Neurology OSCE Skills For Finals

Dr Sam Gardiner FY1

Overview
Intro Cranial Nerve Examinations Peripheral Nerve Examinations As Time Permits: Neuro Histories, CT Head Quiz and a guide to Diabetic Foot reviews.

Cranial Nerve Exam

Probably hardest neuro exam Lots of varied tests, confusing signs Be systematic, test nerve by nerve, in the traditional order If you miss a nerve, dont panic, collect yourself and do it afterwards. Loads of tests you wont actually be expected to do

Nerve I - Olfactory
Have you noticed any change in your taste or smell? To test formally check nasal passages are clear, ask the patient to close their eyes, close one nostril and present strong but common odours and ask the patient to identify them Most common cause of anosmia is URTI, less commonly meningiomas and skull fractures.

Nerve II - Optic
Acuity - Near vision and colour vision Fields Confrontation, scotoma, inattention Reflexes Accommodation, Direct / Consensual, RAPD Opthalmoscope Offer to examine

Blind spot

Nerve III, IV, VI

Inspect

Nerve III, IV, VI

The H

Nerve V - Trigeminal
Test sensation in all three branches, compare side with side. Corneal reflex Mention, DO NOT TEST Motor Clench teeth Massiters/Temporalis Open Mouth Pterygoids Open Jaw Side To Side Masseters Jaw Jerk Brisk in UMN lesions (dont do it)

Nerve VII - Facial

Nerve VII - Facial

UMN Stroke, MS, Tumour LMN Bells Palsy, Herpes Zoster (RamsayHunt) etc Forehead sparing is due to bilateral cortical innervation

Nerve VII - Vestibulocochlear

Test Hearing Webers & Rinnes 512hz tuning fork Webers Place tuning fork on forehead, which ear is loudest? Rinnes, Tuning fork next to ear, then placed on the mastoid process. In conduction deafness, louder over bone than through air Conduction Deafness Wax, otitis media, Pagets Sensorineural Deafness Noise, tumours, infection, Gentamycin

Nerve IX and X Glossopharyngeal & Vagus

Offer gag reflex DO NOT DO! Afferent on IX, Efferent on X Look for uvular deviation

Nerve XI- Accessory

Lesions on ipsilateral side doesnt cross over

Nerve XII- Hypoglossal

Peripheral Nerve Exam

Simpler than cranial nerves Upper limb and lower limbs to examine Same format for both: Inspection Tone Power Co-ordination Reflexes Sensation

Inspection
Same for both upper and lower limbs Only say a few things Be systematic Comment on muscle bulk, wasting, symmetry, fasciculation Comment on tremors, resting or choreiform Comment on skin, scars, neurofibromas, cafe au lait spots

Inspection
Inspect gait if they are able to walk Ataxic Hemiparesis Shuffling High Stepping

Walk behind them as they go, do NOT let them fall! Inspect for pronator drift in upper limbs

Tone
Ask about joint pain Explain For Arms Shake hands, move all the joints increased / decreased tone, cogwheeling etc For Legs Roll the legs, looking for foot lag, lift knee and drop. Test clonus (more than 3-4 beats indicates UMN lesion)

Power
As much a test of communication as of neuro skills. Be clear in your instructions Isolate the Joint above Test each side individually and compare like with like Power is measured 1 5 1 is not moving 3 is overcoming gravity 5 is full strength

Power Upper Limb

Shoulder Abduction Deltoid C5 Put your arms up like this, dont let me push them down Elbow Flexion Biceps C6 Put your arms up like a boxer, pull me towards you Elbow Extension Triceps C7 Now push me away

Power Upper Limb

Finger Extension Extensor Digitorum C7 Dont let me push your fingers down (Isolate at MCP joint) Finger Abduction 1st Dorsal Interosseus T1 Spread your fingers out and dont let me push them together Thumb Abduction Abductor Pollicis Brevis Dont let me push your thumb down

Power Lower Limb

Hip Flexion Iliopsoas L1/L2 Keep your leg straight and lift it off the bed Hip Extension Gluteus maximus S1 Push my hand into the bed

Power Lower Limb

Knee Flexion Hamstrings L5,S1 Bend your knee, foot flat on the bed, pull me towards you Knee Extensors Quadriceps L3/4 Bend your knee, foot flat on the bed, push me away

Power Lower Limb

Knee Flexion Hamstrings L5,S1 Bend your knee, foot flat on the bed, pull me towards you Knee Extensors Quadriceps L3/4 Bend your knee, foot flat on the bed, push me away

Power Lower Limb

Ankle Dorsiflexion Tibialis anterior L4 Hold the ankle at the malleoli, edge of hand against dorsum of foot, push down and say push up against me Ankle Plantarflexion Gastroc & Soleus S1 Same as above but push down Toe Extension Extensor Hallucis Longus L5 One finger on their big toe push up against my finger

Power Lower Limb

Ankle Dorsiflexion Tibialis anterior L4 Hold the ankle at the malleoli, edge of hand against dorsum of foot, push down and say push up against me Ankle Plantarflexion Gastroc & Soleus S1 Same as above but push down Toe Extension Extensor Hallucis Longus L5 One finger on their big toe push up against my finger

Co-ordination
Upper limb Nose to finger test intention tremor Disdiadochokinesia Lower Limb Heel to shin Gait assessment tells you a lot about coordination in lower limbs Rombergs

Reflexes
Very simple to do Hard to remember nerve roots Annoying mneumonics make it easier S1,S2 Ankle Jerk L3,L4 Knee Jerk C5,C6 Biceps, supinator C7, C8 - Triceps

Reflexes
Babinskis sign upgoing plantars Indicative of an UMN lesion
Sign Reflexes Tone Muscle Bulk Plantars Fasciculation Upper Motor Neuron Lesion Hyperreflexia Increased Normal Upgoing None Lower Motor Neuron Lesion Hyporeflexia Decreased Atrophied Downgoing Present

Sensation
Easy as long as you know your dermatomes Touch the sternum with the cotton wool first so they know how it feels Test like against like with eyes closed, ask if it feels the same Offer to test pain but dont do it Light touch (Dorsal column), Pain (spinothalamic) Vibration & Proprioception (Dorsal column)

Sensation
Proprioception, vibration and light touch are lost distally to proximally in polyneuropathies. When testing proprioception, if it is lost, move up to the next joint and find what level it returns at. Same with vibration, move up the bony prominences until it can be felt starting and stopping.

Your Choice
Neuro Histories Neuro Imaging Diabetic Foot Review

Neuro Imaging
Match the history to the CT scan You are an FY1 working in MAU / A&E

Case 1
A 22 year old man is admitted after being hit in the head with a brick during a disagreement with some business associates. He is knocked unconscious, but gets up and runs home. His sister brings him to A&E as he became extremely drowsy and began vomiting a few hours later. Your evil registrar makes you interpret all CTs in multiple choice format. Which is his?

Extradural Haemorrhage
Can deteriorate very quickly Small haematomas in alert patients can be managed conservatively, under close observation Larger haemorrhages or those in patients with focal neurology, rapid deterioration etc need surgical evacuation, burr holes, craniotomies etc.

Case 2
A 60 year old man with a past history of atrial fibrillation and ETOH excess falls down the stairs in his home. He is taken to A&E where you clerk him in. You think he is confused so you request a CT head...

Subdural Haemorrhage
If asymptomatic can be managed conservatively with observation and serial CTs to ensure resolution If symptomatic, large SDH, focal neurology etc, will need craniotomy and evacuation Osmotic Diuretics can be given if raised ICP

Case 3
A 74 year old woman is brought into hospital by her grandson as she has suddenly developed left sided facial weakness (although not in her forehead), slurred speech, is unable to move her left arm. You see her in A&E

MCA Infarct
Typical presentation of stroke FAST screening in the community, Rosier screening in hospital TIAs last less than 24 hours and are reversible, strokes last more than 24 hours. Image the brain to rule out haemorrhagic stroke 300mg aspirin OD for 2 weeks and then long term anticoagulation Thrombolysis with alteplase in specialist centres if indicated.

Case 4
A 52 year old woman with a background of hypertension collapses at work with the worst headache she has ever had which feels like being hit in the back of the head with a baseball bat (something she does not have previous personal experience of). She is admitted through A&E and a CT is taken. You decide to take a shortcut through A&E on your way out of the hospital and are ambushed by a nurse insisting you review the CT scan as she is about to breach and everyone else is at a trauma call.

Subarachnoid Haemorrhage
Caused by the rupture of Berry Aneurysms in the Circle of Willis Associated with hypertension, history of polycystic kidneys, family history of SAH, incidence increases with age CT head is 98% sensitive, if normal CT in suspected SAH, LP must be performed 12 hours afterwards, looking for xanthochromia Typically treated by surgeons, clipping or endovascular coils to repair aneurysms.

Well Done!

Neuro Histories
Headache Seizures & Loss of Consciousness

Headache

Causes of Headache
Migraines Tension Headaches Cluster headaches Subarachnoid Haemorrhage Intracranial mass lesion Temporal Arteritis

Site
Unilateral vs Bilateral Pain? Migraines and cluster headaches are unilateral, Tension headaches typically bilateral Where exactly in the head is the pain? Occipital SAH (Sudden) Temporal Giant Cell / Temporal Arteritis Frontal Cluster headaches, Sinusitis Band-like Tension Headache

Onset
Sudden Vs Gradual Subarachnoid haemorrhage is most sudden, thunderclap, subacute headache may be meningitis Gradual onset, getting worse over weeks / months may be mass lesion Have you ever had pain like this before? Recurring headaches could be tension headaches, migraines or cluster headaches

Associations
Visual disturbances Flashing lights, grainy vision Migraine with aura Amaurosis Fugax Temporary monocular loss of vision, sometimes like a curtain, more often blurring Temporal Arteritis Bilateral blurred vision Malignant Hypertension

Associations
Fever, Neck Stiffness, Petechial Rash, Vomiting Meningococcal meningitis Tears, runny nose, flushed face/forehead Cluster headache Kaleidoscope effects, shimmering lights, scintillating scotoma etc Migraine with aura

Exacerbating Factors
Is it worse at any time in the day? Morning headache Raised ICP Same time of day each time Cluster headache Is there anything you do that makes it worse? Lying down, coughing, straining on the toilet Mass lesion Bright lights Meningitis / Migraine

Relieving Factors
Lying down in a dark room Migraine Pacing around the room Cluster headache Taking loads of codeine Analgesia rebound headache STOP TAKING THE CODEINE

Severity

Other Questions
PMH: Polymyalgia rheumatica (GCA), Polycystic kidneys (SAH), Cancer (mass lesions) DH: Opioids (rebound headache), COCP(migraine with aura) SH: Coffee, stress, (tension headache)

RED FLAG QUESTIONS

Did your headache come on suddenly? Do you have a stiff neck? Any head trauma? Any loss of consciousness or seizures? Is your pain worse in the morning? Does it hurt when you cough or strain on the toilet? Have you lost weight unintentionally?

Management
Tension headache Paracetamol / NSAIDS, rest, relaxation, exercise Migraine NSAIDS, Metoclopramide, 5ht agonists (sumitriptan) Cluster headaches Sumitriptan + oxygen therapy, Verapamil as prophylaxis

Loss Of Consciousness / Seizure

Loss Of Consciousness / Seizure

Common station Lots of potential causes Some important questions can help distinguish between different causes

Loss Of Consciousness / Seizure

During The Episode Before The Episode After The Episode

During The Episode

Did you black out? / Do you remember falling? Syncope and complex seizures involve loss of consciousness. Simple seizures do not involve loss of consciousness. Drop attacks in elderly patients, often with Parkinsons How long were you unconscious/down for? Duration is useful for syncope vs seizure

During The Episode

Did anyone witness the event? Witness histories are invaluable in loss of consciousness / seizure Did you shake while on the floor? Whole body or just part of it? A few twitches is normal in vasovagal syncope, tonic-clonic seizures tend to be longer, more violent Did you lose control of bowels and bladder or bite your tongue? Commonly associated with seizures, tongue biting very suggestive of Tonic-Clonic Is this the first time?

Before The Episode

What were you doing at the time? Alcohol, flickering lights Seizure Long periods of standing, pain, fear Vasovagal Coughing, urinating Situational syncope Turning head / shaving Carotid Sinus Syncope

Before The Episode

How did you feel before you fell? Did you know it was going to happen? Seizures can have auras before, vasovagal syncope is associated with nausea, dizziness, hypoglycaemia makes people feel weak, sweaty and confused. Cardiac causes associated with palpitations

After The Episode

How did you feel after you fell? Did you get better straight away, or take some time? Seizures will have post-ictal states, syncope and other causes will take less time to revert to normal

Other Questions
PMH: Cardiac disease, epilepsy, diabetes , TIA, vascular risk factors DH: Antihypertensives SH: Alcohol, quantify! Do they drive, especially for work?

Investigations
Full Cranial and Peripheral Nerve Examinations Cardio and resp exams Bloods: FBC (anaemia, sepsis), U+Es (electrolyte abnormalities), BMs ECG Neurology / Cardiac assessment Fancy stuff: EEGs, Tilt table tests etc

Diabetic Foot Review

You are the FY1 on diabetes / endocrine medicine and are asked to review Mr Azucars diabetic foot.

Diabetic Foot Review

Obvious bits: Introduction Check name, age occupation WASH HANDS! Explain the purpose of the examination Position the patient on a bed / couch with his shoes and socks off.

Inspection
From the end of the bed inspect the foot, ankle and calf Look for any deformities, Charcots foot etc should be obvious Look at colour of the foot, if red and swollen could be infected. Look at the foot for any ulcers, including between the toes, any calluses on pressure points

Inspection
Look at the skin, is it dry, exzematous, shiny, is there any hair loss or haemosiderin staining? Inspect the shoes! Are they well fitting, specialist shoes or smelly worn out boots with a drawing pin sticking through the sole? Are all the toes present? Any signs of surgery?

Palpation
Feel for temperature with back of hands, is it the same? Feel for the foot pulses, dorsalis pedis, anterior tibial, also feel for popliteal Capillary refill normally < 2 seconds Assess sensation, ie light touch, pinprick in lower limb, starting at feet and moving upward. Assess proprioception and vibration sense

Finishing up
Assess gait, with shoes on To Complete My Examination... Full neurovascular exam Test BMs, HbA1c Review diabetic medications Educate patient about strict blood glucose control, ongoing management of diabetes

FINALLY IT ENDS GOOD LUCK! Thank you for listening My email: samuelgardiner@doctors.org.uk