Neurological Examination Flashcards
Brudzinski sign
Spontaneous flexion of the hips during flexion of the neck by the examiner and indicates meningism.
Kernig’s sign
Can be elicited if meningitis is suspected. Flex each hip in turn, then attempt to straighten the knee while keeping the hip flexed. This is greatly limited by spasm of the hamstrings (which in turn causes pain) when there is meningism due to an inflammatory exudate around the lumbar spinal roots.
CN Exam - Introduction
Introduce Self
Check Patient Details (get Vitals)
Explain examination
Gain consent
Ask patient about pain
CN Exam - General Signs
Consciousness Neck Stiffness
Handedness (shake hands) - left/right dominant
Orientation (AOTTPP)
Acromegaly, Paget’s, basilar invagination, ptosis, proptosis, craniotomy scars
General appearance – comfortable at rest?
Head position – abnormal?
Obvious facial asymmetries?
Position of eyes - normal alignment / strabismus
Abnormality of speech or voice? – dysarthria Signs around the bed - hearing aid / glasses / etc
CN Exam - CNI - Olfactory
Exit: cribriform plate of ethmoid
Observe for rash or deformity
Examine nasal passages for polyps and mucosal thickening
Test smell with isopropyl alcohol wipes hyperosmia (psychosis, migraine, menstruation, encephalitis), parosmia (lesion of olfactory cortex), anosmia (URTI, smoking, fracture, meningitis)
CN Exam - CNII - Optic
Exit: optic foramen
Pupils Size - normal size is approximately 2-4mm in diameter (bright light) Position – assess pupil alignment – mis-alignment noted in strabismus Ptosis – observe for evidence of ptosis Visual acuity 1. Stand the patient at 6 metres from the Snellen chart 2. If patient normally uses distance glasses, ensure they wear them for the assessment 3. Ask the patient to cover one eye & read to the lowest line they can manage 4. Visual acuity is recorded as chart distance (numerator) over number of lowest line read (denominator) 5. Record the lowest line the patient was able to read (e.g. 6/6 which is equivalent to 20/20) 6. You can have the patient read through a pinhole to see if this improves vision 7. Repeat above steps with the other eye If patient is unable to read top line at 6 metres (even with pinhole): 1. Reduce the distance to 3 metres from the Snellen chart 2. Reduce the distance to 1 metre from the Snellen chart 3. Assess if they can count the number of fingers you’re holding up 4. Assess if they can see gross hand movement 5. Assess if they can detect light from a pen torch shone into each each If the patient is unable to perceive light, this suggests they are blind Pupillary reflexes Direct reflex- shine torch into eye - look for pupillary constriction in that eye Consensual reflex - shine torch into eye - look for pupillary constriction in opposite eye Swinging light test- move light in from side of each eye rapidly – relative afferent pupillary defect Accommodation reflex: 1. Ask patient to focus on a distant point (clock on a wall / light switch /etc) 2. Place your finger / an object 15cm in front of the eyes 3. Ask the patient to switch from looking at the distant object to the nearby finger / object 4. Observe the pupils, you should see constriction & convergence bilaterally Colour vision Say you would use Ishihara charts (often don’t have to actually carry this out) Visual fields Sit directly facing the patient, approximately 1 metre away Visual inattention 1. Ask patient to focus on your face & not move their head or eyes during the assessment 2. Hold both arms out, with your fingers in the periphery of both yours & the patients field of vision 3. Remind the patient to keep their head still & their eyes fixed on your face 4. Ask patient to point at which fingers are moving 5. Move the fingers of left & right hand in whichever order you choose 6. Then move the fingers of both hands simultaneously 7. If patient only notes one side moving, this suggests the presence of visual neglect .. Detailed visual fields 1. Ask patient to cover one eye with their hand 2. If the patient covers their right eye, you should cover your left eye (mirror the patient) 3. Ask patient to focus on your face & not move their head or eyes during the assessment 4. Ask the patient to tell you when they can see your fingertip wiggling 5. Outstretch your arms, ensuring they are situated at equal distance between yourself & the patient 6. Position your fingertip at the outer border of one of the quadrants of your visual field 7. Slowly bring your fingertip inwards, towards the centre of your visual field until the patient sees it 8. Repeat this process for each quadrant – at 10 o’clock /2 oclock / 4 o’clock / 8 o’clock 9. If you are able to see your fingertip, but the patient cannot, this would suggest a reduced visual field 10. Repeat this assessment process on the other eye Fundoscopy Preparation 1. Darken the room 2. The patient should have their pupils dilated with short-acting mydriatic eye drops 3. Ask the patient to fixate on a distant object Assess for red reflex 1. Position yourself at a distance of around 30cm from the patients eyes 2. Looking through the ophthalmoscope observe for a reddish / orange reflection in the pupil An absent red reflex may indicate the presence of cataract, or in rare circumstances neuroblastoma Move in closer & examine the eye with the fundoscope Begin medially & assess the optic disc - colour / contour / cupping Assess the retinal vessels – cotton wool spots / AV nipping / neovascularisation Finally assess the macula – ask to look directly into the light – drusen noted in macular degeneration
CN Exam - CNIII - Oculomotor
Exit: superior orbital fissure
Eye movements 1. Ask the patient to keep their head still & follow your finger with their eyes 2. Move your finger through the various axis of eye movement (“H” shape) 3. Ask the patient to report any double vision 4. Observe for restriction of eye movement & note any nystagmus Cover test 1. Ask patient to focus on a target (e.g. your pen top) 2. Cover one of the patients eyes 3. Observe the uncovered eye for movement: No movement = normal response Eye moves temporally = convergent squint Eye moves nasally = divergent squint 4. Repeat the cover test on the other eye
CN Exam - CNIV - Trochlear
Exit: superior orbital fissure
Eye movements 1. Ask the patient to keep their head still & follow your finger with their eyes 2. Move your finger through the various axis of eye movement (“H” shape) 3. Ask the patient to report any double vision 4. Observe for restriction of eye movement & note any nystagmus Cover test 1. Ask patient to focus on a target (e.g. your pen top) 2. Cover one of the patients eyes 3. Observe the uncovered eye for movement: No movement = normal response Eye moves temporally = convergent squint Eye moves nasally = divergent squint 4. Repeat the cover test on the other eye
CN Exam - CNV - Trigeminal
Exit: V1 - superior orbital fissure V2 - foramen rotundum V3 - foramen ovale
Sensory
Assess light touch & pin-prick sensation:
Forehead - opthalmic branch (V1)
Cheek - maxillary branch (V2)
Jaw – mandibular branch (V3)
Compare left to right for each branch
Demonstrate sensation of patients sternum first, to ensure they understand what it should feel like
Motor
- Ask patient to clench teeth & feel for the bulk of masseter and temporalis bilaterally
- Ask patient to open their mouth whilst you apply resistance under the jaw – note any deviation (jaw will deviate to side of lesion) .
Reflexes
Jaw jerk: Ask patient to open mouth loosely
Place your finger horizontally across the chin
Tap your finger with a tendon hammer
Normal = slight closure of the jaw
Abnormal = brisk, complete closure of the jaw – UMN lesion
Corneal reflex - touch cornea using a wisp of cotton wool – observe for direct/consensual blinking
CN Exam - CNVI - Abducens
Exit: superior orbital fissure
Eye movements 1. Ask the patient to keep their head still & follow your finger with their eyes 2. Move your finger through the various axis of eye movement (“H” shape) 3. Ask the patient to report any double vision 4. Observe for restriction of eye movement & note any nystagmus Cover test 1. Ask patient to focus on a target (e.g. your pen top) 2. Cover one of the patients eyes 3. Observe the uncovered eye for movement: No movement = normal response Eye moves temporally = convergent squint Eye moves nasally = divergent squint 4. Repeat the cover test on the other eye
CN Exam - CNVII - Facial
Exit: internal acoustic meatus
Inspect the patients face at rest for asymmetry, paying attention too… Forehead wrinkles Nasolabial folds Angles of the mouth Ask the patient to perform the following facial movements… Raised eyebrows – “raise your eyebrows as if you’re surprised” – observe for asymmetry Scrunched up eyes - “scrunch up your eyes & don’t let me open them” – assess power Blown out cheeks – “blow out your cheeks & don’t let me deflate them” – assess power Baring teeth – “can you do a big smile for me?” – note any asymmetry Purse lips - “can you attempt to whistle for me?” – note any asymmetry Other things to check… Inspect external auditory meatus - herpes zoster lesions – Bell’s Palsy Any hearing changes? - facial nerve supplies stapedius – paralysis results in hyperacusis Any taste changes? - supplies taste sensation to the anterior 2/3 of the tongue
CN Exam - CNVIII - Vestibulocochlear
Exit: internal acoustic meatus
VIII – Vestibulocochear nerve Gross hearing testing 1. Assess each ear individually 2. Whisper a number into the patients ear – 66 and 99 are often used 3. Mask the ear not being tested by rubbing two fingers together beside it to create white noise 4. Ask the patient to repeat the number back to you 5. Assess the other ear in the same way .. Rinne’s test 1. Tap a 512HZ tuning fork & place onto mastoid process- bone conduction 2. When patient can no longer hear the tuning fork, hold it next to the ear – air conduction 3. Ask the patient if they can now hear the tuning fork: Normal = Air conduction > Bone conduction (Rinne’s positive) Neural deafness = Air conduction > Bone conduction Conductive deafness = Bone conduction > Air conduction (Rinne’s negative) Weber’s test 1. Tap a 512HZ tuning fork & place in the midline of the forehead 2. Ask the patient if the sound is louder on a particular side: Normal = sound is heard equally in both ears Neural deafness = sound is heard louder on the side of the intact ear Conductive deafness = sound is heard louder on the side of the affected ear Vestibular testing – turning test Ask patient to march on spot with arms outstretched & eyes closed: Normal – patient remains in the same position Vestibular lesion – patient will turn toward the side of the lesion
CN Exam - CNIX - Glossopharyngeal
Exit: jugular foramen
Assess soft palate & uvula: Symmetry – note any obvious deviation of the uvula Ask patient to say “ahhhh” – observe uvula moving upwards – any deviation? Gag reflex – you won’t do this in the OSCE, but just make sure you mention it! Ask patient to cough- damage to nerves IX & X can result in a “bovine” cough Swallow – ask patient to take a sip of water – note any coughing / delayed swallow
CN Exam - CNX - Vagus
Exit: jugular foramen
Assess soft palate & uvula: Symmetry – note any obvious deviation of the uvula Ask patient to say “ahhhh” – observe uvula moving upwards – any deviation? Gag reflex – you won’t do this in the OSCE, but just make sure you mention it! Ask patient to cough- damage to nerves IX & X can result in a “bovine” cough Swallow – ask patient to take a sip of water – note any coughing / delayed swallow
CN Exam - CNXI - Accessory
Exit: jugular foramen
Ask patient to shrug shoulders & resist you pushing down – trapezius Ask patient to turn head to 1 side & resist you pushing it to the other - sternocleidomastoid Note any unilateral / bilateral weakness present
Upper Limb Rapid Nerve Root Screening
