Neurological Examination Lecture

Slide 1: Neurological Examination LectureSubmitted to AskTheNeurologist.Com in 2007 Author Anon.

Slide 2: Neurological Examination Lecture:- 3 questions of neurologicaldiagnosis1) Is there a lesion ? - Presence of neurological abnormality2) Where is the lesion ? - Location of problem - Requires knowledge of neuroanatomy3) What is the lesion ?

Slide 3: Why perform the neurologicalexamination1. Detect the presence of neurological abnormality2. Localise the abnormality within the nervous system ( may later be confirmed by investigations)

Slide 4: Systematic approach to weaknesse.g. bilateral leg weakness• Muscle• NMJ• Nerve• Nerve roots• Spinal cord• Brainstem• Cerebrum

Slide 5: Basic Plan

• General examination ( vital signs etc)• Conscious state• Cognition• Meningeal signs• Cranial nerves• Motor• Sensory• Cerebellum• Extrapyramidal

Slide 6: DON’T DO EVERYTHING!

• Screening tests vs detailed testing• Problem orientated approach – Screen all systems – Concentrate on systems relevant to complaint – Formal cognitive testing may be skipped if patient is cognitively intact during history and problem seems unrelated • E.g. foot-drop

Slide 7: Conscious stateGlasgow coma scale

•Eyes Eyes /4•Verbal Verbal /5•Motor Motor /6

Normal = 15Created to reflect measure of global brain functionLimited value in neurological patients - Many processes selectively affect components above - e.g. aphasia in a fully “ conscious” patient

Therefore best to record functions individually

Slide 8: Cognition

• MMSE – Score out of 30 – Broad screening test of cognitive function including attention, memory, language – Good for diagnosing / monitoring certain types of dementia especially A.D. – Other types of dementia / cognitive problems require different tests

Slide 9: Cognition 2

• “ Frontal functions” – Attention & concentration ( digit span ) – Abstraction ( explain proverb ) – Judgment • child lost in street..what would you do? – Planning • How to plan a holiday • Draw a clock

Slide 10: Cognition 3

• Frontal release signs – Glabellar tap – Pouting – Rooting – Sucking – Grasp – Palmomental

Slide 11: Other cognitive functions

• Neglect: – Failure to pay attention to area of space – Usually due to right parietal lesions where neglect left-sided space• Praxis: – ability to perform learned action - e.g. dressing , combing hair

Slide 12: Meningeal signs

• Neck stiffness• Brudzinski• Kernig

– Most frequently found in patients with meningitis or SAH

Slide 13: Cranial nerves (a)

• I - smell• II - Acuity ( Snellen chart) - Fundi - Fields ( confrontation) - Pupil resting state and reaction to light - Direct - Consensual - Swinging flashlight test - Pupil reaction to accommodation

Slide 14: Cranial Nerves (b)

• III, IV, VI – Ptosis? – Pupils (already examined) – Movement ( H and X) – Saccades and smooth pursuit – ? Diplopia – ? Nystagmus

Slide 15: Cranial nerves (c)

•V

– Facial sensation – Muscles of mastication – Jaw jerk – Corneal reflex • Afferent = V • Efferent = VII

Slide 16: Cranial nerves (d)• VII – Muscles of facial expression – Taste ant 2/3 tongue – Tensor Tympani

Slide 17: Cranial nerves (e)

• VIII – Nystagmus already noted – Hearing• IX, X – Say ahh (X) – Gag reflex • Afferent = IX • Efferent = X

Slide 18: Cranial nerves (f)

• XI – sternocleidomastoid & trapezius

• XII ( tongue motor examination) – Observation ( atrophy, fasciculations) – Midline protrusion ( ? Deviation) – Power – Dexterity ( fast movement side-to-side)

Slide 19: Upper motor neuron

• Cell body within motor cortex (prefrontal gyrus)

• Axon terminates : – Cranial nerve motor nucleus • “corticobulbar” – Anterior horn of spinal cord • “corticospinal”

Slide 20: Lower Motor Neuron

• Cell body of – Motor cranial nerve nucleus – Anterior horn cell• Axon terminates – Motor end plate ( skeletal muscle) • AKA Neuromuscular junction ( NMJ)

Slide 21: Diagram of motor pathways

Slide 22: Upper Motor Lower Motor Neuron NeuronInspection of Normal Atrophymuscles (disuse atrophy) FasciculationsTone Increased Decreased (unless acute) (or normal)Power (MRC scale) decreased decreased0-5 /5Tendon Reflexes Increased Decreased or Normal (unless acute)Pathological Present Absentreflexes

Slide 23: Sensory System

• Modalities – Pain Spinothalamic – Temperature

– Vibration Post. columns – Proprioception

Slide 24: Neurological Examination Lecture Sensory examination II

• Problem orientated approach

– Left vs Right – Spinal sensory level – Radicular / dermatomal – Nerve distribution – Distal vs Proximal

Slide 25: Which method would youconcentrate on?1. Sudden onset of dysphasia and right sided weakness2. Numbness and paraesthesia in feet with absent ankle jerks3. Acute bilateral leg weakness with loss of sphincter control4. Drop foot

Slide 26: Symptoms and signs ofcerebellar disease (VANISH’D)• Vertigo• Ataxia - usually falls towards lesion• Nystagmus – increased with gaze towards lesion• Intention Tremor• Scanning speech• Hypotonia• Dysdiadochokinesia + Dysmetria

Slide 27: Stability and Gait

• Check ability to stand straight with eyes open• Check ability to stand straight with eyes closed – If significantly worse than with eyes open = positive Romberg sign – Usually signifies defect in pathways involved in proprioception – May signify vestibular disease• Check gait

Slide 28: Extrapyramidal “ TRAP”

• Tremor ( rest, pill-rolling)• Rigidity ( lead-pipe, cog-wheel)• Akinesia / bradykinesia• Postural instability

Slide 29: Neurological Examination Lecture Normal examination

• Patient fully conscious, orientated in time and place with no meningeal signs• PEARLA, Fundi intact, ( acuity and visual fields intact)• Eye movements normal• Facial sensation normal• Face symmetrical• (Hearing normal)• Palate / uvula rises symmetrically• Gag preserved bilaterally• Tongue central

Slide 30: Neurological Examination Lecture:- Normal examination 2

• No atrophy / fasciculations – (muscle inspection)• Tone preserved• Power 5/5 in all 4 limbs• Reflexes symmetrical• No pyramidal signs

Slide 31: Normal examination 3

• Sensation preserved• No cerebellar signs• Romberg negative• Gait normal

Slide 32: Neurological Examination Lecture How to present

• Keep to order• Mention all abnormalities• Include “ core” points ( just described)• Mention all “ important negative points” – Leg weakness… “no sensory level” – History of MS with optic neuritis… “ no RAPD” – Complains of difficulty chewing • Mention power of masticatory muscles

Slide 33: THE END Neurological Examination Lecture

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