Neurological examination Flashcards
What is the neurological approach to a clinical problem?
Where is the lesion?
Where is the aetiology
What is the differential diagnosis?
Investigations
Management
Where can the lesion be?
Brain
Spinal cord
Anterior horn cell
Neuromuscular junction
Muscle
Peripheral nerve
What is the aetiology?
Vascular
Inflammatory/ immune
Trauma
Toxic / metabolic
Infective
Neoplastic
Degenerative
Genetic
How do we perform the neurological examination?
This starts on first meeting the patient
General observation
the patient and surroundings
Preparation
Systematic approach
Practice, practice, practice
What are the 2 examination structures for neurological examinations?
- Gait > Cranial nerves > upper limbs > lower limbs
- Cranial nerves > upper limbs > lowr limbs > gait
Examination for CN 1 olfactory
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
How do we examine CN 2 optic
Visual acuity, visual inattention, visual fields, light reflex,accommodation, fundoscopy
How do we test for visual acuity?
Test each eye separately
(spectacles)
Snellen chart - eye chart at eye doctors
Read newspaper / magazine / finger counting
How do we test for visual inattention?
Block on eye and tell them to follow a pen or something
How to test for visual fields?
Assessed by confrontation using a red pin
Test each eye separately
How do we examine for light reflex and accommodation?
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
How do we test for CN 3 (oculomotor) CN 4 (Trochlear) CN 6 (Abducens)
Extraocular eye movements – H and I shape
Fixation
Saccades
Smooth pursuit
Nystagmus
Features of CN 5 - trigeminal
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
Test for CN 7 - facial - muscles of facial expression
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
Features of CN 8 - vestibulocochlear and tests?
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)
Tests for CN 9 (Glossopharyngeal) and CN 10 (vagus)
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
Features and test for CN 11 - Accessory
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
CN 12 - hypoglossal features and test
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
Features of UMN?
Increased tone (spastic)
Pyramidal weakness
Brisk reflexes
Features of LMN
Muscle wasting and fasciculations
Decreased tone
Depressed or / absent reflexes
Whats the first thing we do when we examine limbs?
Inspection:
Patient and surroundings
Posture
Involuntary movements / tremor
Muscle wasting / fasciculations
Systematic approach to limb examination
Tone > Power > reflexes > co - ordination > sensation
What do we examine for tone?
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
Sign of stroke
Pronator drift
What are the levels/ muscle grades for Power?
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
What is the approach you take to limb weakness?
Unilateral or bilateral
Proximal or distal or global
Pyramidal weakness
Isolated lesion of nerve root or nerve or muscle
How do you examine reflexes?
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
What are the tests for upper limbs?
Tremor and dysmetria Finger-nose test
Fine motor skills
Rapid alternating hand movements (dysdiadochokinesis)
What are the tests for lower limbs?
Heel - shin test
How do we examine for sensation?
2 parts – dorsal column and spinothalamic tract
Vibration and joint position test 128 Hz tuning fork
Light touch and pinprick Dermatomes
How do examine someone’s gait?
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
What are the different types of gait patterns?
Hemiplegic
Spastic
Ataxic
Apraxic / Festinant / Shuffling
High steppage
Waddling
Antalgic
What is the Romberg’s test (modified)
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
