St. Vincent’s University Hospital
Department of Clinical Neurology
Neurology Handbook
Professor Michael
Hutchinson
Professor. Niall
Tubridy
Dr. Christopher
McGuigan
Dr. Sean O’Riordan
The Students
Spr 2 Bleep 260
xxxxxxx
SpR 1 Bleep 117
Intern Bleep 246
SHO Bleep 485
2010
Neurology Undergraduate Teaching and Learning
PART 1
Log on to ucd.ie for access to video on how to do a neurological examination
Page
PART 1
Appendices:
3-7
1.
Examination of the nervous system
2.
Small group information
8
3.
Aid to the examination of motor function
9
4.
Student rota for attendance
10
5.
Review of Progress and end-of-rotation grades and marks
11
6.
Marking scheme and Performance Descriptors
12
7.
Example of scenario sign-up
13
8.
Summary of clinical skills to be acquired
14
9.
Weekly neurology timetable
15
10. Introductions to web-based clinical scenarios
2
16-19
Appendix 1
EXAMINATION OF THE NERVOUS SYSTEM
INTRODUCTION
The following guidance on examination of the nervous system. The objective is to inform teachers and students of the
core methods for performing a basic examination of the nervous system. These should enable the student to detect and
record the physical signs of common and important disorders of the nervous system. The student should understand
the principle behind each test and what it is designed to detect.
It may be necessary to modify and extend the basic examination to deal with individual clinical problems. In practice
individual neurologists use a wide range of techniques for examining the nervous system.
ORDER OF EXAMINATION
The conventional order for describing the examination is:
General appearance
Stance and gait
Higher functions
Cranial nerves
Motor system
Sensory system
In individual cases it may be better to focus the examination first on the affected part. It is often convenient to examine
stance and gait before examining the patient on the couch.
Stance and Gait
Ask the patient to rise from a chair without using their hands and stand still with their feet together.
Ask the patient to stand on their toes and then their heels, steadying the patient by gently holding their hands.
Watch the patient walk across the room turn round and come back to you looking for:
 Whether the gait is normal or abnormal
 Painful gait
 Unsteadiness
 Foot drop
 Hemiparetic gait
 Spastic gait
 Stooped posture, slowness and loss of arm swinging
 Others: marche á petit pas, Waddling gait
If, and only if, the patient is steady, test heel-toe walking
HIGHER FUNCTIONS
Ask if the patient is left or right handed. Establish if the patient is alert and able to give a clear history. If relevant, test for
dysphasia, examine the mental state and perform the Mini Mental State Examination.
CRANIAL NERVES
Cranial Nerve I – Olfactory nerve: (need containers with coffee or peppermint)
Ask if the patient can appreciate taste and smell. Further testing is not necessary unless the patient complains of
abnormal taste or smell or there is a special reason to test olfaction. If testing is needed check that the airway is clear
and test each nostril with a basic smell, such as peppermint or coffee.
Cranial Nerve II - Optic nerve: (need 3- or 6-metre Snellen chart and pinhole)
3
Visual acuity
Ask patient if they are aware of reduced vision in either eye. Test visual acuity wearing distance glasses, if worn, in
each eye separately with Snellen chart. Use 3-metre chart at 3 metres or 6-metre chart at 6 metres, which produce
equivalent results.
If visual acuity less than 6/6 use a pinhole. Record visual acuity right (VAR) X/60 with/without aid of pinhole/glasses
and visual acuity left (VAL) Y/60 with/without aid of pinhole/glasses.
Visual fields (need 7 mm red pin)
Ask patient if they are aware of a field defect in either eye. Establish that the small red pin target (7 mm) is visible with
each eye. Test extent of visual field by testing each eye from each quadrant asking the patient to state as soon as they
can see the pinhead at all (regardless of colour).
Fundoscopy (need ophthalmoscope and darkened room)
Use the ophthalmoscope to examine the fundus of each eye separately with the other eye fixating in the distance. Hold
ophthalmoscope correctly (examining right eye with ophthalmoscope in right hand and using right eye and examining left
eye with ophthalmoscope in left hand and using left eye unless good reason not to be able to do so). The index finger
should be on the focussing wheel. Assess red reflex for presence of media opacities. View fundus at an appropriate
distance from the patient and focus the ophthalmoscope.
Cranial nerves III, IV and VI – Oculomotor, trochlear and abducent nerves: (need torch)
Inspect for ptosis (drooping eyelid), pupil size, strabismus (squint), proptosis.
Test for pupil light reaction and accommodation in each eye separately.
Look for nystagmus within a 30o range.
Cranial Nerve V – Trigeminal Nerve: (need cotton wool, pin or neurotip, tendon hammer)
Ask if the patient has any numbness or altered sensation in the face.
Test light touch in each of the three divisions.
If an abnormality is found determine its extent with a pin.
Test the corneal reflex with a wisp of cotton wool, touching cornea not sclera. Avoid touching eyelashes and eliciting a
‘threat’ reaction.
Cranial Nerve VII – Facial nerve:
Test frontalis – wrinkle the forehead.
Test orbicularis oculi – burying of the eyelashes should be looked for.
Test orbicularis oris – the patient is asked to show their teeth.
Ask about taste.
Cranial Nerve VIII – Auditory and vestibular nerves: (need 256 or 512 Hz tuning fork and auroscope)
Ask if the patient has a problem with their hearing. Test by first speaking and then whispering numbers at three feet
with masking of the non-tested ear using a piece of paper held over the non-test ear and scratching it when speaking or
whispering.
If hearing loss is reported (history or examination) first perform the Weber test. Strike a 256 or 512 Hz tuning fork on
your knee and apply it firmly to the patient’s forehead. Ask whether they hear it more on one side or the other or equally.
The tuning fork lateralises to the side of greater conductive loss or the side with the better cochlea in sensori-neural
hearing loss. Then perform the Rinne test with the same tuning fork. First apply the tuning fork firmly to the mastoid
process and then hold it in front of the external auditory meatus. Ask the patient which is louder. Patients with normal
middle ear function hear better by air than bone conduction.
Examine the external auditory meatus and tympanic membrane with an auroscope.
Examination of the vestibular nerve includes testing stance and gait, see below, and for nystagmus, see above.
4
Cranial Nerve IX – Glossopharyngeal nerve:
Not necessary.
Cranial Nerve X – Vagus nerve: (need torch, tongue depressor)
Ask about difficulty swallowing. Test articulation (for dysarthria), coughing and elevation of the soft palate on saying
Aah! If any of these are abnormal test gag reflex by touching the posterior pharyngeal wall on each side with an orange
stick and comparing the responses.
Cranial Nerve XI – Spinal- Accessory nerve:
Test sternocleidomastoid examined with the head tilted to the opposite side and with resistance against the tester’s
hand placed at the angle of the jaw. The muscle belly is visible and may be palpated. Neck flexion is a useful
screening test but not sufficient.
Test trapezius by asking the patient to shrug the shoulders and palpating the muscles, with shoulders elevated.
Cranial Nerve XII – Hypoglossal nerve: (need torch)
Observe the tongue rest in the floor of the mouth for wasting and fasciculation. Observe protrusion of the tongue and
note deviation.
Observe tongue movements for slowness seen in UMN lesions.
MOTOR SYSTEM
UPPER LIMBS
The patient should be seated with the upper limbs exposed to show the shoulders and their arms outstretched and the
hands supinated and then pronated.
Observation
Look for:
 Any obvious abnormality
 Skin changes (including scars, ulcers, café au lait patches, neurofibromas)
 Deformity (including joint swelling, asymmetry)
 Wasting (especially first dorsal interosseous, abductor pollicis brevis, shoulder muscles)
 Involuntary movements (fasciculation, tremor, dystonia, chorea, myoclonus).
Tone
Test wrist pronation-supination for a pronator catch in spasticity. Test for rigidity by slow rotation of the stabilised wrist.
5
Power
Test the following muscle groups in order, comparing each side as you progress. Each movement should be tested in
isolation: thus to test elbow flexion you must fix the upper arm with your free hand.
Movement
Shoulder abduction
Elbow flexion
Elbow extension
Wrist extension
Extensor digitorum communis
Grip
First dorsal interosseous
Abductor pollicis brevis
Starting position
900 abduction
900 flexion
900 flexion
Full extension
Full extension
Note
Apply pressure over PIP joints
Open patient’s grip
Test in isolation
in a plane at right angles to the palm
Full abduction
Full abduction
Reflexes
Test biceps, supinator (= brachioradialis) and triceps. If the reflexes are absent use reinforcement.
Co-ordination
Ask the patient to touch the tip of your stationary finger, at full stretch, accurately and gently, and then the tip of their
own nose with first one and then the other index finger.
Bradykinesia
Test fine finger movements to detect bradykinesia if parkinsonism is suspected.
LOWER LIMB
Then ask the patient to recline on a couch undressed to shorts
Observation
Look for:





Any obvious abnormality
Skin changes (including hair loss, ulcers)
Deformity (including joint swelling, pes cavus, claw toes)
Wasting (especially quadriceps and tibialis anterior (when the tibia stands out like a keel)
Involuntary movements (fasciculation, tremor).
Tone
Check that the patient does not have pain in their limbs. Roll the leg on the couch and then quickly flex the knee to
detect a quadriceps catch (present in spasticity). Test for ankle clonus.
6
Power
Test the following muscle groups in order, comparing each side as you progress:
Movement
Hip flexion
Hip extension
Knee flexion
Knee extension
Ankle dorsiflexion
Ankle plantar flexion
Extensor hallucis longus
Starting position
Max voluntary flexion
Lying flat
900 flexion
900 flexion
Full dorsiflexion
Full plantar flexion
Full dorsiflexion
Note
Knee straight
Hand under knee
Test for L5 root lesion or
peripheral neuropathy
Co-ordination
Ask the patient to lift the heel high and then carefully place it on the knee of the other limb and run it down the shin
once. This test is difficult to interpret if hip flexion is weak.
Reflexes
Examine the knee and ankle reflexes (with the joints at 900) and (with an orange stick) the plantar responses. If the
reflexes are absent, use reinforcement.
SENSATION
Ask if the patient has noted altered sensation in any part of their body. If the answer is negative, show the patient what
each of the following feel like with their eyes open and them check that they can appreciate them on the distal phalanx
of the index finger and hallux with their eyes closed:
Light touch with your finger tip
Vibration with a 128 Hz tuning fork
Joint position sense
Pinprick with a neurotip or tooth pick with the patient’s eyes open asking whether they can feel that it is sharp and hurts
like a pin.
If the patient reports an abnormality map out its extent with light touch or pinprick testing or compare the two sides and
draw it on a body chart.
7
Appendix 2
Small group information
Your tutor is:
Dr Niall Tubridy
Email:
n.tubridy@svuh.ie
The sessions will take place at:
Monday
2pm (Spr Bleep 117)
Tuesday
2pm (Consultant- arrange in OPD)
Wednesday 2pm (SHO- Bleep 485)
Friday
12 noon (Intern Bleep 246)
The venue will be:
St. Vincent’s Ward, 3rd Floor
If you have any problems contacting your associate tutor, then please contact Dr. Niall Tubridy.
The students in your group are:
Name
E mail
(a)
(b)
(c)
(d)
(e)
(f)
Physiotherapy and neurology nurse teaching at SVUH
Your group may arrange to have one hour’s teaching during the 13-week rotation with a physiotherapist and neurology
nurse specialist.
Physiotherapy
If your group is interested in arranging a physiotherapy teaching session, please contact the Clinical Lead of NeuroRehabiliation
Neurology nursing
Your neurology nurse specialists are Marguerite Duggan, Clinical MS Nurse Specialist.
She can be contacted on Bleep 591
And Heather Kevlighan, Parkinson’s Nurse Specialist (contact on ext 4146)
Neurophysiology
You are encouraged to sign up for one day in the neurophysiology department. Please report to the Neurophysiology
Reception, Ground Floor and ask for Dr. John McHugh. You will need to wear your white coat and ID badge. We suggest
that you locate the department before your allocated day.
Neuroradiology
You are also encouraged to sign up for one half-day in the neuroimaging department. On your allocated day, please report to
the Neuroimaging Reception, 3rd Floor.
On call
You are encouraged to sign up for one night on call.
8
Appendix 3
Aid to examination of motor function
MOVEMENT
MUSCLE
UMN
Shoulder Abd.
deltoid
Elbow Flex
biceps
C5/6
+
musculo-cutaneous
Brachio-radialis
C6
+
radial
Elbow Ext.
triceps
+
C7
+
radial
Radial Wrist Ext.
ECRL
+
C6
Finger Ext.
EDC
+
C7
(+)
PIN
Finger Flex
FPL + FDP index
C8
+
AIN
++
ROOT
REFLEX
C5
axillary
radial
FDP ring + little
Finger Abd.
1st DI
++
APB
++
NERVE
ulnar
T1
ulnar
T1
median
L1/2
femoral
Hip Flex.
iliopsoas
Hip Add.
adductors
L2/3
Hip Ext.
gluteus max.
L5/S1
sciatic
Knee Flex.
hamstrings
S1
sciatic
Knee Ext.
quadriceps
Ankle dorsiflex.
tib. ant.
Ankle eversion
+
+
L3/4
++
++
obturator
femoral
L4
deep peroneal
peroneii
L5/S1
sup.peroneal
Ankle plantarflex.
gastroc./soleus
S1/S2
Big toe ext.
EHL
L5
++
tibial
deep peroneal
9
Appendix 4
 Students must attend and contribute actively to ALL rounds and clinics during the Rotation.
 Students should present at least two cases at rounds in each rotation.
 The tutor in charge of the student rounds will award a mark based on these two presentations (or on the
best two if more than two cases are presented).
 Tutors may take into account the complexity of the case presented.
 Tutors will award a mark for the student’s overall attendance and participation in all rounds in the
Rotation.
 It is the student’s responsibility to ensure that the tutor is fully aware of their attendance and
participation in rounds.
Students should consider the following criteria carefully when preparing a
presentation
Tutors may refer to these criteria in awarding marks
1
Presentation skills including clarity, conciseness, and use of visual aids or
handouts (relevant papers)
2
Description of clinical features
3
Use of relevant tests and investigations
4
Assessment of principal clinical problems and differential diagnosis
5
Development of management plan
6
Evaluation of associated problems (e.g. ethical or public health issues)
7
Use of clinical sciences and literature review to illustrate case
8
Handling of questions and discussion
Marking scheme
Excellent
Good
Competent
Not competent
Not done
Date
9 – 10
7–8
5–6
1–4
0
Neurology case presentation
Attendance and participation
in ALL rounds during this
Rotation
OVERALL MARK /20
I have witnessed this student display a
level of competence appropriate to their
year
Signed (Neurology):
Name (Print)
Date
10
Mark /10
Appendix 5
Academic Clinical and Professional Development
Based on attendance, performance and participation in firm activities, courtesy to staff and
patients, punctuality, acceptance of advice and feedback, confidentiality
Review of Progress:
Satisfactory
Unsatisfactory (if so, why)
Comment on strengths and areas for improvement
* I have no concerns about this student's fitness to practise
* I have the following concerns about this student's fitness to practise and I have referred this
student to Student Advisor
Consultant Name …………………………………..……
Signature ……..………………………………………….
Date …………………
End-of-rotation Review of Progress:
Unsatisfactory (if so, why)
Satisfactory
Comment on strengths and areas for improvement
* I have no concerns about this student's fitness to practise
* I have the following concerns about this student's fitness to practise and I have referred this
student to Student Adviser
Using the Performance Descriptors given in section 9 of the Logbook, the consultants shall
award the end-of-rotation grades and marks
Neurology grade
Neurology mark
Excellent, good, competent, not competent
(0 – 100)
Consultant Name …………………………………..……
Signature ……..………………………………………….
11
Date …………………
Appendix 6
MARKING SCHEME AND PERFORMANCE DESCRIPTORS
For use when awarding marks for in-course assessment
Descriptors
History Taking
(including
communication
skills)
Clinical Examination
(including mental
state examination)
Clinical knowledge
(including clinical
reasoning)
Professional
development
(including
contribution to the
Firm)
85 – 100
Excellent history
taking with some
aspects
demonstrated to a
very high level of
expertise and no
flaws at all
Thorough, accurate
and comprehensive
clinical examination
demonstrating
excellent skills
throughout
Comprehensive and
detailed knowledge in
most topics with no
gaps
Highest standards of
conduct at all times;
highly organized;
excellent attendance
and enthusiastic
member of firm
70 – 84
Well structured,
methodical and
sensitive history
taking at all times; no
errors or omissions
Thorough and
detailed examination
with no significant
errors or omissions
Good knowledge of
most topics with depth
in some areas, and no
significant gaps
50 – 69
Adequately
structured,
methodical, sensitive;
no important
omissions
Able to perform
examination covering
all the essential
aspects of case
Satisfactory knowledge
with few gaps
40 – 49
Barely adequate in
structure, but without
major oversights
30 – 39
Poor and badly
structured
< 30
Very poor and
incomplete
Mark range
Excellent
Good
Competent
Not
competent
Unsatisfactory
examination, with
some errors or
omissions
Inadequate
examination, with
significant errors or
omissions
Rudimentary
examination with
serious errors or
omissions
Unsatisfactory level of
knowledge, with
several errors or
omissions
Inadequate knowledge,
with several significant
errors or omissions
Rudimentary
knowledge with many
serious errors or
omissions
High standards of
conduct and
organization most of
the time; full
attendance and good
contribution to firm
Maintains appropriate
standards of conduct,
attendance and
organization at all
times
Occasional lapses in
conduct or
organization that must
be improved
Clearly below the
required standards of
professional conduct
and behaviour
Displays serious lack
of professional
standards (e.g. rude,
disorganized)
In an average firm of 4 students, a firm head would normally expect to award no more than one student marks
in the “Excellent” range and two students marks in the “Good” range per rotation. The majority of students
should be rated as “Competent”. Only a small minority of students (fewer than one per rotation) are likely to
be found “Not competent” and these should be reported directly to the Student Advisor
12
Appendix 7
Scenario Sign-up
 Students should attend all Scenario teaching sessions.
 Tutors will mark the student’s performance in Scenario teaching (attendance, contribution,
knowledge & enthusiasm) as below.
 The rating will be reviewed by the Tutor when considering the end-of-rotation assessment.
 It is the student’s responsibility to ensure the tutor is aware of his or her attendance and
performance.
No
Title of scenario
Date
completed
1
2
3
4
5
6
7
Overall performance including attendance
and active participation
(circle and/or delete as appropriate):
 Excellent
 Good
 Satisfactory
 Unsatisfactory attendance
 Unsatisfactory participation
I have witnessed this student display a level of
competence appropriate to Phase 3
Signed (Neurology):
Name (Print)
Date
13
Tutor’s initials
Appendix 8
SUMMARY OF CLINICAL SKILLS TO BE ACQUIRED IN NEUROLOGY ROTATION
There are 16 clinical skills which you are required to perform to a satisfactory level in order to
progress. Each of these skills has an accompanying set of performance criteria, similar to that
used in the OSCE assessments. You should be observed performing the task in a clinical
environment or in the Clinical Skills Centre, by an appropriate practitioner.
The skills are assessed as being either carried out competently or not. There is no grading system
for performance. If you do not perform adequately on the first attempt, you may have another
attempt later. You should liaise with your skills assessor as to when it will be possible for you to
present yourself for assessment.
At the end of the rotation this form will be checked by the firm head and the record sent to the
Registry for recording and filing.
You must demonstrate your competence in the skills listed below.
Skills checklists are given in detail on the subsequent pages, each of which must be
signed as competent.
Basic adult neurology, ophthalmology
Take a history from a patient with a neurological complaint
Examine gait and co-ordination
Examine the sensory and motor system in the upper limb
Examine the sensory and motor system in the lower limb
Take a history from a patient with an eye complaint
Examine the eye including use of ophthalmoscope
Perform a mental state examination
Assess memory and cognitive state
Choose and interpret tests and investigations in the adult neurological patient
Observed clinical case (complete history and examination of a neurology patient)
Date
completed
Appendix 9
Weekly Neurology timetable for Clinical Apprenticeship students
Clinical Apprenticeship
Mon
AM
Neurology:
8.00-8.30 am
Radiology
8.30 OPD Team Meeting
9.00-12.30 Consultant Ward Round
Tues
8.30 am
General Neurology
Review Clinic
Thurs
Fri
8am Medical Grand
Rounds
8am Beaumont Hospital
Neurology Grand Round
9am Consultant Ward
Round
Or
Parkinson’s Clinic
11am Consultant Ward
Round
2pm
Consultant Teaching
2pm
Neurology:
2pm
Registrar Teaching
St. Vincent’s Ward
2pm
Intern Teaching
9am General
Neurology Review
Clinic
(Professor
Hutchinson)
2pm
SHO Teaching
Or
Or
Or
3pm Students to clerk patient for next ward round
1.30 pm General
Neurology New Patient
Clinic
(Professor Hutchinson)
1.30pm General
Neurology New
Patient Clinic
(Dr. Tubridy)
1.30pm Dystonia
Clinic
(Dr. Tubridy)
Or Multiple Sclerosis Clinic with Consultant
PM
Weds
8am Neurology
Journal Club (ERC)
12noon Clerk Patients for
Monday Round
Observe Procedures in
Neurology OPD
Or
Observe LP in OPD
You have small group neurology learning most afternoons. You should usually spend the equivalent of about ½ day working independently or in pairs on clerking
neurology patients, and reading in preparation for your small group neurology teaching. If you cannot find patients to clerk, we suggest you contact your associate
tutor in advance and ask him/her to recommend patients that you can clerk, and present to your tutor.
Appendix 10
Introductions to web-based clinical scenarios
Mr Thomas’ Falls
Mr William Thomas, a 59 year old gentleman, presented to hospital on a summers day in 2004
complaining of lethargy, difficulty in getting around and 3 falls recently. He was seen in the
Accident and Emergency Department, where he was found to be stiff, tremulous and quite
agitated and had to be given “calming down” pills. When he had become a more rested, Mr
Thomas said that he had become progressively more and more stiff and slow in the last 8-10
years.
His problems had started approximately ten years back. At this stage he worked as an
asbestos removal specialist and had noticed that his left hand had become increasingly clumsy
and difficult to use. There was also the development of occasional involuntary shaking of this
hand which at times, he was unable to control. The shaking would get worse when he was
tense or anxious and he had also noticed that his writing had been affected. He was lefthanded. Over the next ten years, the stiffness and the shaking has developed to involve his
right side as well and occasionally his neck and his legs. He would spill cups of water or tea
when he attempted to carry them because of tremor. He has increasing difficulty in walking,
turning, sleeping at night particularly turning in bed. He has also experienced some falls and in
particular increasing forgetfulness. He has developed some stiffness around the shoulder
region particularly the left upper limb. This initially was thought to be due to “frozen shoulder”.
Weakness in the right arm
James Clark is a 69 year-old right handed man. He has recently retired from his lifelong office
job as a pension’s advisor. He is in the local A&E department having been brought in by
London Ambulance Service. He presents with a 2-hour history of right-sided arm and leg
weakness and difficulty expressing himself. His wife comments that the right side of his face
has drooped. She has had to give the history because of his speech difficulty. He is examined
on a trolley in the ‘majors’ part of the Accident and Emergency Department.
Numbness in the toes
Mrs A. a 46 year old typist, went to her GP because she had experienced some pain in the right
wrist. She said it would wake her at night and that her hand felt dead.
Her GP elicited the further history that for about 6 months she had had some intermittent
numbness in her toes and sometimes felt as if she were walking on hard stony ground. The
numbness had now become continuous and had spread up to her ankles.
A child with fever and headache
You are working at a district hospital. One evening a GP phones that she has just visited a 4year child at home. His mother called the doctor because her son had been unwell over the
previous 24 hours with fever and increasing headache. In the past few hours he had become
irritable and drowsy and had refused his supper. His younger sister is recovering from chicken
pox.
The GP found him febrile, restless, pale and sick looking and was very sore all over to touch.
There was a faint flea bite type rash on the trunk which blanched on applying the glass test.
The GP was concerned there was neck stiffness and asks your advice re urgent admission and
acute management.
Headache
Mr. K is a 37 year old man who has experienced a constant background headache for the past
18 months. The pain is in both temples and radiate to his neck. He described this pain is a tight
squeezing sensation which tends to be worse in the evening but does not stop him from
performing his normal activities. There are no exacerbating features to this pain and no real
alleviations either. Having a good night sleep usually helps but most painkillers will only “take
the edge off”.
In the last 3 years, he also experienced a different type of headache. These attacks are
episodic, initially coming on once every 2-3 months but in the last 6 months, the frequency has
increased to 2-3 times a week.
The attacks can come on anytime but more commonly during the weekend and last for one
day. These more severe headaches start with stiffness and discomfort in the neck that become
progressively worse and the pain will then spread to one eye. He is nauseated and may vomit
with these attacks. He will have to go to bed or sit in a dark quiet room with this headache.
This morning, Mr. K made an urgent appointment to see his GP because he developed another
severe episode of headache yesterday afternoon. He went to bed after taking some pain killers
but this morning he was alarmed to wake up with drooping of his right eyelid and double vision.
His GP sent him to the hospital and you were asked to see him.
Epilepsy and blackouts
Scenario 1
A 45-year-old man felt tingling in his right hand followed by unilateral stiffness then jerking of
the arm which spread to the face; within 30 seconds he had lost consciousness. According to
witnesses, he then collapsed and convulsed for 3 minutes. When the jerking subsided, he lay
still for 5 minutes and was placed in the recovery position. He gradually came round and the
paramedics walked him to the ambulance. When questioned in the Emergency Room, he
remembered coming round only when already in hospital. He had bitten his tongue, wet himself
and ached all over. He also reported having had brief and transient tingling/stiffness in the right
arm over the last two months, more intensely and more frequently in the last week.
Scenario 2
A 20-year-old continues to suffer from blackouts despite trying 4 anti-epileptic drugs over the
last four years. He tends to collapse when exercising heavily. His mother is very worried about
him. He has a brief warning of feeling faint; he then goes ‘sheet-white’ and falls limply to the
ground, where he twitches, irregularly, for no more than thirty seconds. He does not usually bite
his tongue or wet himself, although he has injured himself. As soon as he comes round he is
upset that he has blacked out, yet again, despite taking his medicine. His physical examination
(CVS and CNS) has always been normal. There is no family history of epilepsy on his mother’s
side. His father had left his mother when he was a toddler, but she thinks he died in his late
30’s of a ‘heart attack’.
Scenario 3
A previously well 6-year-old girl is no longer attentive at school. She seems to stop what she is
doing for a couple of seconds and stares ahead. She then picks up where she left off. She
may have more than 20 such blank spells a day.
Scenario 4
An 18-year-old has had epilepsy from infancy after meningitis that left him with physical and
mental handicap. He has many types of seizures, atypical absences, partial seizures,
myoclonic jerks, tonic seizures and convulsions. Normally, his convulsions last less than five
minutes, usually stopping after 2 minutes without intervention. He was on 4 anti-epileptic drugs,
but recently one of his medications was withdrawn to reduce side-effects. Today he started
convulsing, but this time the fit did not stop by itself as per usual and he is still fitting.
Scenario 5
A 17-year-old has had what she calls, ‘twitches’ in the morning for the last two years. Her arms
would jump and she may drop what she is holding. She also noticed that she felt uncomfortable
with flashing lights. After a late night and a few drinks too many, she got up earlier than usual in
the morning and was rushing. She suddenly collapsed and was seen to convulse for two
minutes. She bit her tongue badly. She was confused on coming round. Her mother had a
history of childhood absence epilepsy but is now fine.
Scenario 6
An 18-year-old has had episodes of feeling unwell for two years. Initially, he would feel a
churning in his stomach then a deja-vu feeling for a few seconds. Sometimes he would have a
run of these. For a year, the feeling has been followed by loss of awareness for about a minute.
During the blank spell, witnesses say that he would be briefly blank without any movement or,
in more prolonged attacks, his left arm might be stiff and flexed at the elbow. His right arm
would fiddle with his clothes and he would smack his lips and swallow. Recovery would take
about thirty seconds, although on one occasion he went on to convulse.
Scenario 7
A previously fit 20-year-old university student starts experiencing up to fifteen ‘turns’ a day.
Sometimes she lies still for half an hour with no movement and no response and, sometimes,
her limbs shake irregularly and her head moves from side to side. Occasionally she arches her
back. Her colour is normal and she does not bite her tongue. When the attacks are over, she
recovers immediately and is alert with no deficit. She is concerned that these attacks may
interfere with her final exams. She is on her third AED without benefit so far. Years ago she
had had similar episodes for about six months at the age of 13.
Scenario 8
A previously fit 24-year-old successful shop manager has a headache and a temperature for a
few days. She wakes up confused one morning and has a blank spell followed by a convulsion.
Her speech is no longer fluent and she has word-finding difficulty. She is also forgetful. She
has further fits over the next 24 hours and is admitted. CT scan shows no masses but lumbar
puncture reveals lymphocytic CSF with normal protein and glucose concentration.
Scenario 9
A teenage girl is at a party. She has not eaten or drunk much that day. There are many people
around. She is in a tight space and feels hot. She is standing in a corner with little room for
movement. Her vision darkens and she feels dizzy and nauseated. She needs some fresh air
and wishes she could lie down. She tries to get out of the room, but blacks out and falls to the
ground. Witnesses say that she slumps and jerks a few times and then comes around, within
less than a minute, looking embarrassed. She is clammy and pale. This had happened before
at school assembly when she had period pains and was standing for too long.
Scenario 10
A 25-year-old falls asleep rather too easily while watching television, in company, at work and
even while eating. He sleeps well at night and wakes up refreshed. His girlfriend says he does
not snore. Sometimes he wakes up and is unable to move, just for a few seconds. He used to
panic with this; sometimes he has vivid dreams which seem so real. Worst of all, if he laughs
too much he becomes floppy and falls. He is lucky as his friends do not pull his leg too often.
Mrs S has difficulty walking
Mrs S, a 30 year old police officer presents complaining of difficulty walking which she first
noticed a week ago and has since gradually become worse. She also now describes:
 Stiffness and weakness particularly affecting her right leg and to a lesser extent her right
arm
 Pins and needles that have gradually spread up from her toes to involve her hands
particularly on the left, but spare her face
 A funny feeling down her body when she bends her neck
 Frequently having to pass urine with urgency but without pain. She has been incontinent of
urine on a couple of occasions.