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OSCE CampNeurological Tutorial for Medical StudentSurat Tanprawate, MD, FRCPT Northern Neuroscience Center Department of Internal Medicine Chiangmai UniversityTopicCommon short neurological case CSF interpretationCommon Neurological Short CaseOSCE Short casesÃĒâŽÂĒ Facial weakness: BellÃĒâŽâĒs palsy ÃĒâŽÂĒ Entrapment neuropathy: Carpal tunnelsyndromeÃĒâŽÂĒ Tremor: ParkinsonÃĒâŽâĒs disease, ET ÃĒâŽÂĒ Ptosis: CN III palsy ÃĒâŽÂĒ Visual ÃŊÂŽÂeld defect: occipital lobe lesion ÃĒâŽÂĒ Generalized weakness???
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Neurological Tutorialfor
Medical StudentSurat Tanprawate, MD, FRCPT
Northern Neuroscience CenterDepartment of Internal Medicine
Chiangmai University
OSCE Camp
TopicCommon short
neurological case
CSF interpretation
Common Neurological Short
Case
OSCE Short cases
âĒ Facial weakness: Bellâs palsy
âĒ Entrapment neuropathy: Carpal tunnel syndrome
âĒ Tremor: Parkinsonâs disease, ET
âĒ Ptosis: CN III palsy
âĒ Visual field defect: occipital lobe lesion
âĒ Generalized weakness???
General Concept
1.Read the instruction
2.Key concept
3.Focus neurological examination
4.Final differential diagnosis
Facial weakness1. Reading the instruction
āļāļđāđāļāđāļ§āļĒāļĄāļĩāļāļēāļāļēāļĢāļŦāļāđāļēāđāļāļĩāđāļĒāļ§āļĄāļē 2 āļ§āļąāļ āļāļāđāļŦāđāļāļēāļĢāļāļĢāļ§āļāđāļĨāļ°āļ§āļīāļāļīāļāļāļąāļĒāļŠāļēāđāļŦāļāļļāļāļāļāđāļĢāļāļāļĩāđāđāļāđāļāđāļāđāļāđāļĄāļēāļāļāļĩāđāļŠāļļāļ
Facial weakness2. Key concept
âĒ Pattern of facial weakness
âĒ āđāļāļ·āđāļāđāļĒāļ UMNL and LMNL
âĒThe presence of signs other than facial weakness
Facial weakness3. Focus neurological exam.
Examine: Each part of facial muscle
âĒ āļĒāļąāļāļāļīāđāļ§ āļŦāļĢāļ·āļāļĒāđāļāļŦāļāđāļēāļāļēāļ
âĒ āļŦāļĨāļąāļāļāļēāļāļĩāđ 2 āļāđāļēāļ
âĒ āļĒāļīāđāļĄ āļŦāļĢāļ·āļ āļĒāļīāļāļāļąāļ
âĒ āđāļāđāļēāļāļēāļ āļŦāļĢāļ·āļ āļāđāļēāļāļēāļāļāļđāđ
āđāļĒāļāļ§āđāļēāđāļāđāļ UMN or LMN weakness
Facial weakness3. Focus neurological exam.
âĒ āļāļđāļŦāļđāļ§āđāļēāļĄāļĩ skin lesion ?
âĒ āļāļĢāļ§āļ lateral rectus āļāđāļēāļāđāļāļĩāļĒāļ§āļāļąāļ(CN 6)
âĒ āļāļĢāļ§āļ facial sensation
âĒ āļāļēāļĄāļŦāļĢāļ·āļāļāļĢāļ§āļ taste sensation
āđāļĄāļ·āđāļāđāļŦāđāļāļ§āđāļēāđāļāđāļ LMN lesion āđāļŦāđāļāļĢāļ§āļāđāļāļīāđāļĄāđāļāļīāļĄUnilateral LMN
weaknessBilateral LMN
weakness
âĒ āļŦāļēcase āļĒāļēāļ āđāļĄāđāļāđāļēāļāļāļ
âĒ DDx. Myasthenia gravis
âĒ GBS
âĒ Myotonic dystrophy
Facial weakness4. Final diagnosis
Bellâs palsy
Facial palsy: LMN facial weaknessāđāļĄāđāļĄāļĩāļāļ§āļēāļĄāļāļīāļāļāļāļāļīāļāļāļ CN āļāļ·āđāļ
āļāļēāļĢāļĢāļąāļāļĐāļēāļāļāļīāļāļēāļĒāļāļđāđāļāđāļ§āļĒ
āđāļŦ āđPrednisolone 1 MKD x 10 dayAnti-viral Rx: Acyclovir 4000 mg/d
Eye care
Numbness of hand1. Reading the instruction
āļāļđāđāļāđāļ§āļĒāļāļēāļāļĩāļāđāļĄāđāļāđāļēāļāļĄāļĩāļāļēāļāļēāļĢāļāļēāļāļīāđāļ§āđāļāđāļāđāļĨāļ°āļāļīāđāļ§āļāļĩāđāļĄāļē1 āđāļāļ·āļāļāļāļāļāļĢāļ§āļāļĢāđāļēāļāļāļēāļĒāđāļĨāļ°āļ§āļīāļāļīāļāļąāļĒāđāļĢāļ
Numbness of Hand2. Key concept
āļāļāļ Carpal tunnel syndrome āđāļŦāļ āđ
Numbness of Hand3. Focus neurological exam.
âĒ āļāļĢāļ§āļāđāļāļ·āđāļāđāļĒāļāļāļēāļāđāļĢāļāļāļ·āđāļāļāļĩāđāļāļēāļĄāļ·āļ(radiculopathy, ulnar neuropathy)
âĒ motor involvement
âĒ sensory distribution
âĒ āļāļĢāļ§āļāđāļāļ·āđāļāļĒāļ·āļāļĒāļąāļ CTS
âĒ Tinelâs sign, Phalenâ test
Motor test
âĒ āļāļĢāļ§āļāļāļĨāđāļēāļĄāđāļāļ·āđāļāļāļĩāđāđāļĨāļĩāđāļĒāļāļāđāļ§āļĒ Median nerve
âĒ Lumbricoides: first, second
âĒ Opponen pollicis
âĒ Abductor pollicis brevis
âĒ Flexor pollicis brevis
LOAF
Opponens Pollicis Abductor Pollicis Brevis
1st Lumbricoidis
âĒ āļāļĢāļ§āļāļāļĨāđāļēāļĄāđāļāļ·āđāļāļāļĩāđāđāļĨāļĩāđāļĒāļāļāđāļ§āļĒ Ulnar n.
Flexor Carpi Ulnaris
1st Dorsal Interosseous
āļāļĢāļ§āļāļāļĨāđāļēāļĄāđāļāļ·āđāļāļāļĩāđāđāļĨāļĩāđāļĒāļāļāđāļ§āļĒ Radial n.
Tricep Brachioradialis
Extensor Carpi Radialis Longus Extensor digitorum
Sensory test
Phalenâs test Tinelâs sign
Ptosis1. Read the instruction
āļāļĒāļļāļ...āļāđāļēāļāļāļĩāđāļĄāļēāļāđāļ§āļĒāļŦāļāļąāļāļāļēāļāļāļĄāļē 5 āļ§āļąāļāļāļāļāļĢāļ§āļāļĢāđāļēāļāļāļēāļĒāđāļĨāļ°āđāļŦāđāļāļēāļĢāļ§āļīāļāļīāļāļāļąāļĒāđāļĢāļ
2. Key concept
Levator palpebrae superioris
âĒCN III palsyâĒNMJ: Myasthenia gravis
Muller muscleâHornerâs syndrome
Focus neurological examination
âĒ Ptosis
âĒ Uni- VS Bilateral
âĒ Complete VS Incomplete
âĒ Extra-ocular movement
âĒ Resting and movement
âĒ Distribution of eye movement
âĒ Pupil
âĒ Normal, dilate, small
InterpretationPtosis Pupil EOM Diagnosis
Unilateral DilateâĒResting: āļāļēāđāļāļāļāļāļāļāļâĒMovement: distribution of CN 3
CN III palsy from
Post com a. aneurysm
Unilateral NormalâĒResting: āļāļēāđāļāļāļāļāļāļāļâĒMovement: distribution of CN 3
CN III palsy from
Diabetes
Unilateral, Incomplete
ptosisSmall âĒEOM: normal or plus
CN 3,4,6 involvedHornerâs syndrome
InterpretationPtosis Pupil EOM Diagnosis
Bilateral NormalâĒLimited EOMâĒāđāļĄāđāļāļēāļĄ distribution of CN 3,4,6âĒāļĄāļĩ facial weak āļĢāđāļ§āļĄ
Myasthenia gravis
Tremor1. Reading the instruction
āļāļđāđāļāđāļ§āļĒāļĄāļĩāļāļēāļāļēāļĢāļŠāļąāđāļāļĄāļē 5 āļāļĩ āļāļāđāļŠāļāļāļāļēāļĢāļāļĢāļ§āļāļĢāđāļēāļāļāļēāļĒāđāļĨāļ°āđāļŦāđāļāļēāļĢāļ§āļīāļāļīāļāļāļąāļĒāđāļĢāļ
Tremor2. Key concept
1. Tremor āļāđāļēāđāļŦāļ
2. āđāļĄāļ·āđāļāļĢāļđāđāļ§āđāļē āļāđāļēāđāļŦāļāđāļĨāđāļ§āļāļķāļāļāļ°āļĢāļđāđāļ§āđāļēāļāļ°āļāļĢāļ§āļāļāđāļēāđāļŦāļāļāđāļāđāļ
āļāļĒāļēāļāļĢāļđāđāļ§āđāļē Tremor āđāļāđāļāļāļ°āđāļĢāļāļāļāļŠāļāļāđāļāđāđāļāđ 3 āđāļĢāļāđāļāđāļēāļāļąāđāļ
Parkinsonâs disease
Essential tremor
Cerebellar tremor
Type of Tremor: 3 āļāđāļēāļāļđāļĄāļ·āļ& āđāļāđāļē āļ§āđāļēāļāļĒāļąāļāđāļ§āļĨāļēāļāļĒāļđāđāđāļāļĒ āđ
āļŦāļĢāļ·āļāđāļĄāđ
1. Resting tremor
3. Focus neurological examination
Type of Tremor: 3 āļāđāļēāļĒāļāļĄāļ·āļāļāļĢāļāļĄāļēāļāđāļēāļāļŦāļāđāļēāđāļĨāļ°
āļāđāļēāļāļēāļāđāļāļāđāļāđāļēāđāļ
2. Postural tremor
3. Focus neurological examination
Type of Tremor: 3 āļāđāļēāļāđāļē Finger to nose test
3. Intention tremor
3. Focus neurological examination
Resting tremorāļāđāļāđāļāļāļĢāļ§āļāļŦāļē signs āļāļ·āđāļ āđāļāļāļ Parkinsonâs disease
âĒ āļāļĢāļ§āļ Tone āļāļāļāļĄāļ·āļ āđāļāļ
âĒ cogwheel rigidity
Resting tremorāļāđāļāđāļāļāļĢāļ§āļāļŦāļē signs āļāļ·āđāļ āđāļāļāļ Parkinsonâs disease
âĒ āļāļĢāļ§āļ āļāļēāļĢāđāļāļĨāļ·āđāļāļāđāļŦāļ§ āđāļ āđfinger tapping āđāļĨāļ°āļāļđāļāļēāļĢāđāļāļīāļ
âĒ Bradykinesia
âĒ āļĢāļ°āļŦāļ§āđāļēāļāđāļāļīāļāļāđāļāļāļāļ§āđāļēāļĄāļĩ āļāļąāļ§āđāļāđāļāđāļāļŦāļāđāļē(stoop posture) āđāļĨāļ°āđāļāļīāļāļāļāļĒāđāļāđāļē āđāļāļāđāļĄāđāđāļāļ§āđāļ(festinating gait)
Resting tremorāļāđāļāđāļāļāļĢāļ§āļāļŦāļē signs āļāļ·āđāļ āđāļāļāļ Parkinsonâs disease
âĒ āļāļĢāļ§āļ postural reflex āđāļāļĒāļāđāļāļĄāđāļāļāļĒāļđāđāļāđāļēāļāļŦāļĨāļąāļāļāļđāđāļāđāļ§āļĒāđāļĨāđāļ§āļāļķāļāļĄāļēāļāđāļēāļāļŦāļĨāļąāļ
âĒ Postural instability āļāļđāđāļāđāļ§āļĒāđāļĄāđāļŠāļēāļĄāļēāļĢāļāļāļĢāļāļāļąāļ§āđāļāđ
Postural tremorāļāđāļāđāļāļāļĢāļ§āļāļŦāļē signs āļāļ·āđāļāđ āļāļāļ hyperthyroid
âĒ āļāļđāļāļēāļ§āđāļēāđāļāļāļŦāļĢāļ·āļāđāļāļĨāđāļē āļāļđ lid retraction
âĒ āļāļąāļāļāļīāļ§āļŦāļāļąāļāļ§āđāļēāļāļ·āđāļāļŦāļĢāļ·āļāđāļĄāđ
âĒ āļāļĨāđāļēāļāđāļāļĄ Thyroid
âĒ āļāļąāļHeart āļāļĢāđāļāļĄāļāļĨāđāļē Pulse (āļĄāļĩAF or Tachycardia?)
Intention tremorāļāđāļāđāļāļāļĢāļ§āļāļŦāļē signs āļāļ·āđāļāđ āļāļāļ cerebellar
dysfunction
âĒ āļāļĢāļ§āļ eye movement āļāļđ nystagmus
âĒ āļāļĢāļ§āļ rapid alternating movement: dysdiadochokinesia?
âĒ āđāļŦāđāđāļāļīāļāļāļĢāļĢāļĄāļāļē āđāļĨāļ° tandem walk test: āļāļđ cerebellar gait ataxia āļāļ°āđāļāļīāļāļāļēāļāļēāļ āđāļĨāļ° tandem walk impair
Visual field defect1. Reading the instruction
āļāļāđāļŠāļāļāļāļēāļĢāļāļĢāļ§āļ visual field, āļāļāļāļāļĨāļāļēāļĢāļāļĢāļ§āļāđāļĨāļ° āļāļāļāļāđāļēāđāļŦāļāđāļāļāļāļ lesion
āļ§āļīāļāļĩāļāļāļŠāļāļ Visual fieldāđāļāļĒ confrontation test
âĒ āļāļāļŠāļāļāļāļĩāļĨāļ°āļāļē(āļāļīāļāļāļēāļāļĩāļĨāļ°āļāđāļēāļ)
âĒ āđāļāļĨāļ·āđāļāļāļ§āļąāļāļāļļāđāļŦāđāļāļĢāļ 4 quadrant
Interpretation
Report visual āļāļĩāđāļāļđāđāļāđāļ§āļĒāđāļŦāđāļ
LeftHomonymous
hemianopia
Lesion at occipital lobe āļāļĢāļāļāđāļēāļĄ
Generalized muscle weakness
Quadriparesis
Muscle testingUpper extremityâĒdeltoidâĒbicep and tricepâĒwrist extensor and flexorâĒhand grip
Lower extremityâĒHip flexâĒHip addution and abductionâĒKnee extension and flexionâĒAnkle dorsiflex and plantarflex
Proximal m. weakness+ normal reflex: muscle disease, NMJ(MG)Distal muscle weakness+decrease reflex: polyneuropathy
DTR
CSF interpretation
CSF interpretation
āļĨāļąāļāļĐāļāļ°āļāđāļāļŠāļāļ
âĒ āđāļŦāđāļāļĨ CSF profile
âĒ Differential diagnosis
âĒ Treatment
âĒ āđāļŦāđāļāļđ special test ex. Gram stain, AFB
âĒ Interpret, diagnosis, treatment
CSF interpretation
âĒ General CSF profile
âĒ Open CSF pressure
âĒ Total cell count, differential cell count
âĒ CSF glucose/plasma ratio
âĒ CSF protein
âĒ Specific test
âĒ culture, stain: gram, AFB
Interpret general CSF profile
Diagnosis Total Cell count Differential count CSF glucose/plasma ratio
CSF protein(g/l)
Normal <5 cell/cu.mm MNC >0.4 <0.45
1.āļāļđ cell āļāđāļāļ: āļāđāļē cell āđāļāļīāđāļĄāđāļŦāđāļāļđ differential count2.āļāļđ glucose āđāļāđāļāļāļąāļ§āļāļĢāļ°āļāļāļāļāļēāļāļāļēāļĢāļāļđ cell3.āļāļđ protein āļāđāļāļĄāļē
CSF Pleocytosis
Diagnosis Total Cell count Differential count CSF glucose/plasma ratio
CSF protein(g/l)
Normal <5 cell/cu.mm MNC >0.4 <0.45
Bacterial meningitis >1000
Predominance of PMN
Normal to marked decrease
Mild to marked elevation
Fungal meningitis Variable
Predominance of lymphocyte Low Elevated
TB meningitis VariablePredominance of
lymphocyte Low Elevated
Viral meningitis <100Predominance of
lymphocyte NormalNormal to elevated
Treatment of MeningitisBacterial meningitis
âĒ āļŠāđāļ lab āđāļāļīāđāļĄ
âĒ āđāļŦ āđABO: cephalosporin(ceptriazone) 2 gm iv q 12 hrs
âĒ Dexa 10 mg iv q 6 hrs x 4 dayāđāļŦāđāļāđāļāļāđāļŦ āđABO 15 min
âĒ supportive care: iv fluid, observe neuro signs
Albuminocytologic dissociation
Diagnosis Total Cell count Differential count CSF glucose/plasma ratio CSF protein
Albuminocytologic dissociation <5 cell/cu.mm mononclear cell normal increase
1.Guillain-Barre syndrome2.Brain tumor3.Multiple sclerosis4.Cerebrovascular thrombosis5.Subarachnoid block
Good Luck
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