neurological examination indiana university department of neurology
TRANSCRIPT
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Neurological Examination
Indiana University Department of Neurology
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OverviewLearn / do in organized sequence General
Vital signs: wt, pulse , BP, temp ( respirations) Skin for café au lait, meningococcal purpura, splinter
hemorrhages Measure OFC ( head size) in kids Listen for bruits in neck ( carotid or vertebral arteries)
Neurological exam Mental status Cranial nerves Motor exam Cerebellar Sensory Station & Gait
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Mental StatusMental Status Level of consciousnessLevel of consciousness
Alert Sleepy but awakens to verbal prompting ( Lethargic) Unresponsive to painful stimuli ( Comatose)
OrientationOrientation To person, place, time, situation
Speech & LanguageSpeech & Language Normal Dysarthric (slurred, nasal) Use of language in symbolic sense Fluency, comprehension, repetition Aphasia: expressive (Broca)/ receptive (Wernicke)
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Mental Status
Parietal Functions Spatial orientation
( R /L) Construction Calculation Stereognosis Gnosis (awareness)
agnosagnosia
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CN I Olfactory nerve
Check each nostril individually with patient’s eyes closed
Use coffee, mint, vanilla, clove
Not ammonia (checks V2)
Anosmia in head trauma frontal lobe tumor Parkinson’s & Alzheimer’s
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Optic System: Overview
Functions: Data acquisition &
transmission Camera control
Eye lids Eye movements Focus
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CN II Optic nerve Visual acuity Visual fields Pupillary light reflex
CN 2 Afferent CN 3 Efferent
Funduscopic exam
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Visual acuity
Visual acuity Corrected (with glasses)
OS left OD right
Ask patient to start at top read down the chart
VA is last line read correctly
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Visual fields
Pt looks at your forehead Check each eye alone Keep equidistance
between you and patient Count fingers in the 4
visual field quadrants Bring in your finger
inward from beyond your periphery to define pts field
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Pupillary light reflex Direct and consensual
Observe pupil size ( mm) Shine light into eye from off center Observe for pupillary constriction in stimulated &
opposite eye
Accomodation As pt looks at close target; eyes converge and pupils
constrict Relative afferent pupillary defect (RAPD)
Light in abnl eye after good eye shows pupil dilation rather than constriction
Present with optic nerve lesions
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Relative afferent pupillary defect
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Optic disk ( optic nerve head)
Retinal vessels Retina
Fundoscopy (ophthalmoscope)
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CN II Optic Nerve
Normal Papilledema
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CN III (oculomotor), IV (trochlear), VI (abducens) Are the eyes
conjugate Puplliary function Evaluate motility
Horizontal Vertical Oblique
Disorders Nerve ( nucleus) Intra-nuclear Supra-nuclear
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Extraocular muscles and their actions•CN III (Oculomotor nerve)
•Superior rectus:
•elevation when the eye is aBducted
•Inferior rectus:
•depression when the eye is aBducted
•Medial rectus: aDduction
•Inferior oblique:
•elevation when the eye is aDducted
•CN IV (Trochlear nerve)
•Superior oblique:
•depression when the eye is aDducted
•CN VI (Abducens nerve)
•Lateral rectus: aBduction
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CN III—lesion causes eye motility problems, ptosis and mydriasis (enlarged pupil)
Third nerve palsy Eye is “down and out”
Pupil abnormalCompression by uncal
herniation or
P-com aneurysm
Pupil normal Nerve infarction
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Left IV nerve palsy
Left hypertropia
Right head tilt….What about the doll’s eyes?
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INO (Internuclear ophthalmoplegia)
Medial Longitudinal Fasciculus ( MLF) Lesion
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CN V Trigeminal
Sensory to face and anterior scalp
Blink reflex Motor to muscles of
mastication (masseter/temporalis)
Test 3 divisions with cotton & pin
Jaw jerk reflex
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CN VII -Facial nerve
Squeeze eyelids closed (like soap in eyes)
Raise eyebrows Smile / pucker Sneer (platysma)
Taste
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Facial Nerve VII relaxed
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Facial Nerve VII contraction
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Corneal reflex afferent 5; efferent 7
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CN VIII Vestibulo-cochlearTwo divisions:
Vestibular: head motion sensing Vertigo / nystagmus / veering gait
Cochlear: Auditory acuity finger rustle / ticking watch Rinne test: use tuning fork & compare perception
of sound via bone and air. In a normal ear air conduction > than bone conduction.
Weber test: tuning fork on the patients forehead. Normal: patient hears sound equally in both ears. .
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CN IX Glossopharyngeal& X Vagus Palatal elevation Gag reflex
(sensory
& motor) Laryngeal
function
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CN XI -- Spinal Accessory SCM--Right SCM turns head to the left Trapezius
Raise shoulders
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CN XII Hypoglossal
Inspect bulk of tongue Protrude tongue
midline vs deviation to one side
Ask to press tongue against inside of cheek
Tongue deviates to the weak side
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Motor Exam Inspection
atrophy, hypertrophy, fasciculation Involuntary movements
tremor, chorea, dystonia, myoclonus, myotonia Muscle Tone (resistance to passive movement)
Hypotonia (floppy) Hypertonia
Spasticity Clasp-knife Rigidity (Lead pipe)
Strength (grade 0 to 5) 0/5 no contraction, 3/5 overcomes gravity, 5/5 normal
Muscle stretch reflexes (0-4+) r” Plantar response: flexor or extensor (Babinski)
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Upper versus Lower motor neuron lesions
Sign UMN LMN
Atrophy +/- yes
Weakness yes yes
Fasciculations no yes
Muscle tone inc dec
Reflexes inc dec
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Motor Exam
Atrophy of intrinsic hand muscles
Calf muscle hypertrophy
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Check strength proximal to distal
shoulder abduction (deltoid) elbow flexion/extension wrist flexion/extension finger flexion/extension finger abduction/adduction
hip flexion, abduction/adduction knee extension/flexion ankle extension (dorsiflexion) / plantar flexion toe extensors / flexors/ abductors
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Muscle stretch reflexes
Reflex Nerve rootBiceps C5 & 6Brachioradialis C5Triceps C7Knee ( quadriceps) L3 & 4Ankle ( gastroc/soleus) S1Masseter CN V
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Muscle stretch reflexes (MSR)
Usually graded 0 to 4 +
0 no response
1+ present but slight in magnitude
2+ present, easily observable
3+ present, “don’t stand in front of pt”
4+ present, recurrent contractions (clonus)
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Testing for ankle clonus (4+)
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Plantar reflex
Toe flexion is normal. Toe extension is abnormal ( Babinski sign)
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Superficial Abdominal Reflex
Stroke anterior abdominal skin toward umbilicus
Rectus muscles Contract in quadrantstimulated
Other superficial reflexes
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Tremor types
Resting tremor : present when limb is relaxed or not in active use Parkinson’s & related disorders
Action / postural tremor :present when body part is in sustained posture ( holding phone, newspaper) Physiological, familial
Intention tremor: present when limb actively / quickly being moved (eating, pointing, applying makeup) Cerebellar lesions
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Cerebellar Functions
Nystagmus (jerky eye movments) Dysarthria (scanning / ataxic speech) Finger-nose-finger Rapid alternating movements (hands) Heel -knee -shin Tandem gait ( heel to toe walking)
Cerebellar testing requires cooperative patient
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Cerebellar: finger-nose finger
Patient extends finger out to your finger
Then moves finger back to nose
The back to your finger
Repeat with your finger in different position
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Cerebellar: finger to nose
Pattern of dysfunction: Actions break into
jerky steps Target may be
missed (dysmetria)
Guy in movie Airplane with the “drinking problem”
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Cerebellar: heel to shin testingCerebellar: heel to shin testing
Patient flexes hip to place heel to knee
Runs heel smoothly down the crest of tibial ( shin) to ankle
Abnormal: heel oscillates above knee & slips off shin
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Sensory Examination
Sensory Modalities: Light touch* Vibration* (dorsal column) Pin* (spinothalamic) Temperature (spinothalamic) Position (dorsal column)
* = most commonly performed in routine examinations
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Sensory Examination
Light touch Use cotton ball Patient closes eyes Present stimulus & ask for response Move from abnormal area to normal
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Sensory Examination
Vibration Tuning fork ( 128 Hz preferred) Apply stimulus to toe or finger Yes / No response or have patient tell when vibration
stops If abnormal distally move proximally: ankle knee wrist
elbow
Significance of deficits which split the forehead or chest
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Sensory Examination
Pin ( pain) sensation Use safety pin or broken cotton swap stick Ask patient to distinguish pin from opposite end
of safety pin ( or your finger tip) Identify abnormal areas and then find normal
ones: distal / proximal vs dermatomal
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Sensory Examination
Position Sense Use toes & fingers Patient closes eyes Move part from straight (neutral) position
into either flexion (down) or extension ( up) Patient reports direction of movement
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Sensory Examination
Temperature Sensation Hot vs Cold Cold used more often Tuning fork often used for this vs tube of cool
water Limb must be warm to properly test Start distally & move proximally
Good for finding “spinal level” in cord lesions
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Gait & Station Testing
Causal walking & then heel to toe ( tandem)
Observe: Stride length Smoothness of movement Symmetry Steadiness during turning
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Gait & Station
Standing (station) Normal foot spread vs wide vs narrow
normal width is feet directly under hips Steady vs unsteady Have patient move feet close together Have patient close eyes
Worsening with eye closure is Rhomberg’s sign (sensory deficit)
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Common Patterns of Abnormality
Foot slap: peroneal palsy / L5 radiculopathy
Spastic/scissoring: corticospinal tract lesion
Waddling: hip girdle weakness muscle diseases / dystrophy
Broad based: sensory or cerebellar
Short stepped with reduced arm swing: basal ganglia (parkinsons)
Non-organic patterns