OSCE - Neurological

Question 1

Examination - JACCO

Answer 1

• Jaundice - Yellowing of skin and sclera of eyes. Can be caused by the build-up of Bilirubin (yellow/brown - the product of red blood cell breakdown):
  
  • Gallstones
  • Alcoholic Liver Disease
  • Pancreatitis
  • Hepatitis
  • Sickle Cell
• Anaemia - Pallor in mucous membranes or dull, pale skin caused by lack of red blood cells.
• Cyanosis - Bluish discolouration of the skin due to poor circulation/inadequate oxygenation of the blood. Peripherally caused by low O₂ in the red blood cells, or problems getting oxygenated blood to the body. Cold temps. can lead to blood vessel narrowing & temporarily blue-tinged skin. Central cyanosis is more serious and can be caused by low cardiac output.
• Clubbing - Deformity of the finger or toenails associated with a number of diseases, mostly of the heart & lungs.
• Oedema - Condition characterised by an excess of watery fluid collecting in the cavities or tissues of the body. Note lower leg/ankle (?sacral?) oedema could be an indication of heart failure

Question 2

Examination - AVPU/GCS

Answer 2

• AVPU
• GCS
• FAST test

Question 3

Examination - Mini-Mental Test

Answer 3

• How old are you?
• What is the time?
• Give the patient an address, ask them to repeat and remember it, and repeat it again at the end of the test.
• What year is it?
• What is the name of where you are now?
• Ask the patient to identify 2 people recognisable to them.
• What is your date of birth?
• When did the 2nd world war end?
• Who is the current prime minister?
• Count backwards from 20 to 1.
• Can the patient repeat the address from earlier?

Question 4

Cranial Nerves - Face - V, VII

Answer 4

• Puff cheeks
• Raise eyebrows
• Scrunch eyes
• Purse lips
• Bare teeth

Question 5

Cranial Nerves - Eyes - II, III, IV, VI

Answer 5

• Visual acuity - Can the patient read from the wall? Can they identify objects?
• Visual fields - Subjective measure of central and peripheral vision.
• Extra Ocular Movements - Can the patient move their eyes in a normal coordinated manner following an object?
• Pupils - Round, reactive, reflex & consensual.
  
  • Unequal: head injury/brain lesion, local trauma, tumour, usually dilated on the same side as the problem(not always).
  • Pinpoint: drugs(opiates), poisons(organophosphates).
  • Dilated: hypoxia, head injury, hypovolaemia & shock, drugs(atropine).
  • Slow/Absent Reaction: drugs, low level of consciousness, hypoxia, shock.
  • Nystagmus: alcohol intoxication, cerebellar damage, many causes.
• Accommodation - in normal light the patient looks at a distant object to dilate the pupils, then have the patient stare at a penlight and slowly move it closer to the patient’s nose. Pupillary response: pupils should constrict and equally move to cross.

Question 6

Cranial Nerves - Nose & Ears - I, VIII

Answer 6

• Ask & note any report of hearing, smell and taste changes.

Question 7

Cranial Nerves - Mouth - IX, X, XII

Answer 7

• Open and say ‘ah’:
  
  • swallow & gag reflexes
  • taste
  • speech & voice(soft palate symmetrical?)
  • uvula(midline?)
• Tongue out - testing hypoglossal

Question 8

Neck & Shoulder

Answer 8

• Shrug - Look for wasting of trapezius muscles.
• Head turns to resistance

Question 9

Power & Tone

Answer 9

• Squeeze fingers, pull towards using biceps - evaluate bicep function, the patient grasps your hands, with their palms facing towards their body, flex the elbows and pull strongly toward their shoulders. Nerves down to C6 must be intact to complete this action.
• Spread Fingers - place your thumb and pointer finger around the edge of the patients closed fingers. provide resistance whilst the patient spreads their fingers. Nerves for finger abduction originate from T1
• Feet downward +/- Plantar Flexion - patient sits with feet flat. Place your hands beneath balls of the feet. Patients that can push down on the ‘gas pedal’/plantarflex the ankle have an intact lateral corticospinal tract between the brain and S1 & S2.

Question 10

Sensation

Answer 10

• Abnormal response to light touch - usual response is yes, if not document patient sensations, mapping areas of deficit/abnormality.
• Romberg test for proprioception - patient stands with feet together for 20-30 seconds then close their eyes. If they are steady with eyes open but unsteady with eyes closed it is a +Rombergs test, as vision compensates for the loss of positional sense.
• Always ask about changes in urination/defecation/saddle anaesthesia if back/sciatic pain is present - Cauda Equina Syndrome(caused by compression/inflammation of lumbar spinal nerves) - Surgical emergency requiring urgent neurological assessment and spinal decompression to prevent permanent dysfunction.

Question 11

Coordination

Answer 11

• Gait - Walking should be rhythmic, controlled & well balanced.
• Heel-Toe walking - a test of voluntary motor function used to evaluate coordination - altered by cerebellar defects.
• Finger-Nose test - a test of voluntary motor function used to evaluate coordination - altered by cerebellar defects.
• Rapid alternative movements - patient repeats rapid movements with hands - abnormal indicates coordination dysfunction/cerebellar defects.

Question 12

Essential Observations

Answer 12

• BM
• BP