Neurology - limbs

1. Neurology - limbs PULSE: Preparation for Finals Tutor name

2. TuBS attendance • https://tutorialbooking.com/

3. Session overview • Common neurological conditions for the OSCE • How to present your findings • Overview of clinical signs • Case presentations and viva questions

4. What is the purpose of an OSCE? “This station tests a student’s ability to perform an appropriate focussed physical examination, demonstrating consideration for the patient, and to report back succinctly describing the relevant findings. It also tests a student’s clinical judgement i.e. the ability to decide the differential diagnosis, choose investigations and formulate a management plan.”

5. Common neurological conditions in the OSCE • Various patterns of weakness or sensory loss

6. Presenting your findings • What were you asked to do? • What were your key positive findings? • What were the important negative findings? • What does this mean? • How would you complete your examination, and what investigations would you do?

7. Example case presentation • 70 year old gentleman, looks well • Asked to look at face and do neurological examination of upper limbs • General observations – walking stick beside bed • Face – right side facial droop • Left arm – intact power, sensation and reflexes • Right arm – hypertonia, power 3/5, sensation impaired over all dermatomes, reflexes brisk • Unable to do up buttons or hold a pen with the right hand Please present your findings.

8. Case 1

9. 65 Year old male, Comfortable at rest. Flexed L arm with extended legs Walking stick by bedside

10. Case 1 - arms • Increased tone in left arm, normal on right • Power 3/5 throughout left arm, normal right • Hyperreflexic left arm, normal right • Coordination • Normal on right • Difficult to assess on left due to weakness • Light touch sensation and proprioception reduced on left arm

11. Case 1 - legs • Increased tone on left, 4 beats of ankle clonus • Power – 4+/5 in extensors, 3-4- in flexors • Brisk reflexes, left>right • Coordination normal on right, left difficult to assess • Sensation is grossly normal, especially peripherally • Left extensor plantar, right normal Please present your findings.

12. To complete my examination… • Full cranial nerve examination (homonymous hemianopia, visual defects) • Assessment of higher cognitive function – speech (dominant hemisphere) and sensory inattention (non-dominant hemisphere) • Cardiovascular examination – including BP, Carotid bruits and murmurs, AF, • Cardiovascular history - modifiable risk factors

13. Differential Diagnoses • Vascular – ischaemia, infarction, embolism, heamorrhage • SOL – malignancy, abcess, hydrocephalus • Inflammatory – MS, Consider the age of the patient when ranking these.

14. Case 2

15. Case 2 -

16. Case 2 - feet

17. Case 2 - lower limb • Tone – normal • Power – reduced ankle dors/plantar, normal at hip and ?knee • Coordination – jerky, uncoordinated • Reflexes – Knee reduced, ankle absent • Sensation – decreased to light touch to mid shin; decreased propriception to ankle • Walk – stomping, broad-based

18. What are the causes of a peripheral neuropathy? Physical trauma • Compression • Pinching • Cutting • Projectile injuries • Strokes including prolonged occlusion of blood flow Others • Shingles • Malignant disease • HIV • Radiation • Chemotherapy Genetic • Charcot-Marie-Tooth syndrome • Friedrich’s ataxia Metabolic/endocrine • DM • Chronic renal failure • Porphyria • Amyloidosis • Liver failure • Hypothyroidism Inflammatory disease • Guillain-Barré syndrome • SLE • Leprosy • Sjogren’s Toxic Alcohol Drugs • Fluoroquinolones • Vincristin • Phenytoin • Nitrofurantoin • Isoniazid Organic metals Heavy metals Excess Vit B6 (pyridoxine) Vit deficiency • B12 • A • E • B1 Most common causes: DM Alcohol Vitamin deficiency

19. Case 3

20. Case 3 - upper limbs • Normal

21. Case 3 - lower limbs • Increased tone and reflexes on right, normal on left • Decreased power on right throughout • Decreased vibration and proprioception on right, normal on left • Decreased pain sensation on left, normal on right • Hyperaesthesia on right, at level of umbilicus • Light touch sensation grossly normal

22. Brown-Sequard Syndrome Causes • Degenerative disease of the spine • Syringomyelia • Cord tumour • Haematomyelia • MS • Angioma • Trauma, e.g. bullet or stab wounds • Myelitis • Post-radiation myelopathy • Motor changes • Ipsilateral UMN signs below the hemisection (corticospinal tract) • LMN signs at the level of hemisection on the same side • Sensory changes • Contralateral pain and temperature loss (upper level of sensory loss usually a few segments below the level of the lesion) spinothalamic tract • Ipsilateral vibration and proprioception loss (dorsal column) • In segment of lesion – ipsilateral anaesthesia and zone of hyperaesthesia

23. Case 4

24. Case 4 - limbs O/E Lower limbs • Increased tone and brisk reflexes • Upgoingplantars bilaterally Upper limbs • Decreased pin-prick in hands • Atrophy and weakness of hand muscles Please present your findings.

25. O/E Lower limbs • Increased tone and brisk reflexes • Upgoingplantars bilaterally Upper limbs • Decreased pin-prick in hands • Atrophy and weakness of hand muscles Diagnosis… Cervical Myelopathy

26. Case 5

27. O/E Lower Limbs • Pinprick & soft touch reduced to knee, symmetrically • Vibration sense reduced to ASIS • Ankle jerks absent (S1, 2) • Plantarsdowngoing • Gait unsteady but fairly narrow based • Difficult tandem walking • Romberg’s positive (sensory ataxia) Upper Limbs Pinprick & soft touch reduced to wrist, symmetrically Vibration sense Normal Reflexes intact

28. Localise the Lesion • Peripheral Neuropathy • ‘Glove and Stocking’ • Likely cause: EtOH XS (+/- B1 deficiency) • Particular causative diseases have predilection for specific nerves or fibre types and for certain components of the nerve course… • Mononeuropathy (tend to be unilateral) – CTS, CPNP • Mononeuritis multiplex – vasculitis, diabetes • Polyneuropathy (diffuse, symmetrical fashion)… • Autonomic neuropathy – diabetes, amyloidosis, GBS

29. Peripheral Neuropathy Aetiology • Inflammatory – GuillainBarré Syndrome, CIDP, RA, SLE, vasculitis • Infective - Leprosy • Toxic – EtOH (+ thiamine deficiency), Drugs (chemo) • Metabolic – Diabetes, Hypothyroid, CKD • Idiopathic (one third of cases cause unknown) • Neoplastic – paraneoplastic, MGUS, myeloma • Deficiency – vitamins B12, B1, B6 • Genetic – HSMN (Charcot-Marie Tooth), Friedrich’s Ataxia Tests Bloods to Ix cause ?Lumbar puncture (GBS/CIDP) Nerve conduction studies Treatment Neuropathic analgesia, Mx underlying cause

30. Case 6

31. Case 6 - limbs O/E • Large sore tongue Lower limbs • Spastic paresis • Romberg positive, wide based gait • Bilateral Babinski sign • Loss of sensation in a stocking distribution • Absent ankle reflexes Please present your diagnosis. Subacute Combined Degeneration of Spinal Cord

32. Case 7

33. Case 7 - limbs O/E Lower limb Paraplegia, with bilateral Babinski sign Bilateral loss of pain and temp Normal JPS and vibration Please present your findings. Anterior Spinal Artery Syndrome

34. ASA Syndrome Infarction of anterior spinal artery Aetiology Aortic insufficiency Vasculitis Trauma/Neoplasia Ischaemia • Complete motor paralysis • Loss of pain and temp (STT) • Bladder & Bowel dysfunction • Dorsal columns intact

35. Case 8

36. Case 8 - neurology O/E • Left ptosis • Diplopia on left and right gazes • Left eye doesn’t fully elevate • Mild facial weakness • Weakness of neck extension • Proximal muscle weakness (MRC 4-) Please present your findings. Myasthenia Gravis

37. Case 9

38. Case 9 - limbs O/E • Flaccid paralysis in arms and legs • Widespread areflexia • Absent sensation in arms and legs • Evidence of sacral sparing – voluntary anal sphincter contraction • Hypotension Please present your findings. Spinal Shock

39. Session overview • Common neurological conditions for the OSCE • How to present your findings • Overview of clinical signs • Case presentations and viva questions

40. Please complete TuBS feedback • Tutor details • For more information on Examining for Finals sessions: • examiningforfinals@gmail.com • www.sefce.net/pulse • Resource updated 2017: Dr A Swan • With thanks to previous contributors: • Dr Emma Claire Phillips • Dr Kristina Lee • Dr Russell Hewett (Neurology Consultant)