Neurology Station

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Neurology Station

• Dr Polly Drew
• Dr Sarah Cleverly
• Dr Kat Wicks

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Possible stations

• Cranial nerve lesion
• Dysphasia or cognitive impairment
• Limb weakness
• Cerebellar ataxia
• Stable post-CVA

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Outline of Teaching session

• Presentations covering each relevant examination
  PNS, CNS, Speech, Cognitive state, cerebellar.
• Divide into three small groups
• Practice examination routine
• Discussion of possible questions you may be asked.

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Peripheral Nervous system
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Contents

• To succinctly examine the peripheral nervous
  system and present your findings to a consultant
  examiner in 6 minutes
• Discuss disease processes behind your clinical
  findings
• Pass the exam.

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Examiners instructions

• Please examine this patient for upper limb
  weakness.relate/dont relate you findings to me
  as you go.
• Please test the sensation in this patients upper
  limb.
• Please examine this patients for lower limb
  weakness.relate/dont relate your findings to me
  as you go.
• ETC

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Upper limb
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Introduction (IPEEP/WIPER)

• Wash hands
• Introduce yourself
• Ask Permission to examine
• Expose the patient legs/arms
• Explain what you are going to do
• Reposition
• Ask the patient if they have any pain

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Stand at the end of the bed STOP Look for a few
seconds Show you are looking around the
bed Walking aids Wheelchair Sugar free drinks?
Soles of shoes?
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LOOK

• Stand at the end of the bed
• Tremor
• Fasiculation
• Scars
• Muscle Wasting
• Deformity
• Cerebellar drift (catching raindrops)

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Tone

• Tests tone at the elbow and wrist in both arms by
  passively bending the joints in an unexpected and
  irregular fashion.
• Comments on supinator catch
• Cogwheel rigidity.

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Power

• Tests power at both shoulder joints.
• Tests power at the elbow joints in both arms.
  (biceps/triceps)
• Tests power at the wrist joint in both arms
• Tests power at the finger joints in both hands
  (radial, median, ulnar)
• Tests fine movement finger/thumb

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Reflexes

• Tests the biceps reflex.
• Tests the triceps reflex.
• Tests the supinator reflex.
• Tests co-ordination with a suitable test (eg.
  finger-nose test, testing for dysdiadochokinesis
  etc.).

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Sensation

• Tests superficial sensation in each dermatome on
  both limbs.
• Tests deep sensation in each dermatome on both
  limbs.
• Tests proprioception at a DIP joint in each hand,
  and successive joints working up the limb if any
  deficit is detected.
• Tests vibration sense at a DIP joint in each
  limb, and successive joints up the limb if any
  deficit is detected, using a 128Hz tuning fork.

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Then.

• Cover the patient up thank them
• Turn to the examiner and present your findings..

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Upper limb examination

• I examined this ladys peripheral nervous system
  of their upper limbs.
• On general inspection, she was comfortable and
  alert at rest and had a cushingoid appearance
  (moon facies, buffalo hump, central obesity,
  supraclavicular fat pads, thinned skin, striae)
• On closer inspection of her upper limbs, her left
  arm was held in a pyramidal flexed posture.
  There was no muscle wasting or fasciculations.
• Tone was increased on the left and normal on the
  right.
• There was pyramidal weakness on the left side
  (the extensor muscles were weaker than the flexor
  muscles) with power ranging from 3-4/5 on the MRC
  scale. Power was normal on the right.
• Reflexes were brisk on the right and normal on
  the left.
• Co-ordination of the left arm was difficult to
  assess because of the flexed posture of the left
  arm. There was no intention tremor or
  dysdiadokinesis on the right side.
• Sensation to light touch was difficult to assess
  but appeared to be impaired distally with a glove
  and stocking distribution. Proprioception was
  normal.
• My impression is one of an upper motor neurone
  lesion affecting the left limb.

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TO COMPLETE MY EXAMINATION..

• I would like to examine the sensation of this
  patients upper limbs
• Examine the lower limbs
• Perform a cranial nerve examination
• Depending on findings investigate for cause

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To complete my examination I would like to

• examine the other modalities of sensation
  including pin prick, vibration and temperature
• examine the peripheral nervous system of the
  lower limbs
• and examine the cranial nerves.

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Cognitive assessment

• 1.      It is especially important in this
  situation to explain why you are seeing the
  patient and what you are going to do. Try to put
  the patient at ease.
•  
• 2.    Ask a one or two general, open questions
  initially to gauge the patient's understanding
  and assessment of the problem.

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AMT

• Age
• Time to nearest hour
• An address
• Year
• Name of hospital
• Recognise 2 people
• DOB
• Year of WW1
• Present Monarch
• Count Back from 20

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MMSE (/30)

•  
• 5        Year, season, month, day, time
• 5        Country, county, city, building, floor
• 3        Register 3 objects
• 5        Spell WORLD backwards or serial 7s
• 3        Recall 3 objects
• 3        3 point command
• 1        Say no ifs, ands or buts
• 2 Name 2 objects
• Follows command from writing
• Writes a sentence
• Copies a drawing
•  

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