Neurological examination Submitted to AskTheNeurologist.Com in 2008 http://www.asktheneurologist.com/Study-Neurology.html

3 questions of neurological diagnosis Is there a lesion ? - Presence of neurological abnormality Where is the lesion ? - Location of problem - Requires knowledge of neuroanatomy What is the lesion ?

Is there a lesion ?

- Presence of neurological abnormality

Where is the lesion ?

- Location of problem

- Requires knowledge of neuroanatomy

What is the lesion ?

Why perform the neurological examination Detect the presence of neurological abnormality Localise the abnormality within the nervous system ( may later be confirmed by investigations)

Detect the presence of neurological abnormality

Localise the abnormality within the nervous system ( may later be confirmed by investigations)

Systematic approach to weakness e.g. bilateral leg weakness Muscle NMJ Nerve Nerve roots Spinal cord Brainstem Cerebrum

Muscle

NMJ

Nerve

Nerve roots

Spinal cord

Brainstem

Cerebrum

Basic Plan General examination ( vital signs etc) Conscious state Cognition Meningeal signs Cranial nerves Motor Sensory Cerebellum Extrapyramidal

General examination ( vital signs etc)

Conscious state

Cognition

Meningeal signs

Cranial nerves

Motor

Sensory

Cerebellum

Extrapyramidal

DON’T DO EVERYTHING! Screening tests vs detailed testing Problem orientated approach Screen all systems Concentrate on systems relevant to complaint Formal cognitive testing may be skipped if patient is cognitively intact during history and problem seems unrelated E.g. foot-drop

Screening tests vs detailed testing

Problem orientated approach

Screen all systems

Concentrate on systems relevant to complaint

Formal cognitive testing may be skipped if patient is cognitively intact during history and problem seems unrelated

E.g. foot-drop

Conscious state Glasgow coma scale Eyes /4 Verbal /5 Motor /6 Normal = 15 Created to reflect measure of global brain function Limited value in neurological patients - Many processes selectively affect components above - e.g. aphasia in a fully “ conscious” patient Therefore best to record functions individually

Glasgow coma scale

Eyes /4

Verbal /5

Motor /6

Normal = 15

Created to reflect measure of global brain function

Limited value in neurological patients

- Many processes selectively affect components above

- e.g. aphasia in a fully “ conscious” patient

Therefore best to record functions individually

Cognition MMSE Score out of 30 Broad screening test of cognitive function including attention, memory, language Good for diagnosing / monitoring certain types of dementia especially A.D. Other types of dementia / cognitive problems require different tests

MMSE

Score out of 30

Broad screening test of cognitive function including attention, memory, language

Good for diagnosing / monitoring certain types of dementia especially A.D.

Other types of dementia / cognitive problems require different tests

Cognition 2 “ Frontal functions” Attention & concentration ( digit span ) Abstraction ( explain proverb ) Judgment child lost in street..what would you do? Planning How to plan a holiday Draw a clock

“ Frontal functions”

Attention & concentration ( digit span )

Abstraction ( explain proverb )

Judgment

child lost in street..what would you do?

Planning

How to plan a holiday

Draw a clock

Cognition 3 Frontal release signs Glabellar tap Pouting Rooting Sucking Grasp Palmomental

Frontal release signs

Glabellar tap

Pouting

Rooting

Sucking

Grasp

Palmomental

Other cognitive functions Neglect: Failure to pay attention to area of space Usually due to right parietal lesions where neglect left-sided space Praxis: ability to perform learned action - e.g. dressing , combing hair

Neglect:

Failure to pay attention to area of space

Usually due to right parietal lesions where neglect left-sided space

Praxis:

ability to perform learned action

- e.g. dressing , combing hair

Meningeal signs Neck stiffness Brudzinski Kernig Most frequently found in patients with meningitis or SAH

Neck stiffness

Brudzinski

Kernig

Most frequently found in patients with meningitis or SAH

Cranial nerves (a) I - smell II - Acuity ( Snellen chart) Fundi Fields ( confrontation) Pupil resting state and reaction to light Direct Consensual Swinging flashlight test Pupil reaction to accommodation

I - smell

II - Acuity ( Snellen chart)

Fundi

Fields ( confrontation)

Pupil resting state and reaction to light

Direct

Consensual

Swinging flashlight test

Pupil reaction to accommodation

Cranial Nerves (b) III, IV, VI Ptosis? Pupils (already examined) Movement ( H and X) Saccades and smooth pursuit ? Diplopia ? Nystagmus

III, IV, VI

Ptosis?

Pupils (already examined)

Movement ( H and X)

Saccades and smooth pursuit

? Diplopia

? Nystagmus

Cranial nerves (c) V Facial sensation Muscles of mastication Jaw jerk Corneal reflex Afferent = V Efferent = VII

V

Facial sensation

Muscles of mastication

Jaw jerk

Corneal reflex

Afferent = V

Efferent = VII

VII Muscles of facial expression Taste ant 2/3 tongue Tensor Tympani Cranial nerves (d)

VII

Muscles of facial expression

Taste ant 2/3 tongue

Tensor Tympani

Cranial nerves (e) VIII Nystagmus already noted Hearing IX, X Say ahh (X) Gag reflex Afferent = IX Efferent = X

VIII

Nystagmus already noted

Hearing

IX, X

Say ahh (X)

Gag reflex

Afferent = IX

Efferent = X

Cranial nerves (f) XI sternocleidomastoid & trapezius XII ( tongue motor examination) Observation ( atrophy, fasciculations) Midline protrusion ( ? Deviation) Power Dexterity ( fast movement side-to-side)

XI

sternocleidomastoid & trapezius

XII ( tongue motor examination)

Observation ( atrophy, fasciculations)

Midline protrusion ( ? Deviation)

Power

Dexterity ( fast movement side-to-side)

Upper motor neuron Cell body within motor cortex (prefrontal gyrus) Axon terminates : Cranial nerve motor nucleus “ corticobulbar” Anterior horn of spinal cord “ corticospinal”

Cell body within motor cortex

(prefrontal gyrus)

Axon terminates :

Cranial nerve motor nucleus

“ corticobulbar”

Anterior horn of spinal cord

“ corticospinal”

Lower Motor Neuron Cell body of Motor cranial nerve nucleus Anterior horn cell Axon terminates Motor end plate ( skeletal muscle) AKA Neuromuscular junction ( NMJ)

Cell body of

Motor cranial nerve nucleus

Anterior horn cell

Axon terminates

Motor end plate ( skeletal muscle)

AKA Neuromuscular junction ( NMJ)

Diagram of motor pathways

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

Sensory System Modalities Pain Temperature Vibration Proprioception Spinothalamic Post. columns

Modalities

Pain

Temperature

Vibration

Proprioception

Sensory examination II Problem orientated approach Left vs Right Spinal sensory level Radicular / dermatomal Nerve distribution Distal vs Proximal

Problem orientated approach

Left vs Right

Spinal sensory level

Radicular / dermatomal

Nerve distribution

Distal vs Proximal

Which method would you concentrate on? Sudden onset of dysphasia and right sided weakness Numbness and paraesthesia in feet with absent ankle jerks Acute bilateral leg weakness with loss of sphincter control Drop foot

Sudden onset of dysphasia and right sided weakness

Numbness and paraesthesia in feet with absent ankle jerks

Acute bilateral leg weakness with loss of sphincter control

Drop foot

Symptoms and signs of cerebellar disease (VANISH’D) Vertigo Ataxia - usually falls towards lesion Nystagmus – increased with gaze towards lesion Intention Tremor Scanning speech Hypotonia Dysdiadochokinesia + Dysmetria

Vertigo

Ataxia - usually falls towards lesion

Nystagmus – increased with gaze towards lesion

Intention Tremor

Scanning speech

Hypotonia

Dysdiadochokinesia + Dysmetria

Stability and Gait Check ability to stand straight with eyes open Check ability to stand straight with eyes closed If significantly worse than with eyes open = positive Romberg sign Usually signifies defect in pathways involved in proprioception May signify vestibular disease Check gait

Check ability to stand straight with eyes open

Check ability to stand straight with eyes closed

If significantly worse than with eyes open = positive Romberg sign

Usually signifies defect in pathways involved in proprioception

May signify vestibular disease

Check gait

Extrapyramidal “ TRAP” Tremor ( rest, pill-rolling) Rigidity ( lead-pipe, cog-wheel) Akinesia / bradykinesia Postural instability

Tremor ( rest, pill-rolling)

Rigidity ( lead-pipe, cog-wheel)

Akinesia / bradykinesia

Postural instability

Normal examination Patient fully conscious, orientated in time and place with no meningeal signs PEARLA, Fundi intact, ( acuity and visual fields intact) Eye movements normal Facial sensation normal Face symmetrical (Hearing normal) Palate / uvula rises symmetrically Gag preserved bilaterally Tongue central

Patient fully conscious, orientated in time and place with no meningeal signs

PEARLA, Fundi intact, ( acuity and visual fields intact)

Eye movements normal

Facial sensation normal

Face symmetrical

(Hearing normal)

Palate / uvula rises symmetrically

Gag preserved bilaterally

Tongue central

Normal examination 2 No atrophy / fasciculations (muscle inspection) Tone preserved Power 5/5 in all 4 limbs Reflexes symmetrical No pyramidal signs

No atrophy / fasciculations

(muscle inspection)

Tone preserved

Power 5/5 in all 4 limbs

Reflexes symmetrical

No pyramidal signs

Normal examination 3 Sensation preserved No cerebellar signs Romberg negative Gait normal

Sensation preserved

No cerebellar signs

Romberg negative

Gait normal

How to present Keep to order Mention all abnormalities Include “ core” points ( just described) Mention all “ important negative points” Leg weakness… “no sensory level” History of MS with optic neuritis… “ no RAPD” Complains of difficulty chewing Mention power of masticatory muscles

Keep to order

Mention all abnormalities

Include “ core” points ( just described)

Mention all “ important negative points”

Leg weakness… “no sensory level”

History of MS with optic neuritis… “ no RAPD”

Complains of difficulty chewing

Mention power of masticatory muscles

THE END