Aims and Objectives Requires some basic knowledge of clinical examinations • Clinical examination station (OSCE) • One way to prepare: ‘Retrospective approach’ • Neurological examination: 4 cases • Cranial nerves will be covered later on in the week • Duration: 60 mins • 2
Clinical examination station: how to prepare? ‘Retrospective approach’ EXAMINATION Perform each step of the • 1. Formulate an OSCE Cases List ROUTINE routine confidently Pick up on signs • 2. Prepare your ‘VIVA’ for those cases Positive signs of diagnosis • PRESENTATION Present findings • ‘Typical’ findings presentation • systematically Risk factors List appropriate • • differentials based on Signs of decompensation • findings List of differentials • VIVA Answer questions • Complications • systematically How would you investigate this patient? • Explain your thinking • How would you manage this patient? • 3
Clinical examination station: how to prepare? ‘Retrospective approach’ EXAMINATION Perform each step of the • 3. Finalise your examination routine ROUTINE routine confidently Pick up on signs • Each step of the routine • Signs you are looking for • Your speech • PRESENTATION Present findings • systematically 4. Practice your examination routine List appropriate • on friends differentials based on findings 5. Go to the wards/clinics looking for VIVA Answer questions • your cases systematically Explain your thinking • 4
Peripheral neurological examination: OSCE Cases list What cases could come up? 1. Hemiplegia/hemiparesis 2. Multiple sclerosis 3. Parkinson’s disease 4. Peripheral neuropathy 5. Myasthenia gravis 6. Motor neuron disease 7. Proximal myopathy This is not a definitive list But by preparing for these you will be better at: • Your exam routine • Looking out for important signs • Formulating your findings systematically • Tackling the VIVA • 5
How to present your findings? I performed a cardiovascular examination on this patient If you have an idea, then Who has signs suggestive of mitral regurgitation back yourself from the start. • It gets the examiner listening My main positive findings are: 1. XXX 2. YYY My relevant negative findings are: RELEVANT negatives 1. XXX (Risk factors) 2. YYY (Signs of decompensation) 3. ZZZ (POSSIBLE associated features) Overall, this points towards a diagnosis of mitral regurgitation Patients will be STABLE 6
Neurological examination: Case 1 Left Right Tone N é 7 beats of ankle clonus (1) Power ~3 in all 5/5 movements Reflexes N é Co-ordination N N Sensation N N 7
Question 1 Which of the below is NOT a feature of an upper motor neuron lesion? A – Fasciculations B – Hoffman’s reflex C – Increased tone D – Weakness E – Spasticity 8
Question 1 Which of the below is NOT a feature of an upper motor neuron lesion? Fasciculations Hoffman’s reflex Increased tone Weakness Spasticity app.bitemedicine.com 9
Explanations Which of the below is NOT a feature of an upper motor neuron lesion? Fasciculations This is a LMN sign which occurs due to muscle denervation causing spontaneous action potentials Hoffman’s reflex Flicking the middle fingernail downward causes thumb flexion. This suggests a UMN lesion Increased tone This is a feature of UMN lesion Weakness Seen in both UMN and LMN disease Spasticity Seen in UMN disease app.bitemedicine.com 10
L R Motor pathways (from brain à muscle) I want to move my R thumb – what happens? Start: UMN start from LEFT primary motor cortex • UMN moves downwards • At medulla • 90% of fibers cross (LATERAL CORTICOSPINAL TRACT) • 10% do not cross (ANTERIOR CORTICOSPINAL TRACT) • (2) 11
L R Motor pathways (from brain à muscle) I want to move my R thumb – what happens? Start: UMN start from LEFT primary motor cortex • UMN moves downwards • At medulla • 90% of fibers cross (LATERAL CORTICOSPINAL TRACT) • 10% do not cross (ANTERIOR CORTICOSPINAL TRACT) • UMN continues until they reach the correct spinal level • Here they synapse with the LMN at the anterior horn of • spinal cord The LMN innervates the responsible skeletal muscles • (2) 12
L R Upper & lower motor neurons What counts as an upper motor neuron ? Brain • Brainstem • Injury to white matter of spinal cord up to level of • synapse So what counts as a lower motor neuron ? Injury to the grey matter of spinal cord at level of • synapse (anterior horn) Injury to axons leaving spinal cord • (2) 13
UMN vs LMN lesions UMN lesion means the LMN is no longer regulated • So LMN response is NOT controlled • Upper motor neuron lesion Lower motor neuron lesion Site Proximal to anterior horn synapse Distal to synapse Tone Spasticity and/or rigidity Flaccid Pronator drift Power Reduced Reduced Upper limb: extensors weaker than • flexors Lower limb: flexors weaker than • extensors Reflexes Hyperreflexia Hyporeflexia Fasciculations Absent Present 14
Neurological examination: Case 1 Left Right Tone N é 7 beats of ankle (1) clonus Power ~3 in all 5/5 movements Reflexes N é Co-ordination N N Sensation N N 15
Neurological examination: Case 1 – Hemiplegia Please present your findings? I performed a neurological examination on this patient who has signs suggestive of a LEFT HEMIPLEGIA My main positive findings are: On general inspection: • Walking frame by bedside • Left sided facial droop • The left upper limb was flexed • Tone appeared to be increased globally on the left side, with a more than 5 beats of ankle clonus • Power was moderately reduced (3/5) globally on the left side with suggestion of a pyramidal • pattern of weakness Reflexes were brisk on the left • 16
Neurological examination: Case 1 – Hemiplegia Please present your findings? My relevant negative findings are: No signs of LMN lesion (no muscle wasting, no fasciculations) • Sensation was normal in all modalities tested • This points towards an UMN lesion, more specifically a left sided hemiplegia 17
Neurological examination: Case 1 – Hemiplegia Please present your findings? My relevant negative findings are: No signs of LMN lesion (no muscle wasting, no fasciculations) • Sensation was normal in all modalities tested • This points towards an UMN lesion, more specifically a L sided hemiplegia Taking into account the patient’s age, the most likely cause would be a right sided stroke secondary to • thrombosis (most common), embolus, or haemorrhage Other possible causes include: • A space-occupying lesion e.g. tumour • A demyelinating process • 18
Neurological examination: Case 1 – Hemiplegia What are your differentials? Vascular causes • Stroke • TIA • Signs < 24hrs • No evidence of acute infarction on brain • imaging Space-occupying lesion • Brain • Demyelinating conditions e.g. multiple sclerosis • Signs disseminated in time & space e.g. sensory, • motor, cerebellar 19
Neurological examination: Case 1 – Hemiplegia This patient has had a stroke, what further examinations could you perform to support this diagnosis? I noted a left sided facial droop. I would also formally examine the cranial nerves Would expect unilateral facial weakness with relative sparing of frontalis • Examine visual fields which may help localise the site of infarct e.g. MCA stroke will give • homonymous hemianopia Assess for cardiovascular risk factors Check radial pulse for AF (embolic stroke) • Auscultate for carotid bruits • Listen for heart murmurs • 20
Neurological examination: Case 1 – Hemiplegia What are the different types of stroke you are aware of? Strokes can be classified by: Pathophysiology or • Location of infarct • Pathophysiology Location (Bamford Classification) (2) Ischaemic (85%) Total anterior circulation stroke (highest mortality) Haemorrhagic (15%) Partial anterior circulation stroke Posterior circulation stroke Lacunar stroke 21
Neurological examination: Case Left Right 2 Tone N N Power 4/5 on distal 4/5 on distal movements of movements of foot, otherwise foot, otherwise normal normal Reflexes N N Co-ordination N N Sensation Sensory loss in Sensory loss in diagram diagram 22
Question 2 Which of the following is NOT a cause of peripheral neuropathy? Diabetes Chronic renal failure Muscular dystrophy Guillain-Barré syndrome Vitamin B12 deficiency app.bitemedicine.com 23
Explanations Which of following is NOT a cause of peripheral neuropathy? Diabetes A common cause Chronic renal failure Uraemia can cause a neuropathy Muscular dystrophy This is a muscle pathology, not a nerve pathology Guillain-Barré syndrome Causes a neuropathy, typically post infection Vitamin B12 deficiency Can cause a neuropathy app.bitemedicine.com 24
Sensory pathways (from skin à brain) 2 main pathways Dorsal column (medial lemniscus) • Touch • Vibration • Proprioception • Anterolateral spinothalamic tract • Pain • Temperature • 25
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