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Phase 2B > Neurological examination > Flashcards

Neurological examination Flashcards

1
Q

What is the neurological approach to a clinical problem?

A

Where is the lesion?
Where is the aetiology
What is the differential diagnosis?
Investigations
Management

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2
Q

Where can the lesion be?

A

Brain
Spinal cord
Anterior horn cell
Neuromuscular junction
Muscle
Peripheral nerve

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3
Q

What is the aetiology?

A

Vascular
Inflammatory/ immune
Trauma
Toxic / metabolic
Infective
Neoplastic
Degenerative
Genetic

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4
Q

How do we perform the neurological examination?

A

This starts on first meeting the patient

General observation
the patient and surroundings

Preparation

Systematic approach

Practice, practice, practice

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5
Q

What are the 2 examination structures for neurological examinations?

A
  1. Gait > Cranial nerves > upper limbs > lower limbs
  2. Cranial nerves > upper limbs > lowr limbs > gait
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6
Q

Examination for CN 1 olfactory

A

Have you noticed a recent change in your sense of smell or taste?

Use bedside products (orange, coffee, chocolate)

Test each nostril separately

Eye closed, patient occludes nostril, stimulus scent presented to non - occluded nostril

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7
Q

How do we examine CN 2 optic

A

Visual acuity, visual inattention, visual fields, light reflex,accommodation, fundoscopy

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8
Q

How do we test for visual acuity?

A

Test each eye separately

(spectacles)

Snellen chart - eye chart at eye doctors

Read newspaper / magazine / finger counting

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9
Q

How do we test for visual inattention?

A

Block on eye and tell them to follow a pen or something

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10
Q

How to test for visual fields?

A

Assessed by confrontation using a red pin
Test each eye separately

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11
Q

How do we examine for light reflex and accommodation?

A

LR: Direct and consensual
Use a bright pen torch

Accommodation: Observed by watching the pupil as gaze is shifted from a distant object to a near object

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12
Q

How do we test for CN 3 (oculomotor) CN 4 (Trochlear) CN 6 (Abducens)

A

Extraocular eye movements – H and I shape

Fixation

Saccades

Smooth pursuit

Nystagmus

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13
Q

Features of CN 5 - trigeminal

A

Sensory via 3 distributions
V1 – ophthalmic
V2 – maxillary
V3 – mandibular

Sensation to anterior 2/3 of tongue

Motor fibres to muscles of mastication

Jaw jerk

Corneal reflex – not performed

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14
Q

Test for CN 7 - facial - muscles of facial expression

A

Raise your eyebrows, shut your eyes tight and don’t let me open them, puff out your cheeks, purse your lips and smile (show me your teeth)
LMN (complete ipsilateral facial weakness) vs UMN (sparing of the forehead) facial nerve palsies

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15
Q

Features of CN 8 - vestibulocochlear and tests?

A

2 divisions - cochlear (hearing) and vestibular (balance)

Test hearing- whisper a number on one ear whilst covering the other. Ask them to repeat it.

If a hearing abnormality is suspected, perform Rinne’s and Weber’s tests (refer to handbook)

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16
Q

Tests for CN 9 (Glossopharyngeal) and CN 10 (vagus)

A

Open mouth wide and assess whether the uvula is in the midline at rest

Say ‘aah’ and note any asymmetry of movement. The uvula will deviate away from the side of a glossopharyngeal nerve palsy

Ask whether any difficulty swallowing (gag reflex is not performed) – CN 9 afferent, CN 10 efferent

(Ask to cough. A bovine (non-explosive) cough suggests a vagal nerve palsy)

Note any hoarseness of the voice

17
Q

Features and test for CN 11 - Accessory

A

Innervation to sternocleidomastoid and trapezius

Sternocleidomastoid – ask to turn head again resistance and palpate the contralateral sternomastoid muscle
Trapezius – ask to shrug shoulders against resistance

18
Q

CN 12 - hypoglossal features and test

A

Inspection at rest

Observe for tongue fasciculations

Ask to push tongue inside mouth against cheek

Move tongue side to side

Tongue is deviated towards the side of the lesion

19
Q

Features of UMN?

A

Increased tone (spastic)

Pyramidal weakness

Brisk reflexes

20
Q

Features of LMN

A

Muscle wasting and fasciculations

Decreased tone

Depressed or / absent reflexes

21
Q

Whats the first thing we do when we examine limbs?

A

Inspection:
Patient and surroundings

Posture

Involuntary movements / tremor

Muscle wasting / fasciculations

22
Q

Systematic approach to limb examination

A

Tone > Power > reflexes > co - ordination > sensation

23
Q

What do we examine for tone?

A

Passively move each joint

Hypertonia, normal or hypotonia

Hypertonia – spasticity or rigidity
Spasticity – velocity dependent, UMN lesion
Rigidity – same irrespective of speed of movement, parkinsonism

24
Q

Sign of stroke

A

Pronator drift

25
Q

What are the levels/ muscle grades for Power?

A

muscle grade Observation
0 No contraction
1 Flicker or trace contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity +resistance
5 Normal power

26
Q

What is the approach you take to limb weakness?

A

Unilateral or bilateral

Proximal or distal or global

Pyramidal weakness

Isolated lesion of nerve root or nerve or muscle

27
Q

How do you examine reflexes?

A

Present or absent

If present – depressed or increased (brisk)

Reinforcement

In lower limb examination – remember to examine the plantar reflex (lateral border of foot towards big toe

28
Q

What are the tests for upper limbs?

A

Tremor and dysmetria Finger-nose test
Fine motor skills
Rapid alternating hand movements (dysdiadochokinesis)

29
Q

What are the tests for lower limbs?

A

Heel - shin test

30
Q

How do we examine for sensation?

A

2 parts – dorsal column and spinothalamic tract

Vibration and joint position test 128 Hz tuning fork

Light touch and pinprick Dermatomes

31
Q

How do examine someone’s gait?

A

Walk normally, then heel to toe
(walk normally, then stand with feet together, then in tandem, then heel to toe)

Posture, balance, stride, arm swing

Pattern recognition

Romberg’s test

32
Q

What are the different types of gait patterns?

A

Hemiplegic

Spastic

Ataxic

Apraxic / Festinant / Shuffling

High steppage

Waddling

Antalgic

33
Q

What is the Romberg’s test (modified)

A

Stands with feet together, arms outstretched in front and hands supinated
(If unable do this with the eyes open – cerebellar lesion)

If can maintain the position with the eyes open but loses balance when eyes are closed - loss of proprioception

Phase 2B (16 decks)

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