Essential Examination, third edition: Step-by-step guides to clinical examination scenarios with practical tips and key facts for OSCEs

Product Information

Optic nerve (Cranial nerve II) – Assessment of the optic nerve function includes a test for visual acuity and visual fields. Each eye is tested separately. Most problems with visual acuity are ophthalmologic in origin; however, damage to this nerve, like pseudobulbar neuritis or pressure from a pituitary tumor, can present with monocular blindness and visual field cuts. The extent of involvement will depend on what they can see during the examination as compared to the baseline. [11] Furthermore, the pupillary light reflex can be tested by shining a light directly into the eye. The afferent limb of this reflex is found on the optic nerve; the sensory input. Shining a light on one eye should show a constriction of the pupils on both eyes. The failure of the pupils to constrict could indicate either an optic nerve lesion, a lesion of the efferent limb (oculomotor nerve), or any lesion along the pathway. A dilated pupil that is unresponsive to light may indicate a lesion on the efferent limb of the pathway, while a constricted pupil can point to a lesion on the cervical sympathetic chain. A fundoscopic examination is also done to visualize the optic disk. Abnormalities like papilledema or retinal hemorrhages are red flags that can point to life-threatening conditions like increased intracranial pressure and subarachnoid hemorrhage. [12] Task-specific tremor is specifically triggered by a task, such as writing, bowing a musical instrument, or using scissors. Whether these unusual tremors are forms of ET or task-specific dystonia is a point of controversy. Soltanzadeh A, Soltanzadeh P, Nafissi S, et al. Wilson’s disease: a great masquerader. Eur Neurol. 2007;57:80-85. Benzodiazepines—Two benzodiazepines, alprazolam and clonazepam, are recommended as second line treatments. A double blind, placebo controlled parallel study (n=24) reported clinical improvement in patients taking alprazolam (P<0.01). 133 Rating scales and psychomotor tests were used for assessment, not accelerometry. Another double blind, placebo controlled trial (n=22) reported that the functional ability and global functioning subsets of a “tremor intensity” rating scale improved (P=0.03) in patients treated with alprazolam. 134 A double blind, placebo controlled trial of clonazepam showed benefit in patients (n=15) receiving up to 4 mg of clonazepam daily (P<0.001). 135 A later study of 14 patients with severe kinetic tremor reported a mean tremor reduction of 71% on accelerometry; the mean clonazepam dose was 2.2 mg. 136

The neurological exam can be intimidating and challenging to perform for most physicians. It is particularly challenging to perform in certain age groups like infants, younger children, and older uncooperative adults. [5]In the examination of a pediatric patient, proper diagnoses begin with understanding which specific age groups are prone to developing certain disease processes. It is also important to keep in mind that the manifestation of certain neurologic illnesses can be vastly different in children and adults. A note on musculoskeletal examination sequenceA commonly used musculoskeletal examination sequence is look, feel, move, special tests, function, distal neurovascular integrity. Alternatively, function (e.g. gait) can be assessed at the start to identify any abnormality and tailor the rest of the examination to focus on this.Some patients fall into an overlap syndrome between PD and ET; these patients typically present with a history of ET for many years, and then develop a rest tremor with mild parkinsonian signs. 5,6 The presence of postural and kinetic tremor out of proportion to that expected in PD should raise the suspicion of a PD/ET syndrome. Before the 1990s, the main surgical intervention for essential tremor was thalamic lesioning. However, this approach fell out of favor with the development of deep brain stimulation (DBS). DBS can be done with or without general anesthesia. A frontal burr hole is drilled and then electrodes are implanted. Microelectrode and macroelectrode recordings can be used to assist in location of leads. The intracranial electrodes are ultimately connected to an implanted pulse generator. Unique and nicely organised clinical examination book … top of the list for anyone in their clinical years. Enjoy!” Defazio G, Conte A, Gigante AF, Fabbrini G, Berardelli A. Is tremor in dystonia a phenotypic feature of dystonia? Neurology. 2015;84:1053-1059.

Patients with Holmes’ tremor have been treated with levodopa; however, this has been effective in only 50% of patients treated.Move – cont’d 11 Passive movement – “Tell me if this causes any discomfort”1! Flex both hip & knee to 90°, hold ankle & knee In a separate column is a collection of key information: potential findings, differential diagnoses of clinical signs and practical tips. Neurology Hands – neurological Upper limb neurology Lower limb neurology Cranial nerves Extrapyramidal neurology / tremor Cerebellar function