OSCE | Batch 2014

The estimated amount of glucose used by an adult human brain each day,
expressed in M&Ms: 250 Harpers Index
Keshi a Lourdes Duyongco
NOTE: Neurology will NOT be included in the Identification
Exam.
Case 1: The Teacher
Case 2: The Businessman
Case 3: The Brave Policeman
A 55 year-old high school teacher develops sudden
weakness of her left arm and leg, and over the next 30
mins, these limbs become even weaker.
When she looks at herself in the mirror, she finds that the
lower half of her face appears to sag, and with
vocalization, there is less movement on the lower left than
on the lower right side of her face.
Her medical records reveal the ff info:
BP: 140/90
FBS: 110 mg/dl
LDL: 120 mg/dl
Total cholesterol: 250 mg/dL
Question1: What is your interpretation of the data?
Stage 1 Hypertension
Diabetes mellitus
High LDL (desirable: <100 )
Hypercholesterolemia (desirable: <200 mg/dL)
When she is seen in the emergency room 1 hour later, she
has almost complete paralysis of the lower part of the left
side of her face and left arm and leg, with an
approximately equal degree of weakness in the face, arm,
and leg.
Question 2: Where is the lesion that is responsible for her symptoms?
(a) Right internal capsule
(b) Left internal capsule
(c) Upper brainstem
(d) Cerebral cortex
ANSWER: A
The most likely location is the right internal
capsule. This is because the corticobulbar
and corticospinal fibers innervating the
contralateral face, arm, and leg are close
together in this location.
These fibers are also close in the upper
brainstem but the patient has no clinical signs
suggesting brainstem disease.
The lesion is less likely to be in the cerebral
cortex because the representation of the
face, arm, and leg are distributed over a
very large region.
Corticospinal Tract
Aka: pyramidal tract
Origin:
1/3 Primary motor cortex (area 4)
1/3 premotor and supplementary motor
regions (area 6)
1/3 parietal/primary somatosensory area
(areas 3,1,2)
Passes through
Posterior limb of internal capsule
Decussation:
Medullary pyramids (90% of the
corticospinal fibers cross at this level and
descend through the spinal cord as the
lateral corticospinal tract) to innervate the
muscles in the distal parts of the extremities,
i.e. hands and feet
10% do not decussate and descend as the
ventral corticospinal tract
Corticobulbar Tract
Terminates in the brainstem to supply the motor nuclei of
the cranial nerves III, IV, V, VI, VII, IX, X, XI, XII
NOTE: cranial nerve motor nuclei receive innervation from both
cerebral hemisphere, and in most cases, the muscles they control
cannot be contracted voluntarily on one side only.
Both the lower facial nucleus, which innervates facial
musculature below the eye, and the hypoglossal nucleus
receive innervation from the opposite cerebral cortex that
is much heavier than the innervation from the ipsilateral
cortex.
Thus, these muscles can be controlled rather independently on the
two sides (try it! ), and a lesion of one cerebral hemisphere
results in weakness primarily on the contralateral side.
Nerve CN Function Type PEARLS
Olfactory I Smell S
Optic II Sight S
Oculomotor III Eye movt (SR, IR, MR, IO), pupillary
constriction, accommodation, eyelid opening
(levator palpebrae)
M
Trochlear IV Eye movt (SO) M
Trigeminal V Mastication, facial sensation (VI ophthalmic,
V2 maxillary, V3 mandibular)
B Jaw deviates toward
side of lesion
Abducens VI Eye movt (LR) M
Facial VII Facial movement, taster from anterior 2/3 of
tongure, lacrimation, salivation
(submandibular, sublingual glands), eyelid
closing (orbicularis oculi), stapedius muscle in
ear
B
Nerve CN Function Type PEARLS
Vestibulocochlear
VIII Hearing, balance S
Glossopharyngeal
IX Taste from posterior 1/3 of tongue,
salivation (parotid), carotid body and sinus
chemo- and baroreceptos, and
stylopharyngeus (elevates pharynx and
larynx)
B
Vagus
X Taste from epiglottic region, swallowing,
palate elevation, midline uvula, talking,
coughing, thoracoabdominal viscera, aortic
arch chemo- and baroreceptors
B Uvula deviates away
from side of lesion
Accessory
XI Head turning (SCM), shoulder shrugging
(trapezius)
M Weakness turning head to
contralateral side of
lesion (SCM), shoulder
droop on side of lesion
(trapezius)
Hypoglossal
XII Tongue movement M Tongue deviates toward
side of lesion
Question 3: Which artery supplies the involved area?
(a) Anterior cerebral artery
(b) Middle cerebral artery
(c) Deep branches of MCA
(d) Deep branches of ACA
ANSWER: C
The internal capsule is supplied
by the deep branches of the
middle cerebral artery.
Review of cortical distribution:
ACA (Anteromedial surface)
MCA (lateral surface)
PCA (posteroinferior surface)
Question 4: What has happened to Ms. S?
ANSWER:
Clinical evaluation led to the diagnosis of ischemic
infarction (stroke) because of cerebrovascular
disease resulting from diabetes mellitus and
hypertension. An MRI study verified the localization
and diagnosis.
She was treated with tissue plasminogen activator
in an attempt to dissolve the clot in vessels
perfusing the internal capsule.
A 55 year old man develops a feeling of stiffness and
clumsiness of his left hand, and when sitting still, he
observes a tremor involving the wrist and fingers of this
hand.
About the same time, he also begins to scuff his left foot on
the floor occasionally while walking.
About 1 year later, the tremor has become constant, and
he trips occasionally because of the misplacement of his
left foot.
What is the most likely diagnosis?
(a) Huntingtons disease
(b) Parkinsons disease
(c) Cerebellar disease
(d) Cerebral Palsy
ANSWER: B
The patient described has a movement
disorder resulting from disease in the
basal ganglia.
The history and findings are
characteristic of Parkinsons disease.
Patients develop bradykinesia, rigidity,
gait instability and tremors, usually
beginning on one side of the body, then
affecting the other. The lines of the face
become smooth and the expression
becomes fixed (masked-like facies)
The neurologist he consulted noticed that he has somewhat
an immobile face and that he blinks frequently.
Additional findings: A 4-6 cycle/second tremor of the left
wrist and fingers, mild rigidity on passive manipulation of
the left arm and left, and slowness of the finger movements
of both hands.
Characteristics Helpful Mnemonics
Parkinsons Disease Lewy bodies
Depigmentation of
substantia nigra pars
compacta (loss of
dopaminergic neurons)
TRAP = Tremor (at rest
eg pill-rolling tremor),
cogwheel Rigidity, Akinesia,
and Postural instability
Huntingtons Disease Autosomal dominant
trinucleotide repeat
disorder
Chorea, depression,
progressive dementia
Expansion of CAG.
Caudate loses Ach and
GABA.
Characteristics Mnemonics
Hemiballismus Sudden, wild flailing of 1 arm +/- leg
Contralateral subthalamic nucleus lesion
(e.g. lacunar stroke in pt with
hypertension)
Loss of inhibition of thalamus thru globus
pallidus
Half ballistic (as in throwing
a baseball)
Chorea Sudden, jerky, purposeless movement
Characteristic of basal ganglia lesion.
Chorea dancing (Greek)
Think choreography
Athetosis Slow, writhing movement
Characteristic of basal gangial lesion.
Athetos not fixed (Greek)
Think snakelike
Myoclonus Sudden, brief muscle contraction Jerks, hiccups
Dystonia Sustained, involunatry muscle
contractions
Writers cramp
TREMORS
Essential/postural tremor
action tremor (worsens when holding posture), autosomal
dominant.
Often self medicate with alcohol (decreases tremors)
Tx: Beta blockers
Resting tremor
Most noticeable distally
Parkisons disease (pill-rolling tremor)
Intention tremor
Slow, zigzag motion when pointing toward a target
Cerebellar dysfunction
APHASIAS
Higher-order inability to speak (vs. dysarthria: motor
inability to speak)
Brocas
Nonfluent aphasia with intact comprehension
(to remember: Brocas Broken Boca)
Brocas area: inferior frontal gyrus
Wernickes
Fluent aphasia with impaired comprehension
(to remember: Wernickes is Wordy but makes no sense!)
Wernickes area: superior temporal gyrus
Global
BOTH affected: Nonfluent aphasia with impaired comprehension
A gunman shoots a 25 year-old policeman in the abdomen
during an armed robbery. The policeman is quickly transported
to the hospital, where he is awake and alert.
PE shows moderate blood loss from wound but stable BP and
pulse
Neurologic exam:
Weakness of R leg with decreased DTR
No response to plantar stimulation of R foot
Loss of position sense and vibration sense in entire R leg
Loss of pain and temp sensation in L leg and L lower abdomen
X-ray:
Bullet lodged in lower thoracic spine
He is taken to surgery, where the abdominal wound is explored and the
bleeding is stopped. No major organ injury has been sustained, and no
attempt is made to remove the bullet.
Over the next several months, the patient recovers most of his strength in the
R leg, but it is stiff when he moves.
Examination 6 mos post-op reveals:
increased DTRs in the R leg
a right extensor plantar response
diminished position sense and vibration sense in the R leg
diminished pinprick sensation in the L leg and lower abdomen.
Question 1: What structures in this man spinal cord have
been damaged to cause the neurologic abnormalities?
Matching Type! (letters may be repeated)
1. Weakness of R leg with decreased
DTR
2. Loss of position sense and vibration
sense in entire R leg
3. Loss of pain and temp sensation in L
leg and L lower abdomen
(a) Right lateral column
(b) Right dorsal column
(c) Left lateral column
(d) Left dorsal column
ANSWER: A. Right Lateral Column
Right corticospinal tract
Note that a lesion caudal/distal to the
decussation causes signs on the ipsilateral side.
results in UMN signs (see next slide)
1. Weakness of R leg with decreased
DTR
2. Loss of position sense and vibration
sense in entire R leg
3. Loss of pain and temp sensation in L
leg and L lower abdomen
ANSWER: B. Right Dorsal Column
Loss of position sense, vibration sense, and
tactile discrimination on the ipsilateral side
below the level of injury.
Because of the paralysis, sensory ataxia,
which may otherwise occur, cannot be
demonstrated readily,
ANSWER: A. Right Lateral Column
Right lateral spinothalamic tract
Loss of pain and temp on contralateral side
beginning one or two dermatomes below the
level of injury
The policeman received an
injury to the right lateral part of
the lower thoracic spinal cord.
Question 2: Is this an UMN or a LMN lesion?
ANSWER: UMN
Motor neuron signs
Signs UMN LMN
Weakness + +
Atrophy - +
Fasciculation - +
Reflexes inc dec
Tone inc dec
Babinski + -
Spastic paralysis + -
Clasp knife spasticity + -
Mnemonics:
Lower MN = lowered
(less muscle mass, muscle
tone, reflexes,
downgoing toes/no
Babinski)
Upper MN = increased
tone, DTRs, toes
Question 2: What condition does the policeman have?
(a) Syringomyelia
(b) Amyotrophic lateral sclerosis
(c) Brown-Sequard Syndrome
ANSWER: C
Lateral hemisection of the spinal cord (e.g. From a bullet or knife wound)
Brown-Sequard. The specific effects in the patient with a chronic lesion can be
understood by considering the fiber tracts and roots affected by the lesion
discussed in the previous slide.
Syringomyelia damages the anterior white commissure of the spinothalamic tract
resulting in bilateral loss of pain and temp sensation.
ALS: both UMN and LM signs; no sensory deficits