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General Physical Examination in Neurological Diseases
This document provides guidance on performing a physical examination of the central nervous system. It outlines examination of various body systems and signs, including attitude, level of consciousness, head, facies, eyes, ears, mouth, neck, skin, extremities, and spine. It describes abnormalities to examine for, such as craniosynostosis deformities of the head, facial palsies, ptosis, neurocutaneous lesions, clubbing, and peripheral nerve disorders. The examination aims to detect neurological deficits or systemic diseases that may involve the CNS.
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General Physical Examination in Neurological Diseases
- 1. GENERAL PHYSICAL EXAMINATION IN CNS CHAIRPERSON: Dr.RAM K STUDENT: Dr. ZAHURA
- 2. ATTITUDE LEVELOF CONSCIOUSNESS STATURE HEAD FACIES EYE,EAR,NOSE,ORAL CAVITY NECK SKIN EXTREMETIES SPINE
- 3. ATTITUDE Decerebrate posture Decorticate posture
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- 8. LEVEL OF CONSCIOUSNESS Consciousness Confusion Somnolence Stupor Coma
- 9. STATURE Arm span >stature Homocystinuria Klinefelters syndrome SHORT TALL CRETINISM HOMOCYSTINURIA DOWNS SYNDROME KLINEFELTERS SYNDROME
- 10. NUTRITION Weight lossand evidence of malnutrition may indicate hyperthyroidism, Alzheimer’s disease, Whipple’s disease, celiac disease, or amyloidosis. Obesity • Prader Willi • Laurence Moon Biedl • Cohens • Carpenters
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- 12. contd... Plagiocephaly produces aflattening of the forehead and the brow on the affected side, with the forehead tending to be excessively prominent on the opposite side
- 13. contd... Trigonocephaly Early closureof this suture may result in a prominent ridge running down the forehead. The forehead looks quite pointed, like a triangle, with closely placed eyes (hypotelorism).
- 14. contd... Scaphocephaly This isthe most common type of synostosis. This suture runs front to back, down the middle of the top of the head. This fusion causes a long, narrow skull.
- 15. contd... Premature closureof cranial sutures can produce a wide variety of abnormally shaped skulls. CLINICAL FEATURES Increased ICP Strabismus amblyopia Orbital hypertelorism Proptosis Restricted eye ball movement Poor visual acquity Orbital hypotelorism corneal exposure Dacrocystitis
- 16. contd... PRIMARY CAUSES Craniosynostosisusually occurs as an isolated condition, but there are numerous syndromes in Crouzon’s, Apert’s, and Carpenter’s syndrome.
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- 19. contd... Palpation ofthe skull may disclose deformities due to old trauma, burr hole, or craniotomy defects, tenderness, or scars. The size and patency of the fontanelles is important in infants as bulging of the fontanelles & suture separation can occur with increased ICP in children.
- 20. contd... Meningoceles andencephaloceles may cause palpable skull defects. Potts puffy tumour
- 21. contd... In thosewith head trauma, ecchymosis over the mastoid (Battle sign) or around the eyes but not extending beyond the orbital rim (“raccoon eyes”) suggests basilar skull fracture.
- 22. contd... Neurofibromas ofthe scalp occur in von Recklinghausen’s disease. Exostoses may indicate an underlying meningioma
- 23. Bruits maybe heard best over the temporal regions of the skull, the eyeballs, and the mastoids. Cephalic bruits may occur with angiomas, aneurysms, arteriovenous malformations, neoplasms that compress large arteries.
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- 25. contd... Hypothyroid faceHyperthyroid face
- 26. contd... Leonine faciesMyasthenic facies
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- 30. contd... RISUS SARDONICUSIN TETANUS
- 31. contd... PERPETUAL SURPRISE– PROCERUS SIGN IN PSP
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- 33. contd... MYOGENIC NEUROGENI C MISCELLANEO US MYASTHENIA GRAVISNEMALINE MYOPATHY ALS CERVICAL DYSTONIA POLYMYOSITIS INCLUSION BODY MYOSITIS SPINAL MUSCULAR ATROPHY ISOLATED NECK EXTENSOR MYOPATHY CARNITINE DEFICIENCY FASCIO-SCAPULO- HUMERAL DYSTROPHY ADULT ONSET ACID MALTASE DEFICIENCY CAUSES OF DROPPED HEAD
- 34. FACE Wrinkling of forehead Myasthenia gravis Third nerve palsy Horners syndrome Absence of wrinkling of forehead Bells palsy Myotonic dystrophy Hyperthyroidism
- 35. Eyebrows and eyelashes Hypothyroidism Secondary syphilis Leprosy Generalized alopecia
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- 38. Eyelids PTOSIS This isdrooping of the upper lid to a level that covers >2 mm of the superior cornea.
- 39. contd... Causes 1. Congenital 2. Acquired (i) neurogenic (ii) myogenic (iii) aponeurotic (iv) mechanical
- 40. contd... Neurogenic ptosis 3rdnerve palsy Horner’s syndrome Multiple sclerosis Myogenic/N-M junction Myasthenia gravis Snake bite Myotonic dystrophy Eaton lambert myasthenic syndrome Oculo-pharyngial muscular dystrophy
- 41. CONJUNCTIVA Phlyctenular keratoconjunctivitis Bitot’s spots Telangiectasia bulbar conjunctiva
- 42. CORNEA Kayser Fleischer ring Wilson’s disease Cholestasis Primary biliary cirrhosis Cryptogenic cirrhosis
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- 44. contd... Corneal ulcers Bellspalsy Trigeminal nerve palsy
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- 46. contd... Brushfield spotson the iris due to Down’s syndrome
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- 48. Cataract Most cataractsare age-related Underlying systemic diseases will result in presenile cataract formation- • Muscular dystrophy • Neurofibromatosis • Congenital rubella • Hypoparathyroidism
- 49. contd... Parkinsonism Infrequent blinking Impaired pursuit movement Hypometric saccades Reflex blepharospasm(Myersons sign) Oculogyric crisis Reverse Argyll Robertson pupil Blepharoclonus
- 50. ORAL CAVITY Leadline along the gums in lead toxicity Notched teeth are a sign of congenital syphilis (Hutchinson teeth).
- 51. TONGUE Macroglossia Downs syndrome Myxedema Microglossia Psudobulbar palsy
- 52. contd... Scarlet redtongue- niacin deficiency Dark red bald tongue- riboflavin deficiency In thiamine defi ciency, the tongue is smooth, shiny, atrophic, and reddened Triple furrowed tongue is seen in myasthenia gravis Lingua plicata in Melkersson-Rosenthal syndrome
- 53. contd... Fasciculation- motorneuron disease,syringomyelia Myotonia- myotonic dystrophy Deviation of tongue to same side on protrusion – hypoglossal nerve palsy
- 54. EAR Examination ofthe ears is particularly important in patients with hearing loss or vertigo. Examination of the ear canal may reveal a glomus tumor in a patient with jugular foramen syndrome vesicles due to herpes zoster infection evidence of a posterior fossa cholesteatoma.
- 55. contd... Cerebrospinal fluid(CSF)otorrhea may cause a clear or bloody ear discharge. Hemorrhage into the middle ear may cause a bulging, blue-red tympanic membrane in patients with basilar skull fracture.
- 56. contd... Hitzelberger’s sign Seenin acoustic neuroma. It occurs due to involvement of the 7th cranial nerve. There is early involvement of the sensory fibers which causes hypoesthesia of the posterior meatal wall.
- 57. NOSE Perforation ofthe nasal septum may be a clue to cocaine abuse,leprosy. A saddle nose may be a sign of congenital syphilis Evidence of bacterial infection in dangerous area of face may be a sign of cavernous sinus thrombosis Watery drainage may be due to CSF rhinorrhea.
- 58. NECK Meningeal irritationmay cause nuchal rigidity, head retraction, and opisthotonos. Neck movement may also be restricted with cervical spondylosis, cervical radiculopathy, and dystonias. In meningeal irritation the primary limitation is in neck flexion; in spondylosis the limitation is either global or primarily in rotation and lateral bending
- 59. contd... In theKlippel-Feil syndrome, syringomyelia, and platybasia, the neck may be short and broad, movement limited, and the hairline low.
- 60. contd... The carotidarteries should be cautiously and lightly palpated bilaterally, one at a time, and, followed by auscultation for carotid bruits. TITUBATION Cerebellar disease Multiple sclerosis Friedreichs ataxia
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- 62. contd... Causes of nerveenlargement
- 63. SKIN Cafe-au-lait macules--Darkbrown hypermelanotic macules with smooth or irregular borders, commonly seen in back, buttocks and trunk. Seen in neurofibromatosis. Also seen in Albright's synd, Fanconi anemia, Bloom syndrome.
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- 65. contd... Freckles similar smallround spots in axilla and inguinal areas are pathognomonic in NF.
- 66. contd... Ash leaf hypopigmentedmacule Hypomelanotic polygonal macules grow upto 5 cm over trunk and buttocks. >3 lesions are seen in 90% of TS patients. Also seen in MEN1, vitiligo, nevus anemicus, koyanagi syndrome
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- 68. contd... Adenoma sebaceum Numerousdiscrete smooth glistening round rubbery papules pinhead to pea size, over butterfly area in the face and nasolabial folds, cheeks, nose, chin. slow growing angiofibroma.
- 69. contd... Shagreen patch Theseare Connective tissue naevi. Skin colored irregular lumpy cobblestone- like plaques in lumbosacral areas which grow to the size of a palm.
- 70. contd... Satellite papulesgrow around a central plaque with orange peel like indentation. Seen in 70% of pts in TS. Also seen in MEN1, Cowden syndrome and Hunter's syndrome.
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- 72. contd... Port winestain
- 73. contd... Leprosy –tuberculoid/ borderline tuberculoid
- 74. contd... Tuft ofhair over lower lumbar region
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- 76. contd... Diabetic dermopathy Necrobiosis lipoidicadiabeticorum Scleredema diabeticorum
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- 78. contd... Cassals collar inpellagra Angular stomatitis
- 79. contd... Dermatomyositis Grotton’s Sign:An erythematous, scaly eruption over the extensor surfaces of the metacarpophalangeal joints and digits
- 80. contd... Heliotrope rash: Areddish-purple eruption on the upper Eyelid accompanied by swelling of the eyelid Most specific rash in DM Only present in a minority of patients.
- 81. contd... Shawl Signand V sign
- 82. contd... Spider angiomasin alcohol abuse Erythema chronicum migrans in lyme disease Purpura and petechiae in thrombotic thrombocytopenic purpura, meningococcemia, and rocky mountain spotted fever
- 83. contd... Livedo reticularisin antiphospholipid syndrome and cryoglobulinemia Hyperpigmentation in nelson’s syndrome, Carotenemia or addison’s disease Herpes zoster causes a vesicular eruption in the distribution of the involved root.
- 84. contd... Hemangiomas ofthe spinal cord may be accompanied by skin nevi in the same metamere. Symmetrically placed, painless, recurring, poorly healing lesions of the extremities may occur in syringomyelia and hereditary sensory neuropathy. Peripheral nerve disease, tabes dorsalis, and myelopathy may produce trophic changes in the skin.
- 85. NAILS Ungual/periungual fibroma Firmpink to skin colored papules, nodules from under the nail bed in toe & finger nails. Seen in 90% of patients in TS.
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- 88. GYNAECOMASTIA Klinefelters syndrome Lepromatous leprosy Kennedy syndrome
- 89. SPINE Tuberculosis andneoplasms of the spine may cause a marked kyphosis (gibbus) Muscular dystrophy often results in an increased lumbar lordosis Scoliosis is common in syringomyelia and friedreich’s ataxia.
- 90. contd... Localized rigiditywith a slight scoliosis and absence of the normal lordosis are symptoms of lumbosacral radiculopathy. Tenderness to percussion over the spinous processes, can occur with localized processes such as spinal epidural hematoma or abscess.
- 91. EXTREMETIES Claw hand Wrist drop Pes cavus(claw foot) • Peroneal muscular dystrophy • Friederichs ataxia • Syringomyelia • Spina bifida occulta • Anterior poliomyelitis
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- 93. contd... Painless arthropathy(Charcot joint) occurs when a joint is deafferented Painless enlargement of the shoulder has been reported as the presenting manifestation of syringomyelia. Decreased peripheral pulses occur in Takayasu’s disease as well as atherosclerosis. Acrocyanosis occurs in ergotism. Diseases of the nervous system are found in association with such skeletal and developmental anomalies as syndactyly, polydactyly, and arachnodactyly.
- 94. REFERENCES Dejongs neurologicexamination , 7th edition Bickerstaffs neurology examination, 6th edition Physical diagnosis-Golwalla, 16th edition Manual of practical medicine- Alagappan,5th edition Harrisons principles of internal medicine.20th edition