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THE NEUROLOGICAL EXAMINATION

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Title: THE NEUROLOGICAL EXAMINATION


1
THE NEUROLOGICAL EXAMINATION
  • Prof Mohammad Abduljabbar

2
Resources
  • Neuroanatomy through Clinical Cases by Hal
    Blumenfeld
  • http//www.neuroexam.com/
  • http//www.utoronto.ca/neuronotes/NeuroExam/main.h
    tm
  • The Technique of the Neurologic Examination by
    William DeMyer
  • DeJongs Neurologic Examination by William W.
    Campbell

3
You must do a minimum basic examination on every
patient but you dont need to do every test
4
Tools of the trade
5
NEUROLOGICAL EXAM
  • MENTAL STATUS
  • CRANIAL NERVES
  • MOTOR EXAM
  • STRENGTH
  • GAIT
  • CEREBELLAR
  • REFLEXES
  • SENSATION

6
MENTAL STATUS
7
Level of Consciousness
  • Awake and alert
  • Agitated
  • Lethargic
  • Arousable with
  • Voice
  • Gentle stimulation
  • Painful/vigorous stimulation
  • Comatose

8
Mental Status Exam
  • 1. Level of alertness,attention and cooperation
  • We can test attention by seeing if the patient
    can remain focused on a simple task, such as
    spelling a short word forward and backward
    (W-O-R-L-D / D-L-R-O-W is a standard), repeating
    a string of integers forward and backward (digit
    span), or naming the months forward and then
    backward. Normal digit span is 6 or more forward,
    and 4 or more backward, depending slightly on age
    and education. Degree of cooperation should be
    noted, especially if it is abnormal, since this
    will influence many aspects of the exam.

9
LANGUAGE
  • FLUENCY
  • NAMING
  • REPETITION
  • READING
  • WRITING
  • COMPREHENSION
  • Aphasia vs. dysarthria

10
Mental Status Exam
  • 3. Speech and language
  • Spontaneous speech Note the patient's fluency,
    including phrase length, rate, and abundance of
    spontaneous speech. Also note tonal modulation
    and whether paraphasic errors (inappropriately
    substituted words or syllables), neologisms
    (nonexistent words), or errors in grammar are
    present.
  • Comprehension Can the patient understand simple
    questions and commands? Comprehension of
    grammatical structure should be tested as well
  • Naming Ask the patient to name some easy (pen,
    watch, tie, etc.) and some more difficult
    (fingernail, belt buckle, stethoscope, etc.)
    objects
  • Repetition Can the patient repeat single words
    and sentences (a standard is "no ifs ands or
    buts")?
  • Reading Ask the patient to read single words, a
    brief passage, and the front page of the
    newspaper aloud and test for comprehension.
  • Writing Ask the patient to write their name and
    write a sentence.

11
MEMORY
  • IMMEDIATE
  • REALLY A MEASURE OF ATTENTION RATHER THAN MEMORY
  • REMOTE
  • 3 OBJECTS AT 0/3/5 MINUTES
  • HISTORICAL EVENTS
  • PERSONAL EVENTS

12
Mental Status Exam
  • 4. Memory for recent and remote events
  • Recent memory Ask the patient to recall three
    items or a brief story after a delay of 3 to 5
    minutes. Be sure the information has been
    registered by asking the patient to repeat it
    immediately before initiating the delay. Provide
    distracters during the delay to prevent the
    patient from rehearsing the items repeatedly.
  • Remote memory Ask the patient about historical
    or verifiable personal events.
  • Memory can be impaired on many different
    timescales. Impaired ability to register and
    recall something within a few seconds after it
    was said is an abnormality that blends into the
    category of impaired attention. If immediate
    recall is intact, then difficulty with recall
    after about 1 to 5 minutes usually signifies
    damage to the limbic memory structures located in
    the medial temporal lobes and medial diencephalon

13
ORIENTATION
  • PERSON
  • NOT WHO THEY ARE BUT WHO YOU ARE
  • PLACE
  • TIME

14
OTHER COGNITIVE FUNCTIONS
  • CALCULATION
  • ABSTRACTION
  • SIMILARITIES/DIFFERENCES
  • JUDGEMENT
  • PERSONALITY/BEHAVIOR

15
Mental Status Exam
  • 6. Apraxia
  • The term apraxia will be used here to mean
    inability to follow a motor command that is not
    due to a primary motor deficit or a language
    impairment. It is apparently caused by a deficit
    in higher-order planning or conceptualization of
    the motor task. You can test for apraxia by
    asking the patient to do complex tasks, using
    commands such as "Pretend to comb your hair" or
    "Pretend to strike a match and blow it out" and
    so on. Patients with apraxia perform awkward
    movements that only minimally resemble those
    requested, despite having intact comprehension
    and an otherwise normal motor exam. This kind of
    apraxia is sometimes called ideomotor apraxia. In
    some patients, rather than affecting the distal
    extremities, apraxia can involve primarily the
    mouth and face, or movements of the whole body,
    such as walking or turning around.

16
Mental Status Exam
  • Folstein Mini-mental status exam
  • This is a screening tool used to follow the
    cognitive decline associated with dementia. It
    has been in wide use since 1975 and takes 5-10
    minutes to administer. It is a limited test
    instrument. This examination is not suitable for
    making a diagnosis but can be used to indicate
    the presence of cognitive impairment, such as
    when dementia or head injury are suspected.
    People from different cultural groups or low
    intelligence or education may score poorly on
    this examination in the absence of cognitive
    impairment and well educated people may score
    well despite having cognitive impairment

17
Mental Status Exam
  • 9. Sequencing tasks and frontal release signs
  • Frontal lobe lesions in adults can cause the
    reemergence of certain primitive reflexes that
    are normally present in infants. These so-called
    frontal release signs include the grasp, snout,
    root, and suck reflexes. Of these reflexes, the
    grasp reflex is the most useful in evaluating
    frontal lobe dysfunction.
  • Patients with frontal lobe dysfunction may have
    particular difficulty in changing from one action
    to the next when asked to perform a repeated
    sequence of actions.This phenomenon is called
    perseveration

18
Mental Status Exam
  • 10. Delusions and Hallucinations
  • Does the patient have any delusional thought
    processes? Does he have auditory or visual
    hallucinations? Ask questions such as, "Do you
    ever hear things that other people don't hear or
    see things that other people don't see?" "Do you
    feel that someone is watching you or trying to
    hurt you?" "Do you have any special abilities or
    powers?"
  • These abnormalities can be seen in toxic or
    metabolic abnormalities and other causes of
    diffuse brain dysfunction, and in primary
    psychiatric disorders. In addition, abnormal
    sensory phenomena can be caused by focal lesions
    or seizures in visual, somatosensory, or auditory
    cortex, and thought disorders can be caused by
    lesions in the association cortex and limbic
    system

19
Mental Status Exam
  • 11. Mood
  • Signs of major depression include depressed mood,
    changes in eating and sleeping patterns, loss of
    energy and initiative, low self-esteem, poor
    concentration, lack of enjoyment of previously
    pleasurable activities, and self-destructive or
    suicidal thoughts and behavior. Anxiety disorders
    are characterized by preoccupation with worrisome
    thoughts. Mania causes patients to be abnormally
    active and cognitively disorganized.

20
CRANIAL NERVES
21
CRANIAL NERVE EXAM
  • I - OLFACTORY
  • DONT USE A NOXIOUS STIMULUS
  • COFFEE, LEMON EXTRACT
  • II - OPTIC
  • VISUAL ACUITY
  • VISUAL FIELDS
  • FUNDOSCOPIC EXAM

22
Cranial Nerve1Olfaction
  • Not tested much unless a frontal lobe tumor is
    suspected
  • May be damaged in patients with closed head
    injuries,nasal obstruction,viral infections, and
    can be abnormal in Parkinsons disease,
    Alzheimers,and Multiple Sclerosis
  • Test by asking if patients can smell,coffee,vanill
    a, or cinnamon in each nostril. Avoid noxious
    odors ( ie NH3)

http//www.neuroexam.com/
23
http//commons.wikimedia.org/wiki/ImageHead_olfac
tory_nerve.jpg
http//www.braininjury.com/images/cranialnerveinju
ry.jpg
24
Cranial Nerve 2Optic Nerve
  • Visual Acuity (test with hand card)
  • Color Vision (loss of color vision especially red
    is an important symptom of optic neuritis)
  • Visual Fields (can be tested at the bedside by
    counting fingers in each quadrant)
  • Visual Extinction (to detect visual neglect)
  • Funduscopic Examination

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26
Cranial Nerve 2 and 3Pupillary responses
  • The size and shape of the pupil should be
    recorded at rest. Under normal conditions, the
    pupil constricts in response to light. Note the
    direct response, meaning constriction of the
    illuminated pupil, as well as the consensual
    response, meaning constriction of the opposite
    pupil.
  • Test the pupillary response to accommodation.
    Normally, the pupils constrict while fixating on
    an object being moved from far away to near the
    eyes.
  • Direct response (pupil illuminated). The direct
    response is impaired in lesions of the
    ipsilateral optic nerve, the pretectal area, the
    ipsilateral parasympathetics traveling in CN III,
    or the pupillary constrictor muscle of the iris.
  • Consensual response (contralateral pupil
    illuminated). The consensual response is impaired
    in lesions of the contralateral optic nerve, the
    pretectal area, the ipsilateral parasympathetics
    traveling in CN III, or the pupillary constrictor
    muscle.
  • Accommodation (response to looking at something
    moving toward the eye). Accommodation is impaired
    in lesions of the ipsilateral optic nerve, the
    ipsilateral parasympathetics traveling in CN III,
    or the pupillary constrictor muscle, or in
    bilateral lesions of the pathways from the optic
    tracts to the visual cortex. Accommodation is
    spared in lesions of the pretectal area.

27
Pupillary Size is determined by the light input,
sympathetic and parasympathetic tone
Text
28
CRANIAL NERVE EXAM
  • III/IV/VI OCULMOTOR, TROCHLEAR, ABDUCENS
  • PUPILLARY RESPONSE
  • EYE MOVEMENTS
  • OBSERVE LIDS FOR PTOSIS
  • V - TRIGEMINAL
  • MOTOR - JAW STRENGTH
  • SENS - ALL 3 DIVISIONS

29
Cranial Nerve 3,4,6Extraocular Movements
  • Observe the eyes at rest to see if there are any
    abnormalities such as spontaneous nystagmus (see
    below)or dysconjugate gaze (eyes not both fixated
    on the same point) resulting in diplopia (double
    vision)
  • Test smooth pursuit by having the patient follow
    an object moved across their full range of
    horizontal and vertical eye movements. Test
    convergence movements by having the patient
    fixate on an object as it is moved slowly towards
    a point right between the patient's eyes
  • In comatose or severely lethargic patients, the
    vestibulo-ocular reflex can be used to test
    whether brainstem eye movement pathways are
    intact. The oculocephalic reflex, a form of the
    vestibulo-ocular reflex, is tested by holding the
    eyes open and rotating the head from side to side
    or up and down

30
Cranial Nerve 5Facial Sensation and Muscles of
Mastication
  • Test facial sensation using a cotton wisp and a
    sharp object. Also test for tactile extinction
    using double simultaneous stimulation.
  • The corneal reflex, which involves both CN 5 and
    CN 7, is tested by touching each cornea gently
    with a cotton wisp and observing any asymmetries
    in the blink response.
  • Feel the masseter muscles during jaw clench. Test
    for a jaw jerk reflex by gently tapping on the
    jaw with the mouth slightly open.

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32
CRANIAL NERVES
  • VII - FACIAL
  • OBSERVE FOR FACIAL ASYMMETRY
  • FOREHEAD WRINKLING, EYELID CLOSURE,
    WHISTLE/PUCKER
  • VIII - VESTIBULAR
  • ACUITY
  • RINNE, WEBER

33
Cranial Nerve 7Muscles of Facial Expression and
Taste
  • Look for asymmetry in facial shape or in depth of
    furrows such as the nasolabial fold. Also look
    for asymmetries in spontaneous facial expressions
    and blinking. Ask patient to smile, puff out
    their cheeks, clench their eyes tight, wrinkle
    their brow, and so on. Old photographs of the
    patient can often aid your recognition of subtle
    changes
  • Check taste with sugar, salt, or lemon juice on
    cotton swabs applied to the lateral aspect of
    each side of the tongue. Like olfaction, taste is
    often tested only when specific pathology is
    suspected, such as in lesions of the facial
    nerve, or in lesions of the gustatory nucleus
  • The upper motor neurons for the upper face
    project to the facial nuclei bilaterally.
    Therefore, upper motor neuron lesions, such as a
    stroke, cause contralateral face weakness sparing
    the forehead, while lower motor neuron lesions,
    such as a facial nerve injury, typically cause
    weakness involving the whole ipsilateral face.

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35
Cranial Nerve 8 Hearing and Balance
  • Test to see can the patient hear fingers rubbed
    together or words whispered just outside of the
    auditory canal and identify which ear hears the
    sound? A tuning fork can be used to perform the
    Weber and Rinne test to evaluate sensorineural
    and conductive hearing loss respectively
  • Hearing loss can be caused by lesions in the
    acoustic and mechanical elements of the ear, the
    neural elements of the cochlea, or the acoustic
    nerve (CN VIII). After the hearing pathways enter
    the brainstem, they cross over at multiple levels
    and ascend bilaterally to the thalamus and
    auditory cortex. Therefore, clinically
    significant unilateral hearing loss is invariably
    caused by peripheral neural or mechanical
    lesions.
  • Vestibular testing is not done routinely.

36
CRANIAL NERVES
  • IX/X - GLOSSOPHARYNGEAL, VAGUS
  • GAG
  • XI - SPINAL ACCESSORY
  • STERNOCLEIDOMASTOID M.
  • TRAPEZIUS MUSCLE
  • XII - HYPOGLOSSAL
  • TONGUE STRENGTH
  • RIGHT XII THRUSTS TONGUE TO LEFT

37
Cranial Nerve 9 and 10Palatal Elevation and Gag
Reflex
  • Does the palate elevate symmetrically when the
    patient says, "Aah"? Does the patient gag when
    the posterior pharynx is brushed? The gag reflex
    needs to be tested only in patients with
    suspected brainstem pathology, impaired
    consciousness, or impaired swallowing.
  • Palate elevation and the gag reflex are impaired
    in lesions involving CN 9, CN 10, the
    neuromuscular junction, or the pharyngeal muscles.

38
Cranial Nerve11Sternocleidomastoid and Trapezius
Muscles
  • Ask the patient to shrug their shoulders, turn
    their head in both directions, and raise their
    head from the bed, flexing forward against the
    force of your hands.
  • Weakness in the sternocleidomastoid or trapezius
    muscles can be caused by lesions in the muscles,
    neuromuscular junction, or lower motor neurons of
    the accessory spinal nerve (CN XI). Unilateral
    upper motor neuron lesions in the cortex or
    descending pathways cause contralateral weakness
    of the trapezius, with relative sparing of
    sternocleidomastoid strength

39
Cranial Nerve12
  • Note any atrophy or fasciculations (spontaneous
    quivering movements caused by firing of muscle
    motor units) of the tongue while it is resting on
    the floor of the mouth. Ask the patient to stick
    their tongue straight out and note whether it
    curves to one side or the other. Ask the patient
    to move their tongue from side to side and push
    it forcefully against the inside of each cheek
  • Fasciculations and atrophy are signs of lower
    motor neuron lesions. Unilateral tongue weakness
    causes the tongue to deviate toward the weak
    side. Tongue weakness can result from lesions of
    the tongue muscles, the neuromuscular junction,
    the lower motor neurons of the hypoglossal nerve
    (CN XII), or the upper motor neurons originating
    in the motor cortex. Lesions of the motor cortex
    cause contralateral tongue weakness.

40
Hypoglossal Nerve Injury
41
MOTOR EXAMINATION
42
Motor Examination
43
Motor Examination
  • Observe Look for any twitches, tremors, abnormal
    movements or postures. Look carefully for
    hypokinesia,decreased eye blinking or staring
    which could be indicative or an extrapyramidal
    disorder such as Parkinsons disease
  • In suspected lower motor neuron disorders,look
    for muscle wasting or fasiculations
  • Palpate muscles in cases of suspected myopathy to
    check for muscle tenderness
  • Passively move each limb to check muscle tone.
    Ask the patient to relax before beginning

44
MUSCLE OBSERVATION
  • ATROPHY
  • FASCIULATIONS

45
ABNORMAL MOVEMENTS
  • TREMOR
  • REST
  • WITH ARMS OUTSTRETCHED
  • INTENTION
  • CHOREA
  • ATHETOSIS
  • ABNORMAL POSTURES

46
TONE
  • INCREASED, DECREASED, NORMAL
  • COGWHEELING
  • CLASP KNIFE

47
Motor Examination
  • Test for subtle weakness first by checking
    pronator drift, finger tapping,
    pronation/supination movements and toe tapping.
  • Then check individual muscles for strength using
    the MRC scale to rate strength

48
STRENGTH
  • STRENGTH
  • GRADED 0 - 5
  • 0 - NO MOVEMENT
  • 1 - FLICKER
  • 2 - MOVEMENT WITH GRAVITY REMOVED
  • 3 - MOVEMENT AGAINST GRAVITY
  • 4 - MOVEMENT AGAINST RESISTANCE
  • 5 - NORMAL STRENGTH

49
STRENGTH EXAM
  • UPPER AND LOWER EXTREMITIES
  • DISTAL AND PROXIMAL MUSCLES
  • GRIP STRENGTH IS A POOR SCREENING TOOL FOR
    STRENGTH
  • SUBTLE WEAKNESS
  • TOE WALK, HEEL WALK
  • OUT OF CHAIR
  • DEEP KNEE BEND

50
REFLEXES
51
MUSCLE STRETCH REFLEXES (DEEP TENDON REFLEXES)
  • GRADED 0 - 5
  • 0 - ABSENT
  • 1 - PRESENT WITH REINFORCEMENT
  • 2 - NORMAL
  • 3 - ENHANCED
  • 4 - UNSUSTAINED CLONUS
  • 5 - SUSTAINED CLONUS

52
MSR / DTR
  • BICEPS
  • BRACHIORADIALIS
  • TRICEPS
  • KNEE
  • ANKLE

53
OTHER REFLEXES
  • Upper motor neuron dysfunction
  • BABINSKI
  • present or absent
  • toes downgoing/ flexor plantar response
  • HOFMANS
  • JAW JERK
  • Frontal release signs
  • GRASP
  • SNOUT
  • SUCK
  • PALMOMENTAL

54
Plantar Response
  • Test the plantar response by scraping an object
    across the sole of the foot beginning from the
    heel, moving forward toward the small toe, and
    then arcing medially toward the big toe. The
    normal response is downward contraction of the
    toes. The abnormal response, called Babinski's
    sign, is characterized by an upgoing big toe and
    fanning outward of the other toes.The presence of
    Babinski's sign is always abnormal in adults, but
    it is often present in infants, up to the age of
    about 1 year.

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CEREBELLAR FUNCTION
  • RAPID ALTERNATING MOVEMENTS
  • FINGER TO FINGER TO NOSE TESTING
  • HEEL TO SHIN
  • GAIT
  • TANDEM

57
Coordination
  • Normal performance of these motor tasks depends
    on the integrated functioning of multiple sensory
    and motor subsystems. These include position
    sense pathways, lower motor neurons, upper motor
    neurons, the basal ganglia, and the cerebellum.
    Thus, in order to convincingly demonstrate that
    abnormalities are due to a cerebellar lesion, one
    must first test for normal joint position sense,
    strength, and reflexes and confirm the absence of
    involuntary movements caused by basal ganglia
    lesions. As already mentioned, limb ataxia is
    usually caused by lesions of the cerebellar
    hemispheres and associated pathways, while
    truncal ataxia is often caused by damage to the
    midline cerebellar vermis and associated pathway
  • Tests for Limb Ataxia include Rapid alternating
    movements, Finger Nose Finger test, and Heel Knee
    Shin test

58
Gait evaluation
  • Include walking and turning
  • Examples of abnormal gait
  • High steppage
  • Waddling
  • Hemiparetic
  • Shuffling
  • Turns en bloc

59
Gait
  • Gait involves multiple sensory and motor systems.
    These include vision, proprioception, lower motor
    neurons, upper motor neurons, basal ganglia, the
    cerebellum, and higher-order motor planning
    systems in the association cortex
  • Observe
  • Stance, how far apart are the feet, posture,
    stability, how high the feet are raised off the
    floor, trajectory of leg swing and whether there
    is circumduction (an arced trajectory in the
    medial to lateral direction), leg stiffness and
    degree of knee bending, arm swing, tendency to
    fall or swerve in any particular direction, rate
    and speed, difficulty initiating or stopping
    gait, and any involuntary movements that are
    brought out by walking. Turns should also be
    observed closely. The patient's ability to rise
    from a chair with or without assistance should
    also be recorded.
  • To bring out abnormalities in gait and balance,
    ask the patient to do more difficult maneuvers
    ie Tandem Gait

60
Romberg Sign
  • Stand with feet together - assure patient stable
    - have them close eyes
  • Romberg is positive if they do worse with eyes
    closed
  • Measures
  • Cerebellar function
  • Frequently poor balance with eyes open and
    closed
  • Proprioception
  • Frequently do worse with eyes closed
  • Vestibular system

61
SENSORY EXAM
62
Sensory Exam
  • The sensory exam relies to a large extent on the
    ability or willingness of the patient to report
    what he is feeling. It can therefore often be the
    most difficult and unreliable part of the
    neurologic exam

63
Primary Sensation
  • Light Touch
  • Pinprick
  • Vibration
  • Joint Position
  • Temperature
  • Two point discrimination
  • The pattern of sensory loss can provide important
    information that helps localize lesions to
    particular nerves, nerve roots, and regions of
    the spinal cord, brainstem, thalamus, or cortex

64
SENSORY EXAM
  • VIBRATION
  • 128 hz tuning fork
  • JOINT POSITION SENSE
  • PIN PRICK
  • TEMPERATURE
  • Start distally and move proximally

65
HIGHER CORTICAL SENSATIONS
  • GRAPHESTHESIA
  • STEREOGNOSIS
  • DOUBLE SIMULTANEOUS STIMULATION
  • BAROSTHESIA
  • TEXTURES

66
Cortical sensation
  • Graphesthesia
  • Sterognosis
  • Double Simultaneous Stimulation
  • Intact primary sensation with deficits in
    cortical sensation such as agraphesthesia or
    astereognosis suggests a lesion in the
    contralateral sensory cortex. Note, however, that
    severe cortical lesions can cause deficits in
    primary sensation as well. Extinction with intact
    primary sensation is a form of hemineglect that
    is most commonly associated with lesions of the
    right parietal lobe. Extinction can also be seen
    in right frontal or subcortical lesions, or
    sometimes in left hemisphere lesions causing mild
    right hemineglect

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