SAN BEDA COLLEGE OF MEDICINE NEUROLOGY:

BATCH 2019 A/Y 2015-2016 MINI OSCE REVIEWER

EXAMINATION OF THE SOMATOSENSORY, AUTONOMIC SYSTEM AND MENINGES

GENERAL RULE:

1. Do not panic.
2. Listen to the history of the patient and make sure to write and remember important details.
3. Bring all needed materials.
4. Make sure to greet and instruct patient accordingly.

SOMATOSENSORY EXAMINATION
A. Definition of Terms

Algesia – pain Analgesia – total loss of sensation

Hypalgesia – partial loss of sensation
Hyperalgesia – increased sensitivity to pain
Allodynia – abnormal perception of pain from a nonpainful stimulus, with delayed
perception and after sensation
Neuralgia – multiple, very severe, electric shock-like pains that radiate into a specific root
or nerve distribution
A.
Pain of Nociceptive -- is divided into somatic and visceral and arises from some local
B.
C. lesion, such as an invasive carcinoma or trauma that stimulates local pain endings.
D. Pain of Neurogenic -- arises from some form of heightened sensitivity poor overactivity
E. from a lesion that affects the peripheral or central nervous system, apart from stimulation
F. of local pain endings.
G. Referred pain- the site at which the Pt feels the pain may not correspond to the site of
H.
lesion.
I.
J. Trigeminal Neuralgia -- a very typical neuralgia, characterized by repetitive excruciating
K. shocks of pains in one or more of the branches of trigeminal nerve.
L. Causalgia – now called reflex sympathetic dystrophy – unbearable, burning, relentless
M. hyperesthesia and hyperalgesia that ensue after injury to a peripheral nerve
N. * – touch or
Esthesia Hypesthesia – partial loss of temperature
feeling Anesthesia – total loss of pain/lack of pain
Pallanesthesia – loss of vibration sense
Hyperesthesia – increased sensitivity to touch
Hyperpathia – extreme overresponse to pain
Anesthesia dolorosa – raised pain treshold
Hyperthermesthesia – increased sensitivity to temperature
Paresthesia – semsations when they accompany a normal external stimulus to the skin
Dysesthesia – spontaneous occurrence without any external stimulus
Grapho -- writing Agraphagnosia – loss of graphic sense

Noso -- disease Anosognosia -- loss of disease awareness

Nosognosia -- sense of awareness disease
Nosology -- science of disease classification
Therm – heat Thermhypesthesia – partial loss of temperature sensation
Thermanesthesia – total loss of temperature sensation

Topo – place Topognosia – sense of localization of skin stimulus.

Proprioception –sense of movement, of position, and of skeletomuscular tension

provided by deep mechanical receptors in muscles, joints, connective tissue, and the
vestibular system .

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B. Pathways

DORSAL COLUMN Discriminating tactile sense ( touch and pressure) and kinesthetic sense (
PATHWAY position and movement).

Ipsilateral

First order Neuron: Dorsal Root Ganglion

Second Order Neuron:
 Fasciculus Cuneatus: Upper Extremities
 Fasciculus Gracilis: Lower Extremities
Third Order Neuron: Ventral Poster lateral nucleus of the Thalamus
(VPL)

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LATERAL SPINOTHALAMIC TRACT Carries sensory modalities for pain and temperature.

Contralateral- decussates at anterior white commisure of the substansia

gelatinosa.

First order Neuron: Dorsal Root Ganglion

Second Order Neuron: Substansia Gelatinosa
Third Order Neuron: Ventral Poster lateral nucleus of the Thalamus (VPL)

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ANTERIOR SPINOTHALAMIC TRACT Carries sensory modalities for crude touch and pressure.

First order Neuron: Dorsal Root Ganglion

Second Order Neuron: Substansia Gelatinosa
Third Order Neuron: Ventral Poster lateral nucleus of the Thalamus (VPL)

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 SAN BEDA COLLEGE OF MEDICINE NEUROLOGY:
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B. SOMATOSENSORY EXAMINATIONS
1. Testing for Somatosensory Dysfunction

Testing for Light  Instruct the patient, “ Maam/ Sir ipikit nyo po ang inyong mata at Start with normal
Touch Sensation may bagay po ako na ipaparamdam sa mukha, sabihin nyo po side.
kung may nararamdaman na kayo.” Make sure to test both sides
Materials: cotton then ask, “ Maam/ Sir, pantay po ba?” NORMAL: Patient
 Sequence: Face, Dorsum of Hand, if not able to identify, proceed was able to identify
to Forehand within the dermatome. For LE, start with the dorsum the stimuli and
of the feet same sequence as UE. reported to have
L R equal sensation on
Ophthalmic (bilateral or
branch (V1) unilateral) part of
Maxillary ____. ( extremity,
branch (V2) cheeks)
Mandibular
branch (V3)
Forearms (C6,
T1)
Thumb and
Little Finger (C6,
C8)
Calves (L4, L5)
Little Toes (S1)
Testing for  Instruct the patient, “ Maam/ Sir ipikit nyo po ang inyong mata at Start with warm
temperature may ipaparamdam po ako ng bagay sa mukha nyo, sabihin nyo po first to avoid
sensation kung warm or cold”. inducing numbness.
 Use tuning fork or finger test: Apply metal shaft of a tuning fork to
Materials: Tuning side of th Pt’s cheek for a few seconds and then remove it and Make sure that
Fork or Hand. apply side of your little finger to the same spot materials are not in
 Alternate finger and tuning fork as you proceed over 3 trigeminal extreme
sensory areas & dorsum of both hands & feet. temperature to
 To sharpen ambiguous results, say “ Saan po yung mas malamig avoid injury.
number 1 [the tuning fork] or number 2 [the finger]?”
 Test temperature discrimination first. If the Pt discriminates NORMAL: Patient
temperature normally, and the history does not suggest neurologic was able
disease, you do not need to prick every Pt with a pin. discriminate
correctly between
L R warm and cold
Ophthalmic upon presenting
branch (V1) stimuli.
Maxillary
branch (V2)
Mandibular
branch (V3)
Forearms (C6,
T1)
Thumb and
Little Finger (C6,
C8)
Calves (L4, L5)
Little Toes (S1)
Testing for Pain  Show the Pt a broken tongue depressor with its sharp and dull Open the tongue
sensation ends. Orient the patient by having it done first in the dorsum of depressor in front
the hand with eyes open.“ Maam/ Sir, eto po yung blunt, eto po of the patient, then
yung sharp.’” break it into half.
Materials: Tongue  Ask the Pt to close eyes and respond sharp or dull when you apply Quantify sensation
Depressor ( blunt and the tongue depressor. .“ Maam/ Sir, sabihin nyo po kung sharp or the sensation.
sharp end)- more blunt yung ipaparamdam ko.’”
preferable than  Use of the tongue depressor: Alternate touching the Pt with the NORMAL: Patient
safety pin two ends of the pin randomly was able to identify
 Make sure that you will not apply too much pressure when doing and localize pain
the test. sensation
 Make about three successive pricks for each stimulus. accordingly.
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 Test the face and dorsum of the hands and feet.(Avoid the horny
skin of the palms and soles).
 If needed, quantify the sensation if it is “100% on the right, what
percent on the left? 50% or 25%, You can also ask, “Gaano po
yung naramdaman nyo? Kasinlaki po ba ng piso?25cents?”

Testing for Pain  Delayed pain and deep pain perception: If the first test suggests a NORMAL: Patient
sensation sensory disturbance, proceed to test the extremities (not done on was able to identify
the face). and localize pain
 Testing for delayed pain: Pinch the dorsum of the Pt’s foot briskly sensation
(Check if there is a delayed response) accordingly.
 Testing for deep pain: Test by squeezing very hard on an Achilles
tendon or a muscle or by compressing very hard over a bony
surface.

Leg raising for Nerve Laseaguie’s Sign(The straight-knee leg raising test) NORMAL: Knee
Root Compression  The patient should be lying supine. Raise the patient’s relaxed and straightens without
straightened leg until pain occurs. Then dorsiflex the foot. Repeat difficulty. No pain
Material: Mat on the other leg or discomfort
 Record the degree of elevation at which pain occurs, the quality reported by the
and distribution of the pain, and the effects of dorsiflexion. patient.
 Sharp pain radiating from the back down the leg in an L5 or S1
distribution (radicular pain) suggests tension on or compression of
the nerve root(s), often caused by a herniated lumbar disc.
 Dorsiflexion of the foot increases the pain. Increased pain in the
affected leg when the opposite leg is raised strongly confirms
radicular pain and constitutes a positive crossed straight leg-raising
sign.

Kernig’s Sign
 Place the patient in supine position and flex the hip at 90 degrees
with the knee flex. Try to extend the knee and note for discomfort.
Repeat on the other leg.
 Record the degree of elevation at which pain occurs, the quality
and distribution of the pain

2. Testing for Dorsal Column Dysfunction

Testing for  Ask the patient to close eyes and place a NORMAL: Patients was able to detect
Vibration Sense vibrating tuning fork on the area and ask him the initial vibration and accurately
to report when the vibration stops. determine when it has stopped.
Material: Tuning  “ Maam/ Sir, ilalagay ko p o itong tuning fork,
Fork ( preferably sabihin po ninyo kung may naramdaman po
128 Hz) kayo at kung kelan natapos na yung vibation”.
 Sequence: nail bed then the bony prominence
of the fingers (knuckles) superior to the nail
bed then the bony prominence of the ulna.
 For LE, start with the sequence as UE.
 Put a few fingers of your other hand on the
bottom-side of this joint. You should be able to
feel the same sensation with your fingers on
the bottom side of the joint.

Directional Scratch  Ask the patient to close eyes and
Test instruct,”Maam/ Sir, may ipaparamdam po ako
sa inyo, sabihin nyo po kung up or down ”.
Materials: Tongue  Sequence: Start at the dorsum of hand, if not
Depressor( cut in able to identify then forearm (dermatome). For
half) LE, start with the dorsum of the feet same
sequence as UE.
Open the tongue depressor in front
of the patient, then break it into half.
NORMAL: Patient was able to
determine the direction of the stimuli
accordingly.

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 The directional scratch test on the dorsum of

the palm and leg may be superior to other
tests of vibratory or position sense.
 Scratch a line across 2 cm and ask patient if
scratch was up or down.
 If unable to perform accurately (ie, 100 %),
repeat with distance systematically increased
to make the test quantitative.

2- Point  With the patient’s eye closed. Provide the NORMAL: Patient should be ableto
Discrimination Test stimulus by applying light and equal pressure identify 2 points at
across the two points. Fingertips at 2 to 5mm apart
Materials: ruler,  Have the patient identify if they feel one or Forearm at 40mm apart
paper clip two points. “Maam/ Sir, sabihin nyo po kung Dorsal hands at 20 to 30 mm apart
ilan yung nararamdaman nyo”.
 Move the two points closer together across
consecutive trials until the patient cannot
distinguish the two points as separate.
 Touch the client on fingertips, forearm and
dorsal hands.

Proprioception  Ask the patient to close their eyes. NORMAL: Patient was able to
 With one hand, grasp the 4th finger or 4th toe correctly identify the motion and
(lesser space covered in the human direction of the specific extremity
homunculus). Place your other hand on the tested.
lateral and medial aspects .
 Orient patient to up and down as follows:Flex
the toe (pull it upwards) while telling patient
what you're doing. Extend toe (pull it
downwards) while informing them of which
direction you're moving it. ”Maam/ Sir eto
yung up, eto yung down.”.
 Then proceed to the test. ”Maam/ Sir
gagalawin ko nap o sabihin po ninyo kung up o
down.”.

AUTONOMIC SYSTEM EXAMINATION

A. Autonomics Pathway
SYMPATHETIC PARASYMPATHETIC
 Fight or Flight  Rest and Digest
Sympathetic Pathway Parasympathetic Pathway
 Thoracolumbar origin  Arises from either brainstem or sacral region
 Intermediolateral nucleus of lateral gray (Craniosacral)
column  Cranial Nerves (III, VII, IX, X) synapses to four
 Axons leave through the anterior root parasympathetic ganglia:
Sympathetic ganglion (origin: Thoracic Nerves)  ciliary (eye) CN III
 Decreased salivation  pterygopalatine (Meckel) (lacrimal gland, nasal
 Increased heart rate mucosa) CN VII
 Bronchiole dilation  otic (parotid gland) CN IX
Celiac Ganglion (origin: Thoracic Nerves to abdominal  submandibular (oral mucosa,
area) submandibular/sublingual glands) CN VII
 Decreased digestion  Postganglionic neurons proceeds to target
 Increased glucose production (liver) areas via trigeminal branches
Inferior Mesenteric Ganglion (origin: Lumbar nerves) CN X (vagus nerve)
 Relaxation of bladder  targets most organs for parasympathetic
 Ejaculation activity (heart, lungs, abdominal area)
Short preganglionic neuron (myelinated)  no ganglion!

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 NT: Acetylcholine Sacral Region (Splanchnic Nerves)

Long postganglionic neuron (unmyelinated)  Relaxes rectum
 NT: Norepinephrine  constricts bladder
Synapses to adrenal medulla have no ganglion  genital erection
 secretion of adrenergics directly to Long, myelinated preganglionic neuron
bloodstream  NT: Acetylcholine
Short, unmyelinated postganglionic neuron
NT: Acetylcholine
B. General Inspection
-observe for the following signs (clinical eye is IMPORTANT)

[]Alopecia/ Hair Loss []Skin Atrophy []Hypertrichosis (abnormal amount of hair growth)
[]Thickening or fragility of the nails []Absent piloerection []Mottling(blotch)
[]Rhinorrhea (runny nose) []Excessive dryness or oral mucosa
[]Decreased hand-wrinkling in water

C. Sympathetic Response
Sweating Abnormalities
Note: When a spoon is drawn over the skin, it pulls smoothly over dry (sympathectomized) skin but irregularly and unevenly over
moist perspiring skin
1. Area of abnormal skin
_____________________________________________________________________
2. Area of excessive sweating
_____________________________________________________________________

D. Lacrimal Gland Tear Production

Note: A convenient and simple bedside assessment can be obtained with Schimer test, done by placing a strip sterile filter paper in
the lower conjunctival sac and measuring the degree of wetting over 5 minutes.

[]Excessive dryness [] Excessive tearing []Ptosis [] Redness [] Itchiness

E. Cardiovascular Manifestation

Note: Normally, systolic blood pressure on standing does not decrease by more than 20mmHg, and the diastolic blood pressure by
not more than 10mmHg. There are more stringent diagnostic criteria that permits a 30 point drop in systolic blood pressure or 15
drop on diastolic blood pressure declines can sometimes be detected by having the patient perform 5-10 squats repeating the
measurements. The Heart Rate should not increase by more than 30 beats per minute above baseline on standing.

Blood Pressure
Blood Pressure – Orthostatic
Hypotension Position Systolic Blood Diastolic Blood Heart
[]Syncope Pressure Pressure Rate (faint)
[]Weakness
Supine

Standing Position

 1 minute after

 3minute after

 5 minute after

Valsalva Maneuver

Deep Breathing

Tilt table testing

[]Tremulousness []Dizziness []Palpitation []Confusion []Slurred Speech

Others: _______________________________________________________________

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Respiratory Manifestation
RR:___________________ ( Normal 12-20 )
Characteristics:_____________________
[]Hyperventilation ( RR >20) []Hypoventilation ( RR <12)
*+Kaussmaul’s Breathing (deep labored Breating)
[]Cheyne-Stokes (central apneas alternating with period of waxing-waning breathing patterns)
Others:_________________________________________

F. Gastrointestinal Manifestations
[] Constipation [] Diarrhea []Dysphagia []Anorexia []Early Satiety []Fecal Incontinence
Others: _______________________________________________

Internal Anal Sphincter Reflex []Present []Absent

G. Genitourinary Manifestation
Bladder
Upper Palpation:__________________________ Usual Urine Volume during Urination:___________
Characteristics of Urine:____________________

EXAMINATION OF MENINGES

Meninges -three layers of protective tissue called the dura mater, arachnoid mater, and pia mater that surround the neuraxis. The
meninges of the brain and spinal cord are continuous, being linked through the magnum foramen.

A. Dura Mater is the most superior of the meningeal layers. This tissue forms several structures that separate the
cranial cavity into compartments and protect the brain from displacement.
 The falx cerebri separates the hemispheres of the cerebrum.
 The falx cerebelli separates the lobes of the cerebellum.
 The tentorium cerebelli separates the cerebrum from the cerebellum.
B. Arachnoid or arachnoid mater is the middle layer of the meninges. In some areas, it projects into the sinuses
formed by the dura mater. These projections are the arachnoid granulation/arachnoid villi. They transfer
cerebrospinal fluid from the ventricles back into the bloodstream
C. Pia mater is the innermost layer of the meninges. It fuses with the ependyma, the membranous lining of the
ventricles to form structures called the choroid plexes which produce cerebrospinal fluid.

Epidural space is a potential space between the dura mater and the skull. If there is hemorrhaging in the brain, blood may collect
here. Adults are more likely than children to bleed here as a result of closed head injury.

Subdural space is another potential space. It is between the dura mater and the middle layer of the meninges, the arachnoid mater.
When bleeding occurs in the cranium, blood may collect here and push down on the lower layers of the meninges. If bleeding
continues, brain damage will result from this pressure. Children are especially likely to have bleeding in the subdural space in cases
of head injury.

Subarachanoid space lies between the arachnoid and pia mater. It is filled with cerebrospinal fluid. All blood vessels entering the
brain, as well as cranial nerves pass through this space. The term arachnoid refers to the spider web like appearance of the blood
vessels within the space.

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Cerebrospinal fluid - a clear liquid produced within spaces in the brain called ventricle produced by the choroid plexus . It is also
found inside the subarachnoid space of the meninges which surrounds both the brain and the spinal cord.

CSF Circulation

Meningitis- inflammation of the meninges.

Clinical Manifestation of Meningeal Irritation

 Nuchal Rigidity
Involuntary muscle spasm limits passive neck flexion
Patient cannot flex neck to place chin on chest
Unreliable in age under 18 months due to underdeveloped neck musculature
Resistance only to neck flexion

 Cervical Rigidity
Erector spinae muscle spasm limits spine movement
Opisthotonos (rigid arched back) may occur.
Any resistance to neck movement in any direction

 Meningismus
triad of nuchal rigidity, photophobia and headache (NPH - "Neil Patrick Harris") without actual infection or inflammation.

REMINDER: Make sure to rule out cervical injury or fracture before performing the procedure. Instruction should be given and keep
patient safe at all times.

Brudzinki’s Test  Place the patient in supine position and place
your hand behind the patient’s head .
 Gently rotate the head and ask for presence of
stiffness.
 Then lift the head off ( head flexion )the bed and
feel for neck muscle tone. Watch out for leg and
knee flexion.
NORMAL: The patient’s neck moves easily
in both planes with chin easily reach the
chest on neck flexion. NO discomfort
reported by the patient.
ABNORMAL: There is noted involuntary
hip flexion. The patient reports pain upon
neck movement . There is noted flexion of
lower extremities.

RATIONALE Hip flexion is the

compensation for the stretched meninges
therefore inhibiting pain felt by the
patient.

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Kernig’s Test  Place the patient in supine position and flex the
hip at 90 degrees with the knee flex.
 Try to extend the knee and note for discomfort.
 Repeat on the other leg.
NORMAL: Knee straightens without
difficulty. No pain or discomfort reported
by the patient.
ABNORMAL: There is resistance and pain
in the ( SPECIFY, unilateral or bilateral)
knee upon extending and pain in
hamstring muscles.

RATIONALE: The pain felt on Kernig's sign

is due to meningeal irritation caused by
movement of the spinal cord within the
meninges.

AUTHORS: CASIL, DELA PAZ, ENCINA, AMER R., FLORES H., FLORES B., FLORES A., JAVIER, GAMBOA, GARRUCHO, BANZON, AGNILA,
DELAS ALAS, BELOSO, CASTILLO W., IMPERIAL J., CHENG, CLOA, HOLGUIN, GARCIA, GULANE, ABENOJA, GUINTO, ALFELOR

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