Neurological Physical Examination Flashcards
1
Q
Parts of Neurological Examination
A
- Mental status
- Cranial nerves (CN)
- Motor system
- Sensory system
- Reflexes
- Disease specific
2
Q
Mental status screening short examination
A
-> should be always performed in the general physical examination
- Level of alertness
- Appropriateness of responses
- Orientation to date and place
3
Q
SCREENING CN examination
A
- Vision (Fields, funduscopic)
- Pupillary light reflex
- Eye movements
- Hearing
- Facial strength (smile, eye closure)
4
Q
SCREENING motor system examination
A
- Strength
- Gait (casual, heel walk, toe walk, tandem walk)
- Coordinations (fine finger movements, finger-to-nose, heel-knee-shin
5
Q
SCREENING sensory system examination
A
- Light touch
- Pain/ temperature
- Proreception
6
Q
SCREENING Reflexes examination
A
- Deep tendon reflexes (biceps, patellar, Achilles)
- Plantar responses
- Meningeal signs
7
Q
Oldfactory nerve examination
A
- Ask about smell
- Ask and test nasal patency
- Test sense of smell (with closed eyes), eg. coffee
8
Q
Optic nerves examination
A
- Visual acuity (ostrość)
- Visual fields
- Pupils
- Fundus -> with ophthalmoscope
9
Q
Pupils examination
A
- Size
- Shape
- Symmetry of both
- The light reaction
1) in the same eye
2) in the opposite eye
3) light reflexion in corneas - Accommodation
10
Q
III, IV and VI nerves examination
A
- Extraocular movements
- Test for convergence
- Look for ptosis
11
Q
Trigeminal nerve examination
A
- Motor
- Sensory
- Corneal reflex (blinking of both eyes)
- Jaw (masseter) reflex
12
Q
Trigeminal nerve examination - motor
A
- Palpate the temporal and masseter muscles with clenched teeth
- Note strength and contraction
- Ask to open jaw and move it from side to side
13
Q
Trigeminal nerve examination - sensory
A
- Test the forehead, cheeks and chin
- Test pain or dull stimulus
- If sensory loss -> temperature sensation (two tubes 1 with hot and 2 with cold water)
14
Q
Facial nerve examination
A
- Look for asymmetry, tics
- Ask patient to:
1) raise both eyebrows
2) frown
3) close both eyes tightly
4) smile
5) show both upper and lower teeth
6) puff out both cheeks
15
Q
VIII nerve examination
A
- Ask patient about hearing
- Whispered voice test (ask to repeat numbers with blocking one ear) -> sensitivity > 90%, specificity > 80%
- If hearing loss is present -> Weber and Rinne test
16
Q
IX and X nerves examination
A
- Listen to patient voice (hoarseness, nasal voice)
- Ask about difficulty swallowing
- Ask patient to say “a” or to yawn -> observe soft palate and the pharynx
- Test gag reflex
17
Q
Accessory nerve examination
A
- Look for atrophy or fasciculations in trapezius and sternocleidomastoid muscles
- Test strength and tone of both muscles -> observe contraction of SCM muscle
18
Q
Hypoglossal nerve examination
A
- Listen to the articulation of the patient’s words
- Inspect patient’s tongue -> look for atrophy, fasciculations or deviation from the midline
- Ask the patient to move tongue from side to side
- Ask the patient to push tongue against the inside of each cheek -> palpate for strength
19
Q
The motor system examination
A
- Ask about dominant side
- Visual examination
- Muscle tone
- Muscle strength
- Coordination
20
Q
Visual motor system examination
A
- Body position
- Involuntary movements (tremors, tics, chorea or fasciculations)
- Muscle bulk -> look for atrophy/ hypertrophy
21
Q
Muscle tone examination
A
- Fingers
- Wrist
- Elbow
- Shoulder
- Ankle
- Knee
22
Q
Muscle strength grading scale
A
0 -> no muscular contraction detected
1 -> a barely detectable flicker or trace of contraction
2 -> active movement of the body part with gravity eliminated
3 -> active movement against gravity
4 -> active movement against gravity and some resistance
5 -> active movement against full resistance without evident fatique (normal)
23
Q
Upper body part muscles strength examination
A
- Opposition of the thumb (C8, Th1, median nerve)
- Finger abduction (C8, T1, ulnar nerve)
- Grip (C7-Th1) -> ask patient to squeeze 2 fingers
- Extension at the wrist (C6-8, radial nerve -> extensor carpi radialis longus and brevis)
- Elbow -> flexion (C5-6 -> biceps and brachioradialis) and extension (C6-8 -> triceps)
- Shoulder
- Strength of the trunk
24
Q
Trunk muscles strength examination
A
- Spine -> flexion, extension and lateral bending
2. Thoracic expansion and diaphragmatic excursion during respiration
25
Lower body part muscles strength examination
1. Hip
1) adduction L2-4 -> adductors
2) abduction L4-5, S1 -> gluteus medius and minimus
3) extension S1 -> gluteus maximus
2. Knee
1) extension L2-L4 -> quadriceps
2) flexion L4-S2 -> hamstrings
3. Foot -> dorsiflexion (L4-5) and plantar flexion (S1)
4. Hallux
26
Coordination examination
1. Rapid alternating movements
2. Point-to-point movement
3. Gait
4. Stance
27
Rapid alternating movements examination
1. Arms -> hand on the thigh -> turn it over -> repeat
2. Rapid finger tapping -> tap the distant joint of thumb with the tip of the index finger
3. Foot -> ask to tap the floor (with ball of the foot)
28
Point-to-point movement examination
1. Finger-to-nose test
1) ask patient to touch your finger -> then his nose -> then move finger and repeat
2) ask patient to touch his nose with finger several times -> then ask to close his eyes and repeat
2. Heel-to-shin test
29
Gait examination
Ask patient to:
1. Walk across the room
2. Walk heel-to-toe
3. Walk on the toes
4. Walk on the heels
5. Hop in place on each foot
6. Do a shallow knee bend
30
Stance examination
1. The Romberg test
2. Test for pronator drift
3. Rebound test
31
The sensory system examination
1. Pain -> spinothalamic tracts
2. Temperature -> spinothalamic tracts (omit when pain sensation is normal)
3. Vibration -> spinobulbothalamic tracts (posterior column)
4. Position -> spinobulbothalamic tracts (posterior column)
5. Light touch -> both tracts
6. Discriminate sensations
32
Discriminate sensations examination
1. Stereognosis -> ability to identify an object by feeling it (place key/ pencil in patients hand)
2. Graphesthesia -> number identification -> write a number in patient palm
3. Two-point discrimination (normally < 5 mm on finger pads)
4. Point localization -> briefly touch a point on the patient's skin -> ask patient to open eyes and point to it
5. Extinction -> stimulate simultaneously 2 areas of the body -> ask patient where he feels it (should feel both)
33
The most important dermatones (sensation)
1. Front and back of the neck -> C3
2. Thumb and lateral part of forearm -> C6
3. Ring and little finger -> C8
4. Nipples -> T4
5. Umbilicus -> T10
6. Inguinal ligament -> L1
7. Knee -> L4
8. Anterior ankle and medial dorsal part of the foot -> L5
9. Perianal area -> S5
34
Reflexes examination
1. Deep tendon reflexes
2. Cutaneous or superficial reflexes
3. Meningeal signs
4. Herniated disc-associated reflexes
35
Reflexes grading scale
```
0 -> Reflex absent
1 -> diminished, lower than normal
2 -> AVERAGE, NORMAL
3 -> brisker than normal
4 -> Very brisk with clonus (rhythmic oscillations between flexion and extension), hyperactive
```
36
Deep tendon reflexes examination
1. The brachioradialis reflex (C5-6, 3-5 cm above the wrist)
2. The biceps reflex (C5-6)
3. The triceps reflex (C6-7)
4. The quadriceps (patellar) reflex (L2-4)
5. The achilles (ankle) reflex (S1)
6. Ankle clonus -> only when other reflexes are hyperactive
37
Ankle clonus examination
1. Support the knee in a partly flexed position (patient should be relaxed)
2. Dorsiflex and plantar flex the foot a few times
3. Then sharply dorsiflex the foot and maintain it that way
4. Look and feel for rhythmic oscillations
38
Cutaneous or superficial reflexes examination
1. The abdominal reflexes (T8-10 above and T10-12 below the umbilicus) -> umbilicus should move towards the stimulus
2. The plantar (Babinski) reflex (L5, S1)
3. The anal reflex (S2-4) -> suggest cauda equina lesions
4. The cremasteric reflex
39
The plantar (Babiński) reflex
1. L5, S1
2. Dorsiflexion of the big toe is 50% sensitive and 99% specific for corticospinal tract lesions
3. Can be positive also in unconscious states from drug or alcohol intoxication and during the postictal period following a seizure
40
Meningeal signs
1. Nuchal rigidity
2. Brudziński's sign
3. Kernig's sign
4. Flatau's sign
5. Amoss' sign (objaw trójnoga)
6. Brdlik's sign
7. Painful pressure on eyeballs -> one of the earliest
41
Nuchal rigidity as meningeal sign
1. Found in 84% of patient with acute bacterial meningitis (30% in all the meningitis)
2. Found also in 21-86% of patients with subarachnoid hemorrhage
42
Brudziński's sign
- > positive when:
1. Upper (neck) -> passive flexion of the neck results in flexion of both the hips and knees
2. Lower (symphyseal, pubic) -> pressure on the pubic symphysis results in flexion of the hip and knee
3. Cheek -> pressure on the cheek results in a rise and flexion of the forearm
43
Kernig's sign
- > positive when:
1. Upper -> passive flexion of the trunk results in flexion of both the hips and knees
2. Lower -> with patient lying on the back -> flex the patient leg in both the hip and the knee in 90 degrees -> then passively straighten the knee -> it's positive when extension is painful (discomfort behind the knee during full extension is normal, but shouldn't produce pain)
3. Weil-Edelman sign -> when during lower Kernig's sign there is dorsiflexion of the big toe when the leg is extended
44
Flatau's sign
- > positive when:
1. Upper -> passive flexing of the neck results in dilation of the pupils
2. Lower -> only in young boys -> repetitive leaning forward and backward results in erection of the penis
45
Amoss' sign (objaw trójnoga)
1. Positive when during sitting down patient supports himself with extended upper limbs
46
Brdlik's sign
1. Positive when there's an inability to touch (kiss) the knees with the head in sitting position
47
Herniated disc-associated reflexes
1. Lasègue's sing (straight leg raise)
| 2. Mackiewicz sign (femoral nerve stretch test)
48
Lasègue's sing (straight leg raise)
1. Lift passively the patient's straightened leg (flexing the thigh at the hip)
2. Positive when sciatic pain occurs in ipsilateral leg
3. Also check pain when lifting healthy leg -> should be contralateral sciatic pain
4. Foot dorsiflexion can further increase leg pain
49
Mackiewicz sign (femoral nerve stretch test)
1. Position of the patient: best on the abdomen or backside
2. Flex passively the knee to the thigh and passively extend the leg in the hip
3. Positive when patient feels anterior thigh pain
4. Suggest L2-L4 disk herniation
50
Disease specific neurological examination
1. Asterixis -> suggest metabolic encephalopathy
- > tremor or sudden, brief flexion of the hand and fingers when the wrist is extended followed by recovery
2. Winging of the scapula
