Physical Exam Flashcards
Motor Weakness Lower Limb
Guillain Barre ep 75
2022.1 Examination lower limb
Generate differential diagnoses
Examination to differentiate potential causes
Discuss investigations
UPPER MOTOR NEURONE LESIONS:
- pyramidal muscle group
- spasticity (tone)
- hyperreflexia
- up-going babinski
LOWER MOTOR NEURONE LESIONS:
- distal muscle groups
- muscle wasting & fasiculations
- Flaccidity (tone)
- Loss of tendon reflexes
- down going babinski
BRAIN:
- Stroke (haemorrhagic vs. ischemic)
- Tumour
SPINAL CORD:
- Inflammatory (Transverse myelitis)
- Compression (tumour, abscess, haematoma, disc prolapse)
- Infarction (spinal artery thrombosis or insuficiency)
NERVE:
- Guillaine Barre
- Multiple Sclerosis
- Amiolateral sclerosis
NEUROMUSCULAR JUNCTION LESIONS:
- Myasthenia gravis
- Botulism
- Lambert Eaton Syndrome
MYOPATHIES:
- drug induced myopathies (statins, amiodarone)
- inflammatory myopathies (polymyalgia rheumatical)
- Thyrotoxic myopathy
- normal sensation
PSYCHOGENIC:
- anxiety
- conversion disorder
Guillain-Barre syndrome (GBS):
- loss of power and reflexes
(patients feel parasthesia ‘tingling/numbness’ but sensation is intact)
- ascending pattern (starts in feet)
- symmetrical
- progressive
- preceding viral illness
- progresses to autonomic dysfunction
- 5% mortality, 30% required intubation and ICU
- prolonged recovery
- Rx IV immunoglobulin or plasma exchange
LP - increased protein
TRANSVERSE MYELITIS:
- preceding infection
- bilateral lower limb weakness
- progresses to autonomic dysfunction
** loss of sensation, paresthesias with a distinct sensory level
** associated back pain
** reflexes present
** because it is a spinal cord lesion there is bowel and bladder dysfunction
LP - pleocytosis (increased cell count)
MRI - typically shows 3-5 spinal cord segments of T2 increased signal occupying greater than two-thirds of the cross-sectional area of the cord with a variable pattern of enhancement.
AMYOTROPHIC LATERAL SCLEROSIS
progressive atrophy and weakness
- degeneration of upper and lower motor neurones
- patients present with rapidly progressing weakness, muscle atrophy, fasciculations, spasticity, hyperreflexia and paralysis
- no autonomic dysfunction
- eventually leads to respiratory failure
- no cure
MULTIPLE SCLEROSIS
- multifocal CNS myelin dysfunction
- scattered neurone demyelination
- paresthesias, gait difficulty, extremity weakness, poor coordination, and vision disturbances often occur with a relapsing and remitting clinical course
EXAM:
- generalised reduced power
- increased tone
- hyperreflexia
- clonus
- upgoing babinski
- impaired vibration and proprioception
- reduced pain and temperature sensation
- optic neuritis with central vision loss preceded by retrobulbar pain
- internuclear ophthalmoplegia
Lower Limb Examination
2022.2 station
focused examination of a patient who has presented with bilateral leg weakness.
Generates a relevant list of differential diagnoses for bilateral lower limb weakness
Lower Limb Neurology
2021.2 station
focused examination of a 50 year old woman who presents with one week of progressive bilateral
lower limb weakness.
generate a list of differential diagnoses
Motor Weakness Differential Diagnoses
Disorders of Neuromuscular Junction:
MYASTHENIA GRAVIS:
- autoimmune condition with antibodies to post synaptic acetylcholine receptors
- demographics (females 10-30yrs, males 50-70yrs)
- fluctuating, “waxing and waining”
- fatiguability - worsens throughout the day
- descending pattern (starts at the head)
- no loss of sensation
- no loss of reflexes or sphincter control
- ocular symptoms first (pupils are not affected)
- progress to bulbar symptoms, then limb and respiratory muscle weakness
- 2 F’s (fatigueability & fluctuating)
bulbar symptoms:
- drooling
- dysphagia
- dysphonia (vocal cord paralysis)
- dysarthria (difficulty articulating)
eye symptoms:
- ptosis
- diplopia
ED tests:
Upward gaze 30sec - causes fatigueability and worsens ptosis and diplopia
Ice pack test - cold temp inhibits acetylcholine esterase –> resolution of ptosis
Bloods - acetylcholine receptor antibodies
Tensilon test - IV endrophonium (acetylcholine esterase inhibitor) –> resolution of symptoms
Neurophysiology testing
Management:
Neurology consultation
Mild - Pyrostigmine 30mg po tds (anticholinesterase inhibitor)
Myasthenia crisis - plasma exchange, IV immunoglobulin, IV glucocorticoids
Facial Trauma Examination
HISTORY:
- How is your vision?
- Do any parts of your face feel numb?
- Does your bite feel normal?
INSPECTION:
Lateral view for dish face with Le Fort III fractures.
- proptosis with retrobulbar hematoma.
- Enophthalmos with blow-out fractures
- Flattening of malar prominence with zygomatic arch fractures.
Raccoon eyes (bilateral orbital ecchymosis)
Battle’s sign (mastoid ecchymosis)
PALPATION:
crepitus, tenderness, step deformities
Intraoral palpation of the zygomatic arch, palpating lateral to posterior maxillary molars to distinguish bony from soft tissue injury.
Assess for Le Fort fractures with mid-face instability
MOUTH:
- Jaw deviation
- malocclusion
- missing teeth
- gaps or step deformity between teeth
- gum and mucosal lacerations
Missing or injured tooth.
Lacerations and mucosal ecchymosis suggest mandible fracture.
Place finger in external ear while the patient gently opens and closes jaw to detect condyle fractures.
Tongue blade test: Patient without fracture can bite down on a tongue blade enough to break blade twisted by examiner.
EYES:
Visual acuity
Pupils - tear drop sign in globe rupture, RAPD
Hyphaema
Check IP with tanometre
NOSE:
Crepitus over any facial sinus suggests sinus fracture.
Nasal septal hematoma appears as blue, boggy swelling on nasal septum.
CSF leak.
EARS:
- Auricular hematoma.
- Hemotympanum.
- Cerebrospinal fluid leak.
Ataxia
2021.1 Examination station
Adult with unsteady GAIT (cerebellar dysfunction)
list differential diagnoses
perform the cerebellar neurological exam
outline investigations with explanation
Watch Geeky medics cerebellar exam video
DIFFERENTIAL DIAGNOSES:
- cerebellar stroke (ischemic or haemorrhagic)
- wernickes encephalopathy
- hydrocephalus
- parkinson’s disease
Toxins + altered mentation:
- acute alcohol intoxication
- sedatives (benzodiazepines)
Toxins but patient is alert:
- carbamazepine
- sodium valproate
- phenytoin
Metabolic:
- hyponatremia
- wernicke’s encephalopathy
EXAMINATION:
Level of alertness
Essential tremors
TRUNCAL ATAXIA:
- observe in sitting position
- do they sway or need help sitting upright
STANDING BALANCE:
- observe stance and balance
- feet together
GAIT ASSESSMENT:
- walk, turn around and walk back
- walk on heels and toes
? broad based GAIT
TANDEM GAIT ASSESSMENT:
ROMBERG’S TEST: proprioception rather than cerebellar function
CO-ORDINATION:
FINGER NOSE TEST:
?dysmetria
?intention tremor
past pointing in cerebellar disease
DYSDIADOCHOKINESIA
- impaired rapid alternating movements
REBOUND PHENOMENA
HEEL SHIN TEST:
?lower limb dysmetria
SPEECH:
- Ataxic dysarthria or slurred staccato speech
“baby hippopotamus”
NYSTAGMUS
- gaze provoked nystagmus
TONE:
- hypotonia in cerebellar disease
REFLEXES:
- hyporeflexia in cerebellar disease
Facial Palsy - unilateral facial paralysis
EM rapid bombs - ep 114
2023.2 Examination station
Generate a list of differential diagnoses
DIFFERENTIAL DIAGNOSES:
Vascular:
- pontine stroke
Infection:
- Suppurative Otitis Media
- Ramsay hunt syndrome (Varicella zoster reactivation)
- Bell’s palsy (HSV reactivation)
Neoplasm:
- Pontine mass
- parotid tumour
Autoimmune:
- Multiple sclerosis
Trauma:
- fracture of ispilateral temporal bone
- facial laceration
EXAMINATION:
Facial nerve examination:
Sparing of the forehead muscles is suggestive of a central (upper motor neuron) lesion
EAR EXAMINATION:
Painful vesicular eruption within the external auditory canal and vestibulocochlear dysfunction in Ramsay Hunt Syndrome
EXAMINE PAROTID GLAND:
CRANIAL NERVE EXAM:
Vertigo
2023.2 Examination station
Perform a focussed exam on a patient with vertigo
PERIPHERAL VERTIGO:
- Benign paroxysmal positional
vertigo - Vestibular neuritis
- Labyrinthitis
- Ménière’s disease
- Vestibular schwannoma
CENTRAL VERTIGO:
- Vestibular migraine
- Cerebellar/brainstem stroke
- Posterior circulation transient ischemic stroke.
- Cerebellar haemorrhage
IMAGING:
Non-contrast CT brain - intracranial haemorrhage
CT angiography arch cow - vertebral artery dissection
CT brain post contrast - cerebellar tumour
MRI - cerebellar ischemia
Examination video on HINTS PLUS exam plus others
Geeky medics osce station on HINTS PLUS
Joint Exam
2023.1 station
Perform a focused
clinical examination of a joint following an injury, provide appropriate differential diagnosis and detail further investigations and management.
Inspection
Palpation
movement (active/passive)
special tests
Upper Limb Neurology
2023.1
focused upper limb neurology
examination. They must provide a differential diagnosis and formulate an investigation and
management plan for the patient.
Candidates who performed well were able to have an understanding of the urgency of this presentation.
History and Examination - Stroke
2022.2 station
assessment and
examination of a patient who has presented with a suspected stroke.
rapid focused assessment:
- History
- Examination
Initial investigations and possible treatment options.
demonstrate knowledge of the attributes of patients who would be considered suitable for clot retrieval and thrombolysis.
NIH stroke
LEVEL OF CONSCISNESS:
1a) alert?
1b) whats the month? whats your age?
1c) can you close your eye? can you open your eyes? can you sqeeze my fingers?
GAZE ASSESSMENT:
- horizontal gaze only
VISUAL FIELDS ASSESSMENT:
- partial hemianopia scores 1
- unilateral hemianopia scores 2
- bilateral hemianopia scores 3
FACIAL NERVE ASSESSMENT:
- minor paralysis 1
- partial paralysis 2
- complete paralysis 3
MOTOR FUNCTION ARMS:
- lift arms to 90 degrees and hold for 10 seconds
MOTOR FUNCTION LEGS:
- lift leg to 30degrees and hold for 5 seconds
ATAXIA:
- finger nose test
- heel shin test
SENSATION (pin prick)
- face
- trunk
- arms
- legs
LANGUAGE
- describe what is happening in the picture
- name the items in the picture
- read from the list of sentences
DYSARTHRIA:
- read the tongue twisters
Neglect/inattention
Diplopia
2021.2 station
Examination of patient with 3 days of double vision and headaches
started with an outline of binocular vs monocular
Shoulder Exam
2021.1 station
physical examination of a patient with a history of shoulder pain.
Shoulder Examination
2023.2 station
Perform a focused examination of a patient postshoulder injury.
- neurological exam
- musculoskeletal exam
Missed diagnosis on previous assessment.
Use open disclosure principles to gain the trust of the patient or relative.
List different types of quality improvement activities and measures.
Develop an appropriate management plan.
- Modify the initial treatment plan in response to newly discovered clinical information.
- Create a safe and clear discharge plan for a patient.
Knee Injury
Ottawa Knee Rules:
*age >55
*patellar tenderness
*head of fibula tenderness
*unable to flex 90 degrees
*unable to weight bear immediately after injury and in ED
ACL injury:
*acceleration-deceleration injury
*associated segond fracture (avulsion fracture of lateral tibial plateau)
Anterior drawer test
Lachman’s test
Pivot shift test
Straight leg raise test holding the heel
Plan:
Analgesia - paracetamol, ibuprofen, prn oxycodone
Zimmer splint
Crutches
ROM exercises - to avoid quadriceps atrophy
Follow up in fracture clinic in 3-5 days
Outpatient surgical repair
Tibial plateau fracture:
