Neurology 1 experience

Merry belated Christmas!

I had neuro 1 on Monday. I’ve been taking some days off after that.

As we all know, this year we’re having the exam with our own teachers in neuro 1. As such, the procedure of the exam, and what they’re focusing on, probably varies from teacher to teacher, although I’m sure they’ll all be lenient at the exam.

My teacher and examiner was Dr. Márton Tóth, who’s a very sweet and fun man. The day before the exam he told the 12 of us who were to have the exam that day to make groups of 3. The first group of three would start at 10:00, the next group of three at 11:00, and so on. That way everyone knew approximately when their exam would be. Why can’t all oral exams do this?

I was in the first group, so at 10 me and the other three students in the first group joined a meeting our teacher had made in the team we usually used for seminars. He told us that we’d get 4 questions from A and B topics, and one question from C topics. He’d told us beforehand that he feels that the topic list is too extensive for this semester, and so he wouldn’t expect much from C topics.

I volunteer to start, so I do. He begins asking:

• Examiner: How do you examine the vision?
• Me: You could use a Snellen chart if you have it available, but if not you could hold up a certain number of fingers at 5 metres distance and ask if they can see them. If they can’t, move closer and repeat.
• E: And what do you do, if at one metre, there is no response? If at zero metres, there is no response? What should you use?
• M: Just a simple light, to see if they can detect light at all.
• E: The so-called candle test, yes. Good, okay.
• M: Please tell me which pyramidal signs you know.
• E: The most important is the Babinski, but also the triflexion response, achilles clonus, patellar clonus.
• M: And in the hand?
• E: I don’t remember the names, but it’s the one where you flick the fingernail.

At this point he asked the next student if they remembered the names of the two pyramidal signs of the hand, but they didn’t either.

• E: Okay. Other pyramidal signs?
• M: Do you mean upper motor neuron lesion signs in general or pyramidal signs specifically? I know upper motor neuron lesions like spasticity, no atrophy, hyperreflexia …
• E: What does hyperreflexia mean?
• M: It means that the response is stronger than usual, or the reflex zone is larger, so you can elicit the reflex at a larger area.
• E: Okay, okay. How do you examine muscle tone?
• M: Okay, so we start for example in the upper limb. We can begin with moving the elbow joint, feeling for flaccidity, rigidity, or spasticity.
• E: Okay. Which type is which? How can you describe them?
• M: Flaccidity is when there is a loss of muscle tone, so the resistance to passive flexion is decreased. Rigidity is a constant, non-velocity-dependent resistance. Spasticity is a velocity-dependent, so that if you do it quickly there is less resistance, and if you do it slowly there is more resistance. The clasp-knife phenomenon is characteristic for spasticity, where there initially is a lot of resistance which suddenly releases. After the elbow you would continue with the wrist …
• E: It’s enough. Please tell me which levels of vigilance you know.
• M: So after normal we have torpidity …
• E: No, torpidity is not that. Vigilance.
• M: Okay, so somnolence.
• E: Yes!
• M: Somnolence is when the patient is sleeping but can be awoken, but after you have stimulated them they fall back asleep. You have sopor, which is deeper, where you can only awake them with a stronger stimulus, like shouting. You have stupor, which is even deeper, where you need strong pain to wake the patient. Then you have coma, where no stimulus would wake up the patient.
• E: Okay. For C topic, you can choose stroke, epilepsy, or Parkinson disease. Which do you want to talk about?
• M: I can do Parkinson disease.
• E: Okay, tell me something about Parkinson disease.
• M: Okay, so the characteristic features of Parkinson include bradydiadochokinesia, hypokinetic gait, micrographia, resting tremor, poor postural stability.
• E: That’s okay. There’s idiopathic Parkinson disease and Parkinson-plus syndromes. Do you know the difference between them?
• M: Parkinson disease is idiopathic, while in Parkinson plus syndromes you have Parkinsonism plus other clinical features. We have for example Lewy body dementia and corticobasal degeneration. In Parkinson plus syndromes there is less response to dopa therapy.
• E: So what are the plus symptoms of Lewy body dementia?
• M: They have dementia, and disinhibition?
• E: Nono, they have hallucinations.
• M: Oh, yes, yeah. Hallucinations.
• E: Okay, you told me about corticobasal degeneration. What are the plus symptoms of it?
• M: I think they have dementia as well, but I don’t remember other plus symptoms.
• E: So cortical degeneration. What happens when the cortex is degenerated? Focal or Broca area, for example. (Pointing to his Broca area)
• M: Aphasia?
• E: Yes. And here (pointing to his temporal lobe I think)?
• M: Uhm.. Apraxia, maybe?
• E: Yes. Lobar symptoms. It is very logical. Now you are learning. Okay, so we have two Parkinson plus syndromes, what is the third one?
• M: Uhm.. (I don’t remember the last two).
• E: You’re very good until now!
• M: I don’t think I remember the last two.
• E: Nono, this is not a good strategy. (We both laugh). This is not good. Never say that. Okay? Can you remember?
• M: *thinking*
• E: Earlier name was Shy-Drager syndrome..
• M: I haven’t heard that name.
• E: There is a Hungarian link, because this professor was working together with professor Komoly in this department, so everybody here knows it very well. It’s multiple system atrophy. There are three subtypes, do you know them?
• M: 🤷‍♂️
• E: MSA-C, MSA-B, and MSA-A. Do you know them?
• M: No, I don’t think I do.
• E: It’s no problem. And the last one?
• M: 🤷‍♂️🤷‍♂️
• E: Can I help you?
• M: Yes please.
• E: The patient is unable to gaze downwards. The vertical eye gaze is inhibited.
• M: (At this point I’m just pretending to think, because I have no idea but don’t want to tell him that)
• E: It was described in Detroit by three people.
• M: (This confused me a lot) I don’t think that helps me
• E: I’m just joking (we laugh). The last one is progressive supranuclear palsy. Have you slept?

Before the exam period he made a big deal that we must make sure to sleep well before our exams.

• M: Yeah, I did sleep! But I’m nervous, so..
• E: Never, never.. for me? Never be nervous. Never be afraid. So now you are between 4 and 5. I can ask you one more question for the 5.
• M: Yes please.
• E: What is the difference between central and peripheral facial palsy?
• M: In central the upper part of the face, the forehead and eye-blinking is not affected. The symptoms are contralateral to the lesion, while in peripheral they are on the ipsilateral side.
• E: Which muscles are affected?
• M: So in both types there is drooping of the corner of the mouth, loss of the nasolabial fold. In peripheral type you can also have hyperacusis and ear pain. The frowning and closing the eyes is impaired. They can’t whistle or blow their cheeks.
• E: Okay. Good. Congratulations.

At this point he told me to stay in the meeting while the others had their exam, which was kind of a drag because I just wanted to leave, but there was no examiner and there are rules for witnesses or something. He didn’t say my grade but because he didn’t say anything I assumed I answered the last question well enough to get the 5.

My exam lasted for 13 minutes. The other two students’ exams lasted longer, so that our session lasted over 1 hour total. All three of us got 5, even though all three of us got multiple questions we couldn’t completely answer. Our teacher is a very nice and kind man, both as a teacher and an examiner.

From what I’ve heard, the exams of the different teachers are quite different, so if you can hear the experience of someone who already had your teacher this exam period, that would be the best. Either way, I’m sure everyone will pass neuro 1 this semester.

My next exam is ob/gyn the 4th of January, but I’m taking some days off until then. Good luck!