Neurological Examination

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Learning Objectives. Select appropriate questions to elicit from the patient with a neurological complaint during a patient interviewDifferentiate

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Neurological Examination

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1. Neurological Examination Physical Diagnosis

2. Learning Objectives Select appropriate questions to elicit from the patient with a neurological complaint during a patient interview Differentiate “normal” from “abnormal” findings on neurological examination Identify common causes of various cranial nerve palsies Differentiate conductive hearing loss from sensorineural hearing loss Determine location of neurological lesion Differentiate amongst the various movement disorders

3. Learning Objectives Differentiate atrophy, hypertrophy, and pseudohypertrophy. Differentiate between spasticity, rigidity, and flaccidity, and identify common causes of each. Differentiate upper motor neuron lesions from lower motor neuron lesions. Differentiate CNS disorders from PNS disorders, and identify location of the lesion & common causes. Compare and contrast the five clinical levels of consciousness. Given a case study perform the appropriate focused history and physical examination and formulate a differential diagnosis

4. Purpose Determine if there is a neurological deficit Sensory Motor Behavioral Coordinative Localize the site of the problem Determine the etiology of the problem

5. Terminology Paresis – slight or incomplete paralysis Paralysis (plegia) – loss or impairment of motor function Hemiparesis Hemiplegia Paraplegia Quadriplegia

6. Terminology Atrophy – a decrease in size Hypertrophy enlargement of an organ or part due to an increase in size of its constituent cells Pseudohypertrophy increase in size without true hypertrophy Spasticity – hypertonicity with increased DTRs Rigidity – stiffness or inflexibility Flaccidity – loss of tone with diminished DTRs

7. Focuses Mental status Cranial nerves Motor function Reflexes Sensory status Coordination and balance

8. History Chief complaint PQRST Headache? Vertigo? Visual disturbance? Tremors or dyskinesias? Weakness? Dysesthesias/Paresthesias? Loss of consciousness?

9. Key components of H&P

10. Mental Status Alertness Attention Orientation Person, Place, Time, & Situation Cognitive function Perception Illusions = misinterpretations of real external stimuli Hallucinations = subjective sensory perceptions in the absence of stimuli Judgment Memory Short-term & long-term Speech Rate & rhythm Spontaneity Fluency Simple vs. complex

11. Levels of Consciousness Alert and Oriented Disoriented Obtunded Drowsy/somnolent Clouded consciousness Slow thought, movement, and speech Stuporous Marked reduction in mental and physical activity Vigorous stimuli needed to provoke a response Comatose Completely unconscious Cannot be aroused by painful stimuli Absence of voluntary movement +/- reflexes

12. Glasgow Coma Scale

13. Malingering (Nonorganic) Hand drop Blindness EOM/I Unilateral diplopia Ammonia reaction (CN V vs. CN I) Absence of pain or weakness in different positions

14. The “Difficult” Patient Observation is key! Use ingenuity! Be patient! Agitated May be threatening or violent Unresponsive Fail to participate Unreliable Inattentive, preoccupied, inconsistent information Hysterical Uncooperative

15. Testing Cognitive Function Information & vocabulary Common Calculating Simple math Word problems Abstract thinking Proverbs Similarities/differences Construction Copy figures of increasing difficulty (i.e. circle, clock)

16. Abnormalities of Thought Processes

17. Abnormalities of Thought Content

18. Delirium vs. Dementia Although confusion and/or disorientation are signs of both Delirium and Dementia, they are different Delirium is an acute confusional state It is potentially reversible Delirium usually occurs over a period of days to months Dementia is slow and insidious It progresses slowly over months to years Dementia is not reversible

19. Visual disturbance Onset? Progression? TIA = brief, intermittent visual loss Migraine = “wavy” Retinal detachment = “drawn curtain” Acute glaucoma = “rainbows” or “halos” Digitalis toxicity = yellow hue

20. Vertigo A sense of spinning Person Environment Suggests dysfunction of Vestibular apparatus Vestibular nerve Differentiate from “lightheadedness” and “faintness” Results from impairment of brain oxygenation

21. Dix-Hallpike maneuver

22. Testing for Aphasia

23. Localization CNS vs. PNS Brain/Brain stem Spinal cord Peripheral nerves Difficult when evaluating: Radicular pain Dysesthesia/paresthesia Tremors Incoordination

24. Localization Cerebrum Impaired intellect, memory, higher brain function Brain stem unconsciousness LMN paralysis with loss of DTRs muscle atrophy with fasciculation LMN + anesthesia peripheral nerve or spinal root UMN involves whole muscle groups increased or spastic muscle tone +/- paralysis with DTR accentuation Positive Babinski

25. Organic Disease Asymmetric pupillary light reflex Abnormal fundus Ocular divergence Nystagmus Muscular atrophy Fasciculations Multiple complex signs/symptoms explained by a single lesion

26. Headache 5th most common reason for OP visit Symptom! (not a disease) Most important diagnostic clue is a steady, bilateral, nonthrobbing pain that is worse in the a.m. May awaken patient Worse with VALSALVA

27. Types of Headaches Tension Sinus Migraine Classic Common Complicated Cluster Post-traumatic Post-LP

28. Types of Headaches Temporal Arteritis ICP Subarachnoid hemorrhage Infection Ocular Trigeminal neuralgia (Tic doloureaux) TMJ syndrome Toxic

29. Headache History Location Unilateral ~ migraine Periorbital ~ glaucoma/uveitis Parietal/Occipital ~ tension Neck ~ meningitis or Subarachnoid hemorrhage Quality “Throbbing” ~ vascular “Intermittent jabbing” ~ Trigeminal neuralgia “Pressure” ~ sinus Radiation? Severity Timing Constant vs. intermittent Worse in a.m. or p.m. Worst headache ever?????

30. Headache History Associated Sx’s Visual disturbance Vertigo N/V Dysesthesias Aura Past medical history Family history Current medication/drug use Suspect an extracranial etiology if pain is the only symptom

31. Physical Examination Appearance Behavior/Mannerisms Gait and Posture Motor behavior Facial expressions Mood vs. Affect MMSE Test Cranial Nerves II through XII Fundoscopic examination

32. Physical Examination Test motor nerve function Grip/SAR (Grade 0-5) Station and gait – ambulate, turn, toes, heels, heel-to-toe, knee bend Romberg Test sensory nerve function Pain +/- Light touch Two point discrimination (normally <5mm) Proprioception/Stereognosis/Vibration Test deep tendon reflexes (0-4+) Test for meningeal irritation - Kernig’s & Brudzinski’s signs Straight leg raise Used to identify potential discogenic injury and nerve root injury Test Coordination Finger-to-nose Rapid alternating movements of hands & feet

33. Reflexes Corneal Pharyngeal Biceps Triceps Brachioradialis Abdominal Patellar (knee jerk) Achilles (ankle jerk) Babinski Positive suggests UMN lesion

34. Cranial Nerves I - Olfactory II - Optic III - Oculomotor IV - Trochlear V - Trigeminal VI - Abducens VII - Facial VIII - Vestibulocochlear (Acoustic) IX - Glossopharyngeal X - Vagus XI - Accessory XII - Hypoglossal

35. Cranial Nerve I Responsible for sense of smell Receptors located in the upper 1/3 of the nasal septum. Test each nostril separately. Identify familiar odors. Avoid noxious substances Unilateral lesion = ipsilateral anosmia

36. Cranial Nerve II Responsible for vision Test visual acuity!!!! Pupillary size Swinging-flashlight test Visual fields Peripheral vision Test by confrontation Fundoscopic examination Papilledema

37. Cranial Nerves III, IV, VI CN III involved in: Pupillary reflex Opening of the eyelids Most extraocular movements CN IV provides downward/inward eye movement CN VI provides lateral eye movement

38. Cranial Nerves III, IV, VI Check pupillary reaction/reflex Direct & consensual Check eye movement through all six Cardinal fields Unilateral complete paralysis is usually caused by increased ICP or an aneurysm Neither eye can move to the contralateral side Eyes “look toward the lesion” Injury may occur secondary to: Infection Orbital fracture Internal carotid aneurysm Mastoiditis Increased ICP Look for nystagmus*

40. Pupil Abnormalities Adie’s (Tonic) pupil sluggish response Argyll Robertson pupil irregular/unequal pupils weak/absent reaction to light exaggerated contraction to accommodation Marcus-Gunn pupil results from reduced afferent input in the affected eye** pupil fails to constrict fully rapidly stimulate each eye in succession and observe the direct and consensual light response in each stimulation of the normal eye produces full constriction in both pupils. immediate subsequent stimulus of the affected eye produces an apparent dilation in both pupils since the stimulus carried through that optic nerve is weaker

41. Pupil Abnormalities Asymmetry of pupil size of >1mm suggests CN III compression Bilateral dilation suggests anoxia or drug affect Unilateral constriction is seen with sympathetic dysfunction (Horner syndrome) or carotid artery dissection Bilateral constriction is seen with: Pontine hemorrhage Drugs (opiates, Clonidine) Toxins (organophosphates)

42. Cranial Nerve V Sensory Ophthalmic branch (sensory) Cornea, conjunctiva, ciliary body, nasal cavity, sinuses, skin of eyebrows/forehead/nose Maxillary branch (sensory) Side of nose, lower eyelid, upper lip Mandibular branch (mixed) Sensory – skin of temporal region, auricles, lower lip/face, anterior 2/3 of tongue, mandibular gums/teeth Motor - innervates the muscles of mastication Cerebral lesion causes contralateral paresthesia Most lesions affect all 3 branches

43. Cranial Nerve V Testing Inspect for tremor of the lips, involuntary chewing movements, and trismus Compare muscle tension bilaterally with teeth clenched Test tactile perception Test sharp-dull discrimination Test temperature perception Test corneal reflex Tests V & VII directly and VII consensually

44. Cranial Nerve VII Motor Muscles of the face, scalp, and ears Autonomic Vasodilation Secretion of submaxillary/sublingual glands Sensory Taste in anterior 2/3 of tongue Ear canal/postauricular Palsies can occur secondary to: Polio, ALS, MS, tumors, syphilis, Lyme disease, Guillain-Barré Syndrome

45. Cranial Nerve VII Inspect for flaccid paralysis Differentiate UMN vs. LMN Elevate eyebrows Close eyes Show teeth Whistle Smile **Central lesions causes contralateral paralysis to lower half of face (below the eyes)

46. Cranial Nerve VIII Responsible for sense of hearing and balance Composed of the cochlear and vestibular nerves Sensory Test hearing

47. Cranial Nerve VIII Look for spontaneous nystagmus Romberg test/sign Functional test of position sense Stand with feet together Close eyes and maintain for 20-30 seconds Usually combined with a check for pronator drift As above Extend arms forward in supinated position Briskly move arms downward (separately) Arms should return smoothly to original position Lesion causes Unilateral deafness Imbalance

48. Cranial Nerve IX Motor Muscles of the pharynx Autonomic Vasodilation Sensory Taste in posterior 1/3 of tongue Pharynx, tonsils, fauces, TM, posterior ear canal Test for Elevation of the uvula Gag reflex Mucosal anesthesia

49. Cranial Nerve X Motor, autonomic, and sensory functions Palate, pharynx, larynx, neck, thorax, and abdomen Branches to: Pharynx Larynx Esophagus Heart Bronchioles Stomach Liver Celiac Perform indirect examination of the vocal cords Lesion cause: Hoarseness/aphonia Dyspnea/stridor

50. Cranial Nerve XI Provides motor to SCM upper Trapezius Testing: Have patient shrug against resistance Head rotation and movement against resistance

51. Cranial Nerve XII Motor to tongue Testing: Tongue movement Midline Tremors Involuntary Atrophy Lingual speech Paralysis causes deviation to the weak side

52. Motor Function UMNs Transmit impulses from cortical nerve bodies to: motor nuclei in brainstem (CNs) Anterior horn cells of spinal cord LMNs Transmit impulses from anterior horn cells through anterior root into peripheral nerves Terminate at the neuromuscular junction

53. Motor Function Inspection Symmetry Muscle bulk; size and contours; flat or concave; unilateral or bilateral; proximal or distal Atrophy Palpation Muscle tone Percussion ? Fasciculations Check motor strength Body position (during movement and at rest) Involuntary movements Location, quality, rate, rhythm, amplitude and relation to posture, activity, fatigue, or emotions If an abnormality exists: Identify muscle(s) involved Central vs. peripheral? Learn muscle innervations

54. Motor Function Muscle tone Slight residual tension in normal relaxed muscle Feel muscle’s resistance to passive stretch Muscle strength Wide variance - stronger dominant side Test by asking patient to actively resist movement If muscles too weak - test against gravity only or eliminate gravity If patient fails to move, watch or feel for weak contraction Suspect decreased resistance? Hold forearm and shake hand loosely Resistance increased? Varies or persists throughout movement

55. Function and Innervations

56. Function and Innervations

57. Motor function Always compare symmetry Note any atrophy Check muscle tone against resistance Cogwheel rigidity = jerky, released in degrees UMN paralysis = spasticity (increased tone) LMN paralysis = hypotonia Test muscle strength Grade 0 to 5

58. Grading Muscular Response

59. Sensory Function Fatigues quickly Efficiency Special attention to areas of: Symptomology Motor or reflex abnormalities Trophic changes Confirm with repeat testing!! Patterns of testing: Symmetrical Distal vs. proximal: scattered stimuli Vary pace

60. Sensory Function Testing Look for abnormality map out boundaries in detail Source of lesion Distribution of sensory abnormalities and kinds of sensations affected +/- motor/reflex abnormality Demonstrate to patient before testing

61. Spinothalamic Tract Pain and temperature Crude touch (light touch without localization) Fibers cross & pass upward into thalamus

62. Pain Sensation Sharp safety pin or other tool Demonstrate sharp & dull Test by: Alternating sharp & dull w/ pt’s eyes closed Ask patient: Sharp or dull? Does this feel same as this? Lightest pressure needed - do not draw blood

63. Temperature Often omitted if pain sensation normal Two test tubes filled with hot & cold water or tuning fork heated or cooled by water

64. Light Touch Wisp of cotton Touch lightly - avoid pressure Ask patient: To respond when touch is felt Compare one area with another

65. Posterior Columns Position and vibration Fine touch Synapse in medulla, cross & continue on to thalamus

66. Vibratory Sense 128 or 256 Hz Tuning fork If impaired, proceed proximally

67. Proprioception Grasp toe by sides - pull away from other toes Demonstrate “up” & “down”

68. Tactile Localization Have pt close eyes Touch pt on R cheek & L arm Ask patient where touch was felt

69. Discriminative Sensations Stereognosis, graphesthesia, two-point discrimination Test ability of sensory cortex to correlate, analyze, & interpret sensations Dependent on touch & position sense Screen first with stereognosis - proceed to other methods if indicated

70. Stereognosis Ability to identify an object by feeling it Place familiar object in patient’s hand & ask patient to identify it Normally patient manipulates it skillfully & identifies it correctly

71. Graphesthesia Perform if inability to manipulate object Ability to identify numbers written in hand Use patient’s orientation

72. Two-Point Discrimination Touch two places simultaneously Alternate stimuli Avoid pain Determine distance

73. Spinal Reflexes: DTRs Segmental levels of DTRs: Supinator reflex C5, 6 Biceps reflex C5, 6 Triceps reflex C6, 7 Abdominal reflexes - upper T8, 9, 10 - lower T 10, 11, 12 Knee (Patellar) L2, 3, 4 Plantar responses L5, S1 Achilles reflex S1 primarily

74. Deep Tendon Reflexes: Grading Grade DTR Response 4+ Very brisk, hyperactive, with clonus 3+ Brisker than average, slightly hyperreflexic 2+ Average, expected response; normal 1+ Somewhat diminished, low normal 0 No response, absent

75. Reflex Hammer - Incorrect Usage

76. Jendrassik’s Maneuver Reinforcement technique Upper extremities clench teeth squeeze thigh Lower extremities lock fingers and pull one against the other

77. Biceps Reflex C5,C6 Elbow Flexion

78. Triceps Reflex C6, C7, C8 Elbow Extension

79. Brachioradialis Reflex C5, C6 Forearm semiflexion/semipronation (NO wrist/hand flexion)

80. Patellar Reflex L2, L3, L4 Knee Extension

81. Achilles Reflex S1, S2 Ankle Plantar Flexion

82. Plantar Reflex L5, S1, S2 Babinski Sign

84. Abdominal Reflexes T8, T9, T10: ABOVE umbilicus T10, T11, T12: BELOW umbilicus

85. Anal Reflex Superficial reflex Loss of anal reflex suggests lesion of S2,3,4 reflex arc Possible lesion of cauda equina

86. Clonus Rhythmic Oscillation Flexion/Extension UMN Lesion

87. Cerebellar Function Requires integration of: Motor system Cerebellar system Vestibular system Sensory system Assessed by: Rapid alternating movements Finger-to-Nose / Heel-to-Knee Test Romberg’s Test Gait

88. Finger-to-Nose Test Finger-to-nose with moving target Stationary finger-to-nose with eyes closed

89. Heel-to-Knee Test

90. Rapid Alternating Movements First with hands Repeat with feet Diadochokinesia = ability to perform RAM Dysdiadochokinesis = slow, irregular, clumsy movements

91. Station, Stance & Romberg’s Test Station & Stance Pt stand with feet together First, eyes open Romberg Test Then, close eyes If okay with eyes open, but sways w/ eyes closed = + Romberg Mainly tests position sense Vision can compensate for loss of position sense

92. Pronator Drift Often performed in conjunction with Romberg test Pronator drift Muscular strength Coordination Position sense

93. Gait Walk across room, turn and walk back Tandem walking Heel & toe walking Hop in place Shallow knee bend Rising from sitting position or stepping up on stool

94. Meningeal Irritation Occur with meningitis & subarachnoid hemorrhage Brudzinski’s Sign Flex the head Marked pain in the neck Patient flexes hip and BLE Kernig’s Sign Pain when raising a straightened LE

95. Lab/X-ray CBC, CMP, U/A Specific drug levels Plain films of the spine CT of the brain & head MRI of the brain & spine Greater resolution then CT for soft tissue/plaques Angiography CSF exam EEG EMG & NCT PET/SPECT

96. Spinal Studies

97. Normal Skull Anatomy

98. Normal L-Spine MRI

99. CSF Obtained through lumbar puncture Indications: Suspected CNS infection (i.e. syphilis) Suspected subarachnoid hemorrhage Contraindicated if cerebral mass/lesion is suspected Measure opening pressure Obtain samples for cell counts, glucose, protein level, and cultures

100. Computed Tomography Gives adequate information about brain anatomy Used primarily to detect hemorrhage & tumors Can be performed with/without contrast Indications: Focal neurologic deficits Altered mental status Head trauma New-onset seizure Increased ICP Suspected mass lesion Suspected subarachnoid hemorrhage (with contrast) Abscess, intracranial tumor (with contrast) Chronic subdural hematoma, infarct, vascular malformation

101. Review of Neurological Exam Six categories: Mental status & speech Cranial nerves Motor function Sensory function Reflexes Cerebellar function Carefully evaluate the hx of the CC CN assessment is essential!

102. Summary Select appropriate questions to elicit from the patient with a neurological complaint during a patient interview Differentiate “normal” from “abnormal” findings on neurological examination Identify common causes of various cranial nerve palsies Differentiate conductive hearing loss from sensorineural hearing loss Differentiate amongst the various movement disorders Differentiate atrophy, hypertrophy, and pseudohypertrophy. Differentiate between spasticity, rigidity, and flaccidity, and identify common causes of each. Determine location of neurological lesion Differentiate upper motor neuron lesions from lower motor neuron lesions Differentiate CNS disorders from PNS disorders, and identify location of the lesion & common causes. Compare and contrast the five clinical levels of consciousness.

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