Neurology OSCE Stations

Neurology OSCE Stations

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

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 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 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 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)