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)

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

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

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

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