Neurological Examination

1. Neurological Examination ดำรงศักดิ์ บุลยเลิศ ภาควิชาอายุรศาสตร์ www.metadon.net

2. Objectives • Demonstrate how to perform complete neurological examination in normal individuals • Demonstrate how to perform complete neurological examination in comatose patients

3. Outline of Neurolgical Examination • Cortical functions • Brainstem functions • Spinal functions • Reflexes and muscle tone • Coordination • Gait and posture • Meningeal irritation • Funduscopic examination • Autonomic examination • Intelligence examination

4. Outline of Neurolgical Examination • Cortical functions • Cranial functions • Motor functions • Sensory functions • Reflexes and muscle tone • Coordination • Gait and posture • Meningeal irritation • Funduscopic examination

5. Neurolgical Examination 1. Cortical functions • Consciousness • Cognitive functions • Language functions • Memory • Stereognosis • Sensory localization • Abstract thinking • Etc.

6. Neurolgical Examination • Consciousness: 2 components • Wakefulness (arousal) • Awareness (content) • Awareness depends on wakefulness • Patients may be awake but not aware • Patients may be aware if and only if they are awake

7. Neurolgical Examination Levels of consciousness • Normal/alert/awake-aware: spontaneous eye opening and responding to command • Drowsy: awake in response to stimulti (loud noise or deep pain stimuli), answering to simple questions, falling asleep if not stimulated • Stuporous: eye opening in response to deep pain, answering simple questions with yes or no • Comatose: no eye-opening in response to pain

8. Neurolgical Examination Content of consciousness (awareness) Orientation is the sign of normal awareness • Time (year, month, day, hour) • Space (the current location of the patient) • Person (people around the patient) Impairment of any of the three signifies disorientation.

9. Rancho Los Amigos Scale (RLAS) Level I - No response to any stimuli - indicates coma Level II - Generalized response, i.e. patient reacts inconsistently and nonpurposefully to stimuli in a non-specific manner, such as eye blinking, changes in breathing rate, gross body movement, and vocalization - indicates coma Level III - Localized response, i.e. patient reacts specifically but inconsistently to stimuli, such as turning head toward a sound or focusing on an object presented and following simple commands in an inconsistent, delayed manner - not considered coma, but stimulation techniques appropriate through Levels III. Level IV - Confused-Agitated, i.e. patient is in a heightened state of activity with severely decreased ability to process information. The patient is detached from the present and responds primarily to his/her own internal confusion. Behavior is often bizarre. Level V - Confused, Inappropriate, Non-Agitated, i.e. patient appears alert and is able to respond to simple commands fairly consistently, but responds to more complex commands in a non-purposeful, random manner and is agitated by external stimuli Level VI - Confused-Appropriate, i.e. the patient shows goal-directed behavior, but is dependent on external input for direction. He/she follows simple directions and shows carryover for tasks that have been relearned, such as self-care activities. Responses may be incorrect due to memory problems, but they are appropriate to the situation. Level VII - Automatic-Appropriate, i.e. the patient appears appropriate and oriented, but goes through daily routines automatically, and has shallow recall of what he/she has been doing. The patient shows increased, but superficial awareness of self and other people, demonstrates decreased judgement and problem-solving abilities, lacks realistic planning for the future, and requires at least minimal supervision for learning and safety purposes. Judgment and other higher level cognitive abilities remain compromised. Level VIII - Purposeful and Appropriate, i.e. the patient is alert and oriented able to recall and integrate past and recent events, is aware of and responsive to the environment, and needs no supervision once learning has occurred. He/she may continue to show decreased reasoning, tolerance for stress, judgment in emergencies or unusual circumstances, and decreased social, emotional, and intellectual capacities.

11. Neurolgical Examination Test of language functions • Naming: watch, pen, cup, etc. • Comprehension: simple commands, e.g., หลับตา ยกมือซ้าย • Repetition “ยายพาหลานไปซื้อขนมที่ตลาด” • Fluency: sing a song, etc.

12. Imp. Imp. N N Imp. Imp. Imp. Imp. Imp. N N N Imp. N N N Aphasia = impaired ability to produce/comprehend language. N = normal, Imp = impaired

13. Neurolgical Examination Memory • Short-term (3-item test) • Registration • Recall • Long-term No localizing significance: limbic system, temporal lobe?

14. Stereognosis ability to perceive the form of an object using the sense of touch • US coins: 1, 5, 10 • Thai coins: 1, 2, 5, 10

15. Stereognosis

16. Neurolgical Examination Sensory localization • Two point discrimination (caliper) • Left-right discrimination (cotton bud)

17. Neurolgical Examination Abstract thinking • banana:orange = cat:dog • Strike while the iron is hot. (Hit the iron while it is still hot)

18. Neurolgical Examination 2. Brainstem functions • Motor functions: III, IV, VI, V, VII, IX, X, XI, XII • Eye movements (III, IV, VI) (do flash) • Muscle of mastication (V) • Facial expression (VII) (do facial palsy) • Uvular movement (X) • Neck rotation (XI) • Tongue movement (XII)

19. Neurolgical Examination 2. Brainstem functions • Sensory functions: I, II, V, VII, VIII, IX, X • Touch • Pain and temperature • Pin prick • Deep pain: supraorbital nerve • Light (vision) • Chemical (smell and taste) • Sound (auditory function) (do tuning fork and audiometry) • Vestibular (head movement) • Movement (proprioception)

20. Neurolgical Examination 2. Brainstem functions • Vision • Visual acuity (Snellen) • Perimetry (confrontation)

22. Neurolgical Examination 2. Brainstem functions • Reflex functions: e.g., • Light reflex: II > III • Corneal reflex: V > VI • Jaw jerk: V > V • Gag reflex: IX > X • Etc.

23. Neurolgical Examination 2. Brainstem functions • Motor functions: III, IV, VI, V, VII, IX, X, XI, XII • Eye movements (III, IV, VI) • Muscle of mastication (V) • Facial expression (VI) • Neck rotation • Tongue movement • Sensory functions: I, II, V, VII, VIII, IX, X • Touch, pain, chemical, sound, light and movement • Reflex functions: e.g., • Light reflex: II > III • Corneal reflex: V > VI • Jaw jerk: V > V • Gag reflex: IX > X • Etc.

24. Central and Peripheral Facial Weakness Gilden D. N Engl J Med 2004;351:1323-1331

25. A Patient with Bell's Palsy Who Has Been Asked to Close His Eyes Bell’s phenomenon Gilden D and Tyler K. N Engl J Med 2007;357:1653-1655

26. Functional Anatomy of the Facial Nerve and Diagnosis of Peripheral Facial Weakness Gilden D. N Engl J Med 2004;351:1323-1331

27. Neurolgical Examination 3. Spinal functions • Motor functions • Muscle tone (resistance against passive movement) • Motor power • 0/5: no contraction • 1/5: muscle contraction, but no movement • 2/5: movement possible, but not against gravity • 3/5: movement possible against gravity, but not resistance • 4/5: movement possible against some resistance • 5/5: normal strength

28. Neurolgical Examination 3. Spinal functions • Motor functions • Some specific nerves • Long thoracic nerve to serratus anterior (C5-6-7) (winged scapula)

29. Neurolgical Examination 3. Spinal functions • Sensory functions • Posterior column pathway • Proprioception: joint position sense • Anterolateral pathway • Pain: superficial pain (pin prick) and deep pain • temperature

30. Neurolgical Examination

31. Neurolgical Examination 3. Spinal functions • Reflex functions • Deep tendon reflexes: biceps (C5-6), triceps (C7-8), quadriceps (L2-4) • Superficial reflexes: abdominal • Pathological reflexes: palmomental

32. Neurolgical Examination

33. Neurolgical Examination 4. Coordination • Equilibratory coordination • Romberg • Tandem walk • Non-equilibratory • Finger to nose, finger to finger, finger to nose to finger • Rapid alternating movement • Heel to knee to shin/toe

34. Neurolgical Examination A word on ataxia or in-coordination Causes due to • Weakness • Proprioceptive impairment • Cerebellar pathways Not all ataxia cases are caused by cerebellar lesion.

35. Neurolgical Examination 5. Gait and posture • Parkinson’s gait

36. Neurolgical Examination 6. Meningeal irritation • Neck stiffness, stiffed neck, stiffness of neck

37. Neurolgical Examination 7. Funduscopic examination • Normal fundus • Unilateral papilledema • Various degree of papilledema

40. Unilateral Papilledema

41. The cardinal funduscopic feature of malignant hypertension is disk swelling, which appears as blurring and elevation of disk margins. The top image also shows a characteristic star-shaped macular lesion caused by leaking retinal vessels; the bottom image also shows a characteristic flame-shaped hemorrhage and dilated veins.

42. Moderate hypertensive retinopathy is characterized by thinned, straight arteries; increased venous caliber; intraretinal hemorrhages; and hard exudates (top). Cotton-wool spots (bottom) are an additional feature of moderate hypertensive retinopathy. They are caused by focal axonal swelling of the retinal nerve fiber layer as a result of small vessel occlusion

43. Thickening and opacification of arteriolar walls (copper wiring) caused by hypertensive arteriosclerosis. Image also shows macular edema.

44. Examples of Mild Hypertensive Retinopathy Figure 1. Examples of Mild Hypertensive Retinopathy. Panel A shows arterio-venous nicking (black arrow) and focal narrowing (white arrow). Panel B shows arterio-venous nicking (black arrows) and widening or accentuation ("copper wiring") of the central light reflex of the arterioles (white arrows). Wong T and Mitchell P. N Engl J Med 2004;351:2310-2317

45. Examples of Moderate Hypertensive Retinopathy Figure2. Examples of Moderate Hypertensive Retinopathy. Panel A shows retinal hemorrhages (black arrows) and a cotton-wool spot (white arrow). Panel B shows cotton-wool spots (white arrows) and arterio-venous nicking (black arrows). Wong T and Mitchell P. N Engl J Med 2004;351:2310-2317

46. Example of Malignant Hypertensive Retinopathy Figure 3. Example of Malignant Hypertensive Retinopathy. Multiple cotton-wool spots (white arrows), retinal hemorrhages (black arrows), and swelling of the optic disk are visible. Wong T and Mitchell P. N Engl J Med 2004;351:2310-2317

47. Classification of Hypertensive Retinopathy on the Basis of Recent Population-Based Data Wong T and Mitchell P. N Engl J Med 2004;351:2310-2317

48. Eye Movements 5 types of eye movements http://www.physpharm.fmd.uwo.ca/undergrad/sensesweb/L11EyeMovements/L11EyeMovements.swf • Smooth pursuit • Saccade • Optokinetics • Vergence • Vestibulo-ocular reflex