Neurological Physical Examination Flashcards
Parts of Neurological Examination
- Mental status
- Cranial nerves (CN)
- Motor system
- Sensory system
- Reflexes
- Disease specific
Mental status screening short examination
-> should be always performed in the general physical examination
- Level of alertness
- Appropriateness of responses
- Orientation to date and place
SCREENING CN examination
- Vision (Fields, funduscopic)
- Pupillary light reflex
- Eye movements
- Hearing
- Facial strength (smile, eye closure)
SCREENING motor system examination
- Strength
- Gait (casual, heel walk, toe walk, tandem walk)
- Coordinations (fine finger movements, finger-to-nose, heel-knee-shin
SCREENING sensory system examination
- Light touch
- Pain/ temperature
- Proreception
SCREENING Reflexes examination
- Deep tendon reflexes (biceps, patellar, Achilles)
- Plantar responses
- Meningeal signs
Oldfactory nerve examination
- Ask about smell
- Ask and test nasal patency
- Test sense of smell (with closed eyes), eg. coffee
Optic nerves examination
- Visual acuity (ostrość)
- Visual fields
- Pupils
- Fundus -> with ophthalmoscope
Pupils examination
- Size
- Shape
- Symmetry of both
- The light reaction
1) in the same eye
2) in the opposite eye
3) light reflexion in corneas - Accommodation
III, IV and VI nerves examination
- Extraocular movements
- Test for convergence
- Look for ptosis
Trigeminal nerve examination
- Motor
- Sensory
- Corneal reflex (blinking of both eyes)
- Jaw (masseter) reflex
Trigeminal nerve examination - motor
- Palpate the temporal and masseter muscles with clenched teeth
- Note strength and contraction
- Ask to open jaw and move it from side to side
Trigeminal nerve examination - sensory
- 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)
Facial nerve examination
- 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
VIII nerve examination
- 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
IX and X nerves examination
- 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
Accessory nerve examination
- Look for atrophy or fasciculations in trapezius and sternocleidomastoid muscles
- Test strength and tone of both muscles -> observe contraction of SCM muscle
Hypoglossal nerve examination
- 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
The motor system examination
- Ask about dominant side
- Visual examination
- Muscle tone
- Muscle strength
- Coordination
Visual motor system examination
- Body position
- Involuntary movements (tremors, tics, chorea or fasciculations)
- Muscle bulk -> look for atrophy/ hypertrophy
Muscle tone examination
- Fingers
- Wrist
- Elbow
- Shoulder
- Ankle
- Knee
Muscle strength grading scale
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)
Upper body part muscles strength examination
- 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
Trunk muscles strength examination
- Spine -> flexion, extension and lateral bending
2. Thoracic expansion and diaphragmatic excursion during respiration
Lower body part muscles strength examination
- Hip
1) adduction L2-4 -> adductors
2) abduction L4-5, S1 -> gluteus medius and minimus
3) extension S1 -> gluteus maximus - Knee
1) extension L2-L4 -> quadriceps
2) flexion L4-S2 -> hamstrings - Foot -> dorsiflexion (L4-5) and plantar flexion (S1)
- Hallux
Coordination examination
- Rapid alternating movements
- Point-to-point movement
- Gait
- Stance
Rapid alternating movements examination
- Arms -> hand on the thigh -> turn it over -> repeat
- Rapid finger tapping -> tap the distant joint of thumb with the tip of the index finger
- Foot -> ask to tap the floor (with ball of the foot)
Point-to-point movement examination
- 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 - Heel-to-shin test
Gait examination
Ask patient to:
- Walk across the room
- Walk heel-to-toe
- Walk on the toes
- Walk on the heels
- Hop in place on each foot
- Do a shallow knee bend
Stance examination
- The Romberg test
- Test for pronator drift
- Rebound test
The sensory system examination
- Pain -> spinothalamic tracts
- Temperature -> spinothalamic tracts (omit when pain sensation is normal)
- Vibration -> spinobulbothalamic tracts (posterior column)
- Position -> spinobulbothalamic tracts (posterior column)
- Light touch -> both tracts
- Discriminate sensations
Discriminate sensations examination
- Stereognosis -> ability to identify an object by feeling it (place key/ pencil in patients hand)
- Graphesthesia -> number identification -> write a number in patient palm
- Two-point discrimination (normally < 5 mm on finger pads)
- Point localization -> briefly touch a point on the patient’s skin -> ask patient to open eyes and point to it
- Extinction -> stimulate simultaneously 2 areas of the body -> ask patient where he feels it (should feel both)
The most important dermatones (sensation)
- Front and back of the neck -> C3
- Thumb and lateral part of forearm -> C6
- Ring and little finger -> C8
- Nipples -> T4
- Umbilicus -> T10
- Inguinal ligament -> L1
- Knee -> L4
- Anterior ankle and medial dorsal part of the foot -> L5
- Perianal area -> S5
Reflexes examination
- Deep tendon reflexes
- Cutaneous or superficial reflexes
- Meningeal signs
- Herniated disc-associated reflexes
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
Deep tendon reflexes examination
- The brachioradialis reflex (C5-6, 3-5 cm above the wrist)
- The biceps reflex (C5-6)
- The triceps reflex (C6-7)
- The quadriceps (patellar) reflex (L2-4)
- The achilles (ankle) reflex (S1)
- Ankle clonus -> only when other reflexes are hyperactive
Ankle clonus examination
- Support the knee in a partly flexed position (patient should be relaxed)
- Dorsiflex and plantar flex the foot a few times
- Then sharply dorsiflex the foot and maintain it that way
- Look and feel for rhythmic oscillations
Cutaneous or superficial reflexes examination
- The abdominal reflexes (T8-10 above and T10-12 below the umbilicus) -> umbilicus should move towards the stimulus
- The plantar (Babinski) reflex (L5, S1)
- The anal reflex (S2-4) -> suggest cauda equina lesions
- The cremasteric reflex
The plantar (Babiński) reflex
- L5, S1
- Dorsiflexion of the big toe is 50% sensitive and 99% specific for corticospinal tract lesions
- Can be positive also in unconscious states from drug or alcohol intoxication and during the postictal period following a seizure
Meningeal signs
- Nuchal rigidity
- Brudziński’s sign
- Kernig’s sign
- Flatau’s sign
- Amoss’ sign (objaw trójnoga)
- Brdlik’s sign
- Painful pressure on eyeballs -> one of the earliest
Nuchal rigidity as meningeal sign
- Found in 84% of patient with acute bacterial meningitis (30% in all the meningitis)
- Found also in 21-86% of patients with subarachnoid hemorrhage
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
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)
- Weil-Edelman sign -> when during lower Kernig’s sign there is dorsiflexion of the big toe when the leg is extended
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
Amoss’ sign (objaw trójnoga)
- Positive when during sitting down patient supports himself with extended upper limbs
Brdlik’s sign
- Positive when there’s an inability to touch (kiss) the knees with the head in sitting position
Herniated disc-associated reflexes
- Lasègue’s sing (straight leg raise)
2. Mackiewicz sign (femoral nerve stretch test)
Lasègue’s sing (straight leg raise)
- Lift passively the patient’s straightened leg (flexing the thigh at the hip)
- Positive when sciatic pain occurs in ipsilateral leg
- Also check pain when lifting healthy leg -> should be contralateral sciatic pain
- Foot dorsiflexion can further increase leg pain
Mackiewicz sign (femoral nerve stretch test)
- Position of the patient: best on the abdomen or backside
- Flex passively the knee to the thigh and passively extend the leg in the hip
- Positive when patient feels anterior thigh pain
- Suggest L2-L4 disk herniation
Disease specific neurological examination
- Asterixis -> suggest metabolic encephalopathy
- > tremor or sudden, brief flexion of the hand and fingers when the wrist is extended followed by recovery - Winging of the scapula