Examination: Neurology Flashcards
What is important to do to ensure tikanga is followed?
Clearly explain reason for exam
Gain permission for exam
Different coloured linen for head (white linen) vs rest of body (other colour) = keeps tapu and noa separate
Correct tone and manner (respectful)
Thank patient
NB: always check especially when touching head and face
WIPER
Wash hands Introduction - full name, role, permission, explanation of procedure Position patient Expose as necessary Examine from patient's RIGHT
Check for pain before starting
Communicate with patient about progress and check on comfort throughout and gain permission throughout
Assess expression for any pain/discomfort
Thank patient and let them know exam is complete
Allow them to put on clothes
Wash hands
General obs of a neurological presentation.
Alert?
Look well?
Distressed/pain?
Body weight?
What are they doing when you first see them?
Mobile/gait abnormalities/mobility aids?
Posture?
Facial symmetry/wasting?
Eyes - ptosis, strabismus, nystagmus, squint?
Speech - quality (nasal/hoarse), articulation (clearness of speech)
Hearing
Muscle wasting: arms/legs
Abnormal movements (tremor/fasciculation)?
What is the testing of balance called?
Romberg’s Test
Which three inputs combine to achieve balance?
Visual input from eyes
Proprioceptive from joints and muscles
Vestibular input from vestibular system
What do we examine for gait and balance?
WIPER
Any pain or discomfort to start
Gait - walk 2/3m away, turn and come back. Walk heel-to-toe, walk on toes followed by walking on heels, squat and stand up (or rise from chair)
What do we look at for gait?
Initiation: assess for apraxia
Phases of gait: swing and stance
Turn: stable/smooth/extra steps
Heel-to-toe: ataxic gait
Walk on heels/toes: balance, distal muscle strength
Squat and stand up: assess for proximal myopathy
How do we assess balance?
Ask for issues with balance before starting
Ask px to stand upright, feet together
Close eyes for up to a minute
Compare steadiness with eyes open/closed
Positive test: patient had to open eyes in order to not fall/lose balance
When would it be appropriate to ask the orientation questions?
If px seems confused when you talk to them
Some else has reported the px seems confused/forgetful
Clinical situation suggest cognition is affected e.g. acute illness, fall, collapse, head injury
List the components of the motor system examination.
Look: inspect
Feel: muscle tone
Move: muscle power
Special tests: coordination and deep tendon reflexes
List components of inspect of the motor system.
Assess symmetry - compare both sides Scars and other skin lesions Muscle hypertrophy Muscle wasting Use of limb - function Posture (decorticate, decerebral, hemiplegic posture with flexion of the upper limb and extension of the lower limb) Gait Abnormal involuntary movements - fasciculations/tremor
What is a tremor?
Oscillatory movement about a joint or group of joints resulting from alternating contraction and relaxation of muscles.
Postural tremor
A fine fast tremor that becomes worse with intentional movement
e.g. physiological tremor - nervous/too much caffeine or benign essential tremor
Pin rolling tremor
Slow, coarse tremor in PD
Worst at rest, improves with movement
More common in upper limbs, asymmetrical
How do we describe tremor?
Speed (fast/slow)
Amplitude (fine/course)
Maximal at rest or maintaining a posture/ carrying out a movement
Action or intention tremor
Absent or minimal at rest
Revealed or exacerbated with intentional movement
Cerebellar damage
Fasciculations
Irregular contractions of small areas of muscle under the skin
Skin twitches and ripples
Occur at rest and not during voluntary movement
LMN pattern of weakness
Hypotonia causes
LMN lesions, cerebellar disease, early phases of cerebral or spinal shock
Hypertonia may cause:
Spasticity
Rigidity
Clonus
What power do we assess in the upper limbs?
Should adduction, abduction and flexion
Elbow flexion and extension
Wrist flexion and extension
Finger flexion, extension, adduction, abduction
What power do we assess in the lower limbs?
Hip flexion, extension. adduction, abduction
Knee flexion and extension
Ankle dorsiflexion and plantarflexion
Eversion and inversion of foot
What are reflexes?
Deep tendon/muscle reflexes
Elicited by applying a sudden stretch to the muscle which contracts reflexively
Deep tendon reflexes of upper limb:
Biceps
Triceps
Brachioradialis
One superficial reflex in lower limb
Plantar reflex (S1-S2) - abnormal (going up) response is associated with UMN lesion
2 deep tendon reflexes in lower limb:
Knee jerk/patellar reflex
Ankle jerk/Achilles reflex
What do we determine when assessing reflexes?
Minimum stimulus that elicits a response
How do we describe reflexes?
Hyperreflexic Normal Diminished Absent Only present when using reinforcement
What affects coordination?
Cerebellar dysfunction
Affected by muscle weakness, proprioceptive loss or extrapyramidal dysfunction
Tests of coordination of upper limb?
Finger nose finger test
Rapid alternating movements
Test of coordination of lower limb?
Heel-shin test
Foot tapping test
UMN lesion
Hypertonia Hyperreflexia Weakness on contralateral side of lesion Minimal muscle atrophy No fasciculations May have associated sensory disturbance
LMN lesion
Hypotonia Weakness on side of lesion Reduced/absent reflexes Muscle atrophy Fasciculations May have sensory disturbance
What do we do to increase reflex in upper limbs?
Upper limbs - clench teeth
Nerve roots for bicep reflex, triceps reflex and brachioradialis reflex?
Biceps reflex: C5, C6
Triceps reflex: C7, C8
Brachioradialis: C5, C6
What may affect the upper limb coordination tests?
If the patient is left or right handed
What is the reinforcement maneovure for the lower limb reflexes?
Ask the patient to pull their interlocked hands apart at the same time the examiner taps the tendon
Nerve roots for knee reflex, ankle reflex and plantar reflex.
Knee - L3, L4
Ankle - L5, S1
Plantar reflex - S1, S2
What are signs of cerebellar disease in the heel-shin test?
Difficulty in placing heel on the knee
Foot slides off the shin
