Part 1

Neurology OSCE for

undergraduate
By
Mohammed Hassan Hilow
6th year student at Kufa university

Email: Med160072@student.uokufa.edu.iq

Mohammed H. Hilow - medical studnet

The content of this presentation is only for
educational purposes

Mohammed H. Hilow - medical studnet

 23 years old university student presented with sudden onset left side
weakness for 1 day of the upper limb started in the hand then spread
to involve all the limb. The patient has flu few days before the attack.
The patient has no LOC, no difficulty of swallowing, no dysphagia, no
seizure and no headache or dizziness. MRI showing below.

Questions :
1- What is the DDX ?
2- What is the likely diagnosis and why ?
3- What is the treatment of this patient ?
Mohammed H. Hilow - medical studnet
Answer

• DDX : MS, ADEM

• Likely DX: MS (age >20 and periventricular lesions)
• Tx: this patient is in acute attack the treatment of choice is steroid
pulse therapy or Plasmophoresis

Mohammed H. Hilow - medical studnet

A 29 yrs old knowing case of MS. She is on
Avonex(IF beta1a) 30mg I.M. weekly. She is
planning to have a baby but she is very worry
about how the disease might affect her pregnancy.
Questions:
1- Can MS patients get pregnant? If yes, When ?
2- Dose the MS attacks frequency change during and after pregnancy ?
3- Can she continue using the same drug during pregnancy? If no what
are the alternatives?

Mohammed H. Hilow - medical studnet

Answer

• MS doesn’t affect fertility. Patient allowed to be pregnant if in the last

year has two or less attacks.
• During pregnancy the MS attacks decrease, but in puerperium the
attacks increase and DMD should be started 2 months before delivery
(some textbooks after delivery)
• No, it is teratogenic. Alternatives are either using steroids during the
second trimester or using Capoxone (articles might mention other
drugs)

Mohammed H. Hilow - medical studnet

17 yrs old female presented with gradual visual loss preceded
by pain in her right eye aggravated by movement. O/E the
patient has central scotoma and sluggish pupillary reflex in the
right eye. Fundoscopy show no changes.

Questions
1- What is the likely diagnosis?
2- What is the next step in approaching this patient?
3- What is the treatment?
4- Is it necessary to follow up this patient why and how ?

Mohammed H. Hilow - medical studnet

Answer

• Optic neuritis
• Send patient for MRI(Post Gd MRI). Around 20% of MS present as
optic neuritis and 50% of MS patient develop Optic neuritis during the
disease course.
• Treatment with methylprednisolone I.V
• Yes, this patient is female and below 35 yrs these increase here risk
to develop MS after optic neuritis. Follow up every 6 months with
MRI.
Mohammed H. Hilow - medical studnet
 1 2

Questions
1- What is the name of this sign?
2- Which of the pictures (1 or 2 ) is positive ? Describe each picture.
3- What are the causes of positive sign ?
4- When it considered as pseudo sign ?

Mohammed H. Hilow - medical studnet

Answer

• Babinski sign
• 1 is negative ( there is planter flexion) 2 is positive (upward or platner
extension with fanning)
• Cause of +ve sign:
• UMNL(CVA)
• Children <1 year
• Coma
• Post ictal satge
• Pseudo-babinski sign: occur in patient with choreoathetosis where
the up going toe is due to hyperkinesia
Mohammed H. Hilow - medical studnet
Questions
1- What is the sign in the picture ?
2- When it considered positive ?
3- causes of positive sign?

Mohammed H. Hilow - medical studnet

Answer

• Hoffman’s sign(equivalent of the Babinski sign)

• Considered positive if the index finger flexed and the thumb
adducted and flexed.
• Causes of +ve sign:
• UMNL
• Agitation
• Hyperthyroidism

Mohammed H. Hilow - medical studnet

 Examiner hand

Questions
1- What is the sign in the picture ?
2- When it considered positive ?
3- causes of positive sign?
Mohammed H. Hilow - medical studnet
Answer
• Wartenberg sign(Babinski of the upper limb)
• It is positive when the thumb is adducted and flexed

Mohammed H. Hilow - medical studnet

Questions
1- Findings ?
2- what is the diagnosis ?
3- What is the likely cause and why ?
4- What are the other causes and how
to differentiate

Mohammed H. Hilow - medical studnet

 Answer

• The left eye complete ptosis and deviation downward outward

• 3rd nerve palsy
• Medical cause - the pupils size are equal
• Surgical causes such as posterior communicating artery aneurysm – in
surgical cause the pupil dilated (mydriasis)

Mohammed H. Hilow - medical studnet

Questions
1- Findings ?
2- what is the diagnosis ?
3- What are the causes ?
4- What is the cause if this patient has
bilateral papilledema?
5- what are the false localizing signs ?

Mohammed H. Hilow - medical studnet

Answer

• The left eye deviated medially

• 6th CN palsy
• SOL, IIH, Vascular
• Increased ICP-e.g IIH
• Neurological signs have been described as ‘false localizing’ if
they reflect dysfunction distant or remote from the expected
anatomical locus of pathology and hence challenging the
traditional clinicoanatomical correlation paradigm. They include
• 3rd, 4th, 5th, 6th CN palsy and papilledema.

Mohammed H. Hilow - medical studnet

50 years old female presented with left side mouth
deviation developed over the last week with inability
to close the eye.
You treated the patient after diagnosing her.
3 months later she complain of mouth twitching in
the left cornear when she closes her eye.

Questions
1- What is your diagnosis?
2- Is it upper or lower motor neuron lesion and
why?
3- What is your explanation to her presentation
after 3 months?
Mohammed H. Hilow - medical studnet
Mohammed H. Hilow - medical studnet
Questions
1- What is the diagnosis ?
2- what are the causes ?

Mohammed H. Hilow - medical studnet

Questions
1- Describe the findings and what is the Dx?
2- Treatment ?
3- complications ?
Mohammed H. Hilow - medical studnet
29 years old female referred to you from the ophthalmology clinic. The
patient has diplopia and ptosis. Patient complain that she feels very
tired at the end of the day.

Questions
1- What are the clinical tests to diagnose this patient ?
2- What other tests you will order?
3- Is imaging important and why?

Mohammed H. Hilow - medical studnet

 Answer
• Ice-pack test for ptosis, Sustained upgaze (60 to 180 seconds),
Sustained abduction of the arms (120 seconds), Counting aloud (1 to
50)
• Edrophonium or neostigmine test, AchR Antibody, Anti-MuSk and/or
LPRP4 antibody, Decrement test, Single fiber EMG
• Yes, important as 75% of patients has either thymus gland hyperplasia
or thymoma these patient may benefit from thymoectomy. (CT or
MRI)

Mohammed H. Hilow - medical studnet

The young female showing in the picture below complains of
weakness that become more severe at the end of the day.

Questions
1- What are the findings in the picture
2- Does pregnancy affect her disease? How ?
3- Treatment lines for this patient?
Few months later the patient presented with
Weakness and she was taking her Drugs as
doctor told her. She has same symptoms of her presentation in addition
to her UTI symptoms.
4- What is the possible cause of this patient deterioration?
Mohammed H. Hilow - medical studnet
 A young man was found unconscious in his office 1 hr ago.

Questions
1- What is the first thing to do?
2- What you would look for to differentiate between metabolic and
structural coma ?
3- What is the test showing below?

Mohammed H. Hilow - medical studnet

Questions for each drug in the pictures
1- Mechanism of action of this drug?
2- Side effects ?
3- Indications ?

Mohammed H. Hilow - medical studnet

Questions
1- Mechanism of action of this drug?
2- Side effects ?
3- Indications ?
4- What is the end dose phenomenon ?
5- What is the on-Off phenomenon

Mohammed H. Hilow - medical studnet

Answer
• 4- The wearing-off effect (also called end-of- dose akinesia):
each dose improves mobility for 1-2 hours but akinesia
rapidly returns.
• 5- The on-off effect: ‘off’ periods of marked akinesia alternate
with ‘on’ periods of improved mobility.

Mohammed H. Hilow - medical studnet

Diabetic 60 yrs old man awakens with left side weakness.
Examination indicates relatively symmetric upper motor
neuron pattern of weakness involving the face, arm, and leg.
There are no sensory abnormalities, No dysphagia, no
dysarthria, no dysphagia, no LOC, no Abnormal movement.

Questions:
1- What is the diagnosis?
2- Which structure involved?
3- What are the types of weakness?

Mohammed H. Hilow - medical studnet

Answer
• CVA
• Internal capsule
• Proximal, distal, pyramidal and segmental

Mohammed H. Hilow - medical studnet

Questions
1- describe what is showing in the picture?
2- What is the diagnosis?
3- Which muscles spared ?
4- what are the causes ?

Mohammed H. Hilow - medical studnet

Answer
• Claw hand
• Ulnar nerve palsy
• Thenar muscles and two lateral lumbrical muscles.
• Causes: cubital tunnel syndrome, damage to the nerve

Mohammed H. Hilow - medical studnet

Questions
1- Name the showing investigation?
2- Indications other than seizure/epilepsy?
3- What are the common patterns showing in epilepsy?
Mohammed H. Hilow - medical studnet
 2
1

Questions
1- Name the showing investigations ?
2- Mention 3 indications ?
3- picture 2 – what is the test? What is the likely diagnosis?
Mohammed H. Hilow - medical studnet
Questions
1- Name the showing sign
2- Describe findings
3- Mention other signs you will find in this patient ?
Mohammed H. Hilow - medical studnet
Answer
• Valley sign
• Good bulk of deltoid and infraspinatus and wasting of other
surrounding muscles
• Calf pseudohypertrophy and Gower’s sign

Mohammed H. Hilow - medical studnet

Questions
1- What is the showing sign?
2- Causes of positive sign ?
3- Other signs might be positive

Mohammed H. Hilow - medical studnet

Answer
• brudzinski sign
• Meningeal irritation (meningitis, SAH)
• Kernig sign, neck stiffness, cheeck sign

Mohammed H. Hilow - medical studnet

Mohammed H. Hilow - medical studnet