Neurology - Sem 3 > OSCE - sem 3 > Flashcards

OSCE - sem 3 Flashcards

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1
Q
  1. What does PIPPA stand for?
A
  1. Positioning
  2. Inspection
  3. Palpation
  4. Percussion
  5. Ascultation
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2
Q
  1. What are the elements of the neurological examination? (5)
A
  1. General appearance, Tone, Power, Reflexes, and Coordination
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3
Q

Patients appearance, What are you looking for?

A
  • How they walk in
  • Muscle wasting
  • Deformities or abnormal positions
  • Fasciculation
  • Dyskinesias
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4
Q
  1. Tone, what are you looking for?
  2. What are the elements?
A
  1. Assessing the resistance of the muscles in passive movement of patients joints
  2. Hypertonia, Spasticity/Clasp knife, Hypotonia, Rigidity
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5
Q

Where are you checking for in upper limb tone?

A
  • Ask the patient to let their limbs go floppy. Then passively move each limb in turn.
  • Distract the patient with conversation
  • Assess upper limb tone by shaking the patient’s hand and moving the arm through different ranges of movement.
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6
Q
  1. When checking power what actions are being tested?
A
  1. Flexion
  2. Extension
  3. Abduction
  4. Adduction
  5. Opposition
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7
Q
  1. What movements can you test in the shoulder?
  2. Elbow?
  3. Wrist?
  4. Fingers?
  5. Thumb?
A
  1. Abduction & Adduction
  2. Flexion & Extension
  3. Extension & Flexion
  4. Flexion & extension & Abduction & Adduction
  5. Opposition & Flexion & Extension & Adduction & Abduction
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8
Q
  1. What movements can you test in the hip?
  2. Knee?
  3. Foot?
  4. Big toe?
A
  1. Flexion & Extension & Abduction & Adduction
  2. Flexion & Extension
  3. Dorsiflexion & Plantarflexion & Eversion & Inversion
  4. Extension
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9
Q
  • What does SOCRATES stand for?
A
  • Site – Location of the pain?
  • Onset – When/how did it start? What made it start?
  • Character – Description, type of pain (e.g. burning, shooting, stabbing, dull)?
  • Radiation – Is it in just one place or does it go anywhere else? Where does it go? Associated features – e.g. nausea, vomiting, neurological deficit
  • Time course – Has it changed since it began? Is it worse/better at certain times of the day?
  • Exacerbating or Relieving factors – Does anything change the pain? Enquire about medication and its effectiveness
  • Severity – Pain intensity- scale 0-10, interference with usual activities/sleep
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10
Q
  1. What are the steps of taking a history?
A
  1. Presenting complaint
  2. History of presenting complaint
  3. Past medical and surgical history
  4. Medications
  5. Allergies
  6. Family history
  7. Social history - Work, Alcohol, Drugs etc.
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11
Q
  1. What is the best way of getting info from a patient?
A
  1. ICE

Ideas

Concerns

Expectations

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12
Q
  1. What are the aspects of the CV systems review?
A
  1. Chest pain
  2. Dyspnoea
  3. Ankle swelling
  4. Palpitations
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13
Q
  1. What are the aspects of the respiratory systems review?
A
  1. Cough
  2. Haemoptysis
  3. Wheezing
  4. Pain
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14
Q

What are the aspects of the GI systems review?

A
  1. Change in weight
  2. Flatulence and heart burn
  3. Dysphagia
  4. Abdominal pain
  5. Vomiting
  6. Bowel habit
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15
Q

What are the apsects of the genitourinary system?

A
  1. Frequency
  2. Pain
  3. Altered bladder control
  4. Menstruation
  5. Sexual activity
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16
Q

What are the aspects of nervous system review?

A
  1. Headache
  2. Loss of consciousness
  3. Dizziness & Vertigo
  4. Speech and related functions
  5. Memory
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17
Q

What are the aspects of mental health assessed during the systems review?

A
  1. Mental health
  2.  Mood
  3.  Sleep
  4. Energy levels
  5. Concentration levels
  6.  Enjoyment of life
  7.  How do they see their future
  8.  Thought of harming themselves or others
  9.  Hallucinations (auditory or visual)
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18
Q

What other systems need to be checked? (3)

A
  1. Endocrine history
  2. Musculoskeletal system
  3. Skin
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19
Q

How do you check CN I?

A
    • Ask if patient has noticed a problem with smelling aromas.
    • Test each nostril in turn by occluding the other & ask if patient can identify smell. Smells such as coffee often used. Ask the patient to close their eyes and waft the smell towards the patient. Ensure you know the smell you are testing! Use a different smell for each nostril.
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20
Q

How do you check CN II?

A
  1. Pupillary reflexes i.e. light reflex & accommodation reflex
  2. Check & compare pupils i.e. size appropriate for lighting in room, equal
  3. Light reflex
  4. Accommodation reflex
  5. CN 2 is the sensory/afferent part of the light reflex
  6. Visual fields
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21
Q

How do you check the pupillary light reflex?

A
  • ask patient to fix on distant object & ask them to place their hand between their eyes like a shark’s fin to shield the light.
  • Shine the light into one eye and watch the response in that eye (it should constrict) - this is called the direct reflex.
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22
Q

How do you check the consensual reflex?

A
  • Do it again but watch the response in the other eye (again this should constrict). This is called the consensual reflex.
  • Repeat by shining the light into the other eye and check both the direct and consensual response.
  • NB Check that the patient isn’t photophobic first & shine torch in from the side rather than directly into the eye.
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23
Q

How do you check the accomodation reflex?

A
  • ask patient to fix on a distant object and then ask them to look at a close object such as your finger. Both pupils should constrict when looking at the close object. Approx 6 inches.
  • CN 2 is the sensory/afferent part of the light reflex
  • CN 2 is the sensory/afferent part of the accommodation reflex.
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24
Q

How do you check the visual fields?

A
  • Place yourself opposite the patient at the same level and approx 1m apart
  • Ask patient to remove their glasses (unless visual acuity is so poor they will not be able to see your fingers/pin)
  • Ask patient to look at your eyes (not your hands) (may need to gently keep reminding them)
  • Ask patient to close one eye (e.g. their left) and you close the one opposite one (your right)
  • Bring your wiggling finger (or white headed pin) in from the periphery of each quadrant to the centre and ask the patient to tell you when they can see it
  • Best to use both your hands in turn for each eye, rather than stretch across
  • Repeat process for both eyes.
  • Compare your visual fields with the patient’s (assumes your fields are normal!)(machine is more accurate)
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25
What else can be checked with CN II?
* Visual acuity - Snellen chart is used - test each eye in turn - example result = 6/60 - patient only able to see at a distance of 6 metres what a healthy eye would be able to see at 60 metres - allowed to get a couple wrong on each line - test with and without glasses * Fundoscopy - will not be covered during this session but there is equipment & information at the end of the handout if there is time available at the end. * Ichihara plates - checks colour vision.
26
How do you check CN III?
* Supplies all the extrinsic muscles of the eye except superior oblique and lateral rectus. Eye will be abducted if there is a palsy. * NB plays part in pupillary reflexes mentioned above. Motor/Efferent part of light reflex and motor/efferent part of accommodation reflex. Pupil with therefore be large and fixed if there is a palsy. * NB supplies levator palpebrae superioris muscle and hence a palsy will cause a ptosis.
27
How do you check CN IV?
* Supplies Superior Oblique muscle (SO4) * ask the patient to adduct and depress the eye so we are just checking that CN 4 is functioning. Patient gets diplopia when they try to look down and in.
28
How do you check CN V (Sensory)?
* 3 sensory branches: Ophthalmic, Maxillary, Mandibular * Test light touch using cotton wool and pin prick using a pin * Demonstrate on sternal area first * Dab not stroke when using the cotton wool * Avoid drawing blood when using the neurological pin (use a new pin for each patient and * dispose of immediately using a sharps bin) (testing not expected) * Start from the top and move down to assess each of the branches, comparing each side. Vary * the time between each point of testing. Ask the patient to close their eyes and to say yes when * they can feel it and also to tell you if it feels the same on both sides. * NB The mandibular branch also supplies sensation to the anterior 2/3rds of the tongue - you can * use a wooden spatula for this
29
How do you check CN V (Motor)?
* Muscles of mastication - Ask patient to clench their teeth whilst feeling and assessing the masseter and temporalis muscles on both sides * Asking the patient to open their mouth against resistance and checking that the jaw descends in the midline. * NB The Mandibular division supplies tensor tympani which decreases the vibrations of the tympanic membrane. So, if it is damaged the patient experiences hyperacusis. * NB Other tests that you should read about but will not be tested today are... * The corneal reflex (sensory 5 and motor 7) * Jaw jerk using a tendon hammer (increased if bilateral 5th upper motor neurone lesions e.g. * Bilateral strokes. NB it may be normal to have an absent or minimal response)
30
How do you check CN VI?
* Abducens = abduction via lateral rectus muscle. Palsy means abduction is paralysed. * Sit or stand opposite the patient. Ask the patient to look at the pen you are holding vertically, and then ask them to follow it only with their eyes. They need to keep their head still and you may need to gently remind them to do this or hold their head still if necessary. Move the pen in a H shape. Remember to look at their eyes before you start moving the pen too. * Ask the patient to tell you if they get any double vision (diplopia). * Check that both eyes are moving as they should be. * Also check for nystagmus. Avoid extremes of gaze or moving it too quickly as this may induce nystagmus in a normal person. NB actually testing for vestibular and cerebellar lesions.
31
How do you check CN VII?
* Ask patient to... (NB can do some of these against resistance too) * Muscles of facial expression * raise their eyebrows * frown * close their eyes tight * blow their cheeks out * smile and show you their teeth * close your lips tightly shut * Upper MN lesion e.g. a stroke - only lower muscles affected i.e. mouth/cheeks (the upper muscles of the face are spared because they have bilateral supranuclear input) * Lower MN lesion e.g. Bell's palsy - upper & lower muscles affected * taste anterior 2/3rds tongue, * Can also ask about: ear stapedius muscle (palsy = hyperacusis) , lacrimal gland (palsy = dry eye), saliva production (palsy = dry mouth)
32
How do you check CN VIII (Hearing)?
* fingers together next to ear and then whispering numbers for the patient to repeat near the other ear. Normal hearing range is approx 60 cm. * Weber's test = place the vibrating tuning fork in centre of forehead and ask if noise is heard in both ears or if it is heard in one ear more than the other. * Rinne's test = place the base of the vibrating tuning fork behind the ear on the mastoid bone and ask the patient to tell you when the sound is lost. Then quickly place the forks of the tuning fork lateral to the ear (but not touching it) and ask the patient to tell you if they can now hear it. Do this test for both ears. * A normal test is for the patient to have an equal Weber's test in both ears and to hear the sound in front of both ears when doing the Rinne's test. Abnormal tests will then need to be interpreted to determine if it is a sensorineural loss or conduction loss.
33
How do you check CN VIII (Vestibular part)?
* Ask patient to walk in a straight line * Romberg's test; Balance depends on CN 8, proprioception, vision and cerebellar function. Ask * patient to stand with feet together & arms by their sides. If patient becomes unbalanced even with eyes open then it suggests a cerebellar lesion. If patient is OK with eyes open but then becomes unbalanced with eyes closed then it is either a problem with proprioception or CN 8 (Romberg's positive). Be prepared to catch them!
34
How do you check CN IX?
* Gag reflex (Glossopharyngeal nerve = sensation and Vagus nerve = motor) * Water swallow test (both CN 9 & 10 but CN 10 more so) - a fully conscious patient takes a sip of water and swallowing is observed. The patient is then asked to speak afterwards * Sensation and taste to posterior 1/3rd tongue (glosso = tongue) * Ask - Parotid gland (palsy = dry mouth)
35
How do you check CN X?
* Uvula movement - CN 10 (Vagus) - ask patient to say ahhh and check that the soft palate on both sides moves upwards and that the uvula moves up in the midline. You can also test the strength of the soft palate but asking the patient to blow their cheeks out and then apply pressure to both cheeks and check that air doesn't escape out of the nose * Gag reflex (Glossopharyngeal nerve = sensation and Vagus nerve = motor) * Parasympathetic supply to thorax and GIT so palsy may cause tachycardia * Power to muscles of larynx so palsy may cause hoarseness. Patient also unable to cough.
36
How do you check CN XI?
* Supplies Sternocleidomastoid muscles (SCM) and Trapezius muscles * Check for hypertrophy, atrophy and power. Test muscles with and without resistance. * SCM - Ask the patient to turn their head both ways (and then against resistance) * Trapezius - Ask patient to raise/shrug shoulders (and then against resistance)
37
How do you check CN XII?
* Provides power to the muscles of the tongue. * Ask the patient to stick out their tongue and check for deviation from the midline. * Ask patient to move tongue from side to side and up and down. * Ask patient to push their tongue into each cheek and keep it there against gentle pressure from * your hand on their cheek. * Also test lingual speech (ask patient to say 'yellow lorry')
38
What are the modalities of the Cranial nerves?
* Some * Say * Marry \* * Money * But * My * Brother \* * Says * Big \* * Brains (!) * Matter * More * M = motor, S = sensory, B = both, \* = also PNS
39
How would you conduct a fundoscopy?
* On/off switch. Also alters brightness (reduce brightness if small pupil or looking at macular as patient is looking directly at light). * Lens dial for refractive error (yours or patient's) - see below * 1 Green filter (can help when looking at retinal vessels/macula etc). * 2 Circle with cross in it - crossed linear polarising filter (can help if corneal reflection). * 3 Circle - one generally used - can alter options by turning the dial below - various sizes (bigger * the better unless small pupil/looking at macular)(use middle sized light unless very small pupil/dilated pupil). Also blue light for when using fluoresceine. Also slit light for looking at contour of cornea/retina etc. * Ask the patient to take their glasses off. * Darkened room. NB Chaperone. * Check red reflex (arms distance-6 inches) then move very close (1-2 inches). * Your right hand and eye for patients right eye. * Make sure you and patient are comfortable. * Ask permission to place your hand on their forehead & gently raise their top lid. * Ask patient to focus on object straight in distance. NB ensure your hair is tied back. * Find optic disc (can follow the 'arrows' on the vessels). * Check all over retina by moving the ophthalmoscope and asking patient to move eyes. Check * macular by asking patient to look directly at light (make light small & dim) (crossed linear polarising filter).
40
What do the black or red numbers mean?
* − Lenses (usually red numbers) corrects for myopia * + Lenses (usually black numbers) corrects for hypermetropia
41
What are you checking for with lower limb tone?
* Ask the patient to let their limbs go floppy. Then passively move each limb in turn. * * Lower limb tone testing begins with rolling both the patient’s legs when they are outstretched. * Can also… * Lift the patient’s leg at the popliteal fossa (do this relatively quickly) to check if the heel remains in contact with the couch (which it should). * Ankle clonus is elicited by rapidly dorsiflexing the foot & consists of rhythmic contractions of the muscle. It is abnormal when sustained (i.e. 5 or more contractions). Particularly associated with spasticity in UMN lesions.
42
When checking for power what are you looking at?
* Try to isolate each joint so that you are only testing one joint at a time. * Ask the patient to do the movement, first without resistance, and then with resistance. * Ask the patient to activate the muscle group first before applying resistance. * Work down the limbs but comparing sides as you do * Begin assessment at the patient’s shoulders and then work down.
43
What myotomes supply the shoulders? What movements are you testing for?
Test shoulder abduction (C5/6) and adduction (C6/7/8)
44
What myotomes supply the elbow? What movement are you testing for?
* Test for elbow flexion (C5/6) and extension (C7/8). * Test wrist extension (C6/7/8) and flexion (C6/7/8).
45
What myotomes supply the fingers? What movements are you testing for?
* Assess finger flexion (C8/T1) by asking the patient to grip two of your fingers. * Finger extension (C7/8). * Finger abduction/adduction (C8/T1). For abduction, ask the patient to spread out their fingers against resistance. For adduction, ask them to grip a piece of paper between 2 fingers and then stop you from removing it. Test it against yourself. * Opposition of the thumb e.g. with little finger (C8/T1). * Abduction of thumb – palm facing up to ceiling and ask the patient to move their thumb up towards the ceiling (C7/8/T1) * Adduction of thumb (C8/T1) * Flexion of thumb (C8/T1) * Extension of thumb (C7/8)
46
Where do you start lower limb power? What myotomes supply the hip? What movements?
* At the hip * Hip flexion (L1/2/3) and extension (L5/S1/S2) * Hip abduction (L5/S1) and adduction (L2/3/4)
47
* What myotomes supply the knee? * What movements?
* Knee flexion (L5/S1) and extension (L2/3/4) * this is elicited by the patient flexing their knee and then maintaining it against resistance, and then trying to extend the knee from this position against resistance.
48
* What myotomes supply the foot? * What movements?
* Foot dorsiflexion (L4/5) and plantar flexion (L4/5/S1/2/3). * Foot eversion (L4/5/S1/2) and inversion with soles facing inwards (L5/S1). * Big toe extension (L5/S1).
49
What do you do when testing for reflexes?
* Hold the hammer loosely and use its weight. Look for muscle contraction * Reflexes may be; normal, increased/brisk, decreased or absent * If after 2 attempts the reflex appears absent then try reinforcement by asking the patient to either grip both hands together or clench their teeth
50
What are the upper limb reflexes?
* Triceps (C6/7/8) (strike tendon directly) * Biceps (C5/6) (fingers on tendon) * Brachioradialis – Supinator (C5/6) (fingers on tendon)
51
What are the lower limb reflexes?
* Knee (L2/3/4) Femoral nerve * Ankle (L5/S1/2) Tibial nerve * Plantar or Babinski reflex (L5/S1/2) Tibial nerve
52
Which myotomes are responsible for the babinski reflex? How is the babinski reflex done?
* Plantar or Babinski reflex (L5/S1/2) Tibial nerve * Start at the patient’s heel and run along lateral border of foot to little toe, then across to big toe. * There are three types of response: * 1 = equivocal response = this frequently occurs and so no information is obtained * 2 = flexor response = all toes flex and curve down and inwards = normal adult * 3 = extensor = big toe extends (dorsiflexion) and the other toes fan out = upper motor neurone lesion in an adult
53
What are the different sensations to be tested?
* Soft touch * Pain - Pinprick * Temperature * Vibration * Proprioception
54
Which tract carries pain to the brain? Which tract carries soft touch sensation? Which tract carries vibration and proprioception?
* spinothalamic tract * anterior spinothalamic tracts. * posterior column
55
What must you do before the sensation exam?
* Explain the procedure fully and clearly. Ensure the patient is in the anatomical position. * Demonstrate the sensation on the sternal area first (with consent). * Ask the patient to close their eyes. Instruct the patient to say ‘yes’ every time they feel it.
56
How do you test soft touch?
* Using cotton wool, assess if the patient can feel it and whether it feels normal. * Touch with the cotton wool; don’t stroke, as the latter will involve different pathways. * Touch at different time intervals, to prevent guesswork. * Work systematically down each limb, comparing the two limbs and ensuring you cover each dermatome. Please refer to specific dermatomes for student revision * Do not put cotton wool in the sharps bin
57
How do you test pain?
* Taking the same approach as for light touch, carefully use a disposable neuro tip to elicit pain sensation. * Please ask the patient to say whether they feel a sharp or dull sensation, as you use the sharp and blunt ends of the neuro tip * Press firmly enough so that you just distort the skin but do not draw blood. * Use a fresh neuro tip for each patient, and dispose of it immediately afterwards in the sharps box. Do not re-sheath the pin.
58
How do you examine temperature?
* Use the end of a tuning fork to assess for cold sensation. This is not the gold standard, but is sufficient as a quick way to examine temperature.
59
How do you examine vibration?
* Tuning fork vibrations can be elicited by squeezing the ends of the forks or banging it against your hypothenar eminence. * Test vibration on both upper limbs by placing the tuning fork distally on a bony prominence. If vibration sense is elicited peripherally, then no further testing is needed. * Ask the patient to confirm that they have felt the vibration (not just the cold/touch) and also to say when the vibration stops.
60
How do you test proprioception?
* Demonstrate for the patient first, and then ask them to close their eyes. * Move the patient’s finger/toe up or down and ask the patient to say in which direction their finger or toe went. * To avoid pressure sensation, hold the patient’s toe or finger at the sides, and vary the sequence to prevent guess work.
61
How do you test upper limb coordination?
* Finger-nose coordination * Ask the patient, using their index finger, to touch their nose and then your finger, looking for normal coordination. * Do this repetitively, and make it trickier by moving your own finger about and asking them to do it more quickly. Make sure the patient’s arm is fully extended each time. Do this for both sides/arms. * Look for intention tremor & past pointing * Test for dysdiadochokinesia * Ask the patient to touch their stationery palm with alternating dorsal and palmar fingers of the other hand * Do this for both sides/arms * Cerebellar drift * Ask the patient to stretch out their hands with palms upwards & with their eyes closed * Assess for any abnormal movement upwards
62
How do you test lower limb coordination? (3)
* Heel-shin coordination: * Ask the patient to place the heel of one leg on the knee of the other leg, and run the heel up and down the straightened leg * Do this for both legs. * Gait * ask the patient to walk in a straight line up to 10 metres, and then come back * Also assess heel to toe walking. * Romberg’s test- * this assesses balance * Ask patients to stand straight, with feet together and arms by their sides * This is repeated with their eyes closed * If there is a problem with proprioception or CN 8 (vestibular pathways), then the patient will lose their balance – so please be ready to catch them. * NB If there is a cerebellar problem, they won’t be able to keep their balance even with their eyes open.
63
What must you do before begining a consultation? (4)
Ask name & DOB of patient Ask for consent Confidentiality Wash hands
64
Which dermatome supply the thigh? (A&P)
L2 & S2 (Posterior)
65
Which dermatomes supply the knee (A&P)?
L3 & S2
66
Which dermatomes supplies the leg?
L5 (Lateral) L4 (Medial)
67
Which dermatomes supply the foot?
S1 & L5
68
Which dermatomes supply the upper arm?
C5 & T2
69
Which dermatomes supply the lower arm?
C6 & T1
70
Which dermatomes supply the hands?
C7 & C8
71
Which dermatomes supply the shoulders?
C4
72
What are the 7 parts of clinical history taking?
History of presenting complaint Past medical and surgical history Medicines Allergies Family history Social history Systems review
73
Neurology - Sem 3
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