cmecde 5558

 

81Neurology

Station 32

Cranial nerve examination

Specifications: You may be asked to limit your examination to certain cranial nerves only, e.g. I–VI,

VII–XII.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the examination and obtain his consent.

• Ensure that he is comfortable.

The examination

The olfactory nerve (CN I)

• Ask the patient if he has noticed a change in his sense of smell or taste. If he has, indicate that

you would perform an olfactory examination by asking him to smell different scents, such as

mint or coffee. Otherwise, the olfactory nerve is not formally tested.

The optic nerve (CN II)

(See Station 51: Vision and the eye examination for more details.)

• Ask the patient whether he wears glasses. If he does, ask him to put them on.

• Ask about any changes in vision and the time frame over which they have occurred. Use the

mnemonic AFRO C (Acuity, Fields, Reflexes, Ophthalmoscopy/Fundoscopy, and Colour vision)

to guide you through the following steps.

• Acuity: Use a Snellen chart from a distance of 6 metres and test near vision by asking the patient

to read test types (or a page in a book).

• Fields: Sit directly opposite the patient, at the same level as him. Ask him to look straight at

you and to cover his right eye with his right hand. Cover your left eye with your left hand, and

test the visual field of his left eye with your right hand. Bring a wiggly finger into the upper left

quadrant, asking the patient to say when he sees the finger. Repeat for the lower left quadrant.

Then swap hands and test the upper and lower right quadrants. Now ask the patient to cover

his left eye with his left hand. Cover your right eye with your right hand and test the visual field

of his right eye with your left hand. Bring a wiggly finger into the upper right quadrant, asking

the patient to say when he sees the finger. Repeat for the lower right quadrant. Then swap

hands and test the upper and lower left quadrants.

• Indicate that you could use a red hat pin to uncover the blind spot and the presence of a central

scotoma.

• Reflexes: See under CN III, IV and VI testing.

• Indicate that you could examine the eyes by direct ophthalmoscopy/fundoscopy.

• Indicate that you could test red/green colour vision with Ishihara plates.

Clinical Skills for OSCEs

82 Station 32 Cranial nerve examination

Figure 22. Visual field defects and their origins.

The oculomotor, trochlear, and abducens nerves (CN III, IV, and VI)

(See Station 51: Vision and the eye examination for more details.)

• Inspect the eyes, paying particular attention to the size and symmetry of the pupils, and excluding a visible ptosis (Horner’s syndrome) or squint.

• Test the direct and consensual pupillary light reflexes. Explain that you are going to shine a

bright light into the patient’s eye and that this may feel uncomfortable. Bring the light in onto

his left eye and look for pupil constriction. Bring the light in onto his left eye once again, but

this time look for pupil constriction in his right eye (consensual reflex). Repeat for the right eye.

• Perform the swinging flashlight test to detect a relative afferent pupillary defect. Swing the light

from one eye to another and look for sustained pupil constriction in both eyes. Intermittent

pupil constriction in one eye (Marcus Gunn pupil) suggests a lesion of the optic nerve anterior

to the optic chiasm.

• Perform the cover test. Ask the patient to fixate on a point and cover one eye. Observe the

movement of the uncovered eye. Repeat the test for the other eye.

• Examine eye movements. Ask the patient to keep his head still and to follow your finger with

his eyes. Ask him to report any pain or double vision at any point. Draw an ‘H’ shape with your

finger. Observe for nystagmus at the extremes of gaze.

• Test the accommodation reflex. Ask the patient to follow your finger in to his nose. As the eyes

converge, the pupils should constrict.

Optic

radiation

Lateral

geniculate

body

Optic

tract

Optic

chiasm

Left Right

Left eye

� Loss of vision

1

2

3

4

5

6

Right eye

Optic

nerve

5

6

3

4

2

1

Neurology

Station 32 Cranial nerve examination 83

The trigeminal nerve (CN V)

Sensory part

• Using cotton wool, test light touch in the three branches of the trigeminal nerve. Compare

both sides.

• Indicate that you could test the corneal reflex, but that this is likely to cause the patient some

discomfort.

Motor part

• Test the muscles of mastication (the temporalis, masseter, and pterygoid muscles) by asking

the patient to:

– clench his teeth (palpate his temporalis and masseter muscles bilaterally)

– open and close his mouth against resistance (place your fist under his chin)

• Indicate that you could test the jaw jerk. Ask the patient to let his mouth fall open slightly. Place

your fingers on the top of his mandible and tap them lightly with a tendon hammer.

The facial nerve (CN VII)

• Look for facial asymmetry. Note that the nasolabial folds and the angle of the mouth are especially indicative of facial asymmetry.

Sensory part

• Indicate that you could test the anterior two-thirds of the tongue for taste.

Motor part

• Test the muscles of facial expression by asking the patient to:

– lift his eyebrows as far as they will go

– close his eyes as tightly as possible (try to open them)

– blow out his cheeks

– purse his lips or whistle

– show his teeth

Ophthalmic

branch

Maxillary

branch

Mandibular

branch

Gasserian

ganglion

Trigeminal

nerve

Figure 23. The three branches

of the trigeminal nerve.

‘Trigeminal’ means ‘three twins’.

Clinical Skills for OSCEs

84 Station 32 Cranial nerve examination

The acoustic nerve (CN VIII)

(See Station 52: Hearing and the ear examination for more details.)

• Test hearing sensitivity in each ear by occluding one ear and rubbing your thumb and fingers

together in front of the other.

• Indicate that you could carry out the Rinne and Weber tests and examine the ears by auroscopy

(see Station 52).

The glossopharyngeal nerve (CN IX)

• Indicate that you could test the gag reflex by touching the tonsillar fossae on both sides with a

tongue depressor, but that this is likely to cause the patient some discomfort.

The vagus nerve (CN X)

• Ask the patient to phonate (say ‘aah’) and, aided by a pen torch, look for deviation of the uvula

to the opposite side of the lesion. Use a tongue depressor if necessary.

The hypoglossal nerve (CN XII)

• Aided by a pen torch, inspect the tongue for wasting and fasciculation.

• Ask the patient to stick out his tongue and look for deviation to the side of the lesion. Now ask

him to wiggle it from side to side.

The accessory nerve (CN XI)

• Look for wasting of the sternocleidomastoid and trapezius muscles.

• Ask the patient to:

– shrug his shoulders against resistance

– turn his head to either side against resistance

After the examination

• Thank the patient.

• Ensure that he is comfortable.

• If appropriate, state that you would order some key investigations, e.g. a CT or MRI.

• Summarise your findings and offer a differential diagnosis.

Conditions most likely to come up in a cranial nerve examination station

Third nerve palsy:

• the eye is depressed and abducted (down and out).

• elevation, adduction, and depression are limited, but abduction and intortion are normal.

• there is a ptosis (drooping of the upper eyelid).

• the pupil may be dilated and unreactive to light or accommodation.

Neurology

Station 32 Cranial nerve examination 85

Bell’s (facial nerve) palsy:

• facial drooping and paralysis on the affected half.

• if the forehead muscles are spared, it is a central rather than a peripheral palsy.

Horner’s syndrome:

• signs of Horner’s syndrome are ptosis, miosis, enophthalmos, and facial anhidrosis.

Cavernous sinus syndrome:

• the cavernous sinus contains the carotid artery and its sympathetic plexus, CN III, IV, and VI,

and the ophthalmic and maxillary branches of CN V.

• signs of a cavernous sinus lesion may include (generally unilateral) proptosis, chemosis,

ophthalmoplegia, and loss of sensation in the first and second divisions of the trigeminal

nerve.

Cerebellopontine angle syndrome:

• lesions in the area of the cerebellopontine angle can cause compression of CN V, VII, and VIII.

• signs may include palsies of CN V and VII, nystagmus, ipsilateral deafness, and ipsilateral

cerebellar signs.

Bulbar palsy:

• lower motor neurone lesion in the medulla oblongata leads to bilateral impairment of

function of CN IX–XII.

• signs include speech difficulties, dysphagia, wasting and fasciculation of the tongue, absent

palatal movements, absent gag reflex.

Pseudo-bulbar palsy:

• upper motor neurone lesion in the corticobulbar pathways in the pyramidal tract leads to

impairment of function of CN IX–XII and also CN V and VII.

• signs include speech difficulties, dysphagia, conical and spastic tongue, brisk jaw jerk,

emotional lability.

Clinical Skills for OSCEs

86 Station 33

Motor system of the upper limbs examination

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the examination and obtain his consent.

• Position him and ask him to expose his arms completely.

• Ask if he is currently experiencing any pain.

The examination

Inspection

• Look for abnormal posturing.

• Look for abnormal movements such as tremor, fasciculation, dystonia, athetosis.

• Assess the muscles of the hands, arms, and shoulder girdle for size, shape, and symmetry. You

can also measure the circumference of the arms.

Tone

• Ensure that the patient is not in any pain.

• Ask the patient to relax the muscles in his arms.

• Test the tone in the upper limbs by holding the patient’s hand and simultaneously pronating

and supinating and flexing and extending the forearm. If you suspect increased tone, ask the

patient to clench his teeth and re-test. Is the increased tone best described as spasticity (claspknife) or as rigidity (lead pipe)? Spasticity suggests a pyramidal lesion, rigidity suggests an

extra-pyramidal lesion.

Power

• Test muscle strength for shoulder abduction, elbow flexion and extension, wrist flexion and

extension, finger flexion, extension, abduction, and adduction, and thumb abduction and opposition. Compare muscle strength on both sides, and grade it on the MRC muscle strength scale:

0 No movement.

1 Feeble contractions.

2 Movement, but not against gravity.

3 Movement against gravity, but not against resistance.

4 Movement against resistance, but not to full strength.

5 Full strength.

Table 13. Important root values in the upper limb – muscle strength

• Shoulder abduction C5

• Elbow flexion C6

• Elbow extension C7

• Wrist extension C6, C7

• Wrist flexion C7, C8

• Finger extension C7 (radial nerve)

• Finger flexion C8

• Finger abduction/adduction T1 (ulnar nerve)

• Thumb abduction/opposition T1 (median nerve)

Neurology

Station 33 Motor system of the upper limbs examination 87

Reflexes

• Test biceps, supinator, and triceps reflexes with a tendon hammer (see Figure 24). Compare both

sides. If an upper limb reflex cannot be elicited, ask the patient to clench his teeth and re-test.

Table 14. Important root values

in the upper limb – reflexes

• Biceps C5, C6

• Supinator C6

• Triceps C7

Figure 24. Testing (A) biceps, (B) supinator, and (C) triceps

reflexes.

Cerebellar signs

• Test for intention tremor, dysynergia, and dysmetria (past-pointing) by asking the patient to

carry out the finger-to-nose test.

– place your index finger at about 2 feet from the patient’s face. Ask him to touch the tip of his

nose and then the tip of your finger with the tip of his index finger. Once he is able to do this,

ask him to do it as fast as he can. And remember that he has two hands!

• Then test for dysdiadochokinesis.

– ask the patient to clap and then show him how to clap by alternating the palmar and dorsal

surfaces of one hand. Once he is able to do this, ask him to do it as fast as he can. Ask him to

repeat the test with his other hand

(A)

(B)

(A)

(B)

(C)

Clinical Skills for OSCEs

88 Station 33 Motor system of the upper limbs examination

After the examination

• Thank the patient.

• Ensure that he is comfortable.

• Ask to carry out a full neurological examination.

• If appropriate, indicate that you would order some key investigations, e.g. CT, MRI, nerve conduction studies, electromyography, etc.

• Summarise your findings and offer a differential diagnosis.

Conditions most likely to come up in a motor system of the upper limbs examination station

Parkinson’s disease:

• motor signs include forward-flexed posture, mask-like facial expression, speech difficulties,

resting tremor, cogwheel rigidity, bradykinesia.

Cerebellar lesion:

• motor signs depend on the anatomy of the lesion, and may include nystagmus, slurred

or staccato speech, hypotonia, hyporeflexia, intention tremor, dysmetria, dysynergia,

dysdiadochokinesis, ataxia.

Ulnar nerve lesion:

• wasting, weakness, numbness, and tingling in the fifth finger and in the medial half of the

fourth finger.

• curling up of the fifth and fourth fingers (‘ulnar claw’) indicates that the nerve is severely

affected.

Median nerve lesion:

• a lesion at the level of the wrist produces wasting of the thenar muscles, weakness of

abduction and opposition of the thumb, and numbness over the palmar aspect of the thumb,

index finger, third finger, and lateral half of the fourth finger.

• a lesion at the level of the forearm produces additional weakness of flexion of the distal and

middle phalanges.

• a lesion at the   level of the elbow or above produces additional weakness of pronation of the

forearm and ulnar deviation of the wrist on wrist flexion.

Radial nerve lesion:

• a lesion at the level of the axilla or above produces weakness of elbow extension and flexion,

weakness of wrist and finger extension with attending wrist drop and finger drop, weakness of

thumb abduction and extension, and sensory loss over the dorsoradial aspect of the hand and

the dorsal aspect of the radial 3½ fingers (usually circumscribed to a small, triangular area over

the first dorsal web space).

• inferior lesions are likely to spare triceps (elbow extension), brachioradialis (elbow flexion),

and extensor carpi radialis longus (wrist extension and radial abduction, but this muscle is

only one of five wrist extensors).

Radiculopathy, affecting a single root nerve (see Table 14)

Hemiplegia/hemiparesis:

• paralysis or weakness on one side of the body accompanied by decreased movement control,

spasticity, and hyper-reflexia (upper motor neurone syndrome).

Myopathy:

• symmetrical weakness predominantly affecting proximal muscle groups.

• in contrast to neuropathy, in myopathy muscle atrophy and hyporeflexia occur very late.

cmecde 258

 

Clinical Skills for OSCEs

70 Station 27 Male genitalia examination

Figure 20. Normal testis and appendages (A), hydrocoele (B), epididymal cyst (C), and varicocoele (D).

Examination of the lymphatics

• Palpate the inguinal nodes in the inguinal crease. Remember that only the penis and scrotum

drain to the inguinal nodes, as the testicles drain to the para-aortic lymph nodes.

After the examination

• Cover up the patient.

• Thank the patient.

• Ensure that he is comfortable.

• Summarise your findings and offer a differential diagnosis.

• Consider a rectal examination to examine the prostate.

• Consider an ultrasound scan if you detect a bulky or painful mass in the scrotum or cannot

palpate the testes.

[Note] In cases of an acutely tender testicle, testicular torsion, which is a surgical emergency, must be ruled out. Epididymoorchitis also presents as an acutely tender testicle, with the patient requiring admission for IV antibiotics.

Conditions most likely to come up in a male genitalia examination station

Hydrocoele:

• collection of fluid in the tunica vaginalis

surrounding the testis.

• presents as unilateral (or less commonly bilateral)

scrotal swelling.

• not tender.

• fluctuant.

• transilluminant.

Epididymal cyst:

• arises in the epididymis.

• epididymal cysts may be multiple and bilateral.

• unlike in a hydrocoele, the testis is palpable quite

separately from the cyst.

• smooth and fluctuant.

• transilluminant.

Varicocoele:

• dilated veins along the spermatic

cord.

• almost invariably left-sided.

• ‘bag of worms’ upon palpation.

• there may be a cough impulse.

• likely to disappear upon lying down.

Direct inguinal hernia (see Station 24)

(B)

Spermatic

artery

vein

(A)

Epididymis

Tunica

vaginalis

(C) (D)

71GI medicine and urology

Station 28

Male catheterisation

Specifications: A male anatomical model in lieu of a patient.

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain the procedure and obtain his consent.

• Position him flat on the couch with legs apart and groin exposed.

The equipment

On a clean trolley, gather:

• A catheterisation pack • A 12–16 french Foley catheter

• Saline solution • A catheter bag

• Two pairs of sterile gloves • A 10 ml syringe containing sterile water

• A 10 ml pre-filled syringe • Adhesive tape

containing 2% lignocaine gel

(Instillagel®)

The procedure

• Gather the equipment (a male catheter is longer than a female one).

• Check the expiry date of the catheter.

• Open the catheter pack aseptically onto a trolley, attach the yellow bag to the side of the trolley,

and pour saline solution into the receiver.

• If pre-filled syringes are not provided with the pack, draw up 10 ml sterile water and 10 ml

lignocaine gel into separate syringes.

• Wash and dry your hands.

• Put on sterile gloves.

• Drape the patient. Some recommend tearing an appropriately sized hole into the drape and

passing the penis through it.

• Place a collecting vessel in the patient’s entre-jambes/crotch.

• With your non-dominant hand, hold the penis with a sterile swab.

• With your dominant hand, retract the foreskin and clean the area around the urethral meatus

with saline-soaked swabs.

• Instil 10 ml of lignocaine gel into the urethra. Hold the urethral meatus closed.

• Indicate that the anaesthetic needs about 5 minutes to work.

• Change into a new pair of sterile gloves.

• Hold the penis so that it is vertical.

• Holding the catheter by its sleeve, gently and progressively insert it into the urethra. Upon feeling resistance from the prostate, hold the penis horizontally so as to facilitate insertion.

• Once a stream of urine is obtained, inject 10 ml of sterile water to inflate the catheter’s balloon,

continually ensuring that this does not cause the patient any pain.

• Gently retract the catheter until a resistance is felt.

• Attach the catheter bag.

• Reposition the foreskin.

• Tape the catheter to the thigh.

Clinical Skills for OSCEs

72 Station 28 Male catheterisation

After the procedure

• Ensure that the patient is comfortable.

• Thank the patient.

• Discard any rubbish.

• Record the date and time of catheterisation, type and size of catheter used, and volume of urine

in the catheter bag.

Examiner’s questions

Indications for catheterisation:

• hygienic care of bedridden patients.

• monitoring of urine output.

• acute urinary retention.

• chronic obstruction.

• collection of a specimen of uncontaminated urine.

• irrigation of the bladder.

• imaging of the urinary tract.

Contraindications:

• pelvic trauma.

• previous stricture.

• previous failure to catheterise.

• severe phimosis.

Complications:

• paraphimosis (from failure to reposition the foreskin).

• urethral perforation and creation of false passages.

• bleeding.

• infection.

• urethral strictures.

73GI medicine and urology

Station 29

Female catheterisation

Specifications:  A female anatomical model in lieu of a patient.

Before starting

• Introduce yourself to the patient.

• Confirm her name and date of birth.

• Explain the procedure and obtain her consent.

• Ask her to undress from the waist down and place a sheet over her.

The equipment

On a clean trolley, gather:

• Two pairs of sterile gloves • A 10 ml pre-filled syringe containing 2% lignocaine gel

• A catheterisation pack (Instillagel)®

• Saline solution • A 10 ml syringe containing sterile water

• A 12–16 french Foley catheter • A catheter bag

• Adhesive tape

The procedure

• Gather the equipment.

• Open the catheter pack aseptically onto a trolley, attach the yellow bag to the side of the trolley,

and pour antiseptic solution into the receiver.

• If pre-filled syringes are not provided with the pack, draw up 10 ml sterile water and 10 ml

lignocaine into separate syringes.

• Wash and dry your hands.

• Put on a pair of sterile gloves.

• Ask the patient to remove hersheet and lie flat on the couch, bringing her heelsto her buttocks

and then letting her knees flop out.

• Drape the patient.

• Place a collecting vessel in the patient’s entre-jambes/crotch.

• Use your non-dominant hand to separate the labia minora.

• Clean the area around the urethral meatus with saline-soaked swabs.

• Coat the end of the catheter with lignocaine gel and instil 5 ml of lignocaine into the urethra.

• Indicate that the anaesthetic needs about 5 minutes to work.

• Change into a new pair of sterile gloves.

• Holding the catheter by its sleeve, gently and progressively insert it into the urethra.

• Once a stream of urine is obtained, inject 10 ml of sterile water to inflate the catheter’s ­balloon,

continually ensuring that this does not cause the patient any pain.

• Gently retract the catheter until a resistance is felt.

• Attach the catheter bag.

• Tape the catheter to the thigh.

Clinical Skills for OSCEs

74 Station 29 Female catheterisation

After the procedure

• Ensure that the patient is comfortable.

• Thank the patient.

• Discard any rubbish.

• Record the date and time of catheterisation, type and size of catheter used, volume of water

used to inflate the balloon, and volume of urine in the catheter bag.

Figure 21. Preparing to insert the

catheter.

75Neurology

Station 30

History of headaches

‘I’m very brave generally’, he went on in a low voice: ‘only today I happen to have a headache’.

Lewis Carroll, Through the Looking Glass

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain that you are going to ask him some questions to uncover the nature of his headaches,

and obtain consent.

• Ensure that he is comfortable.

The history

• Name, age, and occupation.

Presenting complaint and history of presenting complaint

First use open questions to get the patient’s history, and elicit his ideas, concerns, and expectations.

Rule out head injury before enquiring about the pain:

• Site. Ask the patient to point to the site of the pain.

• Onset.

• Character, for example, sharp, dull, throbbing, band-like constriction.

• Radiation.

• Associated factors:

– nausea and vomiting

– visual disturbances such as double vision and fortification spectra

– photophobia

– fever, chills

– weight loss

– rash

– scalp tenderness

– neck pain, stiffness

– myalgia

– rhinorrhoea, lacrimation

– altered mental status

– neurological deficit (weakness, numbness, ‘pins and needles’)

• Timing and duration.

• Exacerbating and relieving factors; for example, activity, stress, eye strain, caffeine, alcohol,

dehydration, hunger, certain foods, coughing/sneezing).

• Severity. Ask the patient to rate the pain on a scale of 1 to 10, and determine the effect that it

is having on his life.

Clinical Skills for OSCEs

76 Station 30 History of headaches

Past medical history

• Current, past, and childhood illnesses.

• Ask specifically about headache, migraine, hypertension, cardiovascular disease, and travel

sickness as a child.

• Surgery.

Drug history

• Prescribed medication. Ask specifically about withdrawal from NSAIDs, opioids, glyceryl

trinitrate, and calcium channel blockers.

• Over-the-counter medication.

• Recreational drugs.

• Allergies.

Family history

• Parents, siblings, and children.

• Ask about migraine and travel sickness.

Social history

• Employment, past and present.

• Housing.

• Mood. Depression is a common cause of headaches.

• Smoking.

• Alcohol use. Alcohol is a common cause of headaches.

• Diet: tea and coffee, cheese and yoghurt, chocolate.

After taking the history

• Ask the patient if there is anything he might like to add that you have forgotten to ask about.

• Ask him if he has any questions or concerns.

• Thank him.

• Summarise your findings and offer a differential diagnosis.

• State that you would like to carry out a physical examination and some investigations to confirm your diagnosis and exclude life-threatening causes of headaches (see box below).

Neurology

Station 30 History of headaches 77

Conditions most likely to come up in a history of headaches station

Tension headaches:

• constant pressure, ‘as if the head were being

squeezed in a vice’.

• pain typically last 4–6 hours but this is highly

variable.

• may be precipitated by stress, eye strain,

sleep deprivation, bad posture, irregular meal

times.

Cluster headaches (‘suicide headaches’):

• excruciating unilateral headache that is of

rapid onset.

• located in the periorbital or temple area, may

radiate to the neck or shoulder.

• associated with autonomic symptoms such as

ptosis, conjunctival injection, lacrimation.

• each headache lasts from 15 minutes to 3

hours.

• headaches most often occur in ‘clusters’: once

or more every day, often at the same time of

day, for a period of several weeks.

Migraines:

• unilateral, dull, throbbing headache lasting

from 4 to 72 hours.

• may be aggravated by activity.

• associated with nausea, vomiting,

photophobia, phonophobia.

• about half experience prodromal symptoms

such as altered mood, irritability, or fatigue

several hours or days before the headache.

• about one-third experience an aura,

commonly consisting of visual disturbances or

neurological symptoms, before or along with

the headache.

• frequency of headaches varies considerably,

but average is about 1–3 a month.

Cranial arteritis:

• unilateral pain in the temporal region.

• associated with scalp tenderness, jaw

claudication, blurred vision, and tinnitus.

• three times more common in females.

• mean age of onset is 70 years.

• urgent treatment is required to prevent

sudden loss of vision.

Cervical spondylosis:

• occipital headaches associated with cervical

pain.

• cervical pain may radiate to the base of the

skull, shoulder, or hand and fingers.

• may be associated with weakness, numbness,

or pins and needles in the arms and hands.

Meningitis:

• severe and bilateral headache.

• may be associated with high fever, neck

stiffness, photophobia, phonophobia, altered

mental status.

Subarachnoid haemorrhage:

• thunderclap headache (‘like being kicked in

the head’) that is of very rapid onset.

• may be associated with vomiting, altered

mental status, neck stiffness, photophobia,

visual disturbances, seizures.

Raised intracranial pressure

• dull, throbbing headache associated with

vomiting, ocular palsies, visual disturbances,

altered mental status.

• may be worse in the morning and may wake

the patient up from sleep.

• aggravated by coughing and head

movement.

• alleviated by standing.

Sinusitis:

• dull and constant headache or facial pain

over the sinuses.

• may be associated with flu-like symptoms and

facial tenderness.

• may be aggravated by bending over or lying

down.

Trigeminal neuralgia:

• intense unilateral facial pain (‘like stabbing

electric shocks’) lasting from seconds to

minutes.

• may occur several times a day.

• triggered by common activities such as

eating, talking, shaving, and tooth-brushing.

• may be associated with a trigger area on the

face.

Clinical Skills for OSCEs

78 Station 31

History of ‘funny turns’

Before starting

• Introduce yourself to the patient.

• Confirm his name and date of birth.

• Explain that you are going to ask him some questions to uncover the cause of his collapse, and

obtain consent.

• Ensure that he is comfortable.

The history

• Name, age, and occupation.

Presenting complaint and history of presenting complaint

First use open questions to get the patient’s story, and elicit their ideas, concerns and expectations.

Think about the common causes of a funny turn, as these should inform your line of questioning.

Ask about:

• Whether the patient remembers falling.

• If the fall was witnessed and if a collateral history is available.

• The circumstances of the fall:

– had the patient just arisen from bed? (postural hypotension)

– had the patient just suffered an intense emotion? (vasovagal syncope)

– had the patient been coughing or straining? (situational syncope)

– had the patient been turning or extending his neck? (carotid sinus syncope)

– had the patient been exercising? (arrhythmia)

– did the patient have any palpitations, chest pain, or shortness of breath? (arrhythmia)

• Any loss of consciousness and its duration.

• Prodromal symptoms such as aura, change in mood, strange feeling in the gut, sensation of

déjà vu.

• Fitting, frothing at the mouth, tongue biting, incontinence.

• Headache or confusion, or amnesia upon recovery.

• Injuries sustained, especially head injury.

• Previous episodes.

Past medical history

• Current, past, and childhood illnesses. Ask specifically about epilepsy, hypertension, heart problems, stroke, diabetes (autonomic neuropathy), cervical spondylosis, and arthritis.

• Surgery.

Drug history

• Prescribed medication. Drugs such as antipsychotics, tricyclic antidepressants, and antihypertensives can cause postural hypotension. Insulin can cause hypoglycaemia.

• Over-the-counter medication.

• Recreational drugs.

• Recent changes in medication.

Neurology

Station 31 History of ‘funny turns’ 79

Family history

• Parents, siblings, and children.

• Ask specifically about epilepsy and heart problems.

Social history

• Smoking.

• Alcohol use.

• Employment, past and present.

• Housing.

• Effect of falls on patient’s life.

After taking the history

• Ask the patient if there is anything he might add that you have forgotten to ask about.

• Ask him if he has any questions or concerns.

• Thank him.

• Summarise your findings and offer a differential diagnosis.

• State that you would like to carry out a physical examination and some investigations to confirm your diagnosis.

Conditions most likely to come up in a history of ‘funny turns’ station

Simple faint:

• loss of consciousness lasting from a few

seconds to a few minutes is preceded by

nausea, sweatiness, dizziness or tightness

in the throat.

• provoked by stressful, anxiety-provoking,

or painful situations (vasovagal syncope),

by coughing or straining (situational

syncope), or by applying pressure upon

the carotid sinus, for example, by wearing

a tight collar, turning the head, or shaving

(carotid sinus syncope).

Postural hypotension:

• loss of consciousness preceded by

dizziness, light-headedness, confusion, or

blurry vision.

• provoked by postural change.

• causes include hypovolaemia (e.g.

dehydration, bleeding, diuretics,

vasodilators), drugs (e.g. tricyclic

antidepressants, antipsychotics, alpha

blockers), and certain medical conditions

(e.g. diabetes, Addison’s disease).

Clinical Skills for OSCEs

80 Station 31 History of ‘funny turns’

Arrhythmia (cardiac syncope):

• may be either a bradycardia or

tachycardia.

• may be provoked by exertion.

• may be associated with palpitations, chest

pain, shortness of breath, fatigue.

• history of heart disease/risk factors for

heart disease are very likely.

• patient should be hospitalised and

placed on a cardiac monitor to rule out

ventricular tachycardia, which can result

in sudden death.

• less commonly, cardiac syncope can be

caused by an obstructive cardiac lesion

such as aortic or mitral stenosis.

Generalised tonic-clonic seizure:

• sudden loss of consciousness

accompanied by fitting, frothing at the

mouth, tongue biting, incontinence.

• seizure lasts for about 2 minutes.

• seizure is followed by confusion and

amnesia.

• seizure may be preceded by an aura

which may involve déjà vu, dizziness,

unusual emotions, altered sense

perceptions, or other symptoms.

Transient ischaemic attack:

• most frequent symptoms include loss of

vision, aphasia, unilateral hemiparesis,

and unilateral paraesthesia.

• symptoms last for a few seconds to a few

minutes and never for more than 24 hours

(by definition).

• loss of consciousness can occur, although

it is very uncommon.