The document provides guidance on performing a neurological examination to systematically evaluate patients for neurological abnormalities. It discusses evaluating the patient's conscious state, cognition, cranial nerves, motor system, sensory system, and extrapyramidal signs. The examination aims to detect any neurological abnormalities, localize them within the nervous system, and determine the specific lesion.

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

2. 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 ?

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

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

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

6. 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

7. 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

8. 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

9. 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

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

11. 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

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

13. 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

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

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

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

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

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

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

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

21. Diagram of motor pathways

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. Sensory System Modalities Pain Temperature Vibration Proprioception Spinothalamic Post. columns

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

25. 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

26. 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

27. 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

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

29. 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

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

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

32. 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

33. THE END