Neurological

Question 1

What is the first question you should ask before performing a neruo exam?

Answer 1

Do you have any pain and if so where? interpret accordingly ie muscle power often appears reduced around a stiff or painful joint - does not mean is a neruo issue

Question 2

What is another question you should ask your patient before commencing?

Answer 2

Are you left or right handed? - patients often perform slightly better with dominant

Question 3

What should you look for on general inspection?

Answer 3

(SWIFT P) 
Scars (don't forget to expose and look at spine)
Wasting 
Involuntary movements 
Tremor 
Fasciculations 
Posture 
- actively look for these things don't just passively observe whats there or you'll miss things

Question 4

How do you test for tone in the upper limbs?

Answer 4

Ask patient to let their arm go floppy whilst you manipulate the joints
Make sure to stabilise and isolate joint when testing
Passively move each joint - normal and even resistance? Hypertonia?
Hypotonia?

Question 5

How do you test for power (against resistance) in the upper limbs?

Answer 5

• Use MRC grading system
  Pronator drift? (UMN lesion)
  Shoulders - flex/ext/abd ie ‘dont let me push them down’/add ie ‘dont let me pull arms away from sides
  Elbow - flex ie ‘dont let me pull arm away/ext ie ‘dont let me push arm towards’/pro/sup
  Wrists - flex - ‘wrists back, dont let me pull down/ext - ‘wrists forwards, dont let me pull up’
  Fingers - flex/ext - ‘fingers out, dont let me push down’)/abd - ‘splay fingers, dont let me push together’
  Thumb - palmar abd - ‘thumbs to ceiling dont let me push down/add/opposition

Question 6

How do you test the reflexes of the upper limbs?

Answer 6

• Ensure upper limb is completely relaxed
  Biceps - tap in antecubital fossa
  Triceps - forearm rested at 90 degrees flexion, tap triceps tendon on posterior arm
  Brachioradialis/supinator - tap 4 inches proximal to base of thumb

Question 7

How do you test the co-ordination of the upper limbs?

Answer 7

Get patient to alternate placing their finger on the examiners outstretched finger then on their own nose
Get patient to place a finger on their own nose with their eyes shut
Get patient to touch their thumb to each fingertip rapidly
Get patient to rapidly alternate between pronation and supination of their hand into their opposite palm (dysdiadochokinesis = inability, MS or cerebellar tumours)

Question 8

How do you test the sensation of the upper limbs?

Answer 8

Soft touch - use fingers, wisp of cotton or soft end of neurotip to assess dermatomes
Pain/pin prick - repeat above with sharp end of neurotip
Proprioception - hold distal phalanx of thumb by its sides, demonstrate up/down movement w/eyes open then shut and see if they correctly identify the orientation
Vibration -using a 128Hz tuning fork placed on the DIP joints of fingers (often the first sensory modality to be lost in DM)

Question 9

What are some other tests for sensation in the upper limb?

Answer 9

Temperature - place a (cold) tuning fork on the dermatomes
Cortical localisation: Stereognosis (place key or coin in hand with eyes closed)
2-point discrimination (two sharp points close together)
Graphesthesia (recognise writing on skin by touch)

Question 10

What is a (modified) Romberg’s test?

Answer 10

An assessment performed before/after a lower limb exam. Stand close to the patient in case you need to catch them.
Get patient to stand with feet together, arms outstretched with hands supinated
If they cannot maintain balance with eyes open = cerebellar lesion
If they can maintain with eyes open but rock/sway when shut = loss of proprioception

Question 11

How do you assess a persons gait?

Answer 11

Perform the assessment before/after a lower limb exam
Assess them walking normally and heel-toe for: balance, posture, stride-length, arm swing - impaired heel-toe may suggest weakness/impaired proprioception/cerebellar disorder

Question 12

How do you test for tone in the lower limbs?

Answer 12

Ask patient to let their leg go floppy whilst you manipulate the joints
Make sure to stabilise and isolate joint when testing
Passively move each joint - normal and even resistance? Hypertonia? Hypotonia?
Leg roll - roll patients leg and watch foot flop independently
Ankle clonus?

Question 13

How do you test for power in the lower limbs?

Answer 13

Hip - abd - ‘move leg away from you’/add - ‘move leg towards you’/flex - ‘raise leg off bed, stop me from pushing down’/ext - ‘stop me from lifting leg’
Knee - flex - ‘bend knee and stop me from straightening’/ext - ‘straighten your leg against resistance’
Ankle - dorsiflex - ‘point foot towards head and dont let me push down’/plantarflex - ‘press against my hand with sole of foot’
Big toe - dorsiflex/plantarflex as above

Question 14

How do you test the reflexes in the lower limbs?

Answer 14

Knee - support relaxed leg by holding under knee, hammer under patella
Ankle - flex knee but keep heel on bed, slightly dorsiflex foot, hammer Achilles tendon
Plantar (Babinski) - run a blunt object along the lateral edge of the sole of the foot, normal is flexion of all toes, Babinski is hallux dorsiflexion with toe fanning

Question 15

How do you test the co-ordination in the lower limbs?

Answer 15

Heel-shin test - get the patient to place the heel of one foot at the top of their opposite shin and stroke it down to their ankle then lift off and repeat the process a number of times

Question 16

How do you test the sensation in the lower limbs?

Answer 16

Soft touch - use fingers, wisp of cotton or soft end of neurotip to assess dermatomes
Pain/pin prick - repeat above with sharp end of neurotip
Proprioception - hold distal phalanx of big toe by its sides, demonstrate up/down movement w/eyes open then shut and see if they correctly identify the orientation
Vibration -using a 128Hz tuning fork placed on the distal phalanx of big toe