1. Neuro/Endo History Taking
Phase 2B Revision Session
George Pickering &
Matthew Morgan
10/10/17
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2. OSCE series 03/10/17 - CVS & respiratory 05/10/17 – GI
10/10/17 - Neuro & Endocrine
12/10/17 - MSK & Rheumatology
Covering mainly history taking
Matt
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3. Contents General OSCE tips Neuro Histories: Common endocrine histories
General Neurological HPC
Neuro histories by presenting symptom
Common endocrine histories
Thyroid
Diabetes
Cases
Kahoot quiz!!
Matt
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4. The OSCE in numbers 16 stations of 8 mins.
6 physical examination stations.
4 history taking stations.
1 holistic care.
1 assessment of chronic disease control.
1 risk assessment.
3 rest stations.
1 minute gap between stations.
10-15 minute break half way through.
You will need these…
We’re not going to bore you with how to take a generic history, as you’ve probably had that many times before and there is a lot to cover in neuro so we’re just gonna crack on...
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5. The OSCE (2) Interpret results of tests.
Suggest the most likely diagnosis, investigation or treatment.
To give an explanation to a patient of their clinical condition (e.g. to explain why a patient with stable angina experiences chest pain on exertion).
We’re not going to bore you with how to take a generic history, as you’ve probably had that many times before and there is a lot to cover in neuro so we’re just gonna crack on...
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6. OSCE top tips No one in our year failed! - Always remember:
Hand washing, introduction, identification, consent
ICE
- Open questions as much as you can  you get the marks if the patient mentions it... You don’t have to ask it specifically!
- Even if you think you know the diagnosis – remember to rule out differential diagnoses!!!
- Summarise if stuck!
- Practise presenting histories to your mates/consultants etc
- Try and remember the patients name!
No one in our
year failed!
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7. Examination
Read the information slip carefully – things may be omitted
Practice on real patients if you can
Find signs on google images/YouTube
Time each other when practicing
Practice some more…
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8. Risk scores
Diabetes risk (diabetes risk score)
Cardiovascular risk (QRisk)
Stroke risk in atrial fibrillation (CHADs2VASc)
Osteoporosis risk (FRAX)
Risk of stroke after TIA (ABCD2)
DVT (Wells' score)
This station is easy marks – just go through the scoring system + take a short focused history
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9. Neurology Histories
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10. General Neurologic Hx
Opening question – how can I help you?/what’s brought you in today?
Site – Where abouts is the pain?
Narrow down: Anywhere else?
Onset – ‘Can you tell me a bit more about how this started?’
Narrow down: ‘What were you doing when it first began?’
Character – ‘Can you describe this pain in more detail for me?’
Narrow down: give options - shooting? Aching?
Radiation – ‘Does the pain move anywhere?’
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11. General Neurologic Hx
Associated features – ‘Did you develop any other sx at same time?’
Narrow down: weakness/numbness/pain/headache/confusion/tremor?
Timing – ‘Does the pain come on at a particular time of day?’
Exac./relieving factors – ‘Does anything make it better or worse?’
Severity – ‘On a scale from 1-10, where 10 is the worst pain imaginable, and 0 is no pain at all, where would you rate it?’
Other – Bladder, bowel, sexual symptoms.
- Weight loss, fever
- Has this ever happened before?
- Assoc sx – ask about other neurological presenting complaints
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12. Neurology These are from your 2b OSCE handbook:
Transient ischaemic attack, amaurosis fugax, CVA
Subarachnoid, subdural and extradural haemorrhage
Epilepsy
Parkinson’s disease, Huntington’s chorea
Migraine, tension headache, cluster headache, GCA, trigeminal neuralgia
Spinal cord compression and cauda equina syndrome
Multiple sclerosis
Myasthenia gravis
Motor neuron disease
Guillain-Barré syndrome
Peripheral neuropathies, Nerve lesions (e.g. spinal nerve root lesions, cranial nerve lesions, carpal tunnel)
Primary and secondary brain tumours
Infection (e.g. meningitis, encephalitis, herpes zoster)
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13. General Neurologic Hx Headache/facial pain Weakness Numbness Collapse
Confusion
Gait change
Tremor
Vertigo/dizziness
Visual change
These are the symptoms you can screen for in a general neurological history
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14. Headache SOCRATES Red flags: Thunderclap headache
Focal neurological signs
Change in mental status
Meningism
Worse on lying down/coughing
SOCRATES + RED FLAGS = 80% of marks according to Majeed’s
Headache is a really nice Hx to get.. Very easy formula... SOCRATES + red flags. Then maybe a few specific questions related to what you think the cause is...
Thunderclap - SAH
Focal neurological signs – physical problem with part of brain (brain haemorrhage, stroke, abscess)
Change in mental status – problem affecting whole brain (raised ICP, encephalitis)
Meningism (triad of photophobia, neck stiffness, headache) – could be meningitis, abscess affecting meninges/SAH
Red eye – acute closed angle glaucoma.
Worse on lying down – generic sign for raised ICP – causes: SOL, haemorrhage
Got basic hx marks
Take through differentials of headache
Quick revision of what you would expect to find
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15. Headache Differentials: Primary headaches: Secondary headaches Tension
Migraine
Cluster
Secondary headaches
Intracranial infections
Intracranial bleeds
↑ ICP
GCA
Already got most marks from SOCRATES + red flags
So just gonna quickly run through headache differentials to mop of those stray marks that you haven’t quite caught in SOCRATES
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16. Headache Unilateral red eye Autonomic features Seasonal clusters
Questions:
Ever had before?
When?
Smoker?
Band like
Questions:
Stress?
?Aura
Unilateral
Throbbing
Photophobia
Phonophobia
Questions:
Visual problems?
Tension – usually described as band-like around forehead. Pts usually describe recent stress/anxiety – consider this when asking about work history. Usually towards the end of the day.
Migraine – unilateral, throbbing/pulsating. Possible aura (scintillating scotoma (spot of lfickering light) is most common). Photophobia, photophonia. Pt goes into quiet, dark room until it is over.
Cluster – around one eye with some extra features (lid swelling, lacrimation, rinorrhoea). Seasonal – will get bouts of them for 6-12w, around the same time each year.
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17. Headache Secondary headaches: Meningitis Encephalitis SAH SDH EDH
↑ ICP
GCA
Useful questions to help differentiate:
Fever?
Head injury/fall?
Speed of onset?
Fever – infective/inflammatory causes
Head injury/fall – more likely to be bleeding
Speed of onset can also give you clues as to the diagnosis
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18. Headache Secondary headaches: Meningitis Encephalitis SAH SDH EDH
↑ ICP
GCA
Meningism:
Other symptoms: Fever, N+V, non-blanching rash
Dx: Blood cultures, LP
Tx: GP - IM BenPen
Hosp - IV cefotaxime
Meningitis - what questions would you want to ask someone if you suspect meningitis?
inflammation of lining of brain. Specific signs: Kernig’s. Brudzinski’s.
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19. Headache Secondary headaches: Meningitis Encephalitis SAH SDH EDH
↑ ICP
GCA
Quite non-specific symptoms.
However usually triad:
Fever
Headache
Change in mental status
Encephalitis – Usually presents like meningitis but usually more predominant symptoms of confusion and altered consciousness
inflammation of brain parenchyma itself – usually viral origin (herpes viruses (herpes simplex most serious)) -
Dx: LP
Tx: IV acyclovir
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20. Headache Secondary headaches: Meningitis Encephalitis SAH SDH EDH
↑ ICP
GCA
Symptoms:
Thunderclap headache
Raised ICP
History:
Usually spontaneous (ruptured berry aneurysm)
Sentinel headaches
PMH – PKD, Ehlers Danlos
Ix: CT
Tx: Endovascular coil/surgical clip
Can be a bit sneaky
CT - BBC
Raised ICP: headache, N+V, confusion, visual disturbance, fixed dilated pupil
Unlikely to get SAH as it is an emergency condition.
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21. Headache Secondary headaches: Meningitis Encephalitis SAH SDH EDH
↑ ICP
GCA
SDH
Elderly?
Alcoholic?
Any recent head injury?
EDH
Recent major head injury?
Within hours?
SDH – tear in bridging veins
Not so much sx.. more RFs for SDH..
Unlikely to get EDH as it is an emergency condition.
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22. Headache Secondary headaches: Meningitis Encephalitis SAH SDH EDH
↑ ICP
GCA
Weight loss?
Cause:
Brain tumour (primary or secondary)
Brain abscess
Intracranial bleed
Symptoms:
Headache worse lying down/coughing
Weakness
N+V
Confusion
Fever?
Trauma?
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23. Headache Secondary headaches: Meningitis Encephalitis SAH SDH EDH
↑ ICP
GCA
GCA – inflammation of branches of external carotid artery  granulomatous thickening and reduced blood supply to distal muscles  claudication
Jaw and tongue claudication – ‘it hurts when I eat!’
Tender scalp/occiput – ‘it hurts when I comb my hair!’
Sudden painless, unilateral LOV (can be transient...) – ischaemic optic neuritis (opthalmic artery supply optic nerve)
Aorta affected... risk aortic dissection
PMR – shoulder and pelvic girdle pain and stiffness
Specific question:
PMH: PMR?
Specific questions?:
‘Does it hurt when you comb your hair?’
‘Does it hurt when you eat?’
‘Any problems with your vision?’
‘Any chest pain radiating to your back?’
Ix: Temporal artery biopsy
Tx: High dose steroids
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24. Visual disturbance Differential: Migraine MS GCA Raised ICP
Myasthenia gravis
What questions would you want to ask if someone describes problems with their vision?
Migraine – more likely headache
MS –will cover later
GCA+raised ICP – already talked about
MG – will be covered by George
So what questions might you want to ask if someone tells you they have a problem with their vision? -
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25. Visual disturbance HPC:
Can you describe exactly what is the problem with your vision?
Spot of flickering light in centre vision which enlarges
Loss of central colour vision
Vision is blurry
Seeing double
When did this start?
Differential:
Migraine MS
GCA
Raised ICP MG
Need to know what exactly is the problem with their vision
Onset
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26. Visual disturbance Ever had before? Associated symptoms:
Weakness? Numbness?
Headache?
Differential:
Migraine MS
GCA
Raised ICP MG
Had before? – reurring problems eg MS, migraine
Associated symptoms - can also give you clues about the cause
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27. Visual disturbance MS Optic neuritis 1st presentation Other questions:
Pain on eye movement
Reduction in central vision
Reduction in colour vision
Other questions:
Weakness? Sensory disturbance?
Ever had before? Where?
Fatigue?
Gets worse in warm bath?
Ix:
LP – Oligoclonal bands
VEP – optic neuritis
MRI
Tx:
- Relapses: Prednisolone
- DMAs: beta-interferon
- Good time to talk about MS as first symptom is often optic neuritis...
- What symptoms?
Remember MS has to be disseminated in space and time - >1 place affected and >1 month apart.
Fatigue not very specific but its another common symptom of MS
DMA = disease modifying agent
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