OSCE - neuro

• 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

• 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)

• 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

• jaw claudication
• diplopia
• beaded or enlarged temporal artery

• affect part of the brain
• simple type (awareness of events intact)
• complex type (diminished awareness)
• may progress to generalized

• affect whole brain
• diminished awareness of events

• 5 kinds:
• absence (phase out)
• myocolonic (mov'ts quick and jerking)
• tonic (stiff muscles)
• atonic ("drop")

• infection
• trauma
• metabolic abnormalities
• congenital abnormalities

• infections
• trauma
• stroke
• tumour

• infections
• trauma
• strokes
• tumours
• metabolic abnormalities

• LP
• absolute contraindication is sign of increased intracranial pressure

• neonates
• elderly

• H. influenzae is less than 4yo and unvaccinated
• N. meningitidis (meningococcus)

streptococcus pneumoniae (pneumococcus)

• pneumococcus
• listeria
• mycobacterium tuberculosis
• gram negative organisms
• cryptococcus neoformans

• acute infection of any kind
• acute encephalitis
• subarachnoid hemorrhage

TIA is a stroke syndrome w neuro symptoms lasting from a few minutes to as long as 24 hours followed by complete functional recovery

• surgically accessible internal carotid artery stenosis >70%
• symptomatic (TIAs, nondisabling stroke, retinal infarction)
• no worse artherosclerotic dz distally
• pt otherwise stable

• stroke +
• clinical evidence of cardiac dz by hx, PE, ECG or CXR

• cardiogenic - anticoagulants ~ warfarin
• artherosclerotic/lacunar/unknown - antiplatelet tx (ASA, clopidogrel)
• significant vessel stenosis - endarterectomy

• DM
• dyslipidemia
• HTN
• smoking

• 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)

the inability to control one's range of motion

defective voluntary muscle coordination

difficult or defective speech attributed to impairments of the tongue

constant involuntary cyclical mov'ts of the eyes

• hypotonia
• ataxia
• nystagmus
• dysmetria
• dysdiadochokinesia (inability to do rapid alternating mov'ts)
• normal sensory exam
• normal or reduced reflexes

• cerebellar hemorrhage or infarction
• trauma
• intoxication
• migraine

• alcoholic cerebellar degeneration
• hypothyroidism
• hydrocephalus
• chronic infection
• vitamin E deficiency
• paraneoplastic syndrome

• loss of taste
• frontal lobe damage
• trauma to cribriform plate

herniation causing opthalmic nerve compression

• temporal muscle wasting
• lateral jaw deviation to the side of the lesion

• 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

• 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

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

• 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)

• 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

cauda equina syndrome

• 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.

• 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

cerebellar dz

• enhanced physiologic tremor
• esential tremor

• parkinsonism
• midbrain tremor

• vitals: postural changes in bp and hr
• mental status: dementia, depression
• CN: masklike facies
• motor: bradykinesia, rigidity, cogwheeling

• vascular: complicated migraine
• metabolic: hypoglycemia
• idiopathic/iatrogenic: seizure (1' or 2'), syncope, myoclonus
• substance abuse/psych: pseudoseizure, hyperventilation, narcolepsy, panic attack, drug intoxication/withdrawal

• 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

• 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

• 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)

• extraocular movements - all positions of gaze (horizontal and vertical), ?double vision
• ?nystagmus on extremes of gaze
• ?smooth pursuit

• fixed, dilated pupil that is "down and out"
• may have ptosis

• unable to look down and in
• c/o difficulty walking downstairs

unable to look laterally w affected eye

• 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

• 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

• auditory acuity (whisper test)
• Weber's
• Rinne's

• 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

• shrug against resistance (trapezius)
• turn head against resistance (sternocleidomastoid)

• stick tongue out and move side to side (deviation to one side on attempted straight = ipsilateral lesion)
• inspect tongue - fasciculations/atrophy

present when the body part is at rest, disappears w activity

present when body part held in fixed posture

• present during mov't
• caused by cerebellar dz

• continues to swing after the tendon is struck
• cerebellar sign

S1,2

L2, 4

C5, 6

C5, 6

C7

• 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

UMN increased, upgoing plantar, see posturing

UMN - weak or absent in a group of muscles, pronator drift

LMN - weak or absent focally, fasciculations

UMN - increased, rigidity, spasticity

LMN - decreased, flaccidity

LMN will have pronounced focal atrophy

UMN may not change