Neuro LOCAS teaching

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Neuro LOCAS teaching

• By Richard Ellis

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First things first

• DONT PANIC!

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Aims
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What cases can you expect?

• Strokes/TIA
• Multiple Sclerosis
• Guillian Barre Syndrome
• Cranial nerves
• Headaches
• Parkinsons Disease
• Epilepsy
• Motor Neurone Disease
• Cerebral Palsy
• Muscular dystrophy
• Mononeuritis Multiplex!

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Signs - Oculomotor palsy

• Partial ptosis (not complete as joint sympathetic
  supply)
• Down and out eye!
• Dilated pupil
• Seen in DM (pupil spared), PCA aneurysm, ?ICP

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Signs - Horners syndrome

• Slight ptosis, Miosis, Anhydrosis, Enophthalmos
• Caused by disruption to the sympathetic chain at
  the superior cervical ganglion

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Signs - Facial nerve palsy

• Weakness of facial muscles
• Unable to close eye (Bells sign)
• Forehead will show if UMN or LMN

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Facial nerve -UMN or LMN
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Signs - Parkinsonian posturing
Head off pillow truncal rigidity
Gun-slinger posture
If you suspect Parkinsons ask about - Trouble
getting in/out of car bed
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Internuclear Ophthalmoplegia

• Pathomnoic for multiple sclerosis
• Failure of adduction on side of lesion
• Seen when testing conjugate gaze as the medial
  longitudinal bundle between CN III VI nucleus
  is damaged
• Nystagmus is usually seen on the opposite side

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How to look slick from the moment you walk in!
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How to look slick in 5 simple steps

• Introduction
• Consent
• Explanation - talk through each step of what
  youre going to do. It makes you look like you
  know what youre doing as well as reminding you!
• Recheck consent - Sometimes the examiner doesnt
  listen the first time
• Exposure

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Follow this structure and go far

• Inspection
• Arms outstreched
• Tone
• Power
• Reflex
• Sensation (Light-touch --gt Pin-prick --gt
  vibration --gt proprioception)
• Co-ordination
• Gait if lower limb

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Inspection

• The usual cliché Its like your driving test,
  make everything obvious.
• Start by looking round the bed and noting any
  splints, walking aids, wheelchairs etc
• Examine pt for wasting, fasciculations, posture
  and

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Scars, steroids and Scally Jewellery
Check the back as well!
Finally say as you havent seen the patient walk
in, so you cant comment on the patients gait!
Mention that you can come back to it if required!
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The Examination

• Chances are youll only be asked to examine one
  part of the neuro system, so upper limb motor,
  power and tone, or lower limb sensory. But be
  prepared to do motor and sensory on one set of
  limbs.
• Cranial nerves are usually the same I.e examine
  the eyes (CN II,III,IV VI). Check for a
  bulbar/psuedobulbar palsy is a bit harsh!

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Final Warning!

• FINALLY dont forget to ask the patient if it
  hurts anywhere before you lay a finger on them!
• Or the patient will shout at you, the examiner
  will shout at you etc etc

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So youve inspected

• Next impress the examiner
• Ask the patient to pull their hands out in front
  of them and close their eyes. It can show
• Weakness (even relatively mild)
• Ataxia
• Loss of proprioception

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So youve inspected

• Next impress the examiner
• Ask the patient to pull their hands out in front
  of them and close their eyes. It can show
• Weakness (even relatively mild)
• Ataxia
• Loss of proprioception

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Tone

• In upper limbs hold hand as if to shake it, other
  on elbow, flex and quickly extend looking for any
  give or leadpipe rigidity, then pronate and
  supinate quickly feeling for supinator catch
  (sign of spasticity) and roll the wrist for
  cogwheeling
• In lower limbs roll the legs or pull upwards
  under the knee, the foot should drag along the
  bed, in spascity whole leg will raise.

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Power

• This isnt a musculoskeletal exam so you can get
  away with one movement to each nerve root.
• Upper limbs C5-T1, ulnar median (radial checked
  with C7)
• Lower limbs L2 - S1

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1, 2, 3, 4

• Easy way to remember which reflexes correspond to
  which nerve roots
• Ankle 1-2 (S)
• Knee 3-4 (S)
• Biceps Supinator 5-6 (C)
• Triceps 7-8 (C)
• Plantar reflex to finish
• Dont forget to reinforce if no reflex!

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Sensation

• Know youre dermatones!
• This is what it feels like, close your eyes
• Light-touch
• Pinprick
• Vibration
• Proprioception
• DONE!

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Co-ordination

• Upper limbs
• Finger nose - past pointing, intention tremor
• Dysdiadochokinesis - spascity
• Lower limbs
• Heel to toe

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Gait

• Many types of abnormal gait
• Antalgic
• Festinating
• Cerebellar
• High stepping - foot drop or proprioceptive
• Ataxic
• Scissor
• Trendelenburg/Waddling gait
• Spastic gait

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Arms and legs Exam Done!

• Thank the patient and look smug with yourself!

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But wait, what about cranial nerves
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Cranial Nerves in no time!

• CN I - Olfactory
• Have you noticed any change in your sense of
  smell?
• CN II - Optic
• Have you noticed any change in your vision?
• Acuity - close each eye read your name tag!
• Fields - dont forget central scotoma
• Pupils - Equal? Direct/Consensual, Accomodation

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Cranial nerves in no time!

• CN III, IV, VI (Oculomotor, trochlear, abducens)
• Eye movements
• Does it hurt? (may indicate optic neuritis)
• Do you see double? - If yes, close one eye, if
  still diplopia refractive problem
• Look for nystagmus

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Cranial nerves in no time!

• CN V (Trigeminal)
• Motor - Clench mouth and feel masseters and
  temporalis.
• Do sounds feel unusually painful? - innervation
  to Tensor Tympani
• Sensory - Check light touch in Ophthalmic,
  maxillary and mandibular regions
• To look shit hot - Corneal reflex CN V afferent,
  CN VII - efferent

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Cranial nerves in no time!

• CN VII (Facial)
• Frown
• Show teeth
• Close eyes
• Purse lips
• Puff out cheeks
• CN VIII (Auditory)
• Have you or anyone else noticed a change in your
  hearing? - Weber/Rinne/balance

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Cranial nerves in no time!

• CN IX X (Glossopharyngeal Vagus)
• Normally I would test the gag reflex now!
• CN IX is responsible for the afferent limb
• CN X for the efferent limb.
• Look at palate and say ahh Uvula deviates away
  from lesion, side of lesion may have no movement.
  CN X lesions can cause dysphagia, hoarse voice.

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Cranial nerves in no time!

• CN XI (Accessory)
• Shrug shoulders
• Turn head against resistance
• CN XII (Hypoglossal)
• Look at tongue for wasting/fasciculations
• Waggle side to side (spastic tongue will be slow)
• Can check strength

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Now look smug!

• Thank the patient!

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Summarising!

• Good to have a set pattern to this
• If you feel confident, dont wait to be prompted
  by the examiner to summarise
• If not, give yourself 30 seconds or so to gather
  the important points on paper before jumping in

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Summarising!

• This is a 34 year old female, who is alert and
  comfortable at rest. On examination of her upper
  limbs she has increased tone on the right with
  brisk reflexes compared to the left which is
  normal. Power is decreased on the right hand side
  compared to the right. Sensation is normal and
  there are no other signs of significance. This is
  all consistent with an upper motor lesion in the
  left hemisphere.

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Summarising!

• May be a good idea to mention which hand they
  normally usually use!
• In that example you give all the positive
  findings and note any important negative ones
• Prompting the location of the lesion will usually
  direct the examiners questions, I.e. why do you
  feel this is the site of the lesion? What are the
  differentials for a lesion in this location?

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What questions will you be asked?

• The variation on questions is pretty limited
• You can usually steer the nature of the questions
  in your favour by what you mention!
• At this level all neurology boils down to What is
  the lesion? Where is the lesion?

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UMN Vs LMN
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Onset related to DDx

• Acute Onset
• Vascular
• Trauma
• Infective
• Sub-acute Onset
• Inflammatory (Infective or autoimmune)
• Metabolic/Endocrine
• Neoplastic
• Chronic Onset
• Neurodegenerative

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What questions will you be asked?

• More than likely unless you cover differentials
  in your summary this will be your first question.
• Avoid eponymous syndromes or you WILL be asked
  about them

HOWEVER, DO USE THEM IF YOU FIND YOUR FRIENDS
APPEAR TO HAVE DONE MORE WORK AND FINALS ARE FAST
APPROACHING!
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What questions will you be asked?

• Differential Diagnosis
• Definition
• Investigations
• Blind Surgeons Retire Early
• Bloods Secretions Radiology Extras/Examn
• Management Options - Divide into
• Conservative
• Medical (know drug e.gs)
• Surgical

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Anything else!

• Will Westons Revision notes are a good place to
  start!
• www.willweston.net/revisionnotes
• Ill pass onto the year reps some notes on each
  of the likely conditions and some stuff on the
  important drugs to forward to the different
  hospitals

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Any questions?