Professional Documents
Culture Documents
Professional Skills
Neurology
YEAR TWO
Prepared by:
Dr I Kerridge
Dr M Parsons
Dr D Williams
Page
The neurological examination may be divided into a number of parts. These are:
1.
MMSE
2.
Higher Centres
3.
Speech
4.
Cranial Nerves
5.
Gait
6.
Cerebellar
7.
Upper limb
8.
Lower limb
Crossover
2.
Be sensitive to the patient. This includes talk to the patients and making any
commands clearly. In many cases the exact wording of commands needs a lot
of practise.
3.
Inspect :
skin, scars
posture
drips/catheters
face
involuntary movements
voice.
4.
Palpation
5.
Tone
6.
Power
7.
Reflexes
8.
Co-ordination
9.
Sensation
The aim of the neurological examination is to recognize various patterns of signs that allow
you to decide:
1.
Hemiparesis
2.
Cortex
3.
CVA
MENTAL STATUS
EXAMINATION
dysfunction.
Specific Test
Points
Orientation (frontal)
Orientation (frontal)
Registration (frontal)
Concentration (frontal)
Naming (dominant
Score
hospital/floor?
World backwards
5. Name wristwatch and pen
Temporoparietal)
frontal)
7. Take this paper in your right hand, fold it
in half and put it on the table.
Three-stage command
(frontal)
Reading (dominant
temporoparietal)
9. Remember the three items from
Part 3 above
Short-term memory
(dominant hippocampal)
Writing (dominant
temporoparietal)
Construction (non-
dominant parietal)
There are a number of alternative tests to the Folsteins MMSE including the Blessed Six
Item Orientation-Memory-Concentration Test.
Total score:
Item
Number of
Score given
errors
Score
possible
x4
x3
x3
4. Count backwards 20 to 1
x2
x3
x2
TOTAL
/30
1.
quoted figure is :
94% Right-handed persons
Left dominant
Mixed dominant
Right dominant
however there are many other figures suggested. In general, the important fact is that almost
all right handed people have left hemisphere dominance, but that some left-handed people have
right or mixed dominance.
2.
ORIENTATION (MMSE)
3.
SPEECH
4.
DOMINANT
: "Gerstmanns"
Acalculia/Agraphia/Left-Right
disorientation/Finger Agnosia
NON-DOMINANT
OCCIPITAL
- Homonomous Hemianopia
- "Cortical" blindness (bilateral)
- Topographical amnesia
- Unable to
6.
TEMPORAL
- STM loss (4 words: honesty, brown, tulip, eyedropper)
- LTM loss (AWhen did WWII start? ... finish?)
- Confabulation (Have we met before?)
- Dysphasia (receptive) and Nominal dysphasia (angular gyms of
temporal lobe)
- Upper Quadrant Hemianopia
7.
FRONTAL
- Anosmia
10
- Proverb interpretation
- Gait ataxia (wide-based, shuffling)
- Primitive reflexes: grasp, pout, snout, suck, palmar-mental
- Incontinence
- Expressive dysphasia (Dominant: Broca's area)
- Personality change
SPEECH
Dysphasia
Fluent -
11
Non-fluent -
Dysarthria
Dysphonia
To Test:
1.
2.
Free speech
12
3.
Comprehension
4.
Repetition/Dysarthria
assessment :
5.
Naming objects
6.
Reading
7.
Writing
13
TYPES OF DYSPHASIA
NON-FLUENT
FLUENT
EXPRESSIVE
RECEPTIVE
CONDUCTIVE
NOMINAL
answer.
disorganized. Unable to
understand written or
of speech normal.
spoken
words/commands.
SITE
BROCAS AREA
WERNICKES AREA
TEMPORAL LOBE
Dominant Posterior
Dominant Temporal
Arcuate Fasciculus
Temporoparietal area:
Gyrus
First Gyrus
Angular gyrus
NAMING
Poor
Poor
Poor
Poor
REPETITION
Poor
Poor
Normal
effort.
COMPREHENSION
Normal
Poor
Normal
Normal
READING
Neologisms paraphrasias
Poor
Normal
Abnormal content
Impaired
Normal
Gerstmanns
Paraphrasia
WRITING
OTHER
Hemiparesis
Hemianopia
overcome
word-finding
difficulty
(circumlocution)
GAIT
Complex.
:Basal ganglia
:Locomotor Region (mesencephalon)
:Cerebellum
:Spinal cord
:Sensory input from joints/muscular afferents
1.
2.
3.
Observe:
posture
arm swing
stride
base
involuntary movements
4.
5.
6.
Screening:
Arms held in front with eyes closed + touch nose + lift arms up
straight and then down to the horizontal.
7.
Stand on toes
(weak gastrocnemius)
8.
Stand on heels
(foot-drop)
9.
Squat
(proximal myopathy)
+/10.
If suspect cerebellar:
1. Walk around chair (fall to side of lesion)
2. March on spot (unterbergers: turn to side of lesion)
1.
High stepping
2.
3.
Waddling (shoulders swap/tilt trunk/flex knee + hip) Weak hip abductors (proximal
myopathy, OA)
4.
5.
6.
7.
Broad-based shuffle and small steps: (marche petit pas) [Normal Pressure
Hydrocephalus (Dementia, incontinence), Multi-infarct Dementia (Hyper-reflexic, brisk
jaw jerk).]
8.
Ataxic/ wide-based.
1.
2.
CRANIAL NERVES
CN 1: OLFACTORY
sensory
usually not tested
may wish to test in the presence of personality disturbance, hemiparesis or visual loss
Test each nostril separately (use easily recognized substance e.g. peppermint oil, oil of
cloves).
CN 2: OPTIC
1.
Observe
Level of eyelid-
Lid retraction
2.
Acuity :
Position of eye
Enopthalmos (Horners)
3.
4.
Fig.1.
The visual pathways as seen from above the brain. Letters A-F refer to visual field defects following
lesions in the corresponding brain areas. Circles indicate
what the left and right eyes see (the left and right visual
fields). Black areas represent visual field defects.
A.
Constricted field left eye (e.g. end-stage glaucoma). When constricted fields are bilateral, it
sometimes signifies hysteria.
B.
C.
D.
E.
F.
5.
6.
Pupils
Afferent
optic nerve
Efferent
PNS component of CN 3
Normal (Anisocoria)
Small pupil
SNS lesion
Large pupil
PNS lesion
: Light Reflex -
direct
consensual
: Accommodation
Abnormal
Fig. 2. The pathways for the pupillary light reflex and accommodation. LGB, lateral geniculate body. The
depicted lesions presumably also interrupt light reflex fibers crossing from the opposite side of the brian stem.
The pathway shown innervating the eye is highly schematic; the light reflex pathway involves only pupillary
constriction, whereas the accommodation pathway affects both pupillary constriction and ciliary body
accommodation.
7.
: Red reflex
CN 3: OCULOMOTOR
CN 4: TROCHLEAR
CN 6: ABDUCENS
Motor to eye
Autonomic
Eye movements have complex control including:
1. Saccadic/command (frontal)
2. Pursuit (occipital/parietal)
3. Vestibular/positional
(cerebellar/vestibular nuclei)
Test
1.
2.
Observe: position of head (head tilted away from the side of a CN 4 lesion).
:
Screen:
Instruct patient to look up, look down, look to the left, look to the
right.
3.
Pursuit movements
: following a pin
4.
Saccadic movements
: finger to fist
5.
Accommodation/convergence
6.
Note: *
In diplopia the false image is usually the outer image. This indicates the
abnormal eye,
e.g.
CN 6
CN4
Comment on Nystagmus
Left INO :
CN 5: TRIGEMINAL
Sensorimotor
Motor to temporalis and masseter sensory to face.
Large sensory nucleus extending from Pons to upper cervical cord: light touch in
Pons, pain/temparature in Medulla/cervical. (Therefore pontine lesions may
demonstrate loss of light touch with preservation of pain and temperature.
Test:
1.
2.
3.
iii Jaw-jerk.
CN 7 :
FACIAL
Facial musculature
Ear
Taste :
Test:
1.
"Smile"
2.
3.
4.
5.
"Whistle"
6.
CN 8 :
AUDITORY
Auditory/vestibular function.
Test:
1.
Hearing
2.
Webers
3.
Rinne's:
4.
Vestibular
: Gait
Nystagmus
Caloric testing
WEBERS
Conductive Deafness
BC>AC
Sensorineural Deafness
AC>BC
CN 9 :
GLOSSOPHARYNGEAL
Sensory
Motor
Stylopharyngeus
Test
CN 10 :
VAGUS
Sensory
External ear
Motor
Test
1.
2.
3.
CN 11:
SPINAL ACCESSORY
Motor :
Test
Supplies
ipsilateral trapezium
ipsilateral sternomastoid
1.
2.
3.
CN 12 :
HYPOGLOSSAL
Motor to tongue
Test
1.
2.
Stick out the tongue: Tongue points toward (pushed) to the weak side.
3.
UPPER LIMBS
1)
2)
3)
4)
INSPECT:
wasting (distal/proximal)
deformity
fasciculation
tremor
5)
Drift -
UMN weakness
(down)
cerebellar
(up: hypotonia)
(impaired JPS)
6)
7)
PALPATE
muscle bulk
tenderness
thickened nerves
median:
wrist
ulnar
elbow
8)
TONE :
9)
POWER (GRADE 0 - 5)
SHOULDER:
Elevation
C3,4 + CN11
Abduction
Adduction
ELBOW:
WRIST:
Flexion
Extension
C7 Triceps (Radial n)
Thumb up
Flexion
Extension
FINGERS:
Extension
Flexion
Abduction
Thumb
10)
REFLEXES :
Biceps
C5
Triceps
C7
BrachioradialisC6
Finger
11)
C8
CO-ORDINATION :Finger-nose
:Dysdiadokokinesis
12)
SENSORY
Pin
Chest wall first
Dermatomal.
Dull or sharp
Start proximally (unless cord compression or
peripheral neuropathy suspected)
C4 chest to shoulders
T2
Axilla
C6 thumb/wrist
T1
elbow
C8
little finger
Median nerve]
NOTE: Small muscles of hand supplied by:
+ T1 nerve root.
Ulnar nerve ]
Therefore look at Abductor digiti minimi, First dorsal interossei, Abductor pollicus
brevis.
1.
APB weak
Median nerve
2.
Ulnar
3.
LOWER LIMBS
1)
GAIT : Can I walk Mr/Mrs ...? If yes ... see Gait exam:
Rhombergs
Normal
Heel-toe
Stand on toes
Stand on heels
Squat
2)
LIE DOWN
3)
OBSERVE -
?IDUC
Wasting: esp
1.
Generalized
2.
Tibialus Anterior/EDB/Quadriceps
3.
4)
PALPATE
Fasciculations
Tremor
Deformities
Tenderness
Bulk
5)
TONE
Thickened nerves
Leg roll
6)
POWER
HIP:
Add+Flex]
Flexion
L2
Ilipsoas (Femoral n)
Extension
L5 S1-2
Abduction
L4-5 S1
KNEE:
ANKLE:
Adduction
L2-3
(Obturator n)
Flexion
L5 S1
Hamstrings (Sciatic n)
Extension
L3
Quadriceps (Femoral n)
Plantarflex
S1
Soleus/Gastrocnemius (tibial n)
Dorsiflex
L4-5
Eversion
L5 S1
Inversion
L4
L5 S1
L4
Quadriceps
Ankle
S1
Gastrocnemius
Plantar-
S1 Plantar or babinski
Anal
S3-4-5
Ant Abdo
Upper
T6-8
Lower
T10-12
Dorsiflex toe -
7)
8)
REFLEXES: Knee
CO-ORDINATION:
Heel-shin
Finger-toe
Foot-tap
9)
SENSORY:
Pin prick
Vibration sense
Proprioception
Soft touch
10)
BACK:
Deformity
Scars
Neurofibroma
L3
knee
L4
to heel (medial)
L5
S1
S2
CEREBELLAR
1.
Maintain posture/balance
2.
3.
4.
STRUCTURE: Complex
Inputs: Ascending
1. spinocerebellar
2. vestib apparatus
Descending
1. pyramidal
2. extrapyramidal
Outputs:
1. Motor cortex
2. Basal ganglia
3. Red nucleus
4. Reticular formation
5. Vestib appartus
EXAMINATION TECHNIQUE
1.
LISTEN:
2.
EYES :
3.
SPEECH: Impaired rate, rhythm and amplitude i.e.Jerky, explosive and loud with
irregular separation of syllables:
4.
UPPER LIMBS
: Drift
: Rebound
: Tremor (agonist hypotonia)
: Hypotonia (loss facilitatory influence on spinal motor neurons)
5.
FINGER NOSE
: Intention tremor
: Past-pointing
6.
RAPID MOVEMENTS
7.
DYSDIADOKOKINESIS
8.
LEGS
: tone
: heel-shin
: foot-tap
9.
SIT ON BED
: truncal ataxia
: reflexes (pendular)
10.
GAIT
PATTERNS
Midline:
Hemispheric:
I.
UNILATERAL
II.
BILATERAL
III.
MIDLINE
IV.
ROSTRAL/VERMIS
(Spares arms)
Alcohol