Neuro OSCE
- Will teabag the shit out of you

- That's why God made brains
and scrotums similar in
appearance

- Hx = establishing chronology
+ Site of symptom Psn

- PE = Determining site of lesion

Grouping of signs/symptoms

Cerebellar signs

a

UMN/LMN

UMN = Pyramidal weakness!!!
- Affects extensors > flexors
- CLONUS IS ALSO AN UMN SIGN

NMJ Probelms (i.e. MG):
- Fatiguability
- Reflexes normal; Tone normal
- Power normal w/ rapid weakening
- Ptosis at the end of the day
- +/- speech dysarthria at the end of the day

Peripheral neuropathy

NB Romberg's = tests sensory ataxia; NOT cerebellar.

a

Higher function

r

Frontal = motor + specialUnsteady gaitC/L HypertoniaC/L ParesisC/L drooping of LOWER 1/2 of faceExpressive aphasiaU/L Loss of smellExpressive aphasiaChanges in personalityParietal lobe = somatic sensotySensory/visual neglectX ProprioceptionX stereognosisImpaired tactile sensation (2 point discrimination, Fine touch, vibration, pain temperature)X reading, writing, calculatingTemporal lobe = auditoryDeafnessTinnitusReceptive aphasiaX memorySeizuresOccipital lobe = visione.g. Visual loss with macular sparingHomonymous hemianopsiaTotal blindness (cortical blindness)

Neuro hx taking (Ask 1, Think 2)

1. Is a bitch

2. 1 thing to ALWAYS ask:
i. Hand dominance!!!

3. 2 things to ALWAYS think of:
 i. Temporal course of illness.
ii. Location of SYMPTOM.

Temporal course (brief overview)

1. Triggers/warnings
i. Triggers: exercise, flashing lights, etc.
ii. Warnings: hallucinations (auditory/visual);
Changes in smell; sensory/motor dysfn, etc

2. Acute onset (mins-hrs):
i. Cerebrovascular: TIA/Isch stroke/Haemorrhage
ii. Seizures
iii. Migraines

3. Subacute (hrs - days):
i. Inflammation (e.g. meningitis, Guillian Barre)

4. Chronic
i. Wks - mths = Tumour
ii. Months - years = Degenerative disorders

5. Disseminated through space and time = MS!!!

6. Don't forget to ask about previous infections

Cardinal symptoms

1. Headache (HA), facial pain, Neck/back pain
2. Cerebrovascular accidents
3. Faints, fits, or funny turns
4. Dizziness/vertigo
5. Vision/hearing/smell
6. Gait
7. Sensory/motor
8. Incontinence
9. Tremor
10. Speech and swallowing
11. Altered cognition

'Neuro Hx overview' in hyperlink

d

Headaches, neck pain
SOCRATES

CBVA

General temporal course:
Acute (minutes)

Gross localization:
Posterior headache = posterior circulation
Anterior headache = anterior circulation
Broca's = Frontal lobe = Expressive dysphasia
Wernicke's = Temporal = Receptive dysphasia

Haemorrhage

r

Intracranial haemorrhage = Intracerebral + subarachnoid haem.I. Intracerebral haemorrhage (bleeding into brain)·       Causes: Per rupture of vessel w/in brain parenchyma·       RF's: HTN·       Psn: Sudden weakness; focal neural signs II. Subarachnoid haemorrhage (bleeding around brain) ·       Defn: Spontaneous bleeding into subarachnoid space·       Causes: AV malformations (i.e. Berry aneurysm)·       RF's : HTN·       Psn :Thunderclap headache, +/- NV; neck stiffness·       Progress: Coma, death

Ischaemia

r

Questions to ask:PC?Onset? Timing?Improvement or worsening?+ Hx of stroke? + F.Hx of stroke?DM? Hyperchol.? Smoking? A-fib?Warfarin? Aspirin?

TIA
- Stroke like syndromes
- Spontaneous resolution w/in 24h
- Amaurosis fugax (transient U/L blindness)

Strokes:
- FOCAL LESIONS

Lacunar

MCA

ACA

Brainstem

Faints, Fits, Funny turns

Don't need to open this shit for OSCE.
Just look at questions in hyperlink.

Dizziness/Vertigo:
Does it come on with HEAD MOVEMENTS?
Is there HEARING LOSS?
Persistent or intermittent?

Vision
- Diploplia
- Blurred vision
- Photophobia
- Visual loss

Which eye?
Which field?
Acute? Gradual?
Preceding event?

Deafness
Acute? Gradual?
U/L, B/L?
+ Pain? + Dizziness?
Changes in facial expression (CN 7)?
Changes in taste?
Preceding ear infection?
Hx trauma?

Gait
- Occurs in the dark (sensory ataxia)?
- Occurs with eyes open (cerebellar)?
- Disappears when running (Pakinsonism)?
- Trouble initiating gait (Parkinsonism)?
- Dance-like movements superimposed on gait (Chorea)?
- Unable to lift toe while walking (Foot drop)?
- Always obtain fall hx

TO LEARN GAIT, SWALLOW WHATEVER MORALS YOU THINK YOU MAY HAVE, & PRACTICE WALKING THEM IN FRONT OF THE MIRROR. LAUGH AT YOUR ABSURDITY.

a

Motor:
- Pure motor?
- Mixed?
- Other associations?
- Location of symptoms?
- Severity?
- Timing, onset?
- Worsening progression?
- Recurring bouts w/ remission? (i.e. MS)
- What is the biggest problem with movement?
 - MG = Fatiguability with repeated movement
 - McArdle's = Improves w/ continued movement
 - Parkinson =Difficulty initiating movement (rigidity)
 - UMN/LMN = Decreased strength = UMN/LMN
 - Cerebellar = Clumsy hand dysarthria
- Frontal = X complex sequence of actions

Sensory:
- Pure sensory?
- Mixed?
- Fine touch (DCML)?
- Pain/Temperature (ST)?
- Neuropathic pain

r

Peripheral = Damage to peripheral NNeuralgia e.g. CN V neuralgia; postherpetic (VZV) neuralgiaShocking + Follows nerve distributionDiabetic neuropathy ant bitingglove/stockings paresthesiaNerve root compression:Follows nerve distributionAssociated with weaknessCentral = Damage to central NSe.g. Post stroke pain/Post spinal cord injuryAllodynia, Hyperalgesia

Dyskinesia:
- At rest? Or with movement?
- Description of tremor
- Resting = Parkinson's
- Intentional = Cerebellar
- At rest & on movement = Benign essential tremor

N.B Intentional tremor = deviation from intended trajectory of motion in a HORIZONTAL PLANE.

N.B BET is relieved by alcohol. Pts @ risk of becoming alcoholic.

a

Speech:
Dysarthria = X Articulation
Dysphasia = Receptive/Expressive
Dysphonia = Damage to vocal cords

Hyperlink not relevant to exam prep

a

Random bits and bobs for MS
- Disseminated through space and time
- Optic neuritis (pain on moving eye; loss of (color) vision)
- INO
- Acute bouts (wks) interspersed w. remission (mths-yrs)
- Permanent loss in function with each attack
- Urthoff's phenomenon (heat intolerance w exercise)
- Lhemitte's sign (electrical tingling on back of neck when neck is bent)
- MS = loads of positive on motor ex.

Lower limb
Is almost identical to UL.
Only key differences will be listed.

1. WIPE

Place, time, person, handedness

2. General observation

PT TO BE SUPINE
Expose the pt if wearing long pants

3. Motor

LL specific
- Tone
- Babinski reflex
- Coordination.
- Gait

Tone

r

TONEAsk patient to let legs go floppy Roll legs medially and laterally at the knee Flxn/extn of knee: support back of knee with one hand, other hand holding ankle Spasticity: put 2 hands under extended leg at knee and quickly flex it (pull it up)  Clonus: see video

Motor

Coordination/Gait

4. Sensory

Thank the patient.
Wash hands.
Summarize findings
Further investigations

Cranial Nerves

CN 1

General observation
- Nasal polyps?

Examination
Smell alcohol wipes

CN 2

General observation
- Glasses on bedside?
- Mydriasis (dilation of pupils)?
- Miosis (constriction)?
- Aniscora (unequal pupillary size)?
- Lacrimation of eyes?

ALWAYS BE EYE-TO-EYE WITH THE PT.
Cover opposite eye as pt.

Visual acuity:
- Mention that you'd use a Snellen chart

r

If the tester is being a dick (which completes the genitalia analogy of this OSCE) and asks you how you'd perform the snellen chart test:Get on the same level as patientMention you'd test pt at a distance as indicated by the chart (10ft OR 20 ft)Tell pt to leave glasses on.Test one eye at a time. DON'T APPLY PRESSURE AGAINST THE EYEBALLTHEN READ THE SMALLEST LINE YOU CAN.Rinse and repeat for near card.

Visual fields
Position: Arm length away from pt; 'eye-to-eye' level.
Pt. covers R eye, you cover L. Swap.
Don't apply pressure on your eye.
 Keep your eyes on the bridge of my nose

i. Test each eye separately for:
a. Peripheral vision (white pin)
b. Central vision (red pin)

ii. Test both eyes for inattention

Mention that you'd do a fundoscopy

CN 2, 3 (Pupillary reflexes)

To be done in these OSCE's:
i. CN 2 test
ii. CN 3, 4, 6 test

Afferent limb = CN 2
Efferent limb = CN 3

Don't forget to DIM THE LIGHTS

a

Direct response:
Illuminated pupil constricts

Consensual response:
Non-illuminated pupil constricts synchronously.

Swinging light test (afferent pupillary defect
Normal = Both eyes constrict when one is illuminated
Both eyes relax a little while light is being swung

RAPD = B/L dilatatn when light is swung to AFFECTED eye
+ Direct response
+ IN PT'S W/ MS & OPTIC NEURITIS!!!!!

CAPD = NO direct response on affected eye

Site of lesion = OPTIC NERVE (N --> Chiasm --> Tract)

Test accomodation
Basically get pt to go 'cross-eyed'
Normal = Convergence + Constriction (miosis)

Site of lesion = OCCIPITAL LOBE (visual cx)

CN 3, 4, 6

General observation
- Same as CN2
- 1 Eye looking down and out (CN 3 lesion)?

Examination
- Pursuit
- Saccades

NB For pursuit and saccades, do horizontal movements first, then vertical

- Eye movements (H)
'Do not move your head, just your eyes.'

Pursuit:
- B/L = Age, alcohol, antipsychotics
- U/L = ALWAYS pathological

Lesion ~ Frontal lobe/Pons

Saccades (PD):
- Look@myfinger, look@mythumb
- This is basically finger-nose test for the eyes.

Lesion ~ Occipital lobe

Eye movements
- 'Tell me if you notice any visual abnormalities.'

CN 5 - V1, V2, V3
Sensory - Cotton wool
Pain - Pin
Temp - Tuning fork

NB. Always establish
a base of reference for
the pt by 1st applying
stimuli to be tested
on the pt's sternum.

CN 5 - V3 motor
- Clench teeth: Masseter
Temporalis

- Open mouth: Deviates to
side of lesion
- OFFER TO DO JAW JERK

CN 5, 7 (Corneal reflex)

OFFER to do in:
i. CN 5 test
ii. CN 7 test

Afferent limb: V1
Efferent limb: VII

CN 7

General observation:
- Widening of the opening b/w eyelids?
- Flattening of nasolabial fold?
- Asymmetry?
- Involuntary movements?
- Drooling?
- Dry eyes?
- Ask about dysphasia/dysphagia
- Ask about taste
- Ask about hyperacusis

OFFER TO TEST TASTE

Then test motor:
- Wrinkle forehead
- Squeeze eyes
- Puff out cheeks
- Bare your teeth
- Squeeze lips together
- Whistle

a

CN 8

Ask about tinnitus/vertigo
i.e. make sure pt is comfortable

Hearing:
- Mask & whisper
- Rhinne's (mastoid --> air)
- Weber's (Teletubby)

Balance:
- Per testing of cerebellar signs (i.e. nystagmus)
- Gait/Truncal ataxia
- Offer to do Hallpike

a

Rinne/Weber interpretation

CN 9, 10

- Highly unlikely to be tested.

- Palate elevation:
If + U/L weakness, deviates TO normal side
- Gag reflex

- 'KA KA KA' - palatal sounds
- 'GO GO GO' - guttural
- 'AAAAHHHHHH'

a

CN 11

General observation
Asymmetry?
Atrophy?
Shoulders on same level?

Examination
- SCM (U/L) - 'Turn your head to the left/right.'
Passive, then active
Always palpate musc belly
- SCM (B/L) - 'Flex your neck down against my palm'

- #shrugs - Passive; then active

CN 12

General observation
Patient to open mouth
Fasciculations? Atrophy?

i. Stick tongue out - deviates TO weak side
ii. Push tongue against cheek and feel

Hodgepodge of relevant information for the motor/sensory examination

Power/Reflex scoring
Types of tone

Sensory Dermatomes

UL

a

LL

a

Motor innervation

Upper limb

1. WIPE
Be sure to check time, place, person.
And FFS, ALWAYS ASK ABOUT HANDEDNESS

2. General observation:
- Surroundings
- Patient (general)
- Patient (neuro specific)
- Pronator drift

PT TO BE SEATED!

3. Motor
- Fasciculations (pt to relax limb)
- Tone (see note)
- Power (Brotip: Get pt. to hold pose in link. That way you
can test all muscles above hand in one go.)
- Reflexes
- Co-ordination
i. Finger/nose
Cerebellar = intentional tremor, dysmetria
ii. Dysdiadochokinesia (cerebellar, PD)
iii. Rebound ("Please lift your arm up quickly from your
sides." cerebellar HYPOtonia = overshoot)

Move from arm to arm for each of the above.

r

Tone (please make your arm floppy AF):@ wrist: rotation, pronation, supination@ elbow: Flexion, extensionDon't forget spasticity (e.g. quickly flex arm. If spastic, there will be a 'catch')

a

4. Sensory

d

Thank the Patient.
Wash your nasty hands.
Summarize findings

Further investigations:
- Full neurological exam
- CT/MRI if indicated

To those new to this:

i. Click "+" to expand the mindmap.
ii. Click symbols on the side of text for hyperlinks
iii. Click top right corner of images to expand them.