Articles

Case 5 – Worsening Tremor

Tim Milligan Neurology

You are seeing Ms. Wilmington, a 63 year old woman, in your outpatient clinic. She tells you that her old tremor is getting worse. Take a focused history of her complaint and perform a focused physical exam.

History

  • Onset of tremor
  • Onset of worsening of the tremor
  • Clarifies if tremor occurs during rest or activity (rest)
  • Difficulty performing specific tasks due to tremor (writing)
  • Change in gait – slowing, fewer steps, less arm swing
  • Stability of gait
  • Need for assistive devices for ambulation
  • Difficulty with fine motor skills
  • Posture changes
  • Difficulty initiating movement
  • Psychomotor retardation
  • Change in affect
  • Difficulty with short term memory
  • Change in voice
  • Effect on ADLs
  • Effect on IADLs
  • Personal history of a psychotic disorder
  • Family history of Parkinson’s and/or essential tremour
  • Current medications
  • Addresses patient’s concerns as to what is causing these symptoms
  • Inquires about symptoms of depression
  • Patient’s concerns about independence

Physical Examination

Vitals/Inspection

  • Measures orthostatic changes – comments on hypotension
  • Inspects for masked face (none)
  • Comments on stooped posture
  • Comments on presence of resting tremor
  • Comments on altered speech

Motor Examination

  • Tests tone in upper extremities – comments on presence of cogwheeling
  • Tests for essential tremor, likely not present
  • Tests for intent tremor, likely not present

Sensory Examination

  • Tests reflexes (normal)
  • Tests for primitive reflexes associated with Dementia – palmomental and glabellar
  • States that a sensory examination should be performed, though it would be normal

Gait Examination

  • Evaluates patient getting up from chair, comments on bradykinesia
  • Comments on shuffling gait
  • Comments on stability of gait
  • Comments on festinating gait and lack of arm swing
  • Performs retropulsion test (positive)

Case 4 – Headache

Tim Milligan Neurology

You are seeing Ms. Davis, a 32 year old woman, in your ambulatory clinic today. She states that she has had a worsening headache over the last week. Take a focused history of this complaint. Then, examine all cranial nerves except for I, II, & VIII.

History

  • Onset and duration of headache
  • Location of headache, unilateral vs. bilateral (entire head, bilateral)
  • Severity
  • Frequency
  • Radiation
  • Quality of headache (dull, diffuse)
  • Alleviating factors
  • Triggers for the headache/aggravating factors
  • Temporal association (headache not worse in mornings)
  • Association with nausea/vomiting
  • Vision changes before or during headache
  • New sensory symptoms: weakness, numbness, tingling in upper or lower extremities
  • Photophobia/phonophobia
  • Association with menstrual cycle
  • Systemic symptoms – weight loss, low energy, anorexia
  • Fever and neck stiffness
  • Personal history of head trauma
  • Personal history of migraines
  • Family history of migraines
  • Effect on daily activities
  • Use of oral contraceptive pills
  • Caffeine intake
  • Smoking and alcohol history

Physical Examination

CN III, IV, & VI

  • Assesses all six cardinal movements of the extra ocular muscles
  • Asks patients about diplopia in all directions of gaze
  • Comments on absence of nystagmus
  • Comments on absence of ptosis

CN V

  • Examines for light touch in all three nerve divisions (forehead, cheek, chin)
  • Palpates masseter and temporalis muscles and comments on bulk
  • Tests masseter muscle power by opposing jaw opening
  • Tests right and left pterygoids muscle power by opposing lateral jaw movement
  • States that the corneal reflex should be tested and explains the procedure

CN VII

  • Raise eyebrows
  • Tightly clench eyes (and tries to open them)
  • Puff cheeks (and tries to deflate them)
  • Show the lower teeth only
  • Comments on the presence/absence of facial asymmetry/droop

CN IX & X

  • Assesses palatal elevation
  • Assesses gag reflex with tongue depressor
  • Asks patient to swallow
  • Tests phonation
  • States that taste on the posterior 1/3 of the tongue should be tested, and describes how

CN XI

  • Assesses power of both sternoclediomastoid muscles
  • Assesses power of both trapezius muscles

CN XII

  • Examines the tongue for fasciculations
  • Asks patient to protrude tongue, examines for deviation
  • Assesses power of tongue in lateral plane

Case 3 – Seizure

Tim Milligan Neurology

You are seeing Oleg Markov, a 15 year old male, in your ambulatory clinic today. He states that he has recently experienced moments during the day where he loses awareness for minutes at a time but soon fully recovers. Take a focused history of this complaint.

History

  • Onset and duration of awareness deficit
  • Frequency
  • Factors which precipitate these episodes
  • Injury sustained as a result of the seizure
  • Post-ictal symptoms: confusion
  • Associated sensory deficits
  • Associated motor deficits
  • Associated cognitive deficits
  • Muscle spasms
  • Anatomical progression of motor involvement (e.g. Jacksonian March)
  • Symptoms suggesting aura
  • Associated incontinence
  • Tongue biting and salivation
  • Automatisms associated with these episodes
  • Personal history of head trauma
  • Congenital neurological disorder
  • Perinatal infection
  • Medications
  • Drug history
  • Personal history of seizure disorder
  • Family history of seizure disorders
  • Effect on daily activities

Case 2 – Ataxia

Tim Milligan Neurology

You are seeing Mrs. Salamanca, a 45 year old female, in your outpatient clinic. She’s been complaining of unsteadiness when she walks. Please perform a complete examination of her coordination.

Physical Examination

Gait

  • Asks patient to walk to assess gait
  • Assesses toe walking
  • Assesses heel walking
  • Assesses tandem gait
  • Comments on wide, ataxic gait with unequal steps

Balance

  • Performs Rhomberg Test

Motor examination

  • Gross: Performs heel to shin test
  • Gross: Performs finger to nose test
  • Fine: Alternating fingers to thumb
  • Fine: Alternating palm to hand
  • Assesses for intention tremor
  • Assesses for dysarthria
  • Assesses for nystagmus

Case 1 – Cranial Nerve Examination

Tim Milligan Neurology

You are seeing Mr. Grimson, a 39 year old man, for numbness of the face as well as a right facial droop. Please examine cranial nerves V and VII

Physical Examination

CN V

  • Examines for light touch in all three nerve distributions (forehead, cheek, chin)
  • Examines for pain/temperature in all three nerve distributions (forehead, cheek, chin)
  • Palpates masseter and temporalis muscles and comments on bulk
  • Tests masseter muscle power by opposing jaw opening
  • Tests right and left pterygoids muscle power by opposing lateral movements of the jaw
  • Tests the jaw reflex using reflex hammer
  • States that the corneal reflex (afferent V, efferent VII) should be tested and explains the procedure

CN VII
Motor:

  • Comments on the presence/absence of facial asymmetry/droop
  • Tests frontalis by asking patient to raise eyebrows
  • Tests orbicularis oculi by asking patient to tightly shut eyes (and tries to open them)
  • Tests orbicularis oris by asking patient to tightly close lips (and tries to open them)
  • Shows upper and lower teeth
  • Puffs cheeks (and tries to deflate them)
  • Shows the lower teeth only (platysmus)
  • States that the corneal reflex should be tested and explains the procedure (efferent limb)
  • States that lacrimation and salivation should also be tested

Sensory:

  • States that taste on the anterior 2/3 of the tongue should be tested, and describes how this examination could be performed

Case 6 – Hand Pain

Tim Milligan Musculoskeletal

You are seeing Mrs. Dawes, a 43 year old female, in your outpatient clinic today. She states that the pain in her right hand is becoming so severe that she can’t even hold a pencil or toothbrush. Take a focused history and perform the necessary physical exam

History

  • Identifies affected hand joints (MCPs, PIPs)
  • Onset of pain
  • Aggravating factors (activity)
  • Alleviating factors (rest, Advil)
  • Character
  • Radiation
  • Association with morning stiffness and duration of stiffness (lasts more than 1 hour)
  • Other affected joints, elsewhere in the body
  • Frequency (intermittent flare-ups)
  • Nighttime pain
  • Fever, night sweats, weight loss, or other systemic symptoms
  • Associated rash
  • Mouth ulcers, dry mouth
  • GI symptoms
  • Associated neurologic symptoms
  • Ophthalmologic symptoms: dry eyes, irritation
  • History of trauma
  • Current medications
  • Personal history of rheumatologic disease
  • Family history of diabetes, thyroid disease, or Celiac disease (autoimmune diseases)
  • Family history of rheumatologic conditions
  • Effect on daily activities

Physical Examination

Inspection of Hand joints, including Wrist

  • Comments on presence/absence of erythema and effusion
  • Comments on deformities, muscle wasting, and deviations

Palpation of hand joints, including the wrist

  • Warmth
  • Tenderness
  • Effusion
  • Crepitus
  • Instability
  • Neurologic exam of hand for power and sensation

Range of Motion

  • Assess active and passive range of motion of all joints in the hand

Extra-articular examination for autoimmune disease

  • General: presence/absence of edema, muscle wasting, cachexia
  • Oral examination: ulcers
  • Respiratory examination: effusions, interstitial disease
  • Musculoskeletal: other effused joints
  • Dermatologic: rashes, ulcers, petechiae
  • Ophthalmologic: iritis

Case 5 – Shoulder Pain

Tim Milligan Musculoskeletal

You are seeing Mrs. Kossopoulos, a 26 year old woman, for shoulder pain that has steadily worsening over the last few weeks , during which time she’s been playing softball. Take a focused history and perform a physical exam.

History

  • Onset and duration of pain (began during softball)
  • Progression
  • Alleviating and aggravating factors (worse when bring arm above the shoulders)
  • Quality and location of pain
  • Radiation
  • Presence of night time or morning symptoms (worsens at night)
  • Sensory symptoms in the affected arm e.g. numbness, tingling
  • Motor symptoms in affected arm e.g. weakness, decreased grip strength
  • Associated stiffness
  • Fever and other systemic symptoms
  • Personal history of arthritis
  • Associated trauma/overuse
  • Past shoulder pain
  • Pain in other joints
  • Occupational history as it relates to the pain
  • Family history of arthritis
  • Effect on daily activities

Physical Examination

Inspection

  • Examines both shoulders for SEADS
  • Assesses all active ranges of motion of shoulder
  • Examines the neck for range of motion
  • States that the elbow should be examined as well

Palpation

  • Palpates shoulder for crepitus, warmth, and effusion
  • Palpates the sternoclavicular, acromioclavicular, and glenohumeral joints for tenderness/deformity
  • Palpates all bony aspects of the shoulder joint
  • Tests passive range of motion for affected shoulder

Special Tests

  • Assesses for rotator cuff pathology
  • Assesses for impingement of muscle tendons
  • Assesses for shoulder instability

Case 4 – Worsening Back Pain

Tim Milligan Musculoskeletal

You are seeing Mr. Del Negro, an active 82 year old male in a walk-in clinic. He told your nurse that his back pain has recently become unbearable. Please take a focused history and perform a focused physical examination.

History

  • Onset of back pain
  • Location, and if pain is unilateral/bilateral
  • Quality of pain (dull)
  • Radiation of pain (none)
  • Alleviating and aggravating factors
  • Medications/therapies that have been attempted/are successful to relieve the pain
  • Associated trauma or overuse injury
  • Sensory loss (none)
  • Parasthesia (none)
  • Motor deficits (none)
  • Fever, weight loss, or other systemic symptoms (none)
  • Bladder or bowel incontinence
  • Past history of back pain
  • Personal history of peripheral vascular disease
  • Smoking history (quantity in pack-years)
  • Dyslipidemia
  • Personal history of malignancy
  • Effect on daily activities

Physical Examination

Inspection

  • Comments on shape of spine – kyphosis, scoliosis, as well as posture
  • Comments on any asymmetry of the back, including swelling, scars, or bruising

Range of Motion/Gait

  • Observes all active ranges of motion for the back
  • Assesses patient’s gait

Palpation

  • Palpates along spinous processes and paraspinal muscles of the back for tenderness
  • Performs straight leg raise on both sides, with and without ankle dorsiflexion (negative)
  • Palpates peripheral pulses (present)
  • States that an abdominal exam should be performed to rule out an abdominal aortic aneurysm

Neurological exam

  • Tests foot sensation (L4, L5, S1)
  • Tests for saddle anesthesia (S3, S4, S5)
  • Tests knee (L4) and ankle reflex (S1)
  • Tests Babinski response
  • Tests power of big toe and foot dorsiflexion, as well as foot plantarflexion (S1)
  • Assesses for hip abduction (L5); states that full hip examination should be performed
  • States that rectal tone should be assessed

Case 3 – Arm Pain Spousal Abuse

Tim Milligan Musculoskeletal

You are seeing Mrs. McNeil, a 31 year old female in your general practice clinic. She states that she recently injured her arm while cleaning her home. Take a focused history of her complaint.

History

  • Inquires about circumstances in which injury occurred
  • Timing of injury
  • Mechanism (patient eventually discloses that she had been physically abused by her husband)
  • Other recent injuries
  • Visits to hospital for other reasons
  • Asks about any medication use
  • Alcohol/drug history
  • Determining social context at home (lives with husband, two young children)
  • Inquires if husband was verbally abusive
  • Inquires if husband was sexually abusive
  • Whether husband has used weapons to harm patient, or has access to weapons
  • Extent of injury in the past
  • Asks if the children have been abused
  • Asks if the children have witnessed spousal abuse
  • Asks if the husband has a substance abuse problem
  • Asks if patient feels safe at home
  • Asks if friends/family are aware of the abuse
  • Inquires about emergency plans to escape in the event of further abuse
  • Asks if she has access to financial resources
  • Asks if she would like help from a counselor
  • Asks if she would like support from community resources
  • Asks if she would like legal counseling

Case 2 – Hip Pain

Tim Milligan Musculoskeletal

You are seeing Mrs. Goldberg, a 76 year old female from a nursing home who has been well until today. She presents to the Emergency Department after being found on the floor of her room in her nursing home. She was alert and oriented when she was found, and has felt well in recent days. Take a focused history and perform all the relevant physical examination maneuvers.

History
Physical Examination

Inspection

  • Examines both hips joints for SEADS (swelling, erythema, muscle atrophy, deformity, skin changes)
  • Assesses all active range of motion for both hips (flexion/extension, abduction/adduction, rotation)
  • Assesses patient’s gait (patient refuses due to pain)
  • States that the lower back and knees should be examined as well

Palpation

  • Palpates hips, PSIS, and ASIS for tenderness
  • Determines real and apparent leg lengths (notes that there is a significant difference)
  • Assesses peripheral pulses
  • Assesses neurologic status of effected limb
  • Tests all passive range of motion for effected hip

Special Tests

  • Performs Trendelenburg’s Test assessing for hip abductor strength
  • Assesses for flexion contracture of effected hip while eliminating lumbar lordosis