Neurology – Topic 12 – GP – Clinical examination – the very basics

today what we're going to talk about is the typical neurological consultation and the three major diagnoses that we'd see in outpatients are people with a seizure and epilepsy people with headaches and people with dizzy spells and of course we see all the conditions like Parkinson's and MS as well but the very most the most common the three most common conditions we see in Neurology our patients are epilepsy migraine or headaches and dizzy spells they'd be what we call the bread-and-butter of neurology and the bulk of our referrals so when we're going to take headache as an example and Danika suffers from headaches so I'm going to use him if he doesn't mind as an example of how I approach it normally and whether that's the right of the wrong way is open to a conjecture but in essence the very first thing we always get is a letter either from a colleague in the hospital or more likely GP and the GP will send in a letter to us and we say oh that looks urgent we're going to see this person quickly the most important thing that have people and do or should do but don't do is read the doctors letter the patient has already been seen by a doctor and thus will look and who know the patient better than you you will know them of course because you're meeting them for the first time so the point is to read carefully the general practitioners refer a letter from that you might get a flavor of what the GP thinks and some the past medical history in addition the second most important thing I think after reading the GPS information is to find out what medication the patient is on because patients will reflect to tell you that there aren't antihypertensive medication because they may have been on it for years that they're on aspirin and if they say they're on aspirin for example you want to know why they're on these drugs if they don't know you need to find out so the GPS letter is a primary thing that we wants to consider and after that you must consider what medication the patient is on and then you proceed to the medical history and as always I'll be terribly formal and you introduce yourself to the patient and say welcome to the our patients thank you very much for coming I'm explained to them what you're going to do so you're going to say I'm going to ask you lots of questions and I'll interrupt a time so bear with me and if it's not clear if it's too much jargon let me know so the first thing asks you don't if you don't mind is what age are you 20 right as I go if we don't mind because I'll have to dictate a letter to your GP later and are you right or left-handed right-handed thus implying very strongly that your speech a hemisphere Dunham's hemisphere where your speech resides is in your on the left hand side and your occupation you a student okay so you need to make sure you don't see any just people working with industrial waste and things like this and people who work with birds and various say and industrial disorders and infectious disease you might be exposed to so what I tend to do is I know you've got your the reason you're presenting a plaint is is one of headaches but I just to clarify that in case I'm missing something I go have you any past medical history and nothing of note have you ever had an operation or anything – minor surgery okay are you allergic to any medication that you're aware of okay and then I always ask about chronic illnesses that people might take for granted almost believe it or not are you diabetic and do you have high blood pressure and do you have have you ever had tuberculosis okay have you had any foreign travel in the last six months no okay and are you on any medication at the moment no no prescribed medication but are you only over-the-counter medications you take anything and cellpadding okay that's very important we'll find it a bit more about that later the dose etc are you married and do any dependents do you smoke do you drink alcohol and is there any family history any history in your family sorry of a headache and or migraine oh my groans you're on your mum's side your dad's side okay now you've been sent by your doctor with a history of headaches now I don't assume these are migraine or any type of headaches in particular so for how long would you say you've been having headaches of any description so about three years and do you have are they all the same type or do you have different types of headaches but I'm gonna have a constant headache and just a fun program we had okay so over the front of your head and that'll be there kind of 24 hours a day seven days a week and we describe that like a stabbing pain a sharp pain or more like a grip like paying a vice-like grip right and would that be worse at any particular times say for instance doing exams from stress they're the worse okay and what would you take when you have one of those headaches right how many would just how many saw a building would you say you take prayer headache or more importantly how many we should take roughly speaking in a week probably going to every time okay so ten times a week so you could take quite a few salt billion per week okay that's fine and with those headaches now just stay with those vice-like grip headaches tension type headaches which I would wager they are and are there any other symptoms that affect your vision your speech or swallow perspect your arms or legs why it's been very sensitive right Lloyd okay right but nothing else now you then mentioned that you get more severe headaches on top of that so we call that first type of headache type a headache the second type of headache you get the more severe ones you get a and how often are they occurring over the last three years or so again rough guides are fine we don't need specifics so once twice a month and if you talk me through one of those more severe episodes how do they start so say for example I always ask how does it start so say you're going to have one in front of me right now what's the first thing you'll notice blurred vision and hollow and so so how long will the vision be blurred for before the headache kind of kicks in if you like okay and then after 20 minutes in an hour you'll find that you develop a headache and can you describe that headache to me these it's like if you take one of these words as it's sharp it's stabbing is it burning it's a throbbing is it lancinating its throbbing and is it more it so it's on one side generally okay and in that situation do you think does bright light bother you or loud noises yeah definitely so what would you normally do in that situation so say you know in evolutionary terms what would you say what what would I do if I'm in that situation what would you do well normally feel quite nauseous as well so it's straight onto so you go to bed and once you fall asleep and do you wake up and the headaches more or less go on well yeah right have you taken would you take more salt putting at that point I will you okay so once to twice a row on one or two occasions a month you'd have these more severe headaches superimposed on a more base line tension type headache and with the more severe headaches again the same question do you have any other symptoms does it affect your speech your swallow your arms legs tingling them on your hands okay but it doesn't affect your speech or swallow okay well that's very clear and so those type of headaches would now seem to me to be much more like a migraine headache so the baseline headache is a tension type headache and for that you're taking probably an excessive amount of over-the-counter medication and sapling is a drug that contains codeine and this can be mildly addictive if not quite addictive and I always see it as this that if you take too much codeine you'll take the edge off the baseline tension headache but then you get a rebound headache and therefore you become gradually more dependent on the cell padding so as a result you've then got a combination of headaches of tension headache and medication overuse headache then the reason for you taking any of this the first place is for fear of what are probably migraine headaches the classics so certainly we've gone from headaches to the GP says that's just headache to three different types of headache and once you explain this to the they say oh okay well that makes sense that you've got tension headaches because you're worried you might have a migraine as well as the stress of life then you take too much medication you develop a medication overuse headache and now you've got three different types so it's not as simple as just saying oh that's migraine here's the drug good luck so the next thing we do is just ask fuelbar the other basic questions is and which are do you grind your teeth and bruxism is tooth grinding which sometimes can cause an instability of the temporomandibular joints and again lead to tension type headaches and easily treated with a nocturnal brace in some situations so the next thing we do then is examine the patients and having done the background history there's a family history of migraine so that will predispose you to all these things and then we examine the patient in a fairly brief manner and we decide then on therapies we might employ okay Danika having taken the full history i'm clearing my mind now what I think is going on but of course I'm going to do a brief examination just to make sure I'm not sure making any assumptions and that's a brief neurological examination looking at eye movements walking that kind of thing and so if you don't mind I'll ask you to stand up and come on over here okay so having discussed your history and I know that you're healthy a guy with no past history of note for the clinical situation I do a brief neurological exam just to make sure I'm not missing anything and this examination is purely for the office and wouldn't apply in an examination circumstances in examination circumstances for students for example so I will be cutting quite a few corners here okay done okay I'm just going to do a brief neurological exam the way I normally do in the clinic okay so first of all thank you once again I'm going to examine your face then your arms and then your legs okay so it's a brief one so the first thing I ask is have you noticed any change in your sense of smell okay and your vision is unchanged okay can you take off your glasses voluntarily please I'm going to ask you to fix on my chin here okay and I'm going to move a finger I want you to tell me which one moves just point to the one that moves thank you great okay now I'm going to ask you to follow my finger so keep your head still and look at my little finger okay so no ptosis pupils are equal no nystagmus head still no if you can look out to the left do you see one or two just one okay keep following that you're doing brilliantly one or two one copters sky great and we were to hold your eyelids as they're coming close to look down so you look down I'm going to hold your eyelids I won't hurt you fantastic now can you look to your left to your right to your left to your right place perfect that's great now I'm just going to touch on the face so if you could close your eyes can you feel me touching you there yeah and there does it feel the same yeah and here and here all the same okay now can you raise up your eyebrows as if you're surprised throwing down as if you're angry squeeze your eyes tightly shut okay open quickly show me your teeth and blow out your cheeks fantastic and have you noticed any change in your sense of hearing no no ringing in your ears or anything better okay and so and can you open your mouth wide for me I head back a little bit and say ah and swallow is okay okay can you put your chin out to your chest I'm going to put my hand in far don't let me hurt you but push against my head my hand I mean push hard wonderful okay that's great and finally can you open mouth once more and stick out your tongue straight perfect that's great I now I'm going to have a little look in the back of your eyes I'm looking for a sense of pressure behind the eyes or papilledema so I'm going to use a light here I'm going to ask that light is going to go towards your eyes I want you to focus on the top corner of the drawer there okay so I'm going to come at you if you like and look at the back your eye it doesn't hurt but it's a bit disconcerting great okay so I can see the disc margins fairly easily watch yourself there same again now with the left perfect no problems there you can put your glasses back on thank you so that's the cranial nerve examination so then I move on to the arms so I'm going to take your hand if you don't mind there's no soreness anywhere is there no okay I'm just going to move it around to get a sense of the tone and I'm going to use both hands at one time just to get the tone that's fine now can you put your arms up like that for me and push up against me but don't let me hurt you push up now push down great like that pull me towards you with your right towards you and push me away well done towards you and away great can you put your hands out straight and up the wrists don't let me bend them and then push me away with them well done and the hands out straight don't let me bend the fingers keep them up and spread the fingers wide apart don't let me push them together and turn the hands over grab my fingers squeeze as tightly as you can that's great now you can rest them back in your lap I'm just going to test your reflexes if you relax as much as you can I'll work around you through your right angles of your arms okay now normally I might undress some at this point if I wasn't sure but usually in the clinic situation you don't need to when I say now will you grit your teeth okay on three one two three now great now now now in a hand across here please great if you just rest your hand of mine and let the hands drop down that's wonderful just two hyphens that's fantastic so that's the upper limb now go to examine your legs okay so you can put your glasses back on thank you all is normal so far now in your own time if you kick off your shoes if you don't budget only take off your socks and just lie back there okay you're comfortable enough no pain in your legs as well same questions really okay I'm going to move your legs around a little bit just to get a feel for the tone of them and I'm going to pick them up fairly smartly like that okay so that's not now with your right leg you lift it straight up on the air like a ballet dancer keep it up and now bring it down okay the left up and now down great can you bend up both knees don't let me straighten your knee and now kick it out straight great don't let me straighten this one and then kick it out straight okay can you up your feet this way keep them up and push me away and away well done easier said than done now I want you just to test your coordination can you take your heel and run it down the side of your leg like that okay and now can you do the same with your left leg once it's grossly normal like that there's nothing to worry about I'm going to test your reflexes now okay the other one if I'm a great now can you bend up your right leg and flop it out towards me I'm going to tap your ankle and can you band up your left leg flop it away from me please great last thing is a bit uncomfortable I'm going to scratch your foot fairly smartly so I always say I'll apologize but I don't really mean it so I'm looking for the movement of the big toe and once it's clearly down like that even through the sock I think is sufficient although purists would disagree with me and you should remove the sock I'll do one more thing then test sensation in the lower limb I always used to nning for can you feel that vibrating yeah so a 128 Hertz tuning fork I'm going to place this on your toe can you feel that vibrating close your eyes now and there okay once that's all normal there's no symptoms of sensory loss or of motor loss I think it's sufficient to do that for a brief in your logical exam thank you and okay well done okay I'm glad to say your neurological examination is entirely normal so if nothing to worry about and once that's the case and I can reassure you that and you really don't need to further test now when people are affair to the and neurology clinic many neurologists will say well you don't need any further tests when the exam is normal I must admit I find that people are under a lot of duress they've seen their general practitioners a few times so I think it's not a bad thing because it's a chronic condition particularly migraine and to do a CT scan or indeed even an MRI scan now I'm aware that there's radiation involved and there is a slightly increased risk but ultimately I believe and there is a debate on this matter that people should have a scan if they've been waiting in the iris system long enough to come to see a neurologist and they're at this stage their anxiety levels are usually quite high but assuming the CT scan which is more than likely to be normal and in an older population one would also do a blood test called an es or and that's looking for temporal arteritis but assuming these things are normal we then explain to the patient the sequence of events in terms of how to manage their headaches the first thing is one must always do is try and empower the patient so they understand what's going on to do that I often give them a leaflet to say have a think about it I've given you an awful lot of information today to say I think you've three types of headaches tension headache with medication overuse involved and migraine superimposed so as a result it's quite difficult to take all that in and walk out and say oh and and despite our best efforts not to use jargon I'm sure some of the words we use our alien unbeknownst to ourselves or despite our hopefully our best efforts and so we give you some information say this will describe to you what we should remind you what I'm saying what I've said today I hope now but more importantly I'd like you to take control of this situation yourself as far as you can so I always recommend the people and use a migraine diary which are and you supplied to us by the migrant society of Island Association around and what this does it says on it it gives a diary to say and every day you have to do a little bit of work yourself and the first column says there's the day and so view of a headache in that day it says what time does it start the headache how long does it last and is it bad really bad or really really bad so so intensity is low medium or high and then can you still do what you normally do can you go to work and you study and do you have any other symptoms such as those you mentioned blurred vision and tingling in your hand and then did you take anything for it because this also helps people who think I know I only take the odds all burden or whatever and in fact they suddenly go well actually gosh I'm taking twenty a week as you kind of even found out yourself in this interview and then you identify any possible triggers did you go out late the night before did you drink too much wine did you eat too much cheese chocolate tends to be precipitant as you probably know and in this day and age you've probably particularly a student and googled all of this at this juncture anyway and probably quite well informed patients tend to be much more well informed these days and have made it quite an effort and to look into these things themselves before going to doctors which is which i think is a great thing so i'll ask you then to fill in that diary when you go home here's some further information and I probably will arrange a CT scan and an es or which you can almost certainly assume or normal but it's more to reassure you than anything else for the future the next major part of the plan is to stop all over-the-counter medication so this tends to frighten patients quite a lot as well they go you know this is a crutch table you know where that has now evolved and we need to take that away a little bit so you need to cut out and slowly if you wish if you feel you can't bear the amount of serpentine or nurofen or any over-the-counter medication you're taking each week to the point that you're taking hardly anything now you'll find that that will then ease the amount of what vice like headaches you're getting because it's a combination of medication overuse and tension that's causing those then if there is temporal mandibular joint instability I'd ask you to see your dentist to fit a Brit to give you a brace that you can fit and just wear it's like a mouth guard or a gum shield you're wearing rugby that you wear at night and that eases tension in the muscles a tooth grinding or teeth grinding and and then the options are to treat the my gram sell my grains themselves sorry and you can either treat it acutely or prophylactically I don't tend to treat am profe with prophylaxis only if people's quality of life is severely affected by which I mean if they're having having more than one or two severe migraines a week almost now others will treat when it's only one or two a month but you you work that out with the patient as to what they want some people are very and against having any medication at all because inevitably they all have potential side effects so what I would say to you that once you if you give it a little time with the diary and you can try and do everything without medication primarily doesn't be fantastic but I write a prescription here for today and for the acute situation when the blurred vision you feel one of these throbbing unilateral migrants type headaches are coming on called a trip time the drug is called a trip time that I'm writing for and you take one of the beginning of an attack and you take it within two hours if it's not gone but you don't take more than two within 24 hours because of potential side effects and yeah you're one always looks up at the past medical history of course to see if is any history of heart disease don't give it to pregnant women but I won't go into that too much detail you can look that up ourselves so a sue at trip ten is the one there's a family of drugs which work through the serotonin system which worked fantastically in severe migraine you can take these acutely if they don't work and you come back in a month or so time and you say you're still having lots of headaches despite this as they right perhaps wise to give you some preventative medication and the preventive medication I would use first-line and would probably be a propranolol which is a beta blocker and I give it ten milligrams three times a day for about a month and then increased twenty three times a day and then thirty three times a day and that seems like an awful lot but it's not really the major thing of course is you don't give it to someone who's a history of asthma if it doesn't work and again the diary was it I always say the diaries like a report card and you can say well oh look you got good results their doctor or no you didn't so we didn't do so well their doctor you say well fair enough not a disaster you weaned off the propranolol though and move on to the second line and if the second line I'd now use is a drug called topi Ramesh and you started 25 milligrams a day and increase over four weeks to 50 milligrams twice a day and you take that for at least four months and then you wind it off again I always say it's like a my body or cordial drink where you take a small dilution first and make the concentration increase and then you dilute it again later on so the patients understand why your what you're doing and you're not in their own where it's poisoning them so take 50 milligrams twice a day of topamax four and four months at a minimum and you can take it for longer and they're side effects that excuse me the side effects of that primarily are weight loss pins and needles in your hands and very rarely language disturbance or the three I always warn people about finally and if that doesn't work my third line is usually passata fan which is Sante migrant which is 0.5 milligrams at night increasing on a weekly basis to 3 milligrams and the main side effect there is weight gain so and you choose your audience so to speak as by potential side effects for people and depending on the individual what drugs are effective when you're looking at someone with headaches or chronic daily headaches you have to think is a primary headache or a secondary headache all I've been talking about earlier on today in this piece is an primary headaches they are those without a clear cause structural cause sometimes however the situation is much more acute if someone comes with to a general practitioner or indeed to the emergency department with an acute severe headache they always describe it as the worst headache they ever had the first thing you must rule out is a subarachnoid hemorrhage usually people describe it as if they've been hit hard with a baseball bat for some reason at the back of their head they feel nauseated their neck is stiff in that situation they need an urgent cat scan and perhaps even a lumbar puncture the second thing you must rule out as meningitis and that will be the there'll be markers of that a more generalized on wellness and much more clearly obviously unwell sorry usually more clearly obviously unwell than someone with a chronic three year history is danica is described today the red flags that we look for are for things that might suggest an onion lying tumor a bleed or hemorrhage or an infection and these are neurological signs and symptoms of manage ISM and the consistency of the headache are crucial and in which case if you're in doubt then someone should be imaged in my view fairly quickly fairly smartly for the other type of headaches we've discussed medication overuse migraine and tension headaches but if it's not those there are other types of headaches such as cluster headaches paroxysmal Hemi crania and cranial is continua and these type of headaches have different markers and we often see an autonomic signs such as injection of the eyes redness of the eyes or ptosis or drooping of the eyelid with these and again these follow are quite a quite a pattern but the common ones are the ones we've discussed here today you


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