INTRODUCTION TO NEUROLOGICAL EXAMINATION

Adrian Pace Neurology Registrar

Why neurological exam is different
1. The CNS cannot be directly palpated, percussed, auscultated etc, so its intactness is only induced indirectly via functional testing. 2. Major part of the exam is stimulus-response testing. 3. Exam findings must then be correlated with (1) patient symptoms and (2) knowledge of neuroanatomy to come to a diagnosis DIFFICULTIES: Neuroanatomy is complex Neurology covers a very wide area of disease Exam very reliant on patient cooperation Functional tests are potentially endless

IMPRESSIONS Neurology is medical µvoodoo-land¶ Neurologists all have OCD

(SOME) NEUROLOGICAL SYMPTOMS
‡ Headache ‡ Dizzyness ‡ Seizures ‡ Altered consciousness ‡ Personality change ‡ Memory loss ‡ Weakness ‡ Stiffness ‡ Disordered sensation ‡ Loss of vision ‡ Loss of hearing ‡ Loss of smell ‡ Abnormal movements ‡ Speech problems ‡ Swallowing problems ‡ Altered mobility ‡ Sphincter control disorders ‡ Sleep disorders ‡ Facial palsy ‡ Coordination difficulties

and so on.....

...REFERRAL LETTER The GP The GP Practice Somewhere in Plymouth PL& $XY Dear Neurology............ . there might have been some weakness.....history of funny turns...........peculiar movements............... I would be grateful if you would see this gentleman/lady I am concerned about.unexplained collapse.. Neurological examination appeared grossly normal Could there be something going on (aka a tumour??) .possibly confused.

Presence of neurological abnormality 2) Where is the problem ? .intrinsic / extrinsic .3 questions of neurological diagnosis 1) Is there a problem ? .Location of problem (CNS / PNS) 3) What is the problem ? .structural / chemical .benign / malignant .

NOTE : THIS PRESENTATION DOES NOT COVER HISTORY .

Sensory .Cranial nerves .general inspection ‡ Conscious state ‡ Cognition ‡ Head / Arms / Legs .appearance .Motor (tone / power / reflexes) .gait .Basic Plan ‡ OBSERVE .Coordination .

OBSERVATION .

SOME ABNORMAL GAITS ‡ ‡ ‡ ‡ ‡ ‡ Spastic Hemiparetic Parkinsonian Foot drop Ataxic Waddling (myopathic) .

SOME ABNORMAL FACIES .

Myoclonic jerks .ABNORMALITIES ON CLOSER INSPECTION ‡ ‡ ‡ ‡ ‡ Muscle wasting Muscle fasiculations Abnormal posture Tremors Involuntary movements .Focal seizures .Athetosis .Chorea .

LEVEL OF CONSCIOUSNESS .

mainly used on acute admissions . many processes selectively affect components Omitted in OP settings.Created to reflect measure of global brain function Limited value.

COGNITION .

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

combing hair) . dressing .what would you do? ± Planning ‡ How to plan a holiday / draw a clock ‡ Neglect ± Failure to pay attention to area of space (usually due to parietal lesions with neglect of contralateral space.g.. ‡ Praxis: ± ability to perform learned action (e.‡ Frontal functions ± Attention & concentration ( digit span ) ± Abstraction ( explain proverb ) ± Judgment ‡ child lost in street.

‡ Frontal release signs during neuro exam Glabellar tap Rooting Pouting Palmomental reflex Grasping .

CRANIAL NERVES .

smell (rarely tested) .Pupils ‡ III.Diplopia / Nystagmus .Ptosis . VI .Saccades and smooth pursuit .Fundi .‡ I ‡ II . IV.Fields ( confrontation) .Acuity (Snellen chart) .Movement .

Corneal reflex Afferent = V Efferent = VII VII .Taste ant 2/3 tongue .‡ V .Tensor Tympani .Facial sensation .Muscles of facial expression .Muscles of mastication .Jaw jerk .

sternocleidomastoid & trapezius XII ( tongue) .Nystagmus .Power . fasciculations) fasciculations) . X .Observation ( atrophy.Gag reflex XI .Dexterity ( fast movement side-toside-toside) .Protrusion (?deviated) .Hearing IX.Say ahh (X) .VIII .

THE MOTOR SYSTEM .

Upper motor neurone ‡ Cell body within motor cortex ‡ Axon terminates : ± Cranial nerve motor nucleus (corticobulbar) ± Anterior horn of spinal cord (corticospinal) Lower motor neurone ‡ Cell body of ± Motor cranial nerve nucleus ± Anterior horn cell ‡ Axon terminates on neuromuscular junction .

TONE ‡ Reduced muscle tone. ‡ Increased tone: 1) SPASTICITY (ie pyramidal) 2) RIGIDITY (ie extrapyramidal) .

POWER ‡ The standard neurological examination involves testing power of two movements at each joint (agonists and antagonists) ‡ The history may suggest more localised problems which require examination of individual muscles (eg nerve lesions of the hand) .

MRC GRADING OF MUSCLE POWER ‡ GRADE 5: NORMAL POWER ‡ GRADE 4: WEAK BUT SOME RESISTANCE ‡ GRADE 3: JUST OPPOSES GRAVITY ‡ GRADE 2: MOVES BUT CANNOT OPPOSE GRAVITY ‡ GRADE 1: VISBLE/ PALPABLE MUSCLE FLICKER ‡ GRADE 0: NOTHING .

normal arms: PARAPARESIS ‡ All four limbs weak: TETRAPARESIS ‡ One limb weak: MONOPARESIS ‡ Proximal muscle weakness ‡ Distal muscle weakness .PATTERNS OF WEAKNESS ‡ Weak arm and leg (same side): HEMIPARESIS ‡ Weak legs.

tumour. abscess ‡ Paraparesis: spinal cord lesion below cervical spine ‡ Tetraparesis: cervical cord lesion ‡ Monoparesis: Tumour at brachial plexus ‡ Proximal weakness: myopathy ‡ Distal weakness: peripheral neuropathy .EXAMPLES OF LESIONS CAUSING PATTERNS ‡ Hemiparesis: hemispheric stroke.

. Reflex actions are mediated via the reflex arc. is an involuntary and nearly instantaneous movement in response to a stimulus. comprised of sensory neurone that perceives the stimulus signal and transfers the signal to inter neurone(s) in your spinal cord then out to motor neurone and to an effector.REFLEXES A reflex. like muscle to react to the stimulus.

reflex spread and extensor plantar responses LOWER MOTOR NEURON LESIONS: reduced or absent reflexes. or focal eg single nerve or root lesion . may be generalised eg neuropathy.REFLEXES UPPER MOTOR NEURON LESIONS: increased tendon reflexes.

Inspection of muscles Tone Power (MRC scale) Tendon Reflexes Upper Motor Neurone Normal (disuse atrophy) Increased (unless acute) decreased Increased (unless acute) Lower Motor Neurone Atrophy Fasciculations Decreased (or normal) decreased Decreased or Normal Absent Pathological reflexes Present .

THE SENSORY SYSTEM .

SENSORY EXAM ‡ VIBRATION ± 128 hz tuning fork ‡ JOINT POSITION SENSE ‡ PIN PRICK ‡ TEMPERATURE Start distally and move proximally .

HIGHER CORTICAL SENSATIONS ‡ ‡ ‡ ‡ GRAPHESTHESIA STEREOGNOSIS DOUBLE SIMULTANEOUS STIMULATION TEXTURES .

COORDINATION .

CO-ORDINATION ‡ Two main types of ataxia: ‡ Cerebellar ataxia (lesions of the cerebellum and its connections) ‡ Sensory ataxia: peripheral neuropathies and spinal cord lesions where dorsal columns are affected .

COORDINATION TESTS Tandem gait Romberg s test Finger to nose test Rapid alternating movements (looking for dysdiadochokinesis) ‡ Heel to shin test ‡ ‡ ‡ ‡ .

THANK YOU .

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