IMPORTANTCE!

1. NEUROLOGICAL EXAMINATIONDr. Lu QinchiDept. Neurology, Ren Ji Hospital Shanghai Second Medical UniversityTel: 63260930-2217Email: qinchilu@hotmail.com

2. IMPORTANTCE! • Despite recent advances in neuroscience and the continuing development of sensitive diagnostic procedures, the essential skill required for the diagnosis remains the clinical neurologic examination • Most neurologic diagnosis can be made on the basis of the history alone

3. SIX PARTS OF THE NEURO EXAM • Mental State & Cognitive Function • Cranial Nerves • Motor System • Sensory System • Reflexes

4. MENTAL STATE& COGNITIVE FUNCTION

5. Mental State & Cognitive Function -Level of consciousness( Mental State) • NORMAL: • patient awake and alert, attentive to surrounding and to the examiner • DEPRESSED: • Sleepy • Lethargic • Stuporous-arrousing only briefly in response to pain stimulation • Comatose-not arousable by pain stimulation

7. Mental State & Cognitive Function-Cognitive function check list • A. Orientation to person, place, and time. • B. Commom knowledge such as “ who is the president” • C. Memory: Short term-name three common objects, then name them again after 5 minutes; Long term-verifiable events from the past

8. Mental State & Cognitive Function -Cognitive function check list • D. Calculations: Serial sevens: count backward from 100, taking away 7 each time. Real-life problem • E. Abstract though: “ How is an apple different from –or the same as – an orange • F.Other: Insight and judgment, concentration, verbal fluency, patients mood, content of though, appropriateness of behavior, and so on.

9. Mental State & Cognitive Function -Language functioning check-up • Broca’s Aphasias • Wernicke’s Aphasias • Conductional Aphasias

10. CRANIAL NERVES

11. CRANIAL NERVES-Olfactory (I) • Ask the patient to identify common scents such as coffee,vanilla,etc, with eyes closed. • Do not use irritants. In testing olfactory nerve function, it is less important to determine whether the patient can correctly identify a particular odor than whether the presence or absence of the stimulus is perceived

12. CRANIAL NERVES-Optic (II) • Visual Acuity-pocket card or wall chart or any reading matter such as news paper • Visual Field • Confrontation Testing-Patient and examiner stand at eye level at about arm’s length. Have the patient cover his own eye • Threat Testing- applied when the patient is less than fully alert or is uncooperative • Fundus ( Ophthalmoscopic ) Examination

13. CRANIAL NERVES-Pupillary Reflexes (II, III) • A normal pupil will constrict (1) in response to direct light, (2) as a consensual response to light in the opposite eye, and (3) to accommodation ( convergence to focus on a close object)

14. CRANIAL NERVES-Control of Extraocular Muscle Movements (III, IV, VI) • Extraocular muscle movements are controlled by the oculomotor (III), trochlear ( IV), and abducens (V) nerves • Volitional Eye Movement-Follow my finger, just with your eyes. Tracing the Letter H • Ask about Diplopia • Nystagmus is rthythmic oscillation of the eyes

15. Unilateral ptosis occurs in Horner’s syndrome, with a small pupil; or in a III cranial nerve lesion, with a large pupil and loss of adductive and vertical eye movement

16. CRANIAL NERVES-Trigeminal Nerve (V) • Facial Sensation • Corneal Reflex-Sweep a wisp of cotton lightly across the lateral surface of the eye ( out of the direct visual field) from sclera to cornea- V, VII • Motor V Testing- Observe the symmetry of opening and closing of the mouth. Ask the patient to clench the teeth and then attempt to force jaw opening • Jaw jerk-brisk indicates UNL

17. CRANIAL NERVE-Facial Strength (VII) • Facial Symmetry-observe the patient’s face for symmetry of the palpebral fissures and nasolabial folds at rest. Ask the patient to wrinkle the forehead, then to squeeze the eyes tightly shut, then to smile or snarl, saying show your teeth • Supernuclear lesion • Nucleus or peripheral lesion • Bilateral Facial Weakness

18. CRANIAL NERVE-Auditory (VIII) • Auditory acuity can be tested crudely by rubbing thumb and forefinger together about 5cm from each ear. If the patient cannot hear the rub, proceed to the follow tests • Rinne Test-hold the base of tuning folk on the mastoid process until the sound is no longer perceived, then bring the still vibrating fork up close to the ear. • Sensorineural loss • Conductive loss • Weber Test

19. CRANIAL NERVE-Auditory (VIII) • Weber Test-lightly strike a tuning fork and place the handle on the midline of the forehead • Conductive loss • Sensorineural loss • Vestibular Function- need to be tested only if there are complaints dizziness or vertigo or evidence of nystagmus • Nylen-Barany( Dix-Hallpike) maneuver test for positional nystagmus

20. CRANIAL NERVE-Glossopharyngeal(IX) & Vagus(X) • Test the function of the palate, pharynx, and larynx • 1.Palatal elevation- say “ah” • 2.Gag reflex ( afferent IX, efferent X)- gently touch each side of the posterior pharygneal wall with a cotton swab • 3.Sensory function-lightly touch each side of the soft palate with the tip of a cotton swab • 4. Voice quality-listen for hoarseness or “breathiness”, suggesting laryngeal weakness

21. CRANIAL NERVE-Accessory (XI) • Sternocleidomastoid- press a hand against the patient’s jaw and have the patient rotate the head against resistance. Pressing against the right jaw tests the left sternocleidomastoid and vice versa • Trapezius-have the patient shrug shoulders against resistance and assess weakness

22. CRANIAL NERVE-Hypoglossal (XII) • Tests for hypoglossal nerve function include the following • 1.Atrophy or Fasciculations-with the patient’s tongue resting in the floor of the mouth, first inspect for atrophy or fasciculations. Then ask the patient to protrude the tongue, and observe for deviation to the weak side • 2. Subtle Weakness-have the patient push the tongue into each cheek against external resistance(opposite hypoglossal m.) • 3. Subtle Dysarthria- Ask the patient to repeat difficult phrases

23. MOTOR SYSTEM

24. Motor Function • Muscle Tone • Decreased( floppy, flaccid, hypotonic) • Normal • Increased( Spastic vs. Rigid) • Muscle Bulk • Atrophy ( or with fasciculation) • Muscle Strength-The classic grading system scores as follows: 5, full strength; 4, movement against gravity and & resistance; 3, movement against gravity only;2, movement horizontally along the surface of the bed;1,palpable contraction but little visible movement; 0, no contraction • Motor Coordination & Gait

25. Tibialis anterior will be weak in upper motor neuron lesions, in polyneropathy, in common peroneal never lesions, and in L5/S1 root lesions due to prolapsed intervertebral disc

26. Motor Coordination & Gait • Cerebellar hemisphere are responsible for coordinating and fine-tuning movements (ipsilateral ) • 1.Finger-to-Nose • 2. Rapid Alternating Movements • 3.Rebound • 4. Heel-Knee-Shin

27. Romberg’s test is a quick and excellent screen for loss of proprioceptive feedback neuropathy or spinal cord disease

28. SENSORY SYSTEM

29. Sensory Function • Large-fiber & Dorsal Column Function • Vibration Sense • Joint Position Sense • Romberg’s Test • Small-fiber & Spinothalamic Function • Temperature Sensation • Superficial Pain Sensation • Light Touch Sensation

30. In the lesion of the somatosensory cortex joint position perception is loss but vibration sensation is not

31. REFLEXS

32. Reflexes • Deep Tendon Reflexes • Bicep Reflex(C5-6) • Tricep Reflex ( C7-8) • Quadiceps ( Patellar, Knee Jerk) Reflex ( L3-4) • Achilles ( Ankle Jerk) Reflex (S1-2) • Pathologic Reflexes • Babinski Sign • Frontal Release Sign • Grasp Sign • Suck Sign • Snout Sign • Glabellar Sign

37. Brisk tendon reflexes signify upper motor lesions, absence reflexes occur in peripheral nerve or nerve root lesions

38. An extensor plantar or Babinski response is a definite immediate sign of an upper motor neuron lesion, presents well before clonus or hyperreflexia

41. Ankle clonus, when sustained or unsustained but of more than six beats duration, provides definite evidence for an upper motor neuron lesion