Neuro OSCE (w/ Approach to Neuro Pt)

What are Cerebellar Tests?

- Access RRAM bilaterally (hand-thigh pat & toe tap) - Finger to noe to finger - Heel to shin - Pronator drift - Rhomberg's test - Assess gait: norma, toe walk, heel walk, hell-to-toe tandem

What should you ask when taking history on a tremor?

- Activities affected - With activity or with rest? - Onset (If sudden, look at alarm sx) - Progression (If progressing gradually, think Parkinson's Dz, essential, Wilson's disease, task specific tremor; if not, physiologic tremor) - Quality- rest, postural, action? - Location (what body parts- hand, head, voice, face, legs, jaw, etc.) - Effect on daily function (task involvement?) - Associated symptoms? - Anything make it worse or better? - Is it unilateral or bilateral? (Unilateral- usually Parkinson's; Bilateral/ symmetrical- usually essential; however early on can be unilateral) - Legs only- think orthostatic tremor - Rigidity? Bradykinesia? Weakness on one side? - Balance problems, shuffling gait, frequent falls? - Urinary/ bowel incontinence, lightheadedness, uncontrolled sweating? - Confusion, hallucinations? - Medications? Medical problems? - Stress, fatigue, anxiety (does it worsen tremor)? - Alcohol improvement? Think essential - Exposure to heavy metals, carbon monoxide?

What medications are associated with potential tremors?

- Amiodarone - Levothyroxine - Caffeine - Cyclosporine - Lithium - Amphetamines - Bronchodilators - Beta-Adrenergic agonists - TCA - Serotonin reuptake inhibitors - Valproic acid - Corticosteroids - Antipsychotic drugs

What are modifying factors for confusion to ask about?

- Are symptoms worse at night? ("Sundowning") (Sundowning: seen w/ both dementia & delirium) - Rapid improvement? (post syncope) - Improvement over minutes to hours? (postictal) - Worse w/ standing? (hypoperfusion) - Any hx of seizures? (Non-convulsive status epilepticus- prolonged seizure) Ask both patient & caregiver!

What are motor (strength) exams for the ankles?

- Dorsiflexion - Plantar flexion - Inversion - Eversion

What are ascending spinal tracts (spinal sensory paths) responsible for?

- Facilitate & mediate sensory impulses - Fine touch, 2-point discrimination, proprioception, pressure, temperature, pain Spinothalamic tract: Sensations of pain, temperature, & light touch Posterior columns: Position sense, pressure, vibration, & discriminative/ fine touch Dermatones: Band of skin innervated by the sensory root of a single spinal segment (LMN)

What are some ways to test Cerebellar function?

- Finger-nose-Finger - Heel-to-shin - Pronator drift - Romberg test - Gait test

What are motor (strength) exams for the elbows?

- Flexion - Extension - Pronation - Supination

What are motor (strength) exams for the wrists?

- Flexion - Extension - Ulnar deviation (abduction) - Radial deviation (adduction)

What metabolic conditions are associated with a tremor w/ an AMS, seizures, or cardiac problems?

- HYPERthyroidism - Hypocalcemia - Hyponatremia - Hypoglycemia

What are motor (strength) exams for the hand?

- Hand grip - Finger abduction - Finger adduction - Thumb opposition

What should you do/ask/ document in every pt encounter?

- Has this happened before? (If so, what happened?) Is it getting worse? - Any trauma? - Have you been ill recently or had sick contacts w/ similar sx? - Ask about risk factors for the CC or your differentials - New medications? Medication changes? - If infection: when was the last time you had this? Any ABx use in the past 6 months? - General ROS: fever/ chills, fatigue, weight changes, n/v - If CC is cardiac, pulmonary, or GI related- ask all 3 ROS - Chronic medical problems and how they are managed- esp. DM - LMP? - Current medications - Allergies to medications/ reaction - Social: tobacco, ethos, drug use current/ prior

What Physical Exam do you do for a HA?

- Light touch sensation - Motor function & Coordination - DTRs Palpation: - Temporal Arteries (temporal arteritis?) - Trigger points - Neck munches & TMJ Fundoscopic Exam? (Palpilledema- Brain Tumor) Look @ body language- facial expression, motion, articulation, sunglasses/ squinting? Used to CONFIRM type of HA & R/O Red Flags

What are the components of a Neurologic Exam?

- Mental Status - Cranial Nerves - Sensory Exam - Motor Exam - Cerebellar Exam - Reflexes - Special Testing

What are primary headaches?

- Migraine - Tension Type Headache - Cluster Headache - Paroxysmal Hemicranias - New daily persistent Headaches - Hemicrania Continua - Hypnic Headache

What must be included in a prescription?

- Name of drug/ strength - Date of Rx - Medication Allergies or "NKDA" - Form (tablet, capsule, etc.) - Dosage & route - How to take it/ route of administration - Frequency and length of administration; or PRN + reason - Purpose of medication - Number to dispense (add write it out beside the number in parentheses) - Number of refills - Signature - Patient name & DOB/ address - Provider address, DEA number - Provider signature

What are secondary headaches?

- Neurological (trigeminal neuralgia) - Ophthalmological (optic neuritis, glaucoma) - Vascular (cerebral thrombosis, subdural hematoma, AV malformation) - Infectious (meningitis, sinusitis) - Idiopathic Intracranial HTN - HTN induced HA - Space occupying lesions (abscess, tumor, mass) - Autoimmune (Temorial Arteritis)

What factors predispose a pt for Carpal Tunnel Syndrome?

- Obesity - Pregnancy - Arthritis - Hypothyroidism - DM - Trauma Associated with: Overuse/ repetitive, work-related activities

What are descending spinal tracts (spinal motor tracts) responsible for?

- Play a role in control of muscle tone & posture - Delicate (precise) & purposeful movement - Resistance to falls Corticospinal tract: Voluntary muscle movements that originate in motor cortex Extrapyramidal Tract: Maintain muscle tone & gross automated movements Cerebellar tract: Coordination of movement; maintenance of equilibrium (UMN)

What are the mandatory subheadings in a focused note?

- Pt demographics - CC - HPI (include ROS +/-, relevant PMHx, FMHx, include relevant previous labs/ imaging/ procedures etc.) - Current medications (add indication, & all relevants- dosage, route, strength, vehicle, frequency, etc.) - Allergies & type of reaction; if no allergies- document NKDA - Social Hx (tobacco, alcohol, drug use) - PE (always vitals & general) - Same day diagnostic test results/ procedure notes & results - Assessment - Plan P-C-H-C-A-S-P-D-A-P: PCH, CA, SPD, AP

What is good pt education for a Tension-Type HA?

- Realignment exercises involving releasing & relaxing peripheral muscles before strengthening to correct muscles (reduces HA in about 50% of pts) - Hydration - Regular Meals - Correct posture - Improve sleep habits - Reduce stressors

What are RF for a Tension Type HA?

- Stress/ muscle tension - Poor posture - Lack of movement (desk work) Cause: - Cranial trigger points aggravated - Increased 5-HT turnover - CGRP released from trigeminal fibers causing neural inflammation & vasodilation (same with migraine, new medications are directed at preventing release)

What are the RF for confusion in a hospitalized pt?

- Use of physical restraints - Malnutrition - >3 Medications added - Use of bladder catheter - Any Iatrogenic event (EX- chemotherapy; resulting from medical treatment)

What should you do during any pt interaction?

- Verify name & DOB - Wash hands - Establish reason for visit (sit down- make pt feel comfortable) - Open ended questioning - Closed ended questioning - Current medications - Allergies - Social hx: drug, alcohol, cigarette use - Physical Exam - Pt education Always inform pt what you are doing at each step of the exam!

What is the Reflex Response Scale used in DTRs?

0 - No response 1+- Diminished- only seen with reinforcement 2+- Normal 3+- Brisk 4+- Hyperactive, associated w/ clonus- UMN lesion

How do you grade muscle strength?

0- No evidence of movement 1- Trace of movement 2- Full ROM, but NOT against gravity 3- Full ROM against gravity, but NOT against resistance 4- Full ROM against some resistance, but weak 5- Full ROM against resistance

What is the percentage of elderly who develop confusion at some point during a hospital admission?

25-50% Seen in up to 20% of elderly pts admitted to the hospital.

If a pt had Cubital Tunnel Syndrome, where would they feel paresthesia?

4th & 5th digits Compression of ULNAR N. Worse @ night & with repetitive motions

What are the MC billing codes we will use?

99203 & 99204 Always need >3 HPI elements and 2-9 ROS systems and 2 past family/ social hx- then just base of decision making with 99204 requiring more risk (and need 9 ROS systems)

What is considered an Episodic HA?

< 15 days per month Chronic: > 15 days per month Short Duration: <4 hours Long Duration: >4 hours

What is Coherence?

Ability to maintain selective attention over time

What is the treatment for an ACUTE Tension Type HA?

Acute Mild: - Topicals: Tiger balm or Basil, Rosemary, Peppermint oil - Massage Therapy: Trigger point for tx & prevention Mild to Moderate: - ADD OTC NSAIDS or Acetaminophen to topicals & massage LIMIT TO 2X/ WEEK! IF 3X or more, pt needs prophylaxis! Risk of chronic med type HA! TTH + Palpable neck muscle spasm: - Muscle Relaxers (Cyclobenzaprine 5-10 mg q8 hours) Severe TTH: - Augment NSAIDS w/ promethazine, diphenhydramine or metoclopramide - Take an acetaminophen/ ibuprofen/ caffeine combo med. (Excedrin OTC)

What is Delirium?

Acute confusional state. REVERSIBLE. Difficulty with attention. Mental status fluctuates. Dx of Delirium is missed in up to 40%-60% of cases Higher rates of hospital readmission. Life-threatening! Reflects serious CNS dysfunction, esp w/ sudden onset. Ex: Subarachnoid hemorrhage, meningitis, ICP

What is Brudzinski's sign?

After forced flexion of the neck there is a reflex flexion of the hip and knee (positive) Tests for Nuchal Rigidity- sign of meningitis

What should be included in the first sentence of the HPI?

Age, sex, most important case information HPI should include: - OLD CARTS - Pertinent positives/ associated sx - Pertinent negatives -Relevant facts from the pts hx pertaining to the CC

Essential tremor is improved by ___.

Alcohol Occurs with ACTIVITY (absent w/ rest!) Bilateral & symmetric Progressive! Worsened w/ stress. Tx: Reassurance, Primidone, Propranolol

What must you do when getting a pt history?

Ask the pt to tell you in their "own words" why they can to the office? "Can you tell me what brought you in today?" Start with open-ended questions! Other questions: When did you first notice it? Where is it? Activities affected by the problem? Has it happened before? Any prior treatments? What made you decide to come in today? What is concerning to you?

What dermatome is the medial clavicle?

C4

What dermatome is the superior anterior aspect of shoulder?

C5

What reflex arc is tested by the biceps reflex?

C5,C6

What reflex arc is tested by the Brachioradialis reflex?

C5- C6

What dermatome is the thumb?

C6

What dermatome is the middle finger?

C7

What reflex arc is tested by the Triceps Reflex?

C7

What dermatome is the little finger?

C8

How to quickly check cranial nerves?

CNI- Olfactory, smell something CNII- Optic, Pupillary response (direct & consensual); vision chart (visual acuity & fields) CNIII- Oculomotor, figure H CNIV- Trochlear, Figure H, Superior oblique CNV- Trigeminal, (M: grit teeth & palpate; S: V1, V2, V3 or forehead, cheek near nose, and chin w/ cotton ball/ q-tip) CNVI- Abducens, Figure H, Lateral Rectus M. CNVII- Facial, raise eyebrows, shut eyes tight, smile with teeth, puff out cheeks CNVIII- Vestibulocochlear, gross hearing w/ whisper or finger rub CNIX- Glossopharyngeal, same as Vagus CNX- Vagus (M: say ahh and look for symmetrical rise of palate & uvula midline), S: Gag reflex CNXI- Accessory, raise shoulders CNXII- Hypoglossal, feel cheek w/ pts tongue pressed against for tongue strength

What is Dementia?

Chronic & progressive. IRREVERSIBLE. Eventually leads to impairment of day-to-day activities. Develops over months to years. Affects: memory, behavior, & cognition.

In assessment always add what?

Chronic or acute & controlled or uncontrolled

What is the diagnostic approach to confusion?

Depends on: - Onset - Presence of focal neurological symptoms (HA, visual changes?) - Age of pt younger- drug use/ withdrawal, trauma, systemic infections older- URI, UTI, anticholinergics, systemic infections, pneumonia, CHF, opiates, hypoxia, hypo-perfusion, renal/ hepatic failure

What is the ICHD-3 Criteria for a Tension Type HA?

Duration: 30 minutes- 7 days HA has 2 or more of the following: 1) Location: Bilateral, frontal, occipital, and/or neck 2) Characteristic: Pressing/ tight/ squeezing (NOT PULSATING) 3) Intensity: Mild to Moderate (1-6 out of 10) 4) Aggravator: Stress, noise, glare, fatigue (NOT PHYSICAL ACTIVITY) 5) Palpable MUSCLE SPASM in affected area HA has BOTH NEGATIVE SX: - NO nausea/ emesis - None or only one: Photophobia or Phonophobia

According to the ICHD-3 Headache Classification Group, what are SHORT Duration Headaches?

Episodic Short Duration Headaches: - Trigeminal autonomic Cephalgia - Hypnic HA Chronic Short Duration Headaches: - Cluster HA - Paroxysmal Hemicranias <4 Hours!

What is the MC type of tremor?

Essential tremor Tremors are the MC movement disorder in adults. Tremor- Arhythmic oscillation of antagonist muscles, in either an alternating or synchronizing fashion. (Is it resting- w/o action or resisting gravity, postural-holding posture, or action-voluntary movement?)

What is Asterixis?

Failure to maintain continuous voluntary tone in the limbs resulting in very brief loss of strength. "flapping tremor"

How to document a CBC?

Far left: WBC Top: Hemoglobin Far right: Platelet Bottom: Hematocrit

What are motor (strength) exams for the knees?

Flexion & extension

What must you do before all sensory exams?

Give pt instructions clearly and ask them to tell you when they feel light touch and if feels the SAME ON BOTH SIDES Pt should have EYES CLOSED!

What is the Jendrassik maneuver and what is it used for?

Hands cupped and interlocked in front of your chest with elbows pointing out. It is a distraction that is helpful with testing reflexes.

According to the ICHD-3 Headache Classification Group, what are LONG Duration Headaches?

Headaches lasting longer than 4 hours: Then distinguish if the HA occurs less than or more than 15 days per week. Episodic Long Duration Headaches: - Episodic Migraine - Episodic Tension Type Headache Chronic Long Duration Headaches: - Chronic Migraine - Chronic Tension Type Headache - New Daily Persistent Headache - Hemicrania Continua Migraine & Tension Type HA are BOTH LONG DURATION, > 4 hours!!!

What are common heart & lung findings for charting purposes?

Heart: RR w/ no murmurs, rubs, or gallops Lung: Clear to auscultation bilaterally General: well-develped, obese, female who appears in no acute distress (or however the appear- in pain, anxious, etc.) HEENT: PERRLA, EOMI, funduscopic exam MS/Ext: UE/LE strength 5/5 with normal tone; radial & femoral pulses 3+ bilaterally, no edema, no evidence of thrombophlebitis, full ROM Neuro: A&O x3, no dysarthria or aphasia, memory intact, no nystagmus, no fasciculations, tremor, or ataxia; (-) Romberg; CNII-XII intact; sensory intact; DTRs: 2+ throughout; Babinski negative bilaterally

What is dysdiadochokinesia?

Inability to perform rapid alternating movements (rapid, rhythmic alternating movements (RRAM) Thigh pat- turn palms up then down and gradually increase in speed Test bilaterally & simultaneously Slow, but regular- Cerebral dysfunction Fast, but irregular- Cerebellar dysfunction

What is a reflex arc required for?

Involuntary defense mechanisms; dependent upon intact afferent, synaptic, efferent neurons

What dermatome is the MID anterior thigh?

L3

What reflex arc is tested by the Patella Reflex?

L3-L4

What dermatome is just above the knee (very inferior) aspect of thigh or medial anterior lower leg?

L4

What dermatome is the anterior thigh just above the knee?

L4

What is being tested with pt walking on heels?

L4 & L5 integrity

What dermatome is on the dorsal aspect of the foot and lateral aspect of lower leg?

L5

What is a normal Babinski reflex in an adult?

Negative: Toes curl downward

What is OLD CARTS?

Onset Location Duration Characteristics? Alleviating/ Aggravating factors? Radiation? Treatments? Severity (1 to 10, with 1- not at all and 10- worst ever)

What is Kernig's Sign?

Patient lies supine, thigh is flexed with knee at 90 degrees, then provider extends the knee Positive: Pain Sign of meningitis

What is the Rhomberg test?

Patient stands with arms at each side with feet together and instructed to close both eyes FOR 20 SECONDS while standing in that position. Observe for steadiness. Stand by pt's side with an arm in front and behind pt to protect pt if they fall!!!

What is a focused assessment?

Performed to assess a specific problem - Pt demographics (name, sex, DOB, DOS) - CC - HPI (includes ROS +/-, and relevant PMHx/ FMHx) - Current Medications (dosage/ how to use/ frequency, etc.) - Allergies - Social hx (tobacco, alcohol, drug use) Ex: No current or prior alcohol or drug abuse - PE (Vitals, General, minimal Cardio & Pulm, and include what is relevant to the CC) - Same-day diagnostic test results/ procedure notes & results - Assessment - Plan - Sign & Date

What is testing performed for Carpal Tunnel?

Phalen's Sign & Tinel's Sign (tap lightly over median N.)

What is a positive Babinski reflex in an adult?

Postive: Toes curl upward Think: UMN lesion! Abnormal!

What is an essential tremor?

Postural or action tremor. Improved with alcohol. Genetic component with positive family history (50%) Usually involves the hand, but can involve the head & voice

What is a physiologic tremor?

Postural tremor. Usually disappears when eyes are closed. Often made worse by stress & caffiene

When is triptan treatment CI?

Pt's with MI, HTN, Cardiovascular disease

How do you test for Clonus (upper neuron lesion- CVA, MS, etc.)?

Quickly dorsiflex & plantar flex ankle to encourage relaxation. Then quickly dorsiflex and hold the foot Observe for involuntary muscle contractions/ relaxations of the foot

What are important questions to ask a pt with confusion?

Recent HA, drug use, & fevers? BUT- Contact caregiver since pt is confused! - Timing (acute/ sudden, previous episodes, or chronic?) - Any history of seizures? Diabetes? Taken insulin? - What is the pt's baseline cognitive function (underlining dementia or cognitive impairment)? If so, for how long? - Any fever, SOB, HA, UTI sx, abnormal motor activity? - Recent medication changes? Is the pt on any medications that are commonly abused? Are they taking too much? Any recent withdrawal? - Recent trauma/ fall?

What is a Parkinson tremor?

Resting tremor. Pill-rolling quality. Hand on lap/ resting with tremor. Stiffness. Slowness. Gait changes.

What dermatome is the lateral aspect of the foot?

S1

What reflex arc is tested by the Achilles Reflex?

S1

What is being tested with pt walking on toes?

S1 integrity

What is the best clinical diagnostic test for Carpal Tunnel Syndrome?

Scratch & Collapse Test Pt has arms in 90 degrees and the pt's thumb is most superior. Have pt apply resistance against your hand with their wrist & then scratch their median N. if pt's strength decreases- test is positive

What are HA characteristics?

See image.

What is the documentation of a normal neuro exam?

See image.

How do you describe a Parkinson's gait?

Shuffling- postural instability, impairment of postural balance, reduced arm swing; Bradykinesia w/ walking & rising from chair "get up & go test" (not symmetric) Also, "Cogwheel" rigidity; resting tremor "pill rolling" Deficit of Dopamine! Tx: Levodopa/ Carbidopa (also, anticholinergics, benztropine (Cogentin), trihexyphenidyl (Artane))

What dermatome is the umbilicus?

T10

What dermatome is the nipple line?

T4

What is the #1 MC type of HA?

Tension Type HA (second MC illness affecting 1 in 5 people worldwide) Follow by, Migraine HA (#2)

How do you document a CMP?

Top: Na, Cl, BUN Bottom: K, CO2, Cr on far right (in end of arrow): Glucose

True or False: There is no formal ROS in a Progress Note?

True HPI should include all pertinent positives/ negatives from ROS

What should be near the top of your differential for an elderly pt with confusion?

UTI A) Primary Causes: - Meningitis - Stroke - Head trauma - Seizures B) Secondary Causes: - Infections - Hypoxia/ poor perfusion - Hypoglycemia - Renal/ hepatic failure - Toxins (Carbon monoxide, heavy metals, pesticides) C) Medications - Alcohol and/or withdrawal - Amphetamines - Anticholinergics - Narcotics - Benzo withdrawal

What is characteristic of a Cluster HA?

Unilateral, periorbital pain described as: sever, piercing, boring Common findings: Nasal congestion, rhinorrhea, ptosis, injected conjunctiva, lacrimation Lasts < 2 hours Abortive therapies: Oxygen, lidocaine, capsaicin, Imitrex, Valproate, lithium, corticosteroids, or cyproheptadine Picture shows Horners Syndrome!

If you suspect peripheral neuropathy, such as B12/ folate deficiency, Lyme disease, diabetes mellitus, neurosyphilis, what can you ask the pt to do?

Walk- watch the pt's gait for SENSORY ATAXIA. (cerebellar test) Associated w/ loss of sensory/ proprioception in the legs - Unsteady, wide-based, stomping gait - Watching the ground while walking - Associated with a (+) Rhomberg due to sx worsening w/ eyes shut - Can have loss of vibration & joint position w/ proprioception test as well

What is the 1st question to ask any patient who c/o a HA?

What is the frequency? What is the duration? Also, - Location? (Unilateral or bilateral) - Intensity/ Disability (directs tx) - Type of Pain (aching, stabbing, throbbing, pulsating) - Does movement increase or worsen pain? Light? Noise? - Any nausea? - Prior treatment?

Timing considerations with confusion:

Within seconds: Seizure, stroke, subarachnoid hemorrhage Minutes to Hours: Drug induced, hypoxia, hypoglycemia Hours to Days: Renal/ Hepatic failure, infection Progression over months: Dementia Quantify sudden onset.....

What are prophylactic treatment for migraines?

Worsened by exercise & associated with nausea! - Propranolol - Valproic Acid - Topamax - TCAs- Elavil - CCC- Vermapril Acute tx: Triptans!

If there is more than one problem during a pt interview then ____.

Write two separate HPIs

Is it possible to have delirium & dementia at the same time?

Yes! Delirium & dementia often coexist! Patient is confused for weeks to months & suddenly becomes worse than baseline. (Superimposed delirium on top of dementia!) Hours to Days: Delirium