Neurology For Finals

Dr. Louise Chesshire & Dr. David Harding 14th February 2013

Aims and Objectives

Neuro OSCE stations Feedback and theory Common neurological diseases Practical neurology for an FY1 Previous Leeds OSCE stations Slide show!!! Some useful reference slides

OSCE STATION 1

Volunteer Please!

1st OSCE station

This 55 year old gentleman has presented to the GP with trouble walking. Please perform a focused neurological examination. This is an 8 minute station. The examiner will stop you after 7 minutes for questions.

Questions
What are your differentials for this patient? What drugs can cause parkinsonism?

Parkinsons Disease
Triad - Resting tremor, bradykinesia and rigidity Face - Mask like, expressionless, little blinking, glabellar tap Gait - Flexed posture, reduced arm swing, festinant, slow to initiate and stop movement Tone increased. Cog wheel/ lead pipe rigidity Tremor- pill rolling Speech extrapyramidal dysarthria (slow, quiet and hesitant ) Micrographia

This is how its done.

OSCE STATION 2

Volunteer Please!

2nd OSCE exam

You are asked to see Gladys, a 75 year old lady who has presented to A+E with a history of difficulty speaking. Please take a focused history. The examiner will stop you after 7 minutes for questions.

BP: 160/95 HR 90 RR: 17 SpO2: 97% RA

PMH: COPD, HPTN, Diabetes.

Questions
What scoring systems are available for assessing risk of stroke after a TIA? What is this ladys score? What is your management plan?

What advice would you give her about driving?

ABCD2 score

Common neurological diseases

Parkinsons Stroke MS Peripheral neuropathy (diabetic). Horners Faical nerve palsy

MS
Two or more episodes of CNS lesions disseminated in time and space. Optic Neuropathy frosted glass/shattered window. Spinal cord lesion spastic paraparesis in limbs. Brainstem demyelination diplopia, vertigo, dyarthria, dysphagia.

MS

Polyneuropathy
Tingling/numbness/burning. Progressive weakness and clumsiness. Loss of tendon reflexes in lower limb. Charcot joint.

Causes of polyneuropathy
A Alcohol B B12 deficiency C carcinoma/chronic renal failure D DIABETES

Guillan Barre, hepatic failure, infection, charcot-marie tooth syndrome.

Neurology as an FY1
What symptoms would prompt you to do a neurological examination? Case study 1 You are bleeped to see a 35 year old female with palliative cholangiocarcinoma c/o sudden onset worst headache ever. HR 140, BP 130/90. RR 35 and she is screaming out help me!. Differentials?

Neurology as an FY1
Case study 2 You are on MAU and are asked to see a 21 year old chap with acute onset dizziness and nausea and generally feeling unwell. Differentials?

Previous Leeds Neuro OSCES

Examine cranial nerves III, IV, VI. Perform fundoscopy to identify words. PNS exam: peripheral neuropathy eg diabetes. Video of Parkinsonism questions about signs Epilepsy counselling

Slide Show
Pens at the ready 40 seconds per slide. 7 slides.

Question 1
What nerve is affected? How is it commonly injured?

Question 2
Alicia is a 25 year old lady who presents with foot drop, wasting of the muscles in the lower leg and decreased sensation in feet, ankles and her legs. What sign is shown? What is the diagnosis?

Question 3
What nerve is affected? What may be causing this?

Question 4
What does this show? Name one common cause.

Question 5
What is the name of this condition? What nerve is affected?

Question 6
What is shown here? Name 2 features demonstrated.

Question 7
Where is the lesion and what is the type of vision called? A) B)

Question 1
What nerve is affected? How is it commonly injured?

Question 2
Alicia is a 25 year old lady who presents with foot drop, wasting of the muscles in the lower leg and decreased sensation in feet, ankles and her legs. What sign is shown? What is the diagnosis?

Question 3
What nerve is affected? What may be causing this?

Question 4
What does this show? Name one common cause.

Question 5
What is the name of this condition? What nerve is affected?

Question 6
What is shown here? Name 2 features demonstrated.

Diabetic Retinopathy
Background Diabetic Retinopathy
Microaneurysms, dot and blot haemorrages, hard exudates

Maculopathy
Accumulation of haemorrhages and hard exudate around the macula often accompanied by decreasing visual acuity

Pre-proliferative Diabetic Retinopathy

Exacerbation of above plus cotton wool spots

Proliferative Diabetic Retinopathy

New vessel formation (near disc and ischaemic areas)

Hypertensive Retinopathy
I generalised arterial narrowing, altered light reflex, increased tortuosity II AV nipping, regions of focal narrowing, III flame and splinter haemorrhages, cotton wool spots (due to retinal oedema), hard exudates IV - papilloedema

Question 7
Where is the lesion and what is the type of vision called? A) B)

Any questions?
GOOD LUCK!

If we can do it, so can you.

OSCE - PNS

OSCE - PNS
Power grading (Medical Research Council Scale) 0 No movement 1 Flicker of movement 2 Movement but not against gravity 3 Movement against gravity but not resistance 4 Weak movement against resistance 5 Normal

OSCE - Cerebellar Signs

Dysdiadochokinesia Ataxia Nystagmus Intention Tremor Speech Hypotonia

PAST pointing Rebound Wide-based gait