Neurological examination

Question 1

Common symptoms of neurological disease

Answer 1

Headaches
Dizzyness
Loss of consciousness (blackouts)
Vertigo
Loss of hearing
Speech disorder (dysphonia, dysarthria)
Sensory (pain, numbness)
Visual disorders (field loss, pupillary reflexes)
Motor disorders (paralysis tremor, co-ordination, twitching, gait)
High functional disorders (memory, psychiatric)

Question 2

Name two abnormalities of language and speech

Answer 2

Dysphasia: impairment of language function

Dysarthria: impaired articulation due to defective movement of the lips, tongue or palate. Can be due to cerebellar or motor dysfunction

Dysphonia: impairment of sound production due to vocal cord lesions

Question 3

Main tests of sensation

Answer 3

Touch - cotton ball

Pain - pinprick

Vibration - tuning fork

Proprioception - joint movements

Temperature (if senses unexpectedly normal)

Two point discrimination (calipers)

Question 4

Name the deep tendon reflexes performed when assessing the PNS

Answer 4

Biceps – C5/6.

Supinator (brachioradialis) – C5/6.

Triceps – C7/8.

Patellar – L3/4.

Ankle (achilles) – S1/2.

Question 5

Muscle wasting

Answer 5

Associated with physical inactivity and myopathies. Normally symmetrical.

Lesions in lower motor neurons cause asymmetrical wasting

Question 6

Fasciculation

Answer 6

Visible muscle twitching at rest. Suggests lesions of lower motor neurons

Question 7

What are the three types of tremor?

Answer 7

Tremors are caused by alternate contraction and relaxation of certain muscle groups.

Action: exaggeration of normal physiological tremor in smooth muscle movements. Common in anxiety, hyperthyroidism and alcohol withdrawal.

Rest: tremor maximal at rest, absent during movement. Typically occurs in Parkinsons

Intention: maximal during movement, absent at rest. Characteristic of cerebellar disorders

Question 8

Babinski sign

Answer 8

Plantar reflex tested by drawing a sharp point along the lateral border from the heel towards the toes. The normal response is flexion (curling) of the toes. In a positive Babinski sign there is extension and fanning of the toes.

Due to a lesion of the upper motor neuron.

Question 9

Cerebellar ataxia

Answer 9

Incoordination that is unaffected by visual feedback. Causes an overshoot of the finger-nose test. Associated with an intention tremor

Question 10

Sensory ataxia

Answer 10

Incoordination due to poor proprioception. More pronounced if patient has eyes closed.

Question 11

How may patients with abnormalities of the parietal lobe or thalamic projections to the parietal lobe present?

Answer 11

Parietal lobe is the main sensory area of the cortex. Patient may have:

sensory inattention: inability to feel a tactile stimulus

abnormal touch localisation

graphesthesia: inability to recognise writing on the skin
sterognosis: inability to perceive and recognise an object by handling it.

abnormal 2-point discrimination

Question 12

How would you test for sensory inattention?

Answer 12

Ask patient to close their eyes and touch right, left then both shoulders. Ability to feel touch on both sides separately but not when touched simultaneously denotes inattention

Question 13

Causes of mononeuritis multiplex

Answer 13

Diabetes

Alcohol

Vasculitis

Syphilis - multiple named nerves affected

Question 14

Radicular lesions

Answer 14

Deficit limited to a single nerve root or a number of roots close together

Question 15

Causes of peripheral neuropathy

Answer 15

Diabetes, alcohol, vitamin B12 deficiency, drugs

Distal sensory loss in the hands and feet.

Question 16

Features of cerebellar lesions

Answer 16

Dysdiadochokinesia/dysmetria

Ataxia

Nystagmus

Intention tremor

Slurred speech/scanning dysarthria

Hypotonia

Question 17

Sydenham’s chorea

Answer 17

Complication of streoptococcal infection. Caused by streptococcal antibody which damages striatal inhibitory neurons. Associated with rheumatic fever.

Question 18

What other neurological tests can be done following examination

Answer 18

Lab tests - blood tests, biospy Lumbar puncture EEG Nerve conduction tests EMG

Question 19

How would you test the integrity of peripheral nerves?

Answer 19

Nerve conduction test. Used to detect the presence or absence of responses and test the nerve conduction velocity in sensory and motor neurones. Electrodes are placed on two points along the course of the nerve. The nerve is stimulated electrically and the response is recorded. Repetitive stimulation is used to test the NMJ.

Question 20

How can you distinguish between different types of damage using nerve conduction tests

Answer 20

Compression leads to focal slowing of activity. Neuropathy results in general slowing of conduction Decrease in amplitude of the wave means there is a problem with transmitter release e.g. myasthenia gravis.

Question 21

Use of electromyography

Answer 21

Used to measure control of muscle. Measures action potentials in motor units. Can be used to distinguish between neuopathic and myopathic disorders. Fibrillation responses indicate muscle hyperexcitability following denervation. Fasciculation responses indicate spontanous activation of individual motor units.

Question 22

Electroencephalogram

Answer 22

EEG is a recording of electrical potential changes in the cerebral cortex obtained by using electrodes on the scalp.

Normal patterns are seen in wakefulness, abnormal discharges recorded in epilepsy, encephalitis, dementia.

Question 23

Overview of nervous system examination

Answer 23

Inspection: posture, gait, muscle wasting, tremor, abnormal movements, vision, hearing, speech, syndromes.

Palpation: assessment of sensory and motor function.

Auscultation: bruits, tinnitus (objective).

Question 24

How is muscle tone assessed?

Answer 24

Observe limb posture

Assess passive movements at the joints (shoulder, elbow, wrist, hip, knee, ankle)

Compare sides

Question 25

Muscle rigidity

Answer 25

Increase in muscle tone which causes resistance to passive movements.

Lead-pipe rigidity: resistance to movement throughout the entire range of movement

Cog-wheel rigidity: periodic resistance to movement in a limb, results in jerks

Clasp-knife rigidity: after an initial resistance to movement, there is a sudden reduction in tone and the limb moves freely throughout the rest of the range of movement.

Question 26

Tests to assess motor co-ordination

Answer 26

alternating movements (dysdiadokinesia)

finger-nose test (tremor, past pointing)

Heel-toe walking

Heel-knee-shin test

Question 27

Signs of raised ICP

Answer 27

seizures

bradycardia and hypertension

papilloedema