Cerebellar Examination By Stas Makaranka

Outline: Causes of cerebellar dysfunction Run through cerebellar examination Examination Practice Practice Questions

Differential Diagnosis Stroke/TIA Alcohol (Intoxication/Wernicke-Korsakoff) SOL - Tumour in posterior fossa/Hydrocephalus Multiple Sclerosis Drugs (e.g. Phenytoin toxicity) Endocrine (Hypothyroidism) Infections (Meningo-encephalitis, intracranial abscess) Trauma Paraneoplastic cerebellar degeneration Genetic/Congenital

DANISH Dysdiadokinesia Ataxia (Romberg’s) Nystagmus (Draw H) Intention Tremor (Touch nose and pen) Slurred, Stacatto Speech Hypotonia/Heel-shin Test

Blueprint: Introduction General Inspection Gait Head Arms Legs Summary DANISH

Wash Hands Introduce Yourself Confirm Name/DOB Explain Examination Gain Consent Appropriate Exposure Pain Anywhere? Introduction General Inspection Gait Head Arms Legs Summary DANISH

Around The Bed (walking aids) Posture – Truncal Ataxia? Appearance – Signs of Neglect (alcoholism?) Introduction General Inspection Gait Head Arms Legs Summary DANISH

Walking In A Straight Line (broad based gait?) Heel To Toe Walking Romberg’s Test (proprioception) Introduction General Inspection Gait Head Arms Legs Summary DANISH

Speech – ask to say British Constitution/Baby Hippopotamus (slurred staccato speech in cerebellar disease) Nystagmus Introduction General Inspection Gait Head Arms Legs Summary DANISH

Co-ordination (finger to nose, dysdiadokinesia) Pronator Drift Rebound Phenomenon Tone Reflexes - Biceps – C5,C6, Triceps – C7, Supinator – C6 (hyporeflexia in cerebellar disease) Co-ordination (finger to nose, dysdiadokinesia) Introduction General Inspection Gait Head Arms Legs Summary DANISH

Tone (leg roll, leg lift) Reflexes (knee jerk – L3, L4, ankle jerk – L5, S1) Co-ordination (heel to shin) Introduction General Inspection Gait Head Arms Legs Summary DANISH

Thank Patient Wash Hands Summarise Findings Say would perform cranial nerve exam/upper and lower limb nerve exams and appropriate imaging (CT/MRI) if indicated Introduction General Inspection Gait Head Arms Legs Summary DANISH

Slurred, Staccato Speech Hypotonia/Heel-shin test Dysdiadokinesia Ataxia Nystagmus Intention Tremor Slurred, Staccato Speech Hypotonia/Heel-shin test Introduction General Inspection Gait Head Arms Legs Summary DANISH

Questions? Introduction General Inspection Gait Head Arms Legs Summary DANISH

Practice Examination 1 Volunteer Please

Practice Examinations Get into pairs One perform the complete examination on the other Ask if you’re not sure how to do something

Practice Questions (1) What are the features of Wernicke’s encephalopathy and what deficiency is present?

Practice Questions (1) What are the features of Wernicke’s encephalopathy and what deficiency is present? Confusion, ataxia, ophthalmoplegia. Thiamine

Practice Questions (2) A positive Romberg’s test is indicative of damage where?

Practice Questions (2) A positive Romberg’s test is indicative of damage where? Dorsal columns of the spinal cord – sensory ataxia If patient ataxic and Romberg’s test is negative, it suggests that the ataxia is cerebellar in nature

Practice Questions (3) Your 27-year old patient displays ataxia when asked to walk across the examination room. You ask him to stand still with his eyes closed and note marked swaying back and forth. When he opens his eyes the swaying persists. Vibration sense is normal on all four limbs. Given the clinical picture in this case, such ataxia is likely due to damage to which of the following structures? A. Dorsal Columns B. Cerebral Peduncles C. Posterior limb of the internal capsule D. Ventral horns of the spinal cord E. Cerebellum

Practice Questions (3) E. Cerebellum

Thanks for coming! Some helpful links: Some helpful resources: http://www.sotonbrainhub.co.uk/ http://geekymedics.com/cerebellar-examination-osce-guide/ http://osce-stations.blogspot.co.uk Some helpful resources: Unofficial guide to passing OSCEs