Ultimate Finals List - Neurology

Neurology

• CNS – During our five minutes rest before my next station (CNS) one of the patients asks to go to the loo. On his walking back I couldn’t help but notice – stooped posture, expressionless face, slow turning and a lovely pill rolling tremor of the right hand. Five minutes rest up – “please examine this man’s gait and then upper limbs” – differential and diagnosis and that’s it... // Neurology - PD with choreoform movements superimposed from drugs - I just homed in on the chorea even though I elicited all the signs of PD doh! // parkinsons disease ( was very well prepared for this after your course!!! ) - Guy with Parkinsons. Asked to examine upper limbs and gait. Obvious rigidity and tremor. Cogwheel rigidity on synkinesis. Demonstrated glabellar tap and asked by examiner to demonstrate bradykinesia. Examiner asked me most likely cause and then other possible causes. Then how I would manage the gentleman- drugs, MDT, palliative care, information, liaison with primary care etc. cranial nerves, bilateral weakness of the upper part of the face, give differentials // Neuro – The patient had an obvious unilateral pill rolling tremor. The examiner asked me to examine the patient's motor function in his upper limbs. I first got the patient to walk and he did have a shuffling gait. I then examined his arms (and used your scheme of examining roots C5-T1, which was very helpful thanks) and found signs consistent with Parkinson's disease in the arm which had the tremor. The examiner asked me my differentials. I said that all my findings would be consistent with a diagnosis of parkinson's and he said "well common things happen commonly" and then asked me questions about the treatment of parkinson's and the impact on a patient's life ("Are there any other questions you would like to ask this patient?")

• Horners syndrome

• Speech assessment - previous MCA and expressive dysphasia Assessing pt’s speech. Glass of water next to pt – I didn’t use it, although probably should have. She’d had a stroke – questions about which area of brain (expressive aphasia). // Speech Exam, woman had expressive dysphasia. Also had arm in flexed extrapyramidal position, which I noticed, but forgot to mention. Not sure if were meant to do writing/reading/ say would do mental state exam. I missed out all those things from my basic speech exam routine I’d learnt! Examiner quizzed me after I’d talked about testing for a conductive aphasia . When I left I heard him telling the actress that he’d never heard of it and needed to go look it up now and that you learn something new every day!! Bit annoying cos if he hadn’t quizzed me about it I would have had extra time to do more speech exam! I expect he passed me on the station though. // Assess speech of patient, expressive dysphasia // There was a actress with a simulated expressive dysphasia, she also had a 'stroke' arm and a deviated tongue,I assessed comprehension, repetition, reading and writing the examiner asked me if I'd like to do anything else, not quite sure what he wanted. // Was then asked where the lesion was in an expressive dysphasia // Speech examination- in actor with right sided arm flexion deformity, Broca's dysphasia (expressive) I forgot the bit about getting them to repeat "British constitution" "baby hippopotamus" "butter" etc. // Assess Speech – Broca’s aphasia // Speech assessment on an elderly lady with a stroke posture (flexed arm, extended leg). She can’t really say anything well (expressive dysphasia) but can understand commands. Begin by asking her a general open question to assess her general speech, i.e. ‘how did you get here today?’ Ask her to say bread, butter, baby hippopotamus, she says Yes, Yes, Yes, then move on to commands which she complies with. Then ask her to say, ‘no ifs ands or buts’ (which tests the connection between brocas and wernickes areas). Can also ask her to say’ka ka ka, la la la, ma ma ma to assess pharynx, tongue and palatial involvement in speech. Finally do not forget to do a mini-mental test, the examiner should stop you half way as the patient cannot answer any questions properly. Examiner then asked what is wrong? Expressive dysphasia due to stroke. Where is pathology? Broca’s area, in frontal left lobe (usually).

• Neuro- Spastic paraparesis. I was asked about possible differentials. // Neuro - lower limb examination of man with "stiff legs" He had spastic paraparesis. Quite good upper motor neurone signs with pyramidal distribution of weakness. //Neuro was spinal cord lesion with bilat UMN signs in legs // Neuro: Pt had scissoring gait, increased tone, bilat brisk reflexes. I presented  findings and said these were consistent with 'spastic paraparesis'. I talked about finding a sensory level but the examiner only wanted me to perform motor exam. I summarised cause of spinal lesion: demyelination, vascular, mitotic change. Examiner said ' well that seems very comprehensive' . // NEURO- my worst station! had a lovely lady with bilateral upper motor neuro signs in her legs, but the power in the legs varied, and sensation was normal I think, I didn’t get to complete my examination so he just asked me what I would do, he then asked me to present my findings and I went blank and could not remember what I had found! he calmed down and asked me what pattern I had found, I said upper motor neuron lesion, he smiled and said hats all he wanted. he then asked where I thought the lesion was considering both legs were effected, I just said a lesion in the spine, he wanted to know where exactly...the bell went, I ran out!

• right sided hemiplegia - upper limb neuro // Neuro: upper limb examination: right sided weakness with UMNL signs...he asked what else wud u like to do.,. I said examine the leg to look for hemiplegia...indicating stroke..he asked where wud the lesion be...in the left lobe....then he said which one vessel wud u like to examine...carotid n listen for bruits....anything else you’d b interested in: ECG for AF or mitral stenosis embolic stroke, since she was bout 40yrs old. // Neuro: stroke, asked about what other systems I would exam...cranial nerves, cvs looking for risk factors, AF, Ix doppler of carotids, got asked about what gait I would expect the patient would have, I answered spastic, scissoring but examiner was after 'hemiplegic'.

• Neuro- man who had car crash, with multiple cranial nerve palsies. Right IIblind(causes relative afferent pupillary defect), right III (part ptosis), left VII. Couldn't finish all 12- included Rinne, Weber, acuity test etc. // CNS: Multiple cranial nerve lesions in a 16 year old girl.(not corellating to any random syndrome i.e. Cavernous Sinus/Jugular Foramen). Decreased visual field on left temporal, left VI nerve palsy, sensorineural hearing loss on left and fasciculation of the tongue. I concluded that it could be due to meningitis. // Neuro cranial nerves exam - loss of smell, blind in one eye, sensorineual deafness, facial nerve palsy - a great learning case!

• Neurological assessment of eyes, meningism, photophobia & headache, SAH & meningitis, obs chart (high BP & low pulse) - visual fields, eye movements, accommodation, Ex & signs - acuity & opthalmoscopy, Kernig's, DDx, Ix - CT/LP //  Hx and Ex of headache and eye pain???? no one knew what that was about!! Examination of eyes - presenting complaint: acute onset severe headache, problem with eyes, high blood pressure. (on the table nxt to pt was a 'sensory neuro' set ie. cotton wool, tuning fork etc..?! also hatpin, pen torch) - asked by examiner to proceed - pt was covering eyes with hands (photophobia) - basically went through eye examination ie. acuity (told not to worry about that as there was another station that tested this), fields, light responses, extraocular eye movements... - then asked for what else I might expect to find on examination with his presenting complaints eg meningism sign - asked to perform tests to elicit this (i did kernigs) - asked about my differential diagnosis: SAH and Meningitis - asked investigations i'd do, CT, LP, bloods - then asked to look at the Blood pressure again and whether this is what i expected if DDx was SAH, it was a high bp so i said yes! (is that right!?!) Overall comment: the examiner really helped me along on this one, she definitely wanted to see what I could do, not what i couldnt. This station had come up either last year or the year before. // Examination station. Patient presents with sudden onset of severe headache. Told not to take a Hx or do a full neuro exam, so i exmained the eye movements. accomodation, pupil reflexes, acuity and fundoscopy. I also tested for neck stiffness, and signs of meningism. asked to present findings and give a differential diagosis. Asked what condition i wanted to exclude and what investigations i would order and what i would find if it was SAH. examiner was happy with that // Actor covering his eyes and shouting out that his head was in a lot of pain!!! Supposed to do all the eye exams but basically you picked up say, an ophthalmoscope, and examiner said 'very good, move on' I also did Kernigs and made him move his neck around. Diagnosis subarachnoid haem and questions on it. // A women with symptoms of a sub arachnoid - 'examine her eyes'

• Neuro - glove and stocking sensory loss - DDx, hemiplegia, myotonic dystrophy // Peripheral neuropathy, very nice case!!! I was asked the differentials after I said peripheral neuropathy secondary to diabetes, I said I didn't know, then the examiner said B12...and then I realised he meant the differentials for the causes, I had a complete panic attack and said "I know these!!!!!!" and then literally machine gunned about 10 causes at the examiner who again smiled to himself. The examiner then asked me what I would prescribe if the patient had neuropathic pain. I said gabapentin and the examiner asked what would be my first line. I then said tricyclics which was apparently fine because the examiner didn't bother asking anymore

• Neuro - post-ear op, VII nerve palsy

• PNS – MS, MND, mixed UMN and LMN signs // Neuro – lower limbs motor. Middle aged gentleman with two walking sticks, wasting of calves, upgoing plantar on right, hyperreflexic on right. Reduced power bilaterally, more on right. Asked differentials and a diagnosis, I said motor neurone disease, to which the examiner asked, ‘what feature is NOT present which you would expect to be present in a patient with MND? I had no idea, examiner said ‘· fasciculation’. // Neuro- asked to perform an neuro exam of the lower limb. Still not sure what it was- mixed UMN and LMN on legs. Spasticity, Increased knee reflexes, decreased ankle reflexes and down going plantars! Normal sensation. She asked for my findings, then differential. She then asked if I thought it was UMN or LMN, I mentioned it was mixed signs. She asked me to pick one. I said UMN and then she asked no more questions!

• Upper limbs neuro and advice for sensory loss over axilliary area - The scenario for the short case was a young man who had been in a car accident with a whiplash injury, all X-rays had come back normal, but several days later he represents with some concerns. On questioning he says he has pins and needles in a patch over the outer upper aspect of his right arm. However on examination he has no pain, no stiffness of his neck and a neurological examination was entirely normal. He then asked for advise about whether he could return to work as a secretary. My flatmate took the osce at another site, the same scenario but a different actor who had mildly reduced power and sensory loss in a C6-8 distribution. She was asked what investigations she might do. 

• There were several stations where I found your advice to be flexible particularly useful- e.g. you are a doc in A&E and a patient presents 3 days post whiplash injury. instructions were not clear as to whether we should examine neuro of arms, locomotor of neck, history or explanation re return to job and physio etc. Obviously time allowing we would have liked to do all of these and most of us squeezed in as much as we could. // Management of whiplash - tingling in neck - examine neck and UL neuro, and reassure pt - examine c-spine, neck movements (and does it cause any tingling) - Tx, Mx, exercise, can i go back to work?

• Neuro - power loss in one leg and sensory loss below knees - struggled with putting the signs together. // The next patient again I was asked to "examine the legs". He had wasting, normal tone, 3/5 power, brisk reflexes and no co-ordination (due to decrease power) in the left leg and a normal right leg. he also had a glove and stocking peripheral neuropathy in both legs. I said he had a peripheral neuropathy and a LMN lesion, but didn't really know. I got asked about my differential for peripheral neuropathy.

• Neuro - common peroneal nerve and median nerve palsy 

• Neuro - patient with neurofibromatosis type 1, asked to examine her skin and then the ulnar nerve and her reflexes, other features? - neuro- neurofibromatosis- patient had many neurofibromas and cafe au lait spots.. asked about differential .. then a bit about the condition, when we would chose to operate.. wheere the neurofibromas can grow and what other problems it may cause....she also had a scar on her forearm which was over the ulnar nerve....then i had to show the examiner how to test for ulnar nerve palsy (thanks to your course i was able to do this well) also asked about hypertension and why these patients get it-

• Visual fields testing-homonymous hemianopia and questions about causes (Stroke, Cerebral tumour, trauma asked which most common) // Visual fields (given red and white pin - I only used the red but not sure) - bitemporal hemianopia but actor was unsure... // Neurology: Examine this patients visual fields. Patient had a bilateral left sided lower quadrantanopia. Asked about where lesion may be and causes. Right sided parietal lobe.

• neuro - i gave him 0/0 power in the limbs because he wouldnt move them when i asked him to... but forgot i had just assessed his gait which was relatively normal....!!

• Cranial nerves: unilateral LMN lesion

• Neuro - obvious diagnoses of myasthenia (bilat ptosis) examiner asked me what I wanted to do next, all the stuff was there for cranial nerves so I did them and discovered a field defect on the Right. A lot of other people said they wanted to examine her for fatiguability and the examiner just let them carry on making her wave her arms around, he gave no indication of which examination you were expected to perform. I found it very useful to ask the examiner at the beginning of each station whether they wanted me to talk through, most said that it was up to me. One consultant told me to remain quiet so that I couldn't prompt myself(?) another said "thank you for asking me what I'd prefer, all of your colleagues rabbit on dreadfully, it's tiresome". Mind you he was about a hundred and ten.

• neuro- cerebellar examination // Cerebellar syndrome secondary to phenytoin toxicity. In addition i performed sensory examination for peripheral neuropathy and examined for diplopia as these are also side effects. Note: scenario only tells you that patient has long standing epilepsy and now presents with a drunken gait please examine as appropriate. Examiner asked me to present findings, give him a Dx ( cerebellar syndrome secondary to phenytoin) // causes of a cerebellar syndrome.

• Oh god - neuro! Said 'do lower limb exam'. Young man had obvious upper motor neurone signs in both legs as even I could get all the reflexes (never normally happens!)But I completely panicked and forgot to make him stand and walk-aargh!! So had lots of time left and started doing sensory exam – loss of sensation in both legs. Diagnosis was obviously MS

• Neuro - this station was the worst station I have ever done in my life. We all felt it was incredibly unfair. We had to perform a cranial nerves examination on a really non-compliant patient. In the end she was so bad at following my instructions that I only managed to get to cranial nerve 5 in 7 minutes, although I think the examiner was aware of why this was because for students after me, he stopped them in their examination much earlier on and just grilled them instead because the patient was really not helpful. In the end she had a VP shunt running down her neck and frontal bossing, which although strictly speaking not part of a neuro exam, were how you were supposed to figure out that this patient has hydrocephalus. And then you had to answer questions on that. If the medschool have got half a brain, they will not use his patient again cos she is not compliant enough for exams.

• NEURO-bilateral weakness one side worse than the other, I thought it was · unilateral with a semi-circular gait, Qs- could it be and what is Brown Sequard?

• neuro, still don’t know what that was I was asked just to do sensory of lower limb patient said he felt everything so I didn’t find anything wrong. though I was asked to Romberg’s and patient was wobbly even though jps was normal so I don’t know! it wasn’t cerebellar either

• Neuro - man with diplopia which miraculously disappeared as I was examining him - he said I was a magical Dr and that I had healed him - a good thing to happen in an OSCE. Had to work out which eye muscle was faulty etc. 

• Neuro - evil station, 'this man has problems with his vision, please examine his cranial nerves'. I was made to perform fundoscopy, test his visual acuity (which was all normal) I got to CN 7 and the bell went, so had to present my findings of my half finished exam! I found his left eye was unable to abduct and he had nystagmus on all aspects of eye movements - so presented my findings. Gave some differentials as cavernous sinus thrombosis, false localising sign of raised intracranial pressure, mononeuritis multiplex from Diabetes and MS and was pressed for more and more diagnoses, which I was then blank! Asked about management - I suggested tests for DM and for MS, but the examiner wanted something else and kept pressing me...and asked 'if you could give his man one thing what would it be...' at which point the bell went and I went tot he next station - turns out the answer was an eye patch as we saw the patient coming out of the room at the end! // Neuro – HORRIBLE!! Missed the lateral rectus palsy and got thoroughly humiliated // Neuro - cranial nerves - 6th CN palsy. Causes, treatment, what to expect on fundoscopy // Neuro – cranial nerves – asked about course of 6th nerve. At that point she said I was doing well and not to worry as my mind went blank. Don’t think I ever knew that!

• Neuro- The worst station. Everything about it was dreadful. Were told the lady had problems swallowing and chewing and asked to examine her cranial nerves. I clarified with the examiner who told me to examine whichever ones I wanted, and so I started with 9-12 thinking I had an idea of what was wrong, only to not pick up any signs. I then for some reason decided to examine the rest of them but in a sporadic, unstructured manner, rather than starting at 1 and working through them. In my defence I think I did this as I was aware of the time constraints but it meant my examination looked unpractised and unstructured and I forgot things. On top of that, the lady had very obscure signs and no-one had a clue what was going on with her.

... and just for fun...

• Neuro lower limb (motor and sensory) (my patient fell asleep after 3 mins and kept snoring then)