Practical Session Feb 2016
- 1. Summary of Practical sessions GP Neurology teaching 25th Feb 2016
- 2. Guidelines for GP upper limb motor examination - Tim Williams 1. Examination will never “trump” a good history 2. Observation is the first rule of medicine – watch patients walk into the consultation room and undress for examination. Formal “inspection thereafter, actively looking for wasting, fasciculation etc. 3. Remember “hard” (wasting, tone changes, reflexes) vrs “soft” (power, incoordination/clumsiness) signs. 4. After inspection think tone, power and reflexes – remember two movements or flexion/extension at each of the major upper limb joints (shoulder, elbow, wrist and fingers). 5. Remember cardinal differences between central (UMN) signs: preserved bulk, increased tone, pyramidal pattern weakness and brisk reflexes), and peripheral (LMN) signs: reduced bulk and tone, weakness and flat/absent reflexes. 6. Think patterns of localisation – single or multiple sites, or even a “system” disorder
- 3. Lower Limb Examination Gina Kennedy + Kirstie Anderson • Gait – if they can walk narrow based and quick (?normal arm swing both sides/turn on one smooth movement/walk heel to toe well/stand on heels and stand on toes and can hop either leg and squat – then little chance of major surprises when examining on the bed – so if you only have time for one thing – look carefully at gait in the corridor • UMN signs: – hyperreflexia, increased tone, upgoing plantars – Causes: any inflammation or SOL above L1, use sensory level to determine where to image • LMN signs: – Fasiculations, reduced/absent reflexes, reduced tone – Causes: anything below L1 such as cauda equina compression, peripheral nerve problem (GBS) • Mixed signs: – Fasiculations and spasticity (MND), absent reflexes and extensor plantars (B12 deficiency)
- 4. Cerebellar ataxia – Adam Cassidy • In the upper limbs look for – Past pointing – Intention tremor – Dysdiadochokinesia • When doing finger-nose testing, ensure the patient stretches fully to reach your finger • In an intention tremor the amplitude increases as the target is approached • If a patient has a postural tremor, this will not disappear on doing the finger-nose test. In such patients the amplitude does not increase as the target is reached and this is a kinetic tremor • Most doctors who think they are seeing an intention tremor are actually seeing a postural and kinetic tremor in somebody with a diagnosis of essential tremor
- 5. Cerebellar ataxia – Adam Cassidy • Very rare to see in general practice • Lots of older people wobble a bit on finger-nose testing and don’t have cerebellar ataxia • Supporting features include gait ataxia, nystagmus and dysarthria • More common causes: – Chronic: Alcoholic cerebellar degeneration – Subacute: Drugs – phenytoin, carbamazepine – Acute: Cerebellar stroke
- 6. Tremor/PD – Naomi Warren • Tremor examination – Observation – at rest, posture, action and with gait – Benign tremors – more symmetrical and postural/action • Parkinson’s Disease – Tremor – asymmetric, rest – Bradykinesia – decrement in “quacking duck” (core feature) – Rigidity – Gait – reduced arm swing
- 7. Cranial Nerves - Joe Guadagno Eye movement disorder (Diplopia) CN III, IV & VI: extraocular muscles 1. are the eyes looking in the same direction? 2. is there nystagmus? 3. is there double vision? • primary position: 4 questions -is there ptosis? • don’t move on until you have answered all 3 questions! Clinical examination 3 questions to ask at each of the 5 stations • cover each eye • uniocular diplopia – ocular/retinal pathology (v rare) – non-organic • more than two images – usually mad • non-neuromuscular causes (eg thyroid) • muscular disorders • neuromuscular junction (myasthenia) • individual cranial nerve palsies (III, IV, VI) • central eye movement problems – gaze palsies – INO – nystagmus Abnormalities • III, IV or VI? • feasible combination? • not simple III/IV/VI + no nystagmus – muscle (CPEO) – NMJ (fatigue) • not simple III/IV/VI + nystagmus – brainstem Very basic rules of thumb! Think - “look straight” “look left” “look right” “look at the tip of your nose” • lesion in medial longitudinal fasciculus • aBducting eye has nystagmus • aDducting eye fails to aDduct • lesion is on the side of failed aDduction Remember INO’s - think MS