Neurological Examination

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Neurological examination lecture

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Neurological Examination

  1. 1. Neurological examination Submitted to AskTheNeurologist.Com in 2008 http://www.asktheneurologist.com/Study-Neurology.html
  2. 2. 3 questions of neurological diagnosis <ul><li>Is there a lesion ? </li></ul><ul><ul><li>- Presence of neurological abnormality </li></ul></ul><ul><li>Where is the lesion ? </li></ul><ul><ul><li>- Location of problem </li></ul></ul><ul><ul><li>- Requires knowledge of neuroanatomy </li></ul></ul><ul><li>What is the lesion ? </li></ul>
  3. 3. Why perform the neurological examination <ul><li>Detect the presence of neurological abnormality </li></ul><ul><li>Localise the abnormality within the nervous system ( may later be confirmed by investigations) </li></ul>
  4. 4. Systematic approach to weakness e.g. bilateral leg weakness <ul><li>Muscle </li></ul><ul><li>NMJ </li></ul><ul><li>Nerve </li></ul><ul><li>Nerve roots </li></ul><ul><li>Spinal cord </li></ul><ul><li>Brainstem </li></ul><ul><li>Cerebrum </li></ul>
  5. 5. Basic Plan <ul><li>General examination ( vital signs etc) </li></ul><ul><li>Conscious state </li></ul><ul><li>Cognition </li></ul><ul><li>Meningeal signs </li></ul><ul><li>Cranial nerves </li></ul><ul><li>Motor </li></ul><ul><li>Sensory </li></ul><ul><li>Cerebellum </li></ul><ul><li>Extrapyramidal </li></ul>
  6. 6. DON’T DO EVERYTHING! <ul><li>Screening tests vs detailed testing </li></ul><ul><li>Problem orientated approach </li></ul><ul><ul><li>Screen all systems </li></ul></ul><ul><ul><li>Concentrate on systems relevant to complaint </li></ul></ul><ul><ul><li>Formal cognitive testing may be skipped if patient is cognitively intact during history and problem seems unrelated </li></ul></ul><ul><ul><ul><li>E.g. foot-drop </li></ul></ul></ul>
  7. 7. Conscious state <ul><li>Glasgow coma scale </li></ul><ul><li>Eyes /4 </li></ul><ul><li>Verbal /5 </li></ul><ul><li>Motor /6 </li></ul><ul><li>Normal = 15 </li></ul><ul><li>Created to reflect measure of global brain function </li></ul><ul><li>Limited value in neurological patients </li></ul><ul><li>- Many processes selectively affect components above </li></ul><ul><li>- e.g. aphasia in a fully “ conscious” patient </li></ul><ul><li>Therefore best to record functions individually </li></ul>
  8. 8. Cognition <ul><li>MMSE </li></ul><ul><ul><li>Score out of 30 </li></ul></ul><ul><ul><li>Broad screening test of cognitive function including attention, memory, language </li></ul></ul><ul><ul><li>Good for diagnosing / monitoring certain types of dementia especially A.D. </li></ul></ul><ul><ul><li>Other types of dementia / cognitive problems require different tests </li></ul></ul>
  9. 9. Cognition 2 <ul><li>“ Frontal functions” </li></ul><ul><ul><li>Attention & concentration ( digit span ) </li></ul></ul><ul><ul><li>Abstraction ( explain proverb ) </li></ul></ul><ul><ul><li>Judgment </li></ul></ul><ul><ul><ul><li>child lost in street..what would you do? </li></ul></ul></ul><ul><ul><li>Planning </li></ul></ul><ul><ul><ul><li>How to plan a holiday </li></ul></ul></ul><ul><ul><ul><li>Draw a clock </li></ul></ul></ul>
  10. 10. Cognition 3 <ul><li>Frontal release signs </li></ul><ul><ul><li>Glabellar tap </li></ul></ul><ul><ul><li>Pouting </li></ul></ul><ul><ul><li>Rooting </li></ul></ul><ul><ul><li>Sucking </li></ul></ul><ul><ul><li>Grasp </li></ul></ul><ul><ul><li>Palmomental </li></ul></ul>
  11. 11. Other cognitive functions <ul><li>Neglect: </li></ul><ul><ul><li>Failure to pay attention to area of space </li></ul></ul><ul><ul><li>Usually due to right parietal lesions where neglect left-sided space </li></ul></ul><ul><li>Praxis: </li></ul><ul><ul><li>ability to perform learned action </li></ul></ul><ul><li>- e.g. dressing , combing hair </li></ul>
  12. 12. Meningeal signs <ul><li>Neck stiffness </li></ul><ul><li>Brudzinski </li></ul><ul><li>Kernig </li></ul><ul><ul><li>Most frequently found in patients with meningitis or SAH </li></ul></ul>
  13. 13. Cranial nerves (a) <ul><li>I - smell </li></ul><ul><li>II - Acuity ( Snellen chart) </li></ul><ul><ul><ul><li>Fundi </li></ul></ul></ul><ul><ul><ul><li>Fields ( confrontation) </li></ul></ul></ul><ul><ul><ul><li>Pupil resting state and reaction to light </li></ul></ul></ul><ul><ul><ul><ul><li>Direct </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Consensual </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Swinging flashlight test </li></ul></ul></ul></ul><ul><ul><ul><li>Pupil reaction to accommodation </li></ul></ul></ul>
  14. 14. Cranial Nerves (b) <ul><li>III, IV, VI </li></ul><ul><ul><li>Ptosis? </li></ul></ul><ul><ul><li>Pupils (already examined) </li></ul></ul><ul><ul><li>Movement ( H and X) </li></ul></ul><ul><ul><li>Saccades and smooth pursuit </li></ul></ul><ul><ul><li>? Diplopia </li></ul></ul><ul><ul><li>? Nystagmus </li></ul></ul>
  15. 15. Cranial nerves (c) <ul><li>V </li></ul><ul><ul><li>Facial sensation </li></ul></ul><ul><ul><li>Muscles of mastication </li></ul></ul><ul><ul><li>Jaw jerk </li></ul></ul><ul><ul><li>Corneal reflex </li></ul></ul><ul><ul><ul><li>Afferent = V </li></ul></ul></ul><ul><ul><ul><li>Efferent = VII </li></ul></ul></ul>
  16. 16. <ul><li>VII </li></ul><ul><ul><li>Muscles of facial expression </li></ul></ul><ul><ul><li>Taste ant 2/3 tongue </li></ul></ul><ul><ul><li>Tensor Tympani </li></ul></ul>Cranial nerves (d)
  17. 17. Cranial nerves (e) <ul><li>VIII </li></ul><ul><ul><li>Nystagmus already noted </li></ul></ul><ul><ul><li>Hearing </li></ul></ul><ul><li>IX, X </li></ul><ul><ul><li>Say ahh (X) </li></ul></ul><ul><ul><li>Gag reflex </li></ul></ul><ul><ul><ul><li>Afferent = IX </li></ul></ul></ul><ul><ul><ul><li>Efferent = X </li></ul></ul></ul>
  18. 18. Cranial nerves (f) <ul><li>XI </li></ul><ul><ul><li>sternocleidomastoid & trapezius </li></ul></ul><ul><li>XII ( tongue motor examination) </li></ul><ul><ul><li>Observation ( atrophy, fasciculations) </li></ul></ul><ul><ul><li>Midline protrusion ( ? Deviation) </li></ul></ul><ul><ul><li>Power </li></ul></ul><ul><ul><li>Dexterity ( fast movement side-to-side) </li></ul></ul>
  19. 19. Upper motor neuron <ul><li>Cell body within motor cortex </li></ul><ul><ul><li>(prefrontal gyrus) </li></ul></ul><ul><li>Axon terminates : </li></ul><ul><ul><li>Cranial nerve motor nucleus </li></ul></ul><ul><ul><ul><li>“ corticobulbar” </li></ul></ul></ul><ul><ul><li>Anterior horn of spinal cord </li></ul></ul><ul><ul><ul><li>“ corticospinal” </li></ul></ul></ul>
  20. 20. Lower Motor Neuron <ul><li>Cell body of </li></ul><ul><ul><li>Motor cranial nerve nucleus </li></ul></ul><ul><ul><li>Anterior horn cell </li></ul></ul><ul><li>Axon terminates </li></ul><ul><ul><li>Motor end plate ( skeletal muscle) </li></ul></ul><ul><ul><ul><li>AKA Neuromuscular junction ( NMJ) </li></ul></ul></ul>
  21. 21. Diagram of motor pathways
  22. 22. Absent Present Pathological reflexes Decreased or Normal Increased (unless acute) Tendon Reflexes decreased decreased Power (MRC scale) 0-5 /5 Decreased (or normal) Increased (unless acute) Tone Atrophy Fasciculations Normal (disuse atrophy) Inspection of muscles Lower Motor Neuron Upper Motor Neuron
  23. 23. Sensory System <ul><li>Modalities </li></ul><ul><ul><li>Pain </li></ul></ul><ul><ul><li>Temperature </li></ul></ul><ul><ul><li>Vibration </li></ul></ul><ul><ul><li>Proprioception </li></ul></ul>Spinothalamic Post. columns
  24. 24. Sensory examination II <ul><li>Problem orientated approach </li></ul><ul><ul><li>Left vs Right </li></ul></ul><ul><ul><li>Spinal sensory level </li></ul></ul><ul><ul><li>Radicular / dermatomal </li></ul></ul><ul><ul><li>Nerve distribution </li></ul></ul><ul><ul><li>Distal vs Proximal </li></ul></ul>
  25. 25. Which method would you concentrate on? <ul><li>Sudden onset of dysphasia and right sided weakness </li></ul><ul><li>Numbness and paraesthesia in feet with absent ankle jerks </li></ul><ul><li>Acute bilateral leg weakness with loss of sphincter control </li></ul><ul><li>Drop foot </li></ul>
  26. 26. Symptoms and signs of cerebellar disease (VANISH’D) <ul><li>Vertigo </li></ul><ul><li>Ataxia - usually falls towards lesion </li></ul><ul><li>Nystagmus – increased with gaze towards lesion </li></ul><ul><li>Intention Tremor </li></ul><ul><li>Scanning speech </li></ul><ul><li>Hypotonia </li></ul><ul><li>Dysdiadochokinesia + Dysmetria </li></ul>
  27. 27. Stability and Gait <ul><li>Check ability to stand straight with eyes open </li></ul><ul><li>Check ability to stand straight with eyes closed </li></ul><ul><ul><li>If significantly worse than with eyes open = positive Romberg sign </li></ul></ul><ul><ul><li>Usually signifies defect in pathways involved in proprioception </li></ul></ul><ul><ul><li>May signify vestibular disease </li></ul></ul><ul><li>Check gait </li></ul>
  28. 28. Extrapyramidal “ TRAP” <ul><li>Tremor ( rest, pill-rolling) </li></ul><ul><li>Rigidity ( lead-pipe, cog-wheel) </li></ul><ul><li>Akinesia / bradykinesia </li></ul><ul><li>Postural instability </li></ul>
  29. 29. Normal examination <ul><li>Patient fully conscious, orientated in time and place with no meningeal signs </li></ul><ul><li>PEARLA, Fundi intact, ( acuity and visual fields intact) </li></ul><ul><li>Eye movements normal </li></ul><ul><li>Facial sensation normal </li></ul><ul><li>Face symmetrical </li></ul><ul><li>(Hearing normal) </li></ul><ul><li>Palate / uvula rises symmetrically </li></ul><ul><li>Gag preserved bilaterally </li></ul><ul><li>Tongue central </li></ul>
  30. 30. Normal examination 2 <ul><li>No atrophy / fasciculations </li></ul><ul><ul><li>(muscle inspection) </li></ul></ul><ul><li>Tone preserved </li></ul><ul><li>Power 5/5 in all 4 limbs </li></ul><ul><li>Reflexes symmetrical </li></ul><ul><li>No pyramidal signs </li></ul>
  31. 31. Normal examination 3 <ul><li>Sensation preserved </li></ul><ul><li>No cerebellar signs </li></ul><ul><li>Romberg negative </li></ul><ul><li>Gait normal </li></ul>
  32. 32. How to present <ul><li>Keep to order </li></ul><ul><li>Mention all abnormalities </li></ul><ul><li>Include “ core” points ( just described) </li></ul><ul><li>Mention all “ important negative points” </li></ul><ul><ul><li>Leg weakness… “no sensory level” </li></ul></ul><ul><ul><li>History of MS with optic neuritis… “ no RAPD” </li></ul></ul><ul><ul><li>Complains of difficulty chewing </li></ul></ul><ul><ul><ul><li>Mention power of masticatory muscles </li></ul></ul></ul>
  33. 33. THE END

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