OSCE - neuro

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OSCE - neuro
2011-01-10 12:14:06
neurology osce

from osce and clinical handbook
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  1. DDx of headache
    • migraine
    • cluster h/as
    • tension h/as
    • meningitis
    • subarachnoid/subdural/epidural hemorrhage
    • temporal arteritis
    • tumour
    • abscess
    • disease of ears/eyes/nose/sinuses/teeth/jaw/temporal mandibular joint or spine
  2. criteria for dx migraines w/o aura
    • minimum of 5 attacks
    • duration is 2-72 h (with or w/o tx)
    • 2 of the following present: unilateral pain, pulsing or throbbing quality, moderate - severe affecting ADLs, pain provoked by routine physical activity
    • one or more present of: n/v/photophobia/phonophobia/ osmophobia
    • no evidence of other causes of h/a

    (with aura = above + neuro dysfunction b/f or during attack)
  3. 6 red flag features of h/a
    • worst h/a of pt's life (esp. if rapid onset)
    • exacerbation of h/a w coughing, sneezing or bending down
    • h/a w seizures, reduced LoC, confusion, focal neuro findings
    • new or progressive h/a persisting for days
    • new-onset h/a in middle age or older
    • change in frequency, severity or clinical features of the usual h/a pattern
    • presence of systemic symptoms including fever, myalgia, malaise, wt loss, scalp tenderness or jaw claudication
  4. signs and symptoms that point to temporal arteritis
    • jaw claudication
    • diplopia
    • beaded or enlarged temporal artery
  5. describe partial seizures
    • affect part of the brain
    • simple type (awareness of events intact)
    • complex type (diminished awareness)
    • may progress to generalized
  6. describe generalized seizures
    • affect whole brain
    • diminished awareness of events

    • 5 kinds:
    • absence (phase out)
    • myocolonic (mov'ts quick and jerking)
    • tonic (stiff muscles)
    • atonic ("drop")
  7. causes of seizures in children
    • infection
    • trauma
    • metabolic abnormalities
    • congenital abnormalities
  8. causes of seizures in adults
    • infections
    • trauma
    • stroke
    • tumour
  9. causes of seizures in elderly
    • infections
    • trauma
    • strokes
    • tumours
    • metabolic abnormalities
  10. key test to dx bacterial meningitis and contraindications for the test:
    • LP
    • absolute contraindication is sign of increased intracranial pressure
  11. what subgroups of pts may not manifest many of the classical S&S of bacterial meningitis?
    • neonates
    • elderly
  12. most common bacterial etiological agents in children with meningitis
    • H. influenzae is less than 4yo and unvaccinated
    • N. meningitidis (meningococcus)
  13. most common bacteria causing meningitis in adults
    streptococcus pneumoniae (pneumococcus)
  14. most common bacteria causing meningitis in elderly/immunocomopromized
    • pneumococcus
    • listeria
    • mycobacterium tuberculosis
    • gram negative organisms
    • cryptococcus neoformans
  15. DDx of meningitis
    • acute infection of any kind
    • acute encephalitis
    • subarachnoid hemorrhage
  16. what is a TIA
    TIA is a stroke syndrome w neuro symptoms lasting from a few minutes to as long as 24 hours followed by complete functional recovery
  17. indications for carotid endarterectomy in stroke pts
    • surgically accessible internal carotid artery stenosis >70%
    • symptomatic (TIAs, nondisabling stroke, retinal infarction)
    • no worse artherosclerotic dz distally
    • pt otherwise stable
  18. indications for echo in stroke pts
    • stroke +
    • clinical evidence of cardiac dz by hx, PE, ECG or CXR
  19. describe 3 sources of strokes and their corresponding tx
    • cardiogenic - anticoagulants ~ warfarin
    • artherosclerotic/lacunar/unknown - antiplatelet tx (ASA, clopidogrel)
    • significant vessel stenosis - endarterectomy
  20. list manageable risk factors for strokes
    • DM
    • dyslipidemia
    • HTN
    • smoking
  21. list some causes of cerebellar lesions
    • infectious (viral, prion)
    • metabolic (hepatic encephalopathy, hypothyroidism, B12 deficiency, thiamine deficiency, hyperthermia)
    • cardiovascular (anoxia, infarction, hemorrhage)
    • genetic (Friedreich's ataxia, ataxia telangiectasia, Ramsay-Hunt dz)
  22. define dysmetria
    the inability to control one's range of motion
  23. define ataxia
    defective voluntary muscle coordination
  24. define dysarthria
    difficult or defective speech attributed to impairments of the tongue
  25. define nystagmus
    constant involuntary cyclical mov'ts of the eyes
  26. describe the physical findings expected in a pt with a cerebellar stroke
    • hypotonia
    • ataxia
    • nystagmus
    • dysmetria
    • dysdiadochokinesia (inability to do rapid alternating mov'ts)
    • normal sensory exam
    • normal or reduced reflexes
  27. list acute causes of ataxia
    • cerebellar hemorrhage or infarction
    • trauma
    • intoxication
    • migraine
  28. list chronic causes of ataxia
    • alcoholic cerebellar degeneration
    • hypothyroidism
    • hydrocephalus
    • chronic infection
    • vitamin E deficiency
    • paraneoplastic syndrome
  29. identify 3 conditions when we MUST test for CNI (olfactory)
    • loss of taste
    • frontal lobe damage
    • trauma to cribriform plate
  30. what does a unilateral pupillary dilation indicate
    herniation causing opthalmic nerve compression
  31. when inspecting the face during a trigeminal nerve exam, what are you looking for?/
    • temporal muscle wasting
    • lateral jaw deviation to the side of the lesion
  32. Describe Bell's palsy (esp. vs. stroke in motor complex)
    • facial nerve CN VII
    • facial paralysis on same side of lesion
    • lower motor neuron lesion so forehead also affected
    • (stroke, upper motor neuron - spares forehead involvement)
    • i.e. to differentiate, ask pt to raise eyebrows, if one side is flat, other wrinkled, it's bell's
  33. DDx for ringing in ears
    • Vascular: arteriovenous malformation, bruits, HTN
    • Infectious: suppurative infection of middle ear or labyrinth
    • Trauma: FB in external canal, head injury
    • Metabolic: anemia, drugs (quinine, salicylates, aminoglycosides, loop diuretics)
    • Idiopathic/Iatrogenic: TMJ dz, hearing loss, meniere's dz
    • Neoplastic: polyp in external canal, acoustic neuroma (unilateral)
    • Substance abuse/Psych: psychogenic
  34. Describe Weber's vs. Rinne's test
    weber's: tuning fork placed equidistance from ears - lateralization means ipsilateral conductive hearing loss or contralateral sensorineural losses

    • rinne's test: tuning fork placed on mastoid process until sound no longer heard then moved to end of auditory canal - done in conjunction with Weber's
    • conductive hearing loss: bone conduction > air conduction
    • Sensorineural hearing loss: air > bone
  35. DDx for unilateral weakness
    • Vascular: stroke (sudden onset), migraine
    • Infectious: CNS abscess
    • Trauma: epidural hematoma, subdural hematoma (gradual onset)
    • Autoimmune/Allergic: MS
    • Idiopathic/Iatrogenic: seizure
    • Neoplastic: CNS tumour (gradual onset, progressive)
  36. DDx for lower back pain
    • Vascular: spinal infarct, spinal hemorrhage, AAA, aortic dissection
    • Infectious: Osteomyelitis, spinal abscess, viral myalgia, UTI, pyelonephritis
    • Trauma: disk herniation, vertebral fracture, osteoarthritis, muscle/ligament strain
    • Autoimmune/Allergic: RA, ank spon
    • Metabolic: Paget's, osteomalacia, osteoporosis
    • Idiopathic/Iatrogenic: pancreatitis, renal stone
    • Neoplastic: metastatic or primary
    • Psychiatric
    • Congenital: spina bifida, spondylolysis
  37. What you need to rule out with all back pain
    cauda equina syndrome
  38. Special MSK tests for low back pain (radicular pain from L5/S1)
    • 1. straight leg raising - pt supine, legs extended. Symptomatic leg passively raised off the bed (knee extended). Positive if pain is worse in affected leg at hip flexion <60 to 90
    • 2. bowstring sign: passively raise pt's symptomatic leg off the bed w knee in slight flexion until just below threshold for radiular pain. Positive if pain elicited through firm compression on popliteal fossa (pain from knee to back)
    • 3. lasegue's sign: passively raise pt's symptomatic leg off be with knee in slight flexion just below threshold of radicular pain. Positive if passive dorsiflexion of ankle worsens pain.
  39. DDx for tremor
    • trauma: PTSD
    • Metabolic: hyperthyroidism, hypoglycemia, Wilson's dxz, metabolic encephalopathy (asterixis)
    • idiopathic/iatrogenic: benign essential tremor, cerebellar dz, parkinson's, myoclonus
    • substance abuse and psych: etoh withdrawal, caffeine withdrawal, drug intoxication, dystonic tremor, psychogenic
    • congenital/genetic: huntington's
  40. intention tremor associated with:
    cerebellar dz
  41. postural tremor classified as
    • enhanced physiologic tremor
    • esential tremor
  42. resting tremor associated with
    • parkinsonism
    • midbrain tremor
  43. name some associated features of parkinsonism
    • vitals: postural changes in bp and hr
    • mental status: dementia, depression
    • CN: masklike facies
    • motor: bradykinesia, rigidity, cogwheeling
  44. DDx for 'repetitive jerks'
    • vascular: complicated migraine
    • metabolic: hypoglycemia
    • idiopathic/iatrogenic: seizure (1' or 2'), syncope, myoclonus
    • substance abuse/psych: pseudoseizure, hyperventilation, narcolepsy, panic attack, drug intoxication/withdrawal
  45. DDx for Dizziness
    • Vascular: stroke, postural hypotension, vasovagal, cardiac arrhythmia
    • Infection: meningitis, labyrinthitis/vestibular neuropathy, cerebellitis
    • trauma: to the head
    • autoimmune: MS
    • metabolic: hypoglycemia, Rx (antibiotics, anticonvulsants, antidepressants)
    • idiopathic/iatrogenic: BPPV, meniere's dz, migraine
    • neoplastic: primary or metastatic
    • psych
  46. DDx for decreased LoC
    • Vascular: intracranial hemorrhage, infarction
    • Infection: meningitis, encephalitis, abscess
    • trauma: to the head
    • metabolic: electrolyte abnormality, hyperthyroidism, uremia, drugs (EtOH, cocaine....)
    • idiopathic: seizure, syncope, catatonia
    • neoplastic: 1' or metastasis
  47. how do we test CNII
    optic nerve
    • each eye separately - Snellen eye chart
    • assess colour vision
    • visual fiels - test each eye separately
    • pupillary response w swinging flashlight and accomodation
    • fundoscopy (red reflex, note optic disc, retinal vessels, retina, papilledema)
  48. how do we test CN III, IV, VI
    oculomotor, trochlear, abducens
    • extraocular movements - all positions of gaze (horizontal and vertical), ?double vision
    • ?nystagmus on extremes of gaze
    • ?smooth pursuit
  49. CN III palsy looks like...
    • fixed, dilated pupil that is "down and out"
    • may have ptosis
  50. CNIV palsy looks like...
    • unable to look down and in
    • c/o difficulty walking downstairs
  51. CN VI palsy looks like...
    unable to look laterally w affected eye
  52. how do we test CN V?
    trigeminal nerve
    • Motor:
    • inspect for temporal wasting and jaw deviation
    • clench teeth while palpating
    • open mouth against resistance

    • sensory:
    • light touch (V1 forehead, V2 medial aspect of cheek, V3 chin)
    • pain
    • corneal reflex
  53. how do we test CN VII
    facial nerve
    • motor:
    • inspect nasolabial folds for flattening, drooping of mouth
    • ask pt to raise eyebrows (frontalis), close eyes tightly (orbicularis oculi), show teeth (buccinator), puff out cheeks (orbiularis oris), tense neck muscles (platysma)

    • sensory:
    • test tast on anterior 2/3 of tongue with sugar, salt and vinegar
  54. how do we test CN VIII
    • auditory acuity (whisper test)
    • Weber's
    • Rinne's
  55. how do we test for CN IX, X
    glossopharyngeal, vagus
    • palate elevation (lesion ipsilateral to side of palate which doesn't elevate)
    • gag reflex
    • swallowing
    • dysarthria (abnormal speech)
    • test taste on posterior 1/3 of tongue using sugar, salt, vinegar
  56. how do we test CN XI
    accessory spinal nerve
    • shrug against resistance (trapezius)
    • turn head against resistance (sternocleidomastoid)
  57. how do we test CN XII
    Hypoglossal nerve
    • stick tongue out and move side to side (deviation to one side on attempted straight = ipsilateral lesion)
    • inspect tongue - fasciculations/atrophy
  58. define a resting tremor
    present when the body part is at rest, disappears w activity
  59. define postural tremor
    present when body part held in fixed posture
  60. define intention tremor
    • present during mov't
    • caused by cerebellar dz
  61. define a pendular reflex
    • continues to swing after the tendon is struck
    • cerebellar sign
  62. achilles reflex tests
  63. patellar reflex tests
    L2, 4
  64. brachioradialis reflex tests
    C5, 6
  65. Biceps reflex tests
    C5, 6
  66. Triceps reflex tests
  67. Describe some primitive reflexes
    (i.e. signs of frontal release)
    • 1. glabellar tap (tap finger midline b/w eyes, positive if blink persists past 3 or 4 taps)
    • 2. snout, suc, root: tap side of pt's mouth or upper lip, positive if lip quiver
    • 3. palmomental reflex: scraping hypothenar eminence, positive if ipsilateral contraction of mentalis muscle
    • 4. Grasp-place: place 2 fingers in pt's palm, + if involuntary grasp
  68. UMN lesion vs. LMN lesion
    UMN increased, upgoing plantar, see posturing
  69. UMN lesion vs. LMN lesion
    motor power
    UMN - weak or absent in a group of muscles, pronator drift

    LMN - weak or absent focally, fasciculations
  70. UMN lesion vs. LMN lesion
    motor tone
    UMN - increased, rigidity, spasticity

    LMN - decreased, flaccidity
  71. UMN lesion vs. LMN lesion
    motor bulk
    LMN will have pronounced focal atrophy

    UMN may not change