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OSCE > Neuro history and examination > Flashcards

Neuro history and examination Flashcards

1
Q

Headache HX

A

SOCRATES

S - uni/bilateral?

O - Sudden/gradual

C - Throbbing / Tight

R - Does it radiate

A -N&V, consciousness, Vision etc

T - Constant/Intermittent, Recurrent?, worse timing (e.g. morning SOL)

E - Noise, Stress, cough / bending (SOL), light, foods (Migraine), combing hair

S - Scale 1-10, worst ever? (SAH)

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2
Q

Headache associated symptoms

Think Headache types, GCA, Meningitis, Malig etc

A 
Nausea/vomiting
altered conscious level, 
rash, 
pyrexia, 
neck stiffness, 
photophobia, 
vision: visual loss, blurred vision, aura, 
tender scalp,
rhinorrhoea/lacrimation?
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3
Q

Altered consciousness Hx

Pre
During
Post
Witness

A 
Onset?
What doing at the time?
Preciptated by: hot room, stress, standing long.
How did they feel before
Associated symptoms
How long to recover
Postictal - amnesia, aggression, crying or weakness
Previous episodes?

Witness: description if possible

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4
Q

Altered consciousness associated symptoms:

Think: Vasovagal, stroke, epilepsy

A

Dizzy, N&V, Aura, Tachycardia, Sweating, Weakness / Parasthesia, Slurred speech, headache, tongue biting / incontinence, Stiffness / Jerking
Awareness, Groans / Crying

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5
Q

General Neuro history

A

Onset
New or Recurrent (getting better or worse? relapsing and remitting?)
Timing
Any previous therapies and effect

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6
Q

Neuro PMH

A 
Trauma: head, spinal
Metabolic / Endocrine: DM
Cancer: mets
Epilepsy
HTN
AF (stroke)
Heart disease
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7
Q

Neuro DH

A

Anticonvulsants
Drugs that lower seizure threshold (Antibiotics, antipsychotics, Anaesthetics e.g ket, lidocaine, fentanyl)
Analgesics
Antidepressants (some also lower seizure threshold)
Insulin
Recreational drug use

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8
Q

Neuro SH

A 
Alcohol
Smoking
Recreational drugs
Occupation
Home circumstances (who, house type etc)
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9
Q

FH

A

Migraine, CVA, IHD, DM

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10
Q

Neuro examination sequence

A 
ALWAYS ASK PAIN 1st
Inspection
Tone
Power
Reflexes
Co-ordination
Sensation
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11
Q

Upper limb Neuro overview

A

Tone

Power

Reflexes

Co-ordination

Sensation

Dont forget to ask dominant hand first

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12
Q

How to assess tone

A

Passively move each joint

There should be normal, even resistance

UMN: Hypertonia (spasticity / rigidity) seen e.g. stroke, PD

LMN: Hypotonia

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13
Q

How to assess power

  • Upper limb
A

Upper:

  • Pronator drift (UMN lesion)
  • shoulder: flex, extend, abduct, adduct
  • elbow: flex, extend, pronate, supinate
  • wrist: flex, extend
  • Fingers: flex, extend, abduction
  • Thumb: Palmar abduction (median), adduction (ulnar), opposition (median)
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14
Q

Reflexes

  • Upper limb
  • Lower limb
  • How to increase signs
A

Upper:
Biceps, Triceps, Brachoradialis,

Lower:
Knee, Ankle
Plantar (Babinski), Ankle clonus

Clenching teeth increases effect

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15
Q

Coordination

  • Upper limb
  • Lower limb
A

Upper:

  • finger to examiners then to own nose repeatedly
  • finger to nose with eyes closed
  • touch thumb to each finger tip
  • Disdiadochokinesis

Lower limb
- Heel-shin test

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16
Q

Sensation

A

Soft touch
Proprioception
Vibration (128Hz fork)
Sterogenesis (cortical localisation: can identify coin or key in hand)
2-point discrimination
Graphaesthesia(recognise writing on the skin)

Would also like to test pain/pinprick and temperature

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17
Q

Inspection neuro

A 
Posture (UMN: upper limb flex, lower limb extend)
Wasting
Tremor
Fasciculations
Involuntary movements
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18
Q

Testing power Lower limb

A

Hip: abduction ,adduction, flexion and extension
Knee: Flexion, extension
Ankle: Dorsiflexion, plantar flexion
Big toe: plantar/dorsiflex

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19
Q

Other tests for Lower limb neuro

A

Rombergs test: stand arms and feet together, arms outstretched and hands supinated.
- if can’t do with eyes open then cerebellar lesion- - if only cant when eyes closed then proprioception loss

Assess gait

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20
Q

Gait types

A

Hemiplegic: upper limb in flexion, leg extended and plantar flexed. patient lurches body to swing paralysed leg around dragging plantar flexed foot

Parkinsonian: slow and shuffling, decreased stride length, loss of arm swing when walking, festinant: increasingly rapid steps to keep upright posture

Steppage: drop-foot from dorsiflex paralysis. must lift foot higher to clear toes and slap on returning to floor. Bilateral suggests polyneuropathy

Ataxic: swings to both sides when trying to do heel-to toe

Antalgic: gait to avoid pain. short stage phase with prolonged swing phase of painful joint/limb

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21
Q

Lower limb dermatomes:

A

L1 hands breadth below inguinal ligament, side of penis and scrotum

L2 Lateral thigh

L3 Medial thigh

L4 Medial leg

L5 Lateral leg

Stand on S1
Squat on S2
Sit on S3
S4…

22
Q

Hip myotomes

  • Hip flexion, adduction and internal rotation
  • Hip extension
  • Hip abduction, external rotation
A

L2-3

L4-5

L5-S1

23
Q

Knee myotomes

  • Knee flexion
  • Knee extension
A

L5-S1

L3-4

24
Q

Ankle myotomes

  • Flexion
  • Extension
A

S1-2

L4-5

25
Q

Tendon innervation

  • Knee
  • Ankle
  • Bicep
  • Tricep
A

L3-4
S1-2

C5-6
C7-8

26
Q

Upper limb dermatomes:

  • C5
  • C6
  • C7
  • C8
  • T1
A

Lateral antecubital fossa

Thumb

Middle finger

Little finger

Medial antecubital fossa

27
Q

Upper limb myotomes

  • C5
  • C6
  • C7
  • C8
  • T1
A

Shoulder abduction/external rotation, elbow flexion

Wrist extension

Elbow extension and wrist flexion

Thumb extension and finger flexion

T1 finger abduction

28
Q

MRC grading of motor power

A

5 = full power against resistance

4 = movement against gravity. reduced power against resistance

3 = Against gravity but not resistance

2 = Muscle active when gravity is eliminated

1 = Fasciculations

0 = No muscle contractions

29
Q

How to present a Psych Hx

A

Presenting complaint and duration

HPC

PMH & mental health

DH including elicit drugs

FH

Personal history (where grew up, education, forensic hx and substance misuse)

Premorbid Hx

MSE

30
Q

Important checks in psych history

A

Risk assessment: harm to self and others

Cognition: orientation in time, place, person, concentration

Mood: current mood

31
Q

MSE pneumonic

A 
Always (appearance)
Be (behaviour)
Sure (speech)
To (thoughts)
Assess (affect)
Patients (perceptions)
Crazy (cognition)
Ideas (insights)
and Risks (risk assess)
32
Q

Appearance and behaviour

A

Build & features (e.g. tattoos

Clothing and kemptness

Hygiene

Gait and posture (hyperactive - mania, hypo active - depression)

Eye contact & rapport (lack may be depressed)

33
Q

Speech

A

Rate (pressured in mania)
Rhythm
Tone (monotonous in depression)
Volume

34
Q

Affect & Mood

A

how is mood generally, does this change?

Affect: what is it? is there a range? how intense (blunt or labile?), congruent?

35
Q

Thoughts (should glean this from patient conversation)

Stream, form, content

A

Stream: pressured thoughts in mania, poverty of thought in depression

Form: linking/organisation of thoughts

  • flight of ideas = quick moving of conversation seen in mania
  • rhyming = linking words like hard and bear
  • loosening association: lack of logical connection between sequence of thoughts. e.g. knights move thinking. Seen in schizophrenia
  • Perseveration: persistent repetition of same thought

Content

  • Delusions: persecutory, reference (e.g. TV is talking about them), Gradniose, guilt, Control
  • Though insertion, withdrawal, broadcast are all first rank
  • Overvalued ideas/pre-occupations dominating life
  • obsessive thought/images/impulses
  • thoughts of self-harm or suicide (was it planned, what was the intent, how, what is preventing them from doing)
36
Q

Perceptions

A 
Dissociative symptoms (Derealisation - world isn't real, Depersonalisation - detached from self)
Illusions (misinterpret real stimulus)
Hallucinations (auditory, visual, tactile/touch, olfactory)
37
Q

Types of auditory hallucination:
2nd person
3rd person
Command

A

2nd - voices talk to patient

3rd - talking about patient (seen in paranoid schizophrenia)

Command - tells them what to do

38
Q

Cognition

A 
consciousness
Orientation
Memory
Literacy
Attention/concentration
Language (naming things, following instructions)
39
Q

Insight

A

Is person aware of their illness and treatment options (different levels e.g. they might recognise the need to see Dr but not realise symptoms are due to mental illness

40
Q

Cranial nerve exam overview

A

Nerves 1-12

Would also like to do: Ophthalmoscopy, Snellen chart, colour vision, blind spot, rinnes and webers test

41
Q

What tuning fork for Rinnes and Webers

A

512Hz

42
Q

Optic nerve (II)

A

Acuity: separately in each eye (how many fingers)
Fields
Inattention
Light reflex (direct and consensual)
Accommodation (focus on different point and then in on finger)

43
Q

CN II, IV, VI

A

Keep head still and follow finger with eyes
Ask about diplopia

Test lid lag with an I in middle

44
Q

CN V (Trigem)

A

Sensation of skin (ophthalmic, maxillary and mandibular branch)
Demonstrate stimulus on the sternum first then close eyes and test

Test motor: clench teeth and palpate masseter and temporalis and open mouth against resistance, test jaw jerk (half open mouth, hit finger which is over midline of lower jaw. jerk = UMN lesion)

45
Q

CN VII (facial)

Could give global score out of 5

A

screw up eyes and nose and not let open by you

puff cheeks

Rise eyebrows

purse lips & show teeth

Bilateral UMN supply to upper face so may be spared in CVA

46
Q

CN VIII (vestibulocochlear)

A

cover one ear and whisper in other and repeat

If abnormality suspected then do Rinne and Weber to determine type

HallPike can be done if dizziness is presenting symptom

47
Q

Glossopharygeal (IX) and Vagus (X)

A

Open mouth wide - look if uvula mid line

Say ahh to note symmetry of movement (deviation in glossopharyngeal nerve palsy)

ask if difficulty swallowing (if no and water then test)

Ask to cough (non-explosive suggests vagal palsy)

48
Q

CN XI Accessory

Could also give strength rating out of five

A 
Test trapezius (shrug against resistance) 
Test Ternomastoids by asking to turn head against resistance whilst palpation sternocleidomastoid
49
Q

CN XII Hypoglossal

A

open mouth and look at tongue (fasciculations)

Protrude tongued note deviation (towards the side of lesion)

Push tongue into cheek and check power

50
Q

Cerebellar

A

DANISH

D - disdiadochokinesis
A - Ataxia giving wide gait
N - coarse, slow and on the side of the lesion
I - intention tremor using finger nose test
S- dysarthritic speech e.g. repeat C,C,C or L,L,L
H - Heel toe walk

OSCE (9 decks)

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