Osce Checklist Neuro

Front 1

list 10 parts of the screening neuro exam

Back 1

1. Well vs. Unwell

2. Vitals

3. GA

4. Mental status

5. Handedness

6. Cranial nerves

7. Motor

8. Sensory

9. Coordination/cerebellar

10. Gait

Front 2

frontal release signs? (included under mental status)

Back 2

Glabellar tap..

Front 3

4 parts of motor exam

Back 3

1. tone (screen UMN with pronator drift)

2. bulk

3. strength

4. reflexes

Front 4

4 parts of sensory exam

Back 4

1. light touch

2. pain/temp

3. proprioception (very SMALL movements)

4. vibration

Front 5

parts of coordination/cerebellar exam 6

Back 5

1. bradykinesia

2. coordination

3. tremor

4. nystagmus

5. hypotonia, pendular reflexes)

6. dysarthria

Front 6

parts of Gait exam 8

Back 6

1. rhomberg here as they are standing

2. rising from a chair

3. posture

4. arm swing

5. "base" of the gait (wide or narrow)

6. stride length/height

7. turning

8. add'l maneuvers as required

Front 7

examining for diplopia

Back 7

d

Front 8

General inspection of eyes

Back 8

trauma, inflammation, erythema, discharge

Front 9

Exam of CN II

6 big points to hit

Back 9

1. visual acuity with snellen chart

2. colour perception

3. visual fields

4. examine pupils via light reflex

5. check for accommodation

6. fundoscopic exam

Front 10

note on VA : test one eye at a time!

Back 10

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Front 11

color perception:

Back 11

test red perception on snellen chart

Front 12

2 rules for examining visual fields

Back 12

1. only test one eye at a time

2. compare to your field of vision. if testing left eye, close your right eye and only do things you can see

Front 13

visual fields: 2 methods

Back 13

1. static technique

2. kinetic technique

Front 14

how to examine light reflex

Back 14

1. ensure room is dim

2. shine light between eyes, check that both peoples constrict

3. If anisocoria present, move to CN III exam

4. if anisocoria absent, proceed to swinging flashlight test

5. if pupils do not react, check for argyle robertson pupil

Front 15

HOW to check for argyle robertson pupil

Back 15

= bilateral small pupils that reduce in size when the patient focuses on a near object (they accommodate) but do not constrict when exposed to bright light

Front 16

how to check for accommodation

Back 16

have patient fix on a point far away and then suddenly look at at an object eg finger that moves close to their face.

Front 17

Next: exam of III, IV, and VI

first glance: how do palsies of each of these present?

Back 17

III: down and lateral

IV: eye up and medial

VI: eye directed medially

Front 18

lids; significance of ptosis

Back 18

suggests CN III palsy or myasthenia gravis

Front 19

Thyroid opthalmopathy) 4

Back 19

proptosis, lid edema, lid lag, lid retraction?

Front 20

examining for diplopia: explain the cover/uncover test

Back 20

1. monocular if diplopia extinguishes with one eye covered but not with the other eye covered

2. binocular if diplopia vanishes with either eye covered

3. monocular: suggests optho etiology, binocular suggests neuro/muscular cause

Front 21

if binocular diplopia detected, determine :

which mm is weak

and which eye is the problem?

Back 21

which mm is weak: which direction makes the diplopia worse narrows it down to two possible extraocular mm.

which eye is the problem: use red glass. the most peripheral image belongs to the affected eye

or ask patient to close one eye: if the more peripheral image is extinguished, that is the affected eye.

Front 22

CN VI palsy: what is one thing that can exacerbate diplopia

Back 22

distance vision will cause diplopia

Front 23

how to test for CN IV palsy

Back 23

ask pt to tilt head towards affected side. CN IV palsy shows hypertropia

Front 24

stroke vs bells palsy (essentially UMN vs. LMN cranial nerve findings)

Back 24

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Front 25

CN II: how would stroke affect visual field

Back 25

depends on site of lesion.. homonymous hemianopia or quadrantanopia

Front 26

how would stroke affect visual acuity?

Back 26

should be normal..

Front 27

stroke: what would findings in pupillary response to light and accommodation?

Back 27

normal exam in stroke (unless brainstem? or horners)

Front 28

swinging flashlight test in stroke

Back 28

should be normal. both pupils should constrict strongly

RAPD is an issue with CN II ..

Front 29

review: triad of horner's syndrome

Back 29

ipsilateral miosis, ptosis, and anhidrosis

Front 30

stroke: III, IV, and VI

Back 30

binocular diplopia possible.

also note gaze preference towards side of lesion

Front 31

checking V: sensation:

Back 31

both sides, 3 divisions

1. light touch: test with cotton/kleenex

2. pain sensation

stroke: sensation may be diminished in hemi distribution

Front 32

Motor exam of V

Back 32

1. mm wasting

2. clench teeth, feel masseters

3. test pterygoids: ask patient to open their mouth against your hand

Front 33

V: jaw jerk reflex

Back 33

jaw jerk reflex.

mouth hanngs loosely open. use finger as a brace, hit with hammer, and look for reflex closing of jaw.

unilateral stroke: jaw jerk testing usually normal

Front 34

V: corneal reflex

Back 34

touch cornea, look for direct and consensual blink

may be absent in brainstem stroke

Front 35

afferent and efferent component of corneal reflex

Back 35

afferent: CN V

efferent: CN VII

Front 36

VII: facial nerve

Inspection

Back 36

facial symmetry and presence of passive motor signs

possible changes to tearing? and may report changes to hearing (hyperacusis via stapedius involvement)

Front 37

signs of VII involvement (stroke or bell's palsy)

Back 37

nasolabial fold flattening, mouth droop, retracted eyelids, other asymmetry

Front 38

VII: motor exam

4

Back 38

1. forehead wrinkling (absent = LMN. able to wrinkle = UMN) NB

2. close eyes tightly, resist you trying to open them

3. puff out cheeks

4. show teeth

Front 39

quick screen for VIII

Back 39

hearing acuity: rub fingers toogether at side of patients head: move inward till patient hears noise.

compare with other side

Front 40

IX and X: sensory

Back 40

gag reflex (plus taste to posterior 1/3 of tongue, which we don't test here)

Front 41

IX and X: motor 3

Back 41

say "AH" to check palatal elevation

have patient drink water and assess swallowing

comment on gag reflex, but don't check...

Front 42

findings if there's a lesion to IX, X?

Back 42

in brainstem stroke, asymmetric absence of gag reflex and / or dysphagia may occur..

diminished palate elevation may occur ipsilateral

Front 43

testing XI

Back 43

cortical stroke: patient may have weakness in ipsilateral SCM and contralateral trapezius...?

Front 44

testing XII

Back 44

ask patient to stick out tongue

branstem stroke: deviates to side of lesion

cortical stroke: away from side of lesion

Front 45

Motor exam:

inspection

Back 45

bulk, atrophy, fasciculations (no suspected abnormality in acute stroke)

Front 46

Motor exam: tone

Back 46

1. flaccid (LMN)

2. velocity dependent = spastic (stroke)

3. rigid = velocity independent (Parkinson's?)

Front 47

scale for testing muscle strength

Back 47

Front 48

note: how does UMN lesion affect upper and lower limb strength?

Back 48

Flexion predominates in upper limb, extension predominates in lower limb

Front 49

testing mm strength: list that goes through the exam

Back 49

Front 50

Motor exam: 4 tests to do after strength

Back 50

+ reflexes!!

Front 51

when to perform coordination and gait?

Back 51

Front 52

exam of arm weakness (UMN vs LMN)

Back 52

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Front 53

arm weakness: Inspection 3

Back 53

1. Bulk (mainatined in UMN, down in LMN)

2. fasciculation (LMN)

3. position of arm (decerebrate posture = UMN)

Front 54

arm weakness: Motor exam

0. pronator drift

1. check tone

2. list the myotomes you would check

Back 54

Front 55

arm weakness: motor exam

1. check arm reflex

2. special test...

Back 55

Front 56

arm weakness: sensory exam:

1. which dermotomes to check?

2. findings if anterolateral pathway disrupted?

3. findings if DCML disrupted

Back 56

anterolateral: pain, temp, light touch

DCML: proprioception, vibration, light touch

Front 57

notes:

1. demonstrate on one side, and state that you would compare with the other side of the body

2. offer to demonstrate techniques

Back 57

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Front 58

If UMN signs found when examining arm, what else might be present given left arm weakness is due to a right cortical lesion? 4

Back 58

1. left lower face droop with forehead sparing

2. cortical sensation loss: 2 point discrim, stereognosis, graphesthesia, localization of tactile stimulus, extinction

3. extension of leg (spastic paralysis)

4. left visual field neglect

Front 59

patterns of weakness that would be characteristic of

1. Radial neuropathy

2. C6 radiculopathy

3. C7 radiculopathy

Back 59

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Front 60

Patterns of sensory loss AND DTRs in

1. radial neuropathy

2. C6 radiculopathy

3. C7 radiculopathy

Back 60

Front 61

Back 61

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Front 62

onto exam of Foot drop.

ddx of foot drop? 3

Back 62

1. sciatic nerve

2. peroneal nerve

3. L5 radiculopathy

Front 63

foot drop-motor exam. strength testing if peroneal nerve injury? 3

Back 63

weak ankle dorsiflexsion (tib ant.), eversion (peroneus), and toe extension (ext dig.)

Front 64

foot drop-motor exam. strength testing if L5 radiculopathy 6

Back 64

1. weak ankle dorsiflexion

2. weak plantarflexion (gastroc)

3. hip extension (glut max)

4. hip abduction (glut med)

5. knee flexion (hamstrings)

6. toe extension (ext dig

Front 65

foot drop-motor exam. strength testing findings of sciatic nerve injury

Back 65

1. ankle dorsiflexion (tib ant)

2. eversion

3. knee flexion

4. ankle plantarflexion

5. ankle inversion

6. toe exetnsion

Front 66

suggested approach to foot drop

wrt order of testing weakness. NB

Back 66

1. test sciatic: IF a) plantarflexion and b) toe flexion are intact, tibial nerve and therefore sciatic is intact.

2. THEN distinguish L5 from peroneal by testing

a) knee flexion

b) hip extension

c) hip abduction

all of these are innervated by L5, but are above peroneal nerve.

Front 67

foot drop-motor exam. reflexes

explain significance of achilles reflex finding

Back 67

peroneal nerve does NOT contribute to achilles reflex.

therefore, if diminished or absent, suggests sciatic neuropathy or L5 radiculopathy

Front 68

sensory testing in foot drop. summary given here, refer to tables for details ..

Back 68

Front 69

note: sensory distributions for L5, sciatic, and peroneal n.

Back 69

Front 70

special tests for sciatic neuropathy/L5 radiculopathy

Back 70

Front 71

gait in peroneal vs. sciatic vs. L5

Back 71

Front 72

Examination of cerebellar ataxia

prompt: seeing a patien twith pernicious anemia and who is also a heavy alcoholic.. differentiate sensory ataxia from a dorsal column issue or cerebellar ataxia

Back 72

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Front 73

general appearance: 1 relevant finding related to speech, in addition to well/unwell, etc.

Back 73

cerebellar ataxia: patient may have dysarthria.

slurred, slow, and irregular in rhythm and volume

Front 74

Cranial nerves, motor, and reflexes.. not expected to complete in this particular prompt

Back 74

d

Front 75

Sensory exam in ataxia :

relevant findings with light touch, temp and pain?

Back 75

may see dimiished light touch if DCML sensory ataxia

Front 76

sensory exam in ataxia: how to assess vibration?

Back 76

check against bony prominennces. begin with sternum. test the distal interphalangeal joints first.

if the patient can feel those, there is no need to test proximally

Front 77

vibration: findings in ataxia?

Back 77

cerebellar: no findings

DCML sensory ataxia: diminished vibration sense

Front 78

ataxia: how to test proprioception

Back 78

grasp patients toe or finger lightly at the sides and bend it up and down.

with patient watching, demonstrate UP and DOWN.

Have patient close their eyes, and ask if they detect motion, and which direction it is.

Front 79

proprioception: findings in ataxia 3

Back 79

normal: this may be incorrect 10% of time

cerebellar ataxia: no expected finding

DCML ataxia: poor detection

Front 80

onto special tests..

list the special tests to do in cerebellar ataxia 6

Back 80

1. finger-nose test

2. heel-knee-shin

3. dysdiadochokinesia

4. hypotonia

5. nystagmus

6. rhomberg

Front 81

and don't forget Gait!

findings in cerebellar vs. sensory ataxia

Back 81

cerebellar: wide based gait, staggering or swaying possible

DCML sensory ataxia: patient looks down, walks as if throwing feet, feet slap ground. "high-steppage gait"

Front 82

how to perform finger nose testing?

relevant findings?

Back 82

Front 83

heel knee shin testing..

how to perform

relevant findings

Back 83

1. ask P to move heel of one leg down the shin of opposite leg. repeat on other side

2. cerebellar ataxia: may notice decompensation of movement. ie. patient moving heel abnormally high before starting the maneuver.

Front 84

4 tests for dysdiadochokinesia + relevant findings

Back 84

1. forearm pronation an supination

2. hand clapping

3. finger tapping?

4. foot stamping

in cerebellar ataxia, may notice slower speed and irregular rhythm, range, and accuracy.

dysdiadochokinesia = inability to perform rapid movements

Front 85

how to assess for hypotonia

Back 85

stabilize joint from above and passively flex and extend limb in slow, repetitive fashion. compare with other side.

tone may be reduced

Front 86

wtf?

Back 86

Front 87

what type of nystagmus consistent with cerebellar lesion?

Back 87

conjugate horizontal jerk nystagmus (both eyes moving together, with an abnormal slow drifting in one direction, than fast jerk in other direction.

NOT expected in DCML sensory ataxia...

Front 88

romberg test:

Back 88

ask patient to stand with feet together and closed eyes for 60 sec. look for swaying.

only positive in sensory ataxia

Front 89

fundamental signs of cerebellar ataxia? 4

Back 89

1. cerebellar gait

2. nystagmus

3. hypotonia

4. dysarthria

Front 90

fundamental signs of DCML sensory ataxia

Back 90

1. high-steppage gait

2. positive rhomberg

3. impaired proprioception

4. impaired vibration in affected limbs

Front 91

Parkinson's checklist

Back 91

d

Front 92

PD: GA and vitals

Back 92

comment and offer to assess..

Front 93

PD: inspection. 6 points

Back 93

1. resting tremor

2. dry skin (xeroderma)

3. decreased blinking

4. hypersalivation

5. lack of facial expression w/ conversation

6. softened, breathy voice

Front 94

features of resting tremor 5

Back 94

1. slow frequency tremor upon resting limb

2. asymmetrical

3. classic pill-rolling tremor

4. aggravated by stress

5. inhibited by movement

Front 95

PD: 4 special tests to hit

Back 95

1. bradykinesia

2. glabellar tap

3. test rigidity

4. parkinsonian gait

Front 96

how to test bradykinesia (4)

Back 96

1. tap fingers, beginning with index finger and moving laterally

2. inching and circling: patient rapidly pinches together index finger and thumb of one hand while simultaneously performing a circling movement with the index finger of their opposite hand. instruct p. to direct gaze towards the circling finger to distract.

3. twiddling: patient rapidly circumducts their hands over each other. inspect for asymmetry of movement

4. tapping of heels, one foot at a time

Front 97

glabella tap reflex

Back 97

percuss patients forehead with index finger. both eyes should reflexly blink

blinking should extinguish after 5-10 cycles.

persistent blinking is positive sign (Myerson sign)

Front 98

how to test rigidity

Back 98

1. pick a joint: elbow, wrist, ankle

2. pick a side: the side with the most prominent tremor

3. passively range the joint

4. feel for "lead pipe rigidity" or cogwheeling (alternating periods of resistance and relaxation)

Front 99

note: why to test rigidity slowly

Back 99

make sure the increased tone is not velocity dependent

Front 100

features of parkinsonian gait

Back 100

1. flexed posture of neck, trunk, hips, arms

2. difficulty initiating gait, freezing, en block turning

3. small, flat footed shuffling steps with narrow base

4. diminished arm swing

5. festination (involuntary speeding up)

6. retropulsion: poor postural control. stand in front of wall with patient in front of you, while giving them a pull from behind

Front 101

what are 5 features that suggest a parkinson plus syndrome

Back 101

1. marked autonomic dysfunction (postural hypotension, neurogenic bladder or bowel

2. early severe dementia

3. pyramidal findings (any UMN. hyperreflexia, spasticity, babinski)

4. cerebellar findings (limb ataxia, gait ataxia, nystagmus)

5. supranuclear gaze palsy (difficulty looking down)