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THE NEUROLOGICAL EXAMINATION PARTOSCEs OSCE SERIES • Introduction to the station • Neurological examination – Upper Limb SESSION • Neurological examination – Lower Limb STRUCTURE • Relevant investigations • Neuro-imagingThe general format of an OSCE Station: A lot of it is just acting! History / Examination You MUST practice histories, examinations and clinical Data Interpretation skills regularly Clinical Skill Be confidentà the hardest part is getting to the starting line! Follow up questions SPOT DIAGNOSIS - HEAD ACHES A 20 YEAR OLD MAN PRESENTS WITH A HEADACHE, FEVER AND NECK STIFFNESS. HE ALSO HAS DIFFICULTY LOOKING AT LIGHTS AND A MENINGITIS NON-BLANCHING RASH ON HIS LOWER LEGS. UNIVERSITY STUDENT. A 42 YEAR OLD WOMAN PRESENTS WITH A SEVERE HEADACHE OF SUBARACHNOID SUDDEN ONSET AT THE BACK OF HER HEAD. SHE IS A HEAVY SMOKER.HAEMORRHAGE HER FAMILY HISTORY INCLUDES PCKD. A 55 YEAR OLD MAN PRESENTS WITH A GRADUALLY WORSENING HEADACHE THAT IS WORSE ON COUGHING AND LEANING FORWARDS. SPACE OCCUPYING Hx OF VOMITING. THE PAIN SOMETIMES WAKES HIM AT NIGHT. HE WAS LESION TREATED 5 YEARS AGO FOR COLON CANCER. A 65 YEAR OLD WOMAN PRESENTS WITH A UNILATERAL HEADACHE, TEMPORAL PARTICULARLY IN HER LEFT TEMPORAL AREA. SHE HAS A RAISED E A. ERITIS (GCA) A 60 YEAR OLD WOMAN PRESENTS WITH A SEVERE HEADACHE THAT IS WORSE WHEN WATCHING TV IN A DARK ROOM. SHE HAS A RED EYE ACUTE ANGLE AND DECREASED VISUAL ACUITY. ON EXAMINATION, HER PUPIL ISCLOSURE GLAUCOMA SEMI-DILATED AND DOES NOT REACT TO LIGHT. A 26 YEAR OLD WOMAN PRESENTS WITH HEADACHE OF SUBACUTE IDIOPATHIC ONSET, WORSE LYING DOWN, AND REDUCED PERIPHERAL VISUAL INTRACRANIAL FIELDS. ON FUNDOSCOPY SHE HAS BILATERAL PAPILLODEMA. BMI=35.HYPERTENSION Role Foundation Year 1 Doctor (FY1) Setting Emergency Department Patient Mr Steve Rodgers, a 84 y/o male presents with bilateral arm weakness. STUDENT Student tasPerform a focused examination of his upper limb neurological function and initiate a management plan including pertinent investigations. INSTRUCTIONS TIPS FOR ALL PHYSICAL EXAMINA TIONS! • Always perform WIPE (Wash hands, Introduce yourself, check Patient details, Explain why you are there) • Examine from the paties RIGHT side • For general inspection, LOOK at the patient and around the bed for a good few moments • Be SYSTEMATIC and try to look slick • PUT ON A SHOW! à When talking during the examination, say “there is no evidence of….” rather than “I am looking for …”NEUROLOGICAL Why do we EXAMINATION perform neurological exams? Localisation of potentàs where in the nervous system is there an issue? Motor problà at the most basic level, we need to try and work out whether there is an UPPER (i.e. brain or spinal cord) or LOWER (i.e. nerve root, peripheral nerve, neuromuscular junction or muscle) motor neuron lesion NEUROLOGICAL Upper vs Lower EXAMINATION Motor Neuron Lesions Picture credits: https://www.pinterest.co.uk/pin/412009065888475953/NEUROLOGICAL EXAMINATION So how do we elicit this information? IS Inspection THE Tone PHYSCIAN Power REALLY Reflexes Sensation SO Co-ordination COOL?NEUROLOGICAL EXAMINATION Upper LimbNEUROLOGICAL WIPE EXAMINATION “Hello, my name is … and I am a … year medical student. Please could I confirm your name and date of birth. I have been asked to perform an examination of the neurological function of your arms. This involves me having a look at your arms and shoulders, testing a few of the muscles in your arms and hands, and then testing a bit of the sensation in your upper limb. Does that sound okay? Do I have your consent? Before we begin, can I just ask if you are in any pain at the moment? The examination should not be painful but if you feel any discomfort at any point, please let me know and we can slow down or stop.”General Inspection Any peripheral stigmata of neurological disease, such as mobility aids? SWIFT – Scars/Symmetry, Wastage of muscles, Involuntary movements, Fasciculations, Tremor Scar from carpal tunnel surgery Right arm muscular atrophy Fasciculations Picture credits: https://www.carpalrx.com/carpal-tunnel-surgery-scar / https://www.researchgate.net/figure/Right-upper-limb-showing-atrophy-at-wrist-and-small-muscles-of-hand_fig1_316168740/ https://makeagif.com/gif/fasciculationmuscle-twitch-gaI-rZ INTENTION TREMOR (present in Tremor cerebellar diseaswe’ll speak about later ESSENTIAL TREMOR PARKINSONIAN DYSTONIC TREMOR TREMOR Dystonia = uncontrolled and Postural tremor: worse if arms Resting, 'pill-rolling' outstretched tremor sometimes painful muscle movements (spasms) Bilateral, upper limbs Unilateral Jerkier tremor Improved by alcohol and rest Titubation Alongside Abnormal posture More common than essential Often strong family history Bradykinesia, Rigidity tremorGeneral Inspection PRONATOR DRIFT Any peripheral stigmata of Ask patient to stretch out arms in front neurological disease, such as of them & hold them out with palms mobility aids? facing up, eyes closed – hand drifts down/pronates if UMNL SWIFT – Scars/Symmetry, Pronator drift indicates abnormal Wastage of muscles, Involuntary function of corticospinal tract in movements, Fasciculations, contralateral hemisphere Tremor Picture Credits:https://www.stepwards.com/?page_id=1416General Inspection PRONATOR DRIFT Tone Any peripheral stigmata of Ask patient to stretch out arms in frontatient’s arm and support neurological disease, such as of them & hold them out with palms elbow – “Let your arms go mobility aids? facing up, eyes closed – hand drifttotally floppy” – test each down/pronates if UMNL movement for abnormal tone SWIFT – Scars/Symmetry, Wastage of muscles, Involuntary Pronator drift indicates abnormIf struggling to relax – “tap your movements, Fasciculations, function of corticospinal tract in Tremor contralateral hemisphere knee with your other hand” Tone Upper Limb Picture Credits: https://www.geekymedics.com HYPERTONIA Spasticity vs Rigidity SPASTICITY RIGIDITY Extrapyramidal tract lesions Pyramidal tract lesions (e.g. stroke) (e.g. Parkinson’s Disease) Velocity-dependent à the faster you move the limb, the worse it is Velocity independent Typically accompanied by weakness 2 main types: Cogwheel rigidity (tremor superimposed on hypertonia), lead pipe rigidity (uniformly increased tone throughput movement of the muscle) Picture credits: https://www.youtube.com/watch?v=B88BNYWVkWEGeneral Inspection PRONATOR DRIFT Tone Any peripheral stigmata of Ask patient to stretch out arms in frontient’s arm and support neurological disease, such as of them & hold them out with palmselbow – “Let your arms go mobility aids? facing up, eyes closed – hand driftotally floppy” – test each down/pronates if UMNL movement for abnormal tone SWIFT – Scars/Symmetry, Wastage of muscles, Involuntary Pronator drift indicates abnorIf struggling to relax – “tap your movements, Fasciculations, function of corticospinal tract in Tremor contralateral hemisphere knee with your other hand” Power Myotomes Compare each individual movement with other side Shoulder abduction – C5 (check dominant side first) Elbow flexion – C6 Elbow extension – C7 Grade power out of 5 (MRC Finger flexion – C8 Scale)à 5 = normal, 3 = Finger abduction – T1 able against gravity but not against resistance Power Go through each myotome methodically Shoulder abduction – C5 Elbow flexion – C6 Elbow extension – C7 Finger flexion – C8 Finger abduction – T1 Picture Credits: https://www.medistudents.com/osce-skills/upper-limb-neurological-examinationGeneral Inspection PRONATOR DRIFT Tone Any peripheral stigmata of Ask patient to stretch out arms in frontient’s arm and support neurological disease, such as of them & hold them out with palmselbow – “Let your arms go mobility aids? facing up, eyes closed – hand driftotally floppy” – test each down/pronates if UMNL movement for abnormal tone SWIFT – Scars/Symmetry, Wastage of muscles, Involuntary Pronator drift indicates abnorIf struggling to relax – “tap your movements, Fasciculations, function of corticospinal tract in Tremor contralateral hemisphere knee with your other hand” Reflexes Power Myotomes Compare each individual Sensation movement with other side Shoulder abduction – C5 (check dominant side first) Elbow flexion – C6 Co-ordination Elbow extension – C7 Grade power out of 5 (MRC Finger flexion – C8 Scale)à 5 = normal, 3 = On the next Finger abduction – T1 able against gravity but not slide… against resistance Reflexes Upper limb • Brachioradialis reflex (C5,C6) • Biceps reflex (C5, C6) • Triceps Reflex (C7) Picture credits: https://www.researchgate.net/f-of-a-spinal-reflex-arc-A-pin-in-the-skin-produces-an-input_fig1_327199446 Ask patient to close eyif difficulty eliciting reflexes, Reflexes ask patient to clench teeth (helps muscles to relax) Upper Limb Hoffman’s Sign: Flick distal phalanx of otherr finger/thumb flexion = positive Indicates injury to corticospinal pathway Picture Credits: https://thirdwashcould.xyz/?utm_campaign=3R60Iq_6TwnSLaZnPTupNSKfvhj857wOWHP26RZmXuw1&t=main9 Sensation Reflexes • Light touch Upper limb • Pain (Pin Prick) • Brachioradialis reflex (C5,C6) • Temperature • Biceps reflex (C5, C6) • Vibration • Triceps Reflex (C7) • Proprioception *Reference point on sternum first* Light touch Pain (Pin Prick) Temperature Test each of the sensory modalities in each dermatome separately (reference point on sternum first) Picture Credits: https://www.healthline.com/health/dermatome#dermatomes -chart / https://simpleosce.com/examinations/neurological/uppe-rimb-neuro-examination.php Vibration • Pinch end to initiate vibration of the tuning fork • Place on distal to proximal bony prominences • No need to move proximally if felt distally Proprioception 128 HERTZ • Ask patient to close their eyes • Hold joint on side (not on nail bed) • Define what is up and down • Use thumb and big toe to check proprioception Picture Credits: https:///products/142761879- https://radiol/upper-limb-and-shoulder-girdle/ https://www.pinterest.com/pin/273664114829415340/ What’s the point in all this? Check at least one modality from each of the dorsal columns and spinothalamic tracts in each dermatome Picture Credits: https://www.youtube.com/watch?v=_G-d8gKIlOw Reflexes Sensation • Light touch Upper limb • Pain (Pin Prick) • Temperature • Brachioradialis reflex (C5,C6) • Vibration • Biceps reflex (C5, C6) • Proprioception • Triceps Reflex (C7) *Reference point on sternum first* Summarise To complete the examination… Co-ordination your findings with a • Explain to the patient the ”Piano playing”, picking up pen concluding examination has finished lid/coin • Thank patient & restore statement clothing! Finger to nose test • Wash your hands Dysdiadochokinesia On the next Not coordinated – Dysmetria = Ipsilateral Cerebellar slide… pathologyNEUROLOGICAL Concluding statement EXAMINATION “Today I examined … , a … year old male. On general inspection, the patient appeared comfortable at rest, with normal speech and no other stigmata of neurological disease. There were no significant findings in neurological examination of the upper limb, with no evidence of muscle wastage or fasciculations indicative of a lower motor neuron lesion on inspection. Tone and power were normal, with an MRC grade of 5 bilaterally for power. Reflexes were all present, and function and sensation were normal. In summary, this was a normal upper limb neurological examination. To complete the examination, I would like to perform … “NEUROLOGICAL EXAMINATION Lower LimbNEUROLOGICAL EXAMINATION “IS THE PHYSCIAN REALLY SO COOL?” InspectiSWIFT Tone Tone Lower Limb Suddenly pull each foot into dorsiflexion à > 3 beats = Clonus Clonus is involuntary and rhythmic muscle contractions caused by a permanent lesion in descending motor n(.e., UMNL) Picture Credits: https://www.geekymedics.com / https://www.grepmed.com/images/5175/video-clinical-clonus-physicalexam-neuroNEUROLOGICAL EXAMINATION “IS THE PHYSCIAN REALLY SO COOL?” InspectioSWIFT Tone Power Power Go through each myotome methodically Hip flexion – L2 Knee extension – L3 Ankle dorsiflexion – L4 Big toe extension – L5 Ankle plantarflexion – S1 Picture Credits: https://www.medistudents.com/osce-skills/lower-limb-neurological-examinationNEUROLOGICAL EXAMINATION “IS THE PHYSCIAN REALLY SO COOL?” InspectioSWIFT Tone Power Reflexes Reflexes Lower limb • Knee-jerk reflex (L3,L4) • Achilles tendon reflex (S1) • Plantar reflex (L5,S1) Picture Credits: https://thirdwashcould.xyz/?utm_campaign=3R60Iq_6TwnSLaZnPTupNSKfvhj857wOWHP26RZmXuw1&t=main9 / https:// www.youtube.com/watch?v=jK0JS2OsvKANEUROLOGICAL EXAMINATION “IS THE PHYSCIAN REALLY SO COOL?” InspectionSWIFT Tone Power Reflexes Sensation Light touch Pain (Pin Prick) Temperature Test each of the sensory modalities in each dermatome separately (reference point on sternum first) Picture Credits: https://www.healthline.com/health/dermatome#dermatomes -chart / https://simpleosce.com/examinations/neurological/lowe-rimb-neuro-examination Vibration Picture Credits: https://www.healthline.com/health/dermatome#dermatomes-chartNEUROLOGICAL EXAMINATION “IS THE PHYSCIAN REALLY SO COOL?” InspectioSWIFT Tone Power Reflexes Sensation Co-ordination Coordination Can the patient walk normally? à Gait assessment Romberg test = test of the body's sense of positioning (proprioception), which requires healthy functioning of the dorsal columns of the spinal cord In the Romberg test, the standing patient is asked to close their eyes; increased loss of balance is interpreted as a positive Romberg's test Heel-to-shin test à Place heel on knee and ask patient to run it down the shin in a straight line May be abnormal if there is loss of motor strength, proprioception or a cerebellar lesion Picture Credits: https://makeagif.com/gif/examination-of-motor-system-and-reflexes-huvXN4 Abnormal Gait ATAXIC GAIT PARKINSONIAN HIGH-STEPPING GAIT GAIT Small, shuffling Broad-based, unsteady Can be unilateral or and associated with steps, stooped bilateral and is either cerebellar posture and reduced typically caused by pathology or sensory arm swing (initially foot drop (weakness of unilateral) ataxia ankle dorsiflexion) The patient will require several small steps to turn around Extras… - DANISH (Signs of cerebellar dysfunction) D – Dysdiadochokinesis (inability to perform rapid alternating movements) A – Ataxia (lack of voluntary coordination of muscle movements) N – Nystagmus (involuntary rhythmic oscillations of the eye) I – Intention tremor S – Staccato (explosive speech, odd pauses/emphasis)– Cerebellum controls coordination of tongue H – Hypotonia / Heel-shin test Credits: https://gfycat.com/querulousacidicgannet / https://commons.wikimedia.org/wiki/File:Nystagmus_eye_movement.gif / https:// gfycat.com/corrupthelplessadeliepenguinNEUROLOGICAL INVESTIGATIONS You’ve done a top-notch neurological examinationbut what comes next? “HE-BOXES” History/Examination – Bloods, Orifices, X-rays (imaging), ECG/EEG, Special testsNEUROLOGICAL “HE-BOXES” INVESTIGATIONS SPECIFIC EXTRA INVESTIGATIONS ANY NEURO CAUDA EQUINA EPILEPSY / PRESENTATION HEADACHE SYNDROME SEIZURE STROKE NEUROPATHY ABCDE ASSESSMENT Basic observations Full neuro exam – UL/LL Clistroke –gns of BEDSIDE Cranial nerve exam PR exam EEG Visual fields (Fundoscopy) Glucose Urine Dip FBC LFTs Glucose B12 BLOODS Toxicology Clotting Screen Glucose / U&Es screen HbA1c CRP / ESR IMAGING, Head CT EEG, LP only if no CT scan to rule Nerve EEG MRI out conduction SPECIAL Lumbar puncture signs of SOL haemorrhagic studies TESTS causes CSF Analysis Pathogen Appearance Polymorphs Lymphocytes Protein Glucose Normal Clear Normal Normal Normal Normal Bacteria Yellowish Increased Normal Very High Decreased Virus Clear Normal Very High Normal Normal Tuberculosis Yellowish Normal Very High Increased Decreased Fungi Yellowish Normal Very High Normal Normal/LowInterpreting imaging • WASH HANDS • Name, DOB, Same patient • State the modality • State plane of imaging • State the time the imaging was taken and if it was the latest one available • State your observations that you SEE in the picture • State your suspicion • State your differentials with justification based on previous parts of the station SPOT DIAGNOSIS A 74 YEAR OLD WOMAN PRESENTS AFTER A NUMBER OF FALLS. SHE IS AN ALCOHOLIC AND HAS HAD PERSISTENT HEADACHES FOR THE PAST CHRONIC SUBDURAL FEW WEEKS. HER CT SCAN SHOWS A DARK, CRESCENTIC COLLECTION HAEMATOMA THAT FOLLOWS THE CONVEXITY OF THE BRAIN. A 32 YEAR OLD MAN PRESENTS TO A&E WITH AN INABILITY TO MOVE BROWN-SEQUARD HIS LEFT LEG AFTER BEING STABBED. ON EXAMINATION HE HAS LOST SYNDROME VIBRATION AND PROPRIOCEPTION IN HIS LEFT LEG AND CANNOT FEEL (lateral hemisection of PINPRICK OR TEMPERATURE CHANGES IN HIS RIGHT LEG. the spinal cord) A 59 YEAR OLD MAN PRESENTS WITH INCREASED TONE IN HIS LEGS AMYOTROPHIC WITH AN ABSENCE OF BICEPS REFLEX. HE REPORTS THAT HIS UNCLE LATERAL SCELEROSIS ALSO HAS THIS CONDITION. A 30 YEAR OLD WOMAN PRESENTS WITH LOSS OF VISION IN HER MULTIPLE RIGHT EYE ASSOCIATED WITH PAIN ON EYE MOVEMENT. SIX MONTHS SCLEROSIS AGO, SHE HAD TINGLING AND NUMBNESS IN HER LEFT HAND. A 27 YEAR OLD WOMAN PRESENTS WITH A TINGLING AND DECREASED CHARCOT-MARIE- SENSATION IN HER PERIPHERIES. SHE REPORTS REPEATED EPISODES OFTOOTH SYNDROME SPRAINED ANKLES AND ON EXAMINATION WALKS WITH A HIGH STEPPING GAIT. PLEASE FILL OUT THE FEEDBA CK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK! @OSCEazyOfficial @osceazyofficial OSCEazy Osceazy@gmail.com