NuTH GP Event 19/04/2018

1. Summary of Practical sessions
GP Neurology teaching
19th April 2018

2. Guidelines for GP upper limb motor
examination
1. Examination will never “trump” a good history
2. Observation is the first rule of medicine – watch patients walk into the
consultation room and undress for examination. Formal “inspection thereafter,
actively looking for wasting, fasciculation etc.
3. Remember “hard” (wasting, tone changes, reflexes) vrs “soft” (power,
incoordination/clumsiness) signs.
4. After inspection think tone, power and reflexes – remember two movements or
flexion/extension at each of the major upper limb joints (shoulder, elbow, wrist
and fingers).
5. Remember cardinal differences between central (UMN) signs: preserved bulk,
increased tone, pyramidal pattern weakness and brisk reflexes), and
peripheral (LMN) signs: reduced bulk and tone, weakness and flat/absent
reflexes.
6. Think patterns of localisation – single or multiple sites, or even a “system”
disorder

3. Lower Limb Examination
• Gait – if they can walk narrow based and quick (?normal arm swing both sides/turn on
one smooth movement/walk heel to toe well/stand on heels and stand on toes and can
hop either leg and squat – then little chance of major surprises when examining on the
bed – so if you only have time for one thing – look carefully at gait in the corridor
• UMN signs:
– hyperreflexia, increased tone, upgoing plantars
– Causes: any inflammation or SOL above L1, use sensory level to determine where
to image
• LMN signs:
– Fasiculations, reduced/absent reflexes, reduced tone
– Causes: anything below L1 such as cauda equina compression, peripheral nerve
problem (GBS)
• Mixed signs:
– Fasiculations and spasticity (MND), absent reflexes and extensor plantars (B12
deficiency)

4. Cerebellar ataxia
• In the upper limbs look for
– Past pointing
– Intention tremor
– Dysdiadochokinesia
• When doing finger-nose testing, ensure the patient stretches fully
to reach your finger
• In an intention tremor the amplitude increases as the target is
approached
• If a patient has a postural tremor, this will not disappear on doing
the finger-nose test. In such patients the amplitude does not
increase as the target is reached and this is a kinetic tremor
• Most doctors who think they are seeing an intention tremor are
actually seeing a postural and kinetic tremor in somebody with a
diagnosis of essential tremor

5. Cerebellar ataxia
• Very rare to see in general practice
• Lots of older people wobble a bit on finger-nose
testing and don’t have cerebellar ataxia
• Supporting features include gait ataxia,
nystagmus and dysarthria
• More common causes:
– Chronic: Alcoholic cerebellar
degeneration
– Subacute: Drugs – phenytoin,
carbamazepine
– Acute: Cerebellar stroke

6. Tremor/PD
• Tremor examination
– Observation – at rest, posture, action and with gait
– Benign tremors – more symmetrical and
postural/action
• Parkinson’s Disease
– Tremor – asymmetric, rest
– Bradykinesia – decrement in “quacking duck” (core
feature)
– Rigidity
– Gait – reduced arm swing

7. Cranial Nerves
Eye movement disorder (Diplopia)
CN III, IV & VI: extraocular muscles
1. are the eyes looking in the same direction?
2. is there nystagmus?
3. is there double vision?
• primary position: 4 questions
-is there ptosis?
• don’t move on until you have answered all 3
questions!
Clinical examination
3 questions to ask at each of the 5 stations
• cover each eye
• uniocular diplopia
– ocular/retinal pathology (v rare)
– non-organic
• more than two images
– usually mad
• non-neuromuscular causes (eg thyroid)
• muscular disorders
• neuromuscular junction (myasthenia)
• individual cranial nerve palsies (III, IV, VI)
• central eye movement problems
– gaze palsies
– INO
– nystagmus
Abnormalities
• III, IV or VI?
• feasible combination?
• not simple III/IV/VI + no nystagmus
– muscle (CPEO)
– NMJ (fatigue)
• not simple III/IV/VI + nystagmus
– brainstem
Very basic rules of thumb!
Think -
“look straight”
“look left”
“look right”
“look at the tip of
your nose”
• lesion in medial
longitudinal
fasciculus
• aBducting eye
has nystagmus
• aDducting eye
fails to aDduct
• lesion is on the
side of failed
aDduction
Remember INO’s - think MS