Neurological Flashcards
Scenario: This station requires the candidate to apply knowledge and skills in the assessment and examination of a 31year old year old woman who presented with weakness in her right lower limb after laproscopic removal of a small ovarian cyst the previous afternoon. The candidate must also demonstrate knowledge of relevant investigations and possible differential diagnoses. The areas to be examined are:
Focused Medical History:
• Establishing the precise nature of the physical complaint (paresis and anaesthesia) and define the extent of the problems. History should also rule out symptoms in other body areas.
• Exploration of possible complications of surgery and may include questions about abdominal pain, distension or discomfort; bladder and bowel continence; any bleeding PV or PR.
• Exploration of possibility of neurological disease and may include questions about spinal disease; whether spinal anaesthesia was used or LP done; history of trauma; history of other medical problems including diabetes, hormonal disorders (eg: thyroid) and seizures.
• Exploration of possibility of vascular pathology in the leg and may include questions about swelling, calf pain, etc.
• History about infective pathology may include questions about temperature and other routine observations.
• Recognition of the benefit of collateral history regarding the surgery from the treating gynaecologist.
Focused Psychiatric History:
• Brief history about reported emotional distress the previous day and exploration to rule out any current depressive syndrome including a brief mental state.
• History about the loss of previous pregnancy, fears about fertility and history of previous mental illness.
• Family history of psychiatric illness and some questions exploring personality variables may also be
appropriate.
Focused Physical Examination:
Includes appropriate commentary of the examination
• Inspection of the right lower limb and comparison with the normal limb: includes observations about colour, swelling and temperature. Inspection for wasting, abnormal movements and fasciculation.
• Neurological examination of the lower limbs:
o Examination of sensory function: Touch, pain and proprioception (temperature may also be tested)
to establish the distribution of loss.
o Examination of Motor functions: Strength, tone, reflexes (knee, ankle and Babinski/plantar). Assessment of gait (If the candidate attempts/requests to test gait, patient will reply “ I cannot walk as I can’t move my right leg”). May include assessment of coordination (knee-heel test). Test for coordination will be normal on the left side.
o Hoover sign: For a patient with weakness of hip extension: You have already found weakness of hip extension on direct voluntary testing. Ask the patient to flex their good leg against resistance while keeping your hand under the heel of the weak leg. If you feel downward pressure that was not there before and you have palpable evidence of inconsistency in the examination.
o Examination for vascular pathology: peripheral pulses, calf tenderness, swelling
o Homan’s sign: Elicitation: With the knee in the flexed position, forcibly dorsiflex the ankle.Response: Pain in the calf with this manoeuvre may be consistent with the diagnosis of deep venous thrombosis.
Note: Attempt/request to examine abdomen or groin are discouraged as per scripted prompt.
Investigations: routine bloods, thyroid function, blood sugars, CT/ultrasound of abdomen; ultrasound of deep veins in the leg.
Presentation of Physical findings: Candidate should be able to describe his/her physical findings clearly, including the fact that patient’s symptoms are neurologically unexplainable. Candidate may also mention patient’s current calmness and indifference compared to previous night’s emotional distress.
Differential diagnoses would include: • Complications of surgery:
o Lesions of the lumbo-sacral plexus secondary to surgery or other pelvic disease (eg: infections).
o Deep vein thrombosis of the pelvic/leg/calf veins
• Peripheral arterial disease
• Spinal disease
• Radiculopathies and Peripheral neuropathies
• Conversion Disorder
Hoover’s sign for conversion disorder
Hoover’s sign1 is a manoeuvre aimed to separate organic from non-organic paresis of the leg. The sign relies on the principle of synergistic contraction. Involuntary extension of the “paralysed” leg occurs when flexing the contralateral leg against resistance. It has been neglected, although it is a useful clinical test.
