Here is a nice quote from an article by Dr Alfred Gordon in 1906 : "In October 1904, I demonstrated before this Society a...
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Blepharoclonus
Blepharoclonus is an interesting clinical sign often omitted from the routine neurological examination. What is it? And what are the causes?
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Movement disorders: an important piece of the puzzle
Many neurology trainees feel compelled to pursue a subspecialty (e.g. epilepsy, stroke, neuroimmunology, neuromuscular, movement disorders). However, some of us prefer to remain in general neurology....
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Eye exam in neurology: keep it simple
Short cuts are necessary in clinical practice. However, one needs to take care not to skip too much of the physical examination. Yet, the complete omission of any eye exam is surprisingly common in...
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Surfer's myelopathy
Myelopathy refers to neurological deficits that arise from spinal cord dysfunction. The classical triad of signs indicating myelopathy is:
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Cerebral small vessel disease: surprisingly common
If you send elderly patients for an MRI brain, you will frequently encounter a report of cerebral small vessel disease. Often the non-specific finding of multiple small white matter hyperintensities is...
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Therapeutic trial: often worth a try in neurology
Older clinicians are adept at the art of the therapeutic trial. In day-to-day clinical medicine, this management option refers to the use of a treatment in a non-standard manner. For example, (a) where...
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Managing expectations: a 2-way street
As doctors or medical students, who we interact with professionally is worth considering for a moment: patients, admin staff, nurses, doctors, students, family members etc. However, it is much more...
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Internuclear ophthalmoplegia (INO): an acronym worth knowing
There are several potential causes of an internuclear ophthalmoplegia (INO). These include ischaemia, demyelination, tumour & inflammation. For those who work in a hospital environment, the two...
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On the importance of brevity
Are you guilty of talking too much? When you have a discussion with others, would it be better described as a lecture? And your patients and colleagues can't get a word in? While is it nice to have the...
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Doctors are bad at business: why?
Ask any accountant or financial planner: 'Which occupation is the least savvy when it comes to business?'. The answer is usually doctors and dentists. Let's first consider some of the many reasons for...
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Doctors are bad at business: 5 steps for success
For those who disagree with the claim that doctors are bad at business, take at look at why this is the case here. There are many advantages to being good at business:
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Palilalia in Parkinson's disease
Over time, patients with Parkinson's disease often display a softer voice (i.e. hypophonia). There are, however, several other speech-related manifestations of this condition. All in all, the...
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Tendon hammers: do you have a favourite?
The most popular tendon hammer in the UK and Australia is the Queen Square reflex hammer. Apparently, this was invented by Miss Wintle, a senior nurse in the National Hospital for Nervous Diseases...
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Hyperacusis: don't forget to ask!
Hyperacusis is uncommon. When seeing neurology patients, you will need to specifically enquire. This serves as a good example of the occasional need for 'closed questions' in medicine. So what is...
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When is foot drop not foot drop?
Foot drop can prove challenging to diagnose. The standard causes are nicely laid out by Dr J D Stewart here. An easy to use summary is also available from another Neurology Night School piece here. If...
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Non-organic foot drop: rare but not impossible
Foot drop is a common clinical scenario. The most well known causes are listed elsewhere in NNS (here). Rarely, foot drop is secondary to a functional neurological disorder. So, how common is that?
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Antecubital fossa cannula: beware!
The median nerve is commonly compressed distally - at the wrist - which results in the well-known carpal tunnel syndrome (CTS). Diagnosis and management is usually quite straightforward. CTS causes...
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Let's put IM injections to the buttocks behind us
There are many instances in medicine (and neurology) where the treatment is worse than the disease - aegrescit medendo. This sentiment can also apply to unsafe or unnecessary medical procedures. Let's...
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Obesity and neurology: speak up
Obesity is now considered a global epidemic with a prevalence of 13% of all adults in 2016. This could reach 18% by 2025. As a useful guide, a BMI of >25 means you are overweight and if >30,...
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Hypertension: a stitch in time saves nine
The guidelines on hypertension are important but often complex. Many would view repeated readings of a BP >130/80 as hypertension. For those who wish to delve into the detail further, the American...
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Easy assessment of mononeuropathies: high vs low?
Sometimes simple is better. Let's take mononeuropathies for example. When assessing a patient with suspected neuropathy, it can be helpful to apply well established clinical pointers. Often in...
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The ALS split hand
A large proportion of patients with amyotrophic lateral sclerosis (ALS) will display a characteristic pattern of muscle atrophy in the hands. This is termed the 'ALS split hand' as the wasting...
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Four facts about the fourth cranial nerve
Learning neuroanatomy can be a chore. Let's keep this short and to the point then... Here are four interesting facts about the very interesting trochlear nerve.
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Superior oblique myokymia
Superior oblique myokymia is a rare entity. It causes unilateral nystagmus and the patients describe uniocular vertical diplopia and oscillopsia. This benign condition is usually idiopathic and...
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Fix frustrations with simple systems
Over the years as a consultant neurologist, I will occasionally leave work frustrated or irritated by a memorable (but negative) event. This can be with a patient, family member, colleague or...
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Erythema ab igne: old and forgotten?
A little reading can save a lot of time. Maintaining an interest in old case reports can save us (and our patients) from wasted effort, money and anxiety. Conditions or syndromes easily recognised by...
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How to study in med school and beyond: one size does not fit all
Here at Neurology Night School we devote an entire section to study techniques. You may find that your approach to exams is quite different to fellow students or work colleagues. Those of us who have...
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Immunosuppression & immunomodulation in neurology: traps to avoid
The use of immunosuppressive or immunomodulatory agents in neurology has transformed the specialty from largely diagnostic to, now, largely therapeutic. With these advances comes a heavy...
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Passing the FRACP written exam: simple, not easy
The vast majority of candidates who sit the FRACP written exam in Australia and New Zealand will pass it. But that doesn't mean it's easy! Let's look at some practical tips on how to make your study...
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The art of history taking in medicine
You may have heard this phrase before: the art and science of medicine. We should expand the phrase to incorporate 'business' but that is a topic for another day. For now, let's look at the art of...
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Hospital ward rounds: too slow?
Ward rounds are a curious means of doing business. Don't you agree? Let's consider the humble ward round from the perspective of time. What is the optimal time taken to complete a productive hospital...
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SMART: a rare complication
There are several potential side effects of cranial radiotherapy. Some occur acutely whereas others are delayed. An example of a rare delayed complication is termed SMART syndrome: stroke-like migraine...
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Ocular side effects of prednisolone
In clinical neurology, prednisolone is used for a range of conditions: acute and chronic. Although the benefits are plain to see, the side effects should not be overlooked. The complications of steroid...
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Sodium valproate: side effects of a global medication
Sodium valproate is the most prescribed anticonvulsant worldwide. It has a broad spectrum of activity in epilepsy and is available in different formulations: oral liquid, oral tablet and intravenous...
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Neurology in a hospital: the good, the bad and the ugly
What comes to mind when you think of hospital-based neurology? Many neurology trainees see this as their ultimate goal. Eventually, we must all decide: (a) remain working within a hospital service or...
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10 Traps in Neurology
Clinical neurology is usually quite straightforward. On occasion, that is not the case. We, as doctors, can fall into a range of cognitive 'traps'. Knowing in advance the 'traps' to watch out for is...
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Neurology study tips: medical students and junior doctors
Let's be honest, the majority of medical students and doctors who study neurology, do so under duress. An exam looms not far in the future - written or clinical. That obstacle must be crossed...
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Beware assumptions: neurology & business
Some assumptions are helpful in clinical medicine. They serve to reduce cognitive overload and allow the treating doctor to move through their workload more efficiently. Let's look at a few positive...
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Dysphagia denial
When patients present with features of motor neurone disease, myopathy, myasthenia gravis or stroke, it is particularly important to screen for dysphagia. This begins with a careful history (e.g. ask...
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Anterior abdominal sensory loss
Peripheral neuropathy is a common scenario in clinical neurology. Patients will present with distal lower limb sensory loss, paraesthesia and neuropathic pain - often worse at night. Management of the...
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Physical signs of anxiety
It's surprising how anxious new patients can be. There are several helpful strategies we, as clinicians, can employ. For patients who don't know what to expect at an upcoming neurology appointment, a...
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Hospital intern errors: lessons from 20 years ago
Learning from the errors of others is helpful as it increases your chances of a smooth journey through medicine. Most of us are wise enough to adopt this approach. For those who tend to rush ahead,...
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