Neurological Exam Flashcards
What does DANISH stand for in a cerebellar examination?
D = Dysdiadokinesia
A = Ataxia
N = Nystagmus
- Follow finger “H”
I = Intention Tremor
- Finger to nose test
S = Slurred/Staccato/Speed of Speech
- “British Constitution”/”Baby hippopotamus”
H = Hypotonia
What should you inspect for in (both upper and lower limb) neurological exam?
Inspection
Observe for clues around the bed –
There are is/no wheelchair, walking stick or urinary catheter
General appearance –
There is/no limb deformity and posture appears…?
- Scars
- Wasting of muscles
- Involuntary movements – dystonia / chorea / myoclonus
- Fasciculations
- Tremor – Parkinson’s disease / essential tremor
Don’t forget to look at the face for clues:
e.g hypomimia (lack of expression) in Parkinson’s disease,
ptosis and frontal balding in myotonic dystrophy,
ptosis and ophthalmoplegia in myasthenia gravis.
How do you conduct an upper limb neurological examination?
I Tony Powers, reflexively sense, proprioception + co-ordination
Inspection = around bed, general pt, SWIFT + Pronator drift
Tone = wrist, forearm, elbow and shoulder
Power = Shoulders, elbow, wrist, fingers and thumb
Reflex = Biceps, triceps, supinator
Sensation = (1) light touch, (2) pinprick, (3) vibration
Proprioception = (1) Finger up and down (eye shut) [move to more proximal joints if they cannot tell]
Coordination = intention tremor, dysdiadokinesia, pronator drift
How do you conduct a lower limb neurological examination?
I Walk Tony Powers, & Reflexively sense proprioception and co-ordination
Inspection: Around bed, general and SWIFT
Walk/Gait: (1) Walking to end of room and back -?ataxic, parkinsonian, high stepping, waddling, hemiparetic; (2) Tandem (Heel to toe) gait; (3) dorsiflexion power; (4) Rombergs test
Tone: {Keep pt floppy] (1) leg roll, (2) leg lift, (3) ankle clonus
Power: Hip, Knee, Ankle, big toe
Reflexes: Knee jerk, ankle jerk, plantar reflex
Sensation: Light touch, pin prick, vibration
Proprioception: use big toe (move more medially if unable)
Co-ordination: heel to shin test
How do you conduct a cranial nerve examination?
- Bedside
- general pt Inspection
- Olfactory nerve -Have you noticed any change in sense of smell?
- Optic
- inspect Pupils - size, shape symmetry
- Visual acuity –> snellen chart at 6M one per eye (<2 wrong at lowest line they can), pinhole if needs glasses but dont have, otherwise wear glasses. If bad then go to 3M/1M/Fingers/Hand/Light
- Pupil reflexes: direct and consensual –> swinging light
- accommodation reflex
- colour (ishiohara plates)
- visual fields (one eye at time)
- fundoscopy
- occulomotor, trochlear and abducens
- eye movements - H shape
- cover test 1 per eye
- Testing CN 5 - Trigeminal
- Sensory touch and pinprick on: forehead cheek jaw LHS–>RHS
- Motor
- teeth clench
- resisted jaw shut
- reflex
- Jaw jerk
- (corneal reflex)
- CN 7 - Facial nerve
- check face for asymmetry –> forehead wrinkles, nasolabial folds, mouth angles
- raised eyebrows (asymmetry?)
- Closed eyes (resisted power)
- Blown out cheeks (resisted power)
- Smiling/show teeth (asymmetry)
- Purse lips
- Close lips (resisted power)
- CN 8 - vestibulochochlear nerve
- gross hearing test
- rinne’s test
- webers test (forehead)
- vestibular testing/ Unterberger test and/or head thrust test
- CN 9 and 10 - glossopharyngeal and Vagus nerve
- Uvular deviation, mention: gag reflex, then assess cough and swallow
- CN 11 - Accessory nerve
- resisted shrug
- resisted SCM head turn
- CN 12 - Hypoglossal nerve
- inspect for wasting and fasiculations at rest
- protrude tongue
- push tongue in cheek for power
What should you look for on inspection in an upper limb neurological examination?
[in intro; i’ll explain more about each bit as we go along]
Look for clues around the bed–> e.g. wheelchair / walking sick / urinary catheter
General appearance - ?limb deformity or posturing
Face: hypomimia [Parkin], ptosis, frontal balding [MD], opthalmoplegia [myas gravis]
Closer insepction: SWIFT [scars, muscle Wasting, Involuntary movements, fasciulations or tremor]
fine tremor with arms out (while arms are out…)
AND “LOOK” for pronator drift (e.g. drifts from pronation, palms up)
cerebellar rebound
sensory inattention
How do you assess tone in an upper limb neuro examination?
Floppy arm
pronate and supinate - ?spastic catch [UMN, worse by ic velocity]
flex and extend elbow joint, flex/extend/abduct/adduct the shoulder
NOTE: character of movement ?smooth, ic/dc tone (flaccid)
Feel for rigitity and cogwheeling (PD)[extra-pyramidal]{rigidity=velocity INdependent; feels same if fast or slow = lead pipe rigidity}
How do you assess tone in an upper limb neuro exam?
test one side at a time comparing like for like, stabilising & isolating the joint when testing
- Shoulder abd/adduction = push down and pull up
- elbow flex/extens = boxer arms
- wrist ext/flex = cock wrist
- finger ext and abd = straight and splayed
- thumb abduction = thumb to ceiling
*
How do you assess deep tendon reflexes in the upper limb?
- biceps, triceps, supinator
how do you assess sensation in an UL neuro exam?
Light touch - cotton wool on dermatomes
- dorsal/posterior columns and spinothalamic tracts
Pin-prick sensation
- spinothalamic tracts
- glove distribution of sensory loss = peripheral neuropathy & move distal to proximal
Vibration sensation
- Assesses dorsal/posterior columns
- big tuning fork for big body and small for small ears
What are the upper limb dermatomes?
middle finger -C7
little finger - C8
Thumb - C6
mid/medial forearm - T1
medial arm - T2
Shoulder - C5
How do you assess proprioception in UL neuro?
- assesses dorsal/posterior columns
- distal phalanx of thumb - move it up and down while watch then close eyes and repeat
- if unable to identify go finger –> wirst –> elbow –> shoulder
How do you assess co-ordination in an UL neuro exam?
- finger to nose
- ?past pointing or dysmetria - cerebellar pathology
- could also be impaire din sensory ataxia (proprioception loss)
- or weakness in the arm
- Dysdiadochokinesia
- inability to perform rapidly alternating movement–> ?cerabellar ataxia, sensory atacia or pakinsonism
What gait abnormalities may there be on LL neuro exam?
Gait
- Ask the patient to walk to the end of the room and back – assess posture, arm swing, stride length, base, speed, symmetry, balance and for abnormal movements.
- Some common types of gait abnormality to observe for:
- Ataxic: broad-based and unsteady. As if drunk. From cerebellar pathology or a sensory ataxia. Often won’t be able to tandem gait either. With a sensory ataxia, the patients watch their feet intently to compensate for proprioceptive loss. In a cerebellar lesion, may veer to one side.
- Parkinsonian: small, shuffling steps, stooped posture and reduced arm swing (initially unilateral). Several steps taken to turn. Appears rushed (festinating) and may get stuck (freeze). Hand tremor may be noticeable.
- High-stepping: (either unilateral or bilateral) caused by foot drop (weakness of ankle dorsiflexion). Also won’t be able to walk on their heel(s).
- Waddling gait: shoulders sway from side to side, legs lifted off ground with the aid of tilting the trunk. Caused by proximal lower limb weakness, e.g. myopathy.
- Hemiparetic: one leg held stiffly and swings round in an arc with each stride (circumduction).
- Spastic paraparesis: similar to above but bilateral – both are stiff and circumducting. Feet may be inverted and “scissor”.
- Tandem (heel-to-toe) gait – ask to walk in a straight line heel-to-toe – an abnormal heel-to-toe test may suggest weakness, impaired proprioception or a cerebellar disorder
- Heel walking – assesses dorsiflexion power
- Toe walking - plantarflexion power
What standing test should be done in a LL neuro exam?
- Rombergs test
- feet together eyes closed ~1 minute
- is +ve test if they lose balance
- suggests sensory ataxia
