Neurology: History Taking & Examination Flashcards
Alongside usual history taking sections, suggest some key things to explore in neurological history
- MUST CLARIFY onset, progression & pattern!!
- Weakness
- Tremors/shaking
- Difficulty swallowing or talking
- Sensory changes: numbness, paraesthesia, allodynia
- Confusion
- Dizziness
- Visual changes (blurred, double, reduced acuity, reduced visual fields)
- Headaches
- Nausea/vomiting
- Bowel & bladder function
- Neck stiffness
- Hx of infection
- Hx of trauma
- Impact on daily activities
- Psychosocial impact
There are numerous different neurological examinations you can do and you may have to select the most appropriate one (as opposed to doing them all); state some of the different neurological examinations you can do
- Comprehensive
- Lower limb
- Upper limb
- Cerebellar
- Cranial nerve
What does a comprehensive neurological examination involve?
- Mental status (often get idea by just doing the examination & can investigate any concerns as they arise)
- Level of consciousness (AVPU, GCS)
- Attention/concentration
- Orientation
- Speech
- Memory
- Calculation
- Visuospatial awareness
- Cranial nerves
- Motor function
- Gait
- Muscle bulk/wasting
- Tone
- Power
- Coordination (e.g. heel to shin, Romberg’s)
- Reflexes
- Biceps, triceps, brachioradialis, knee jerk, ankle jerk
- Plantar responses
- Jaw jerk
- Gag reflex
- Sensation
- Pain & temp
- Proprioception
- Vibration
- Light touch
For a lower limb neurological examination, state:
- Equipment you need
- How you want patient exposed
- Position want patient
- Equipment: tendon hammer, neurotip, cotton wool, tuning fork 128Hz
- Expose legs (typically only in underwear, can give blanket to cover)
- Initialy standing but then for tone onwards lying on coach (don’t need to be flat)
Outline the 10 sections of the lower limb neurological examination
- Introduction
- General inspection
- Patient
- Surroundings
- Gait
- Romberg’s
- Tone
- Power
- Reflexes
- Sensation
- Coordination
- Completing the examination
What will you look for in general inspection section of your lower limb neurological examination?
Surroundings
- Walking aids
- Shoes (e.g. built up)
- Prescriptions/medical
Patient
- Scars
- Wasting of muscles
- Tremor
- Fasciculations
- Pseudoathetosis (abnormal writhing movements typically of fingers due to failure of proprioception)
- Chorea
- Tardive dyskinesia
- Myoclonus (brief, involuntary twitching of a muscle or muscle group)
- Hypomimia (reduced degree of facial expression associated with PD)
- Eyes: ptosis, opthlamoplegia
What will you do in the gait section of your lower limb neurological examination?
-
Assess normal gait (walk end of room, turn, come back)
- Stance
- Type of gait
- Stability/balance
- Speed
- Arm swing (reduced in PD- often unilateral initially)
- Turning (PD & cerebellar disease find hard to turn)
- Assess tandem/heel-to-toe gait (sensitive for identifying pathology with cerebellar vermis [e.g. alcohol induced cerebellar degeneration] but also weakness of flexor muscles or sensory ataxia)
What will you do in the Romberg’s test section of your lower limb neurological examination?
- Stand within arms reach of pt (in case they fall)
- Ask pt to put feet together and keep arms by side
- Ask pt to close their eyes
- Observe for falling:
- Falling without correction is POSITIVE and is abnormal
- Swaying with correction is NOT positive and is normal
*Romberg’s used to assess for loss of proprioceptive or vestibular function (sensory ataxia). Based on idea that you need at least 2 of proprioception, vestibular function and vision to maintain balance when standing. If have deficiencies in proprioception or vestibular function then will struggle when vision eliminated.
What will you do in the tone section of your neurological examination?
*Must do on each leg and compare. Ask pt to let legs fully relax.
- Leg roll (roll each leg. Assess muscles involved in hip rotation)
- Leg lift (lift each knee briskly off bed & observe. Normal= heel remain in contact with bed. Hypertonia= heel lift off bed)
-
Ankle clonus
- Position the patient’s leg so that the knee and ankle are slightly flexed, supporting the leg with your hand under their knee, so they can relax.
- Rapidly dorsiflex and partially evert the foot to stretch the gastrocnemius muscle.
- Keep the foot in this position and observe for clonus. Clonus is felt as rhythmic beats of dorsiflexion and plantarflexion. If more than 5 beats of clonus are present, this would be classed as an abnormal finding.
Brief note on spasticity vs rigidity from geeky medics
Spasticity vs rigidity
Spasticity is associated with pyramidal tract lesions (e.g. stroke) and rigidity is associated with extrapyramidal tract lesions (e.g. Parkinson’s disease). Spasticity and rigidity both involve increased tone, so it’s important to understand how to differentiate them clinically.
Spasticity is “velocity-dependent”, meaning the faster you move the limb, the worse it is. There is typically increased tone in the initial part of the movement which then suddenly reduces past a certain point (known as “clasp knife spasticity”). Spasticity is also typically accompanied by weakness.
Rigidity is “velocity independent” meaning it feels the same if you move the limb rapidly or slowly. There are two main sub-types of rigidity:
- Cogwheel rigidity involves a tremor superimposed on the hypertonia, resulting in intermittent increases in tone during movement of the limb. This subtype of rigidity is associated with Parkinson’s disease.
- Lead pipe rigidity involves uniformly increased tone throughout the movement of the muscle. This subtype of rigidity is typically associated with neuroleptic malignant syndrome.
What will you do in the power section of your lower limb neurological examination?
- Hip flexion: lift your leg off the bed & don’t let me push your leg down
- Hip extension: don’t let me lift your leg off the bed
- Knee flexion: bend your leg so that your foot is flat on bed and then don’t let me pull your leg towards me
- Knee extension: try & straighten your leg whilst I try to stop you
- Ankle dorsiflexion: put your legs flat on bed, cock your foot backwards, don’t let me push your foot down
- Ankle plantarflexion: point your foot downwards, like you’re pushing a car pedal, don’t let me pull it up
- Big toe extension: point your big toe upwards and don’t let me push it down
KEY NOTES:
*Must stabilise & isolate the relevant joint for each assessment
*Do on each leg and compare
Remind yourself what myotome each of the following tests:
- Hip flexion
- Hip extension
- Knee flexion
- Knee extension
- Ankle dorsiflexion
- Ankle plantar flexion
- Great toe extension
- Hip flexion: L1/L2 (iliofemoral nerve)
- Hip extension: L5/S1/S2 (inferior gluteal nerve)
- Knee flexion: S1 (sciatic nerve)
- Knee extension: L3/L4 (femoral nerve)
- Ankle dorsiflexion: L4/L5 (deep peroneal nerve)
- Ankle plantar flexion: S1/S2 (tibial)
- Great toe extension: L5 (deep peroneal nerve)
Remind yourself of the MRC muscle power scale
Explain the difference in presentation between an UMN lesion and LMN when doing power assessment
What will you do in the reflexes section of your lower limb neurological examination?
-
Knee-jerk reflex:
- Either support pts lower limb or ask to hang legs over end of bed
- Tap patellar tendon
- Observe for extension of knee
-
Ankle-jerk reflex:
- Method 1: support leg so hip slightly abducted, knee flexed and ankle dorsiflexed. Tap Achille’s tendon and observe for contraction of gastrocnemius/plantar flexion of foot
- Method 2: ask pt to kneel on chair and hold back of it to keep steady, tap Achilles tendon etc…
-
Plantar reflex:
- Use your L hand to hold L foot and vice versa
- Run blunt object along lateral edge of sole of foot moving towards base of little toe then turn medially to run across transverse arch
-
Observe big toes:
- Normal= flexion of big toe and flexion of other toes
- Abnormal/Babinski’s sign= extension of great toe and spread of other toes
NOTES
*Pts limbs must be completely relaxed
*Hold tendon hammer at end to allow gravity to help you get a good swing
*If reflex appears absent, make sure pt fully relaxed and perform reinforcement manoeuvre by asking pt to clench teeth whilst you elicit reflex
What will you do in the sensation section of your lower limb neurological examination?
- Light touch sensation: cotton wool (DCML & ST)
- Pin-prick sensation: sharp end neurotip (ST)
- Vibration sensation: tuning fork (DCML)
- Proprioception: hold distal phalanx of toe by its sides and hold the distal interphalangeal joint of big toe whilst move
NOTES
*Check at least one modality from DCLM and ST
*Demonstrate normal sensation on sternum (ask pt to say yes if they feel it and it feels the same)
*Get pt to close their eyes
*Do each dermatome (or glove & stocking if that’s the distribution you are expecting) and compare each leg at each region before you progress to next region
Remind yourself of the lower limb dermatomes and where you should assess for each
- L1: inguinal region and the very top of the medial thigh
- L2: middle and lateral aspect of the anterior thigh
- L3: medial aspect of the knee
- L4: medial aspect of the lower leg and ankle
- L5: dorsum and medial aspect of the big toe
- S1: dorsum and lateral aspect of the little toe
Remind yourself of peripheral nerve distribution of lower limbs
What will you do in the coordination section of your lower limb neurological examination?
-
Heel to shin test
- Ask pt to put left heel on right knee and run it down shin in straight line
- Then ask them to return their left heel to starting position on right knee
- Ask them to repeat the movement continually until you say stop
- Repeat for other leg
Interpretation:
- Dysmetria (incoordination): suggests cerebellar pathology
- NOTE: weakness may also result in difficulty with this movement so ensure you have assessed power prior
What would you do in the completing the examination section of the lower limb neurological examination?
- Thank patient
- Dispose of PPE
- Summarise findings
- Additional examinations & investigations:
- Upper limb neurological examination
- Cerebellar assessment
- Cranial nerve examination
- Blood tests- depending on findings
- Imaging (e.g. CT or MRI….) - depending on findings
Outline the 10 steps of the upper limb neurological examination
- Introduction
- General inspection
- Pronator drift
- Tone
- Power
- Reflexes
- Sensation
- Coordination
- Dysdiadokinesia
- Completing the examination
What equipment will you need for the upper limb neurological examination?
How do you want the patient exposed for the upper limb neurological examination?
How do you want the patient positioned for the upper limb neurological examination?
- Equipment: tendon hammer, cotton wool, neurotip, tuning fork 128Hz
- Exposed so you can see all of arms & hands
- Sit on side of examination couch or lie at 45 degrees
What will you do in the general inspection section of the upper limb neurological examination?
- Surroundings:
- Walking aids
- Prescriptions/medical
- Patient
- Scars
- Wasting of muscles
- Tremor
- Fasciculations
- Pseudoathetosis (abnormal writhing movements typically of fingers due to failure of proprioception)
- Chorea
- Tardive dyskinesia
- Myoclonus (brief, involuntary twitching of a muscle or muscle group)
- Hypomimia (reduced degree of facial expression associated with PD)
- Eyes: ptosis, opthlamoplegia
What will you do in the pronator drift section of the upper limb neurological examination
- Ask pt to put arms straight out in front of them with palms facing up; observe for 20-30secs for signs of pronation
- If pronation does not occur, ask pt to close eyes and observe again (can accentuate effect as they are then relying on proprioception alone)
Interpretation: if forearm pronates, with or without downward movement, pt has pronator drift on that side; indicates contralateral pyramidal tract lesion. Pronation occurs because in UMN lesion supinator muscles are typically weaker than pronator muscles
In bedside teaching, reg said if you push down and there is overcompensation it indicates…?
What will you do in the tone section of the upper limb neurological examination?
- Shoulder: circumduction
- Elbow: flexion & extension
- Wrist: circumduction
NOTES
*Support pt’s arm by holding hand & elbow
*Pt must fully relax and let you control movement
*Feel for abnormalities of tone as you asses e.g. spasticity, rigidity, cogwheeling, hypotonia
Outline difference between cogwheel rigidity and lead pipe rigidity
- Cogwheel rigidity involves a tremor superimposed on the hypertonia, resulting in intermittent increases in tone during movement of the limb. This subtype of rigidity is associated with Parkinson’s disease.
- Lead pipe rigidity involves uniformly increased tone throughout the movement of the muscle. This subtype of rigidity is typically associated with neuroleptic malignant syndrome.
What will you do in the power section of the upper limb neurological examination?
- Shoulder abduction: bend your elbows and bring your arms out to the side like a chicken. Don’t let me push your shoulder down
- Should adduction: now bring your elbows a little closer to your sides (45 degrees); don’t let me pull your arms away from your sides
- Elbow flexion: bend your elbows; keeping your elbows by your side don’t let me pull your arm away from you
- Elbow extension: keeping elbows bent and by your side don’t let me push your arm down towards your thigh
- Wrist extension: hold your arms out in front of you with palms facing the ground, make a fist, cock your wrists back and don’t me push them downwards
- Wrist flexion: now point/cock your wrists downwards and don’t let me push them up
- Finger extension: hold your fingers out straight and don’t let me push them down
- Finger abduction: splay your fingers outwards and don’t let me push them together
- Thumb abduction: turn your hand over, put your thumb in the middle of your palm, now point your thumbs to the ceiling and don’t let me push them down
Remind yourself ow what myotome & nerve each of the following tests:
- Shoulder abduction
- Shoulder adduction
- Elbow flexion
- Elbow extension
- Wrist extension
- Wrist flexion
- Finger extension
- Finger abduction
- Thumb abduction
*
- Shoulder abduction: C5 (axillary nerve)
- Shoulder adduction:C6/C7 (thoracodorsal nerve)
- Elbow flexion: C5/C6 (musculoskeletal nerve)
- Elbow extension: C7 (radial nerve)
- Wrist extension: C6 (radial nerve)
- Wrist flexion: C6/C7 (median nerve)
- Finger extension: C7 (radial nerve)
- Finger abduction: T1 (ulnar nerve)
- Thumb abduction: T1 (median nerve)
Explain the difference in presentation between an UMN lesion and LMN when doing power assessment
What will you do in the reflexes section of the upper limb neurological examination?
-
Biceps reflex (C5/C6):
- Locate biceps tendon
- Place thumb of non-dominant hand over tendon
- Tap thumb with hammer
- Observe for contraction of biceps and flexion of elbow
-
Supinator/brachioradialis reflex (C5/C6):
- Locate brachioradialis tendon (posterolateral wrist ~4inches from base of thumb)
- Put two fingers over tendon
- Tap fingers with hammer
- Observe for contraction of brachioradialis muscle and associated flexion, pronation or supination of forearm at elbow
-
Triceps reflex (C7):
- Locate triceps tendon (can be done by getting pt to relax arm at 90 degrees with you supporting their forearm)
- Tap tendon with hammer
- Observe for contraction of triceps and extension of elbow
NOTES
*Pt’s muscles must be completely relaxed
*Hold tendon hammer at end to allow gravity to help a good swing
*If reflex appears absent, make sure pt is fully relaxed and perform a reinforcement manoeuvre by asking pt to clench teeth while you tap tendon
What will you do in the sensation section of you upper limb neurological examination?
- Light touch sensation: cotton wool (DCML & ST)
- Pin-prick sensation: sharp end neurotip (ST)
- Vibration sensation: tuning fork (DCML)
- Proprioception: hold distal phalanx of toe by its sides and hold the distal interphalangeal joint of big toe whilst move
NOTES
*Check at least one modality from DCLM and ST
*Demonstrate normal sensation on sternum (ask pt to say yes if they feel it and it feels the same. With the neurotip [pain] must test the sharp end and tell them this is sharp and the blunt end and tell them this is blunt but the only test the sharp)
*Get pt to close their eyes
*Do each dermatome (or glove & stocking if that’s the distribution you are expecting) and compare each leg at each region before you progress to next region
Remind yourself of the lower limb dermatomes and where you should assess for each
- C5: the lateral aspect of the lower edge of the deltoid muscle (known as the “regimental badge”).
- C6: the palmar side of the thumb.
- C7: the palmar side of the middle finger.
- C8: the palmar side of the little finger.
- T1: the medial aspect antecubital fossa, proximal to the medial epicondyle of the humerus.
Remind yourself of peripheral nerve distribution of upper limb
State the expected sensory loss pattern for each of the following:
- Mononeuropathy
- Peripheral neuropathy
- Radiculopathy
- Spinal cord damage
- Thalamic lesions
- Myopathies
What will you do in the coordination section of the upper limb neurological examination?
-
Finger-to-nose test:
- Position your finger so that pt has to fully stretch their arm to reach it with their finger
- Ask pt to touch their nose with tip of index finger then touch your finger tip
- Ask pt to continue doing this as fast as they can until you tell them to stop
-
Dysdiadokinesia
- Ask pt to place left palm on top of right palm
- Ask them to turn over their left hand and touch the back of their hand onto their right palm then return to original position
- Ask pt to repeat sequence as fast as they can until you tell them to stop
Intepretation
- Finger-to-nose test: dysmetria or intention tremor. Presence of both indicates ipsilateral cerebellar pathology
- Dysdiadokinesia: ipsilateral cerebellar pathology
What is an intention tremor?
A broad, coarse, low-frequency tremor that develops as a limb reaches the endpoint of a deliberate movement.
What would you do in the completing the examination section of the upper limb neurological examination?
- Thank pt
- Dispose PPE
- Summarise findings
- Further assessments & investigations:
- Lower limb neurological examination, cerebellar examination, cranial nerve examination
- Bloods (dependent on suspected pathology)
- Neuroimaging (e.g. CT or MRI)
Remind yourself of the DANISH mnemonic for cerebellar lesions
- Dysdiadokinesia
- Ataxia
- Nystagmus
- Intention tremor
- Slurred, staccato speech
- Hypotonia/heel-shin test
In OSCE, identifying that nystagmus is present is enough. However, it can be further classified based on 4 things; state these
- Type of nystagmus: e.g. jerk, pendular,
- Direction of nystagmus: most nystagmus has fast and slow phase; the direction is the direction of the fast phase. In cerebellar lesions the direction is towards the side of the lesion
- Direction of gaze: is nystagmus present on horizontal or vertical gaze
- Plane of nystagmus: are nystagmus beats in horizontal or vertical plane
How do you test CNIII, CNIV and CNVI?
-
Observing eye movements
- Hold finger ~30cm in front of their face and ask them to focus on your finger; observe for any deviation in eye position
- Move your finger through H shape and observe for any restriction in movement and nystagmus
-
Assess for strabismus
- Light reflex test (ask pt to look straight ahead and shine torch towards both eyes and look for light reflex- should be central and symmetrical)
- Cover test
- CNIII: down & out position, ptosis, mydriasis*
- CNIV: vertical & torsional diplopia so pt’s often have head tilt with double vision that is worse walking downstairs*
- CNVI: inability to abduct affected eye*
How do you test CNVII (facial nerve)?
- Inspection of face for asymmetry
-
Sensory assessment
- Ask if any changes to taste
-
Motor assessment
- Ask about hearing changes (paralysis of stapedius can result in hyperacusis)
- Facial movements:
- Raised eyebrows: assesses frontalis – “Raise your eyebrows as if you’re surprised.”
- Closed eyes: assesses orbicular oculi – “Scrunch up your eyes and don’t let me open them.”
- Blown out cheeks: assesses orbicularis oris – “Blow out your cheeks and don’t let me deflate them.”
- Smiling: assesses levator anguli oris and zygomaticus major – “Can you do a big smile for me?”
- Pursed lips: assesses orbicularis oris and buccinator – “Can you try to whistle?”
**REMEMBER: facial nerve palsy caused by LMN lesion present with weakness of all ipsilateral muscles. Facial nerve palsy caused by UMN lesion presents with unilateral facial weakness with sparing of upper facial muscles.
How do you test CNXI (accessory nerve)?
- Inspect SCM & trapezius for wasting
- Trapezius: ask pt to raise shoulders and resist you pushing them down
- SCM: ask pt to turn head to side and resist you pushing them
How do you test CNXII (hypoglossal nerve)?
- Inspection of tongue (wasting, fasciculations)
- Tongue protrusion (deviation towards affected side)
- Tongue weakness (put finger on pt’s cheek and ask them to push their tongue against it. Do each side)
Remind yourself of the GCS scoring system
State the 6 brainstem reflexes that are tested to see if someone is brain dead
Explain how to perform the oculocephalic/doll’s eye reflex
What do the results mean?
Performing the Examination
- First, must EXCLUDE cervical spine injury
- Turn head & observe eyes:
- Turn to right
- Turn to left
- Extend neck
- Flex neck
Results
- Eye moves in opposite direction to head movement= normal
- Eyes move to one side but not to another= brainstem lesion
- Eyes fail to move in any direction: bilateral brainstem lesions
- Limitation abduction 1 eye: CNVI palsy
What would you do in other/functional tests in Parkinson’s examination?
- Ask them to write a sentence/copy squiggle/draw spiral with L and R hand (looking for asymmetrical micrographia)
- Ask pt to undo and do up their top button (assess dexterity & speed of movement)
State 3 key questions/bits of information to establish to help you lateralise a lesion
-
Central or peripheral nervous system
- Motor: UMN or LMN
- Sensory (remember spinal nerves & cranial nerves are peripheral nervous sytem)
-
Laterality
- Cerebral hemisphere pathology produces contralateral symptoms
- Basal ganglia pathology produces contralateral symptoms
- Cerebellum pathology produces ipsilateral symptoms
- Cranial nerve pathology produces ipsilateral symptoms
-
Anatomical patterns of involvement
- Hemispheric lesions: contralateral sensory & motor affecting one side of body, cognitive deficits, visual field abnormalities
- Brainstem lesions: “crossed deficits” (involvement of face on one side of body and involvement of legs and arms on other side of body), cranial nerve palsies
- Spinal cord lesions: deficits below the level of the lesion
- Polyneuropathy: distal symmetrical sensory deficits and weakness (usually affects lower limbs more), areflexia
- Myopathies: proximal weakness, no sensory loss/only motor component
