NEUROLOGICAL EXAMINATION

Dr Ahmed YoussefLecturer of internal medicine &

nephrology

• Personal H:– Handness– Occupation (driver)

• C/O:– Onset, course & duration

• Family H:– Heredofamilial ataxia– Familial periodic paralysis– Peroneal mus. atrophy

• Past H:2 T Trauma, TB2 S Syphilis, Similar attack 2 H HTN, Heart disease2 D DM, Drugs1 E ENT1 F Fever

• HPI:– 12 items

History

HPI

• Motor

• Sensory

• Trophic

• Cranial n

• ↑ ICT

• Fits

• Speech

• Sphincter

• Gait

• Mental

• Hypoth

• Other

Motor

• Involuntary: extra ∆ , fasiculation• State• Tone• Weakness• Ataxia (cerebellum)

• Dist or prox• Stat or Kinetic• Disappear e sleep or

Not

• UL or LL• Rt or Lt• Dist or Prox• Flexor or Extensor• Abductor or Adductor

• Drunken gait• Intension tremors• dysdidoko• +ve romberge• Improve on bed

Sensory

• Superficial: Pain, Temp, Touch• Deep: Position, Mov., Vibr.• Cortical: Steriog, T. loc., T. discr.

• Ulcers: (N.B. : painless)

If +ve : pattern• Sensory level• hemihypoth• Glove & stock• Jacket loss

Trophic changes or deformities

Cranial n• ①:• Anosmia

• ②:• Acuity• Field

• ③,④,⑥:• Diplopia• Ptosis• Squint

• ⑤:• Sensory

• Pain,Temp• Motor

• Masticat.

• ⑦:• Sensory

• Tast ant ⅔• Motor

• Eey clos.• Mouth clos.

• ⑧:• Deaf• Tinitus• Vertigo

• ⑨, ⑩:• Dysph (phar)• N. regur (palat)• N. tone (palat)• Hoarsn (lary)

• ⑪:• Shoulder elev• neck side mov

• ⑫:• Tounge mov

↑ ICT• Papilledema• Headache• Vomiting

• Aura• Post effect• Cons. Loss• Gener. Or local• March

Fits

Speech• Aphasia: (higher neurolo. center lesion):

– Receptive(sensory):• Spoken(Auditory)(aud recogn area lesion)• Written(Visual)(visual recogn area lesion)

– Expressive(motor):• Spoken (broca’s area lesion)• Written(Agraphia)(exner’s area lesion)

• Dysarthria: (articul system lesion):– ∆: bilateral→ slurred (psudobulbar)– Extra ∆ → slow monotonus– Cerebellar → stacatto– Cr n → slurred (true bulbar)

Sphincters

• Consciousness• Hallucination• Memory

Gait

Mental

Hypothalamus

• D.I.• Polyphagia• Hypogonadal• Hypersomnia• Hyperpyrexia

Other systems affection

Examination

• Motor

• Sensory

• Trophic

• Cranial n

• ↑ ICT

• Fits

• Speech

• Sphincter

• Gait

• Mental

• Hypoth

• Other

• General examination

• Neurological examination:

Mental• Consciousness• Memory• Mode• Orientation• Behavior• Intelligence

Patient is co-operative, alert, fully conscious, well orientated to time, persons and place of normal mode and memory and of average intelligence

EXAMINATION – LEVEL OF CONSCIOUSNESS (AROUSAL)

Level of Consciousness (Arousal): Techniques and Patient Response

Level Technique Abnormal Response

Alertness Speak to the patient in a normal tone of voice. An alert patient opens the eyes, looks at you, and responds fully and appropriately to stimuli (arousal intact).

Lethargy Speak to the patient in a loud voice. For example, call the patient’s name or ask, “How are you?”

A lethargic patient appears drowsy but opens the eyes and looks at you, responds to questions, and then falls asleep.

Obtundation Shake the patient gently, as if awakening a sleeper.

An obtunded patient opens the eyes and looks at you, but responds slowly and is somewhat confused. Alertness and interest in the environment are decreased.

Stupor Apply a painful stimulus. For example, pinch a tendon, rub the sternum, or roll a pencil across a nail bed. (No stronger stimuli are needed.)

A stuporous patient arouses from sleep only after painful stimuli. Verbal responses are slow or even absent. The patient lapses into an unresponsive state when the stimulus ceases. There is minimal awareness of self or the environment.

Coma Apply repeated painful stimuli. A comatose patient remains unarousable with eyes closed. There is no evident response to inner need or external stimuli.

Glasgow Coma Scale

SpeechRead Sorat El Fateha• Aphasia: (higher neurolo. center lesion):• Dysarthria: (articul system or Cr n. lesion):

Trophic changes or deformities

Motor

• Involuntary: extra ∆ , fasiculation• State• Tone• Weakness• Ataxia (cerebellum)

• Reflexes

• Dist or prox• Stat or Kinetic• Disappear e sleep or

Not

• UL or LL• Rt or Lt• Dist or Prox• Flexor or Extensor• Abductor or Adductor

• Drunken gait• Intension tremors• dysdidoko• +ve romberge• Improve on bed

•Rapid alternating movem•Finger-to-Nose /Finger•Heel-to-Knee Test•Romberg’s Test•Gait

Sensory or Cerebellar ataxia:

• -ve romberg• Intension

tremors

Tone

• 6 joints + don’t forget support before joint• Tone is the resistance appreciated when

moving a limb passively• “Normal Tone”• Hypotonia

– “Central Hypotonia”:shock UMNL, cerebellar– “Peripheral Hypotonia”: LMNL, myopathy

• Hypertonia– Spasticity (Corticospinal Tract = ∆ )– Rigidity (Basal Ganglia, Parkinson’s = extra ∆ )

Flexion at the elbow (C5, C6, biceps) Extension at the elbow (C6, C7, C8, triceps) Extension at the wrist (C6, C7, C8, radial nerve) Squeeze 2 fingers as hard as possible ("grip," C7, C8, T1)Finger abduction (C8, T1, ulnar nerve) Oppostion of the thumb (C8, T1, median nerve) Flexion at the hip (L2, L3, L4, iliopsoas) Adduction at the hips (L2, L3, L4, adductors) Abduction at the hips (L4, L5, S1, G. medius and minimus) Extension at the hips (S1, gluteus maximus)Extension at the knee (L2, L3, L4, quadriceps)Flexion at the knee (L4, L5, S1, S2, hamstrings) Dorsiflexion at the ankle (L4, L5) Plantar flexion (S1)

Weakness: examine the following

Muscle(s) Function Primary Nerve OriginDELTOID Shoulder abduction Axillary C5-C6

BICEPS Elbow flexion Musculocutaneous C5, C6

TRICEPS Elbow extension Radial C6, C7, C8

WRIST EXTENSORS Radial C6, C7, C8

WRIST FLEXION Median C6, C7

HAND GRIP Grasp Fingers Median C7, C8, T1

FINGER ADDUCTION Median C7-T1

FINGER ABDUCTION Ulnar C8, T1

THUMB OPPOSITION Median C8, T1

HIP FLEXION Iliopsoas L2, L3, L4

HIP EXTENSION Gluteus maximus S1

Quadriceps Knee extension L2, L3, L4

Hamstrings Knee flexion L4, L5, S1, S2

Tibialis anterior Foot dorsiflexion Deep peroneal L4, L5

Gastrocnemius Ankle plantar flex mainly S1

Ext hallicus longus Extens of great toe L5

Weakness: examine the following

Upper limb:Shoulder:

AdductionAbductionFlexionExtensionLat rotationMed rotationserratus ant.

Elbow:FlexionExtension

Wrist:FlexionExtension

Weakness: examine the following

HandThumb

Oppon pollicis Abd pollicis Add pollicis Flexor pollicis Exte pollicis

Other fingers:AbductorsAdductorsFlexionExtensionLumbricalis

Abdom. mus:Flexion

Lower limb:Hip:

FlexionExtensionAdductionAbduction

Knee:FlexionExtension

Ankle:DorsiflexionPlanter flexion

Trunk mus:extension

C4C5

C5C6C7C7C8

C8T1

T7-T12

L1,2

L2,3,4

L4,5

L5, S1

S1,2

S1,2

Grading Motor Strength

Grade Description

0/5 No muscle movement

1/5 Visible muscle movement, but no movement at the joint

2/5 Movement at the joint, but not against gravity

3/5 Movement against gravity, but not against added resistance

4/5 Movement against resistance, but less than normal

5/5 Normal strength

Deep (tendon jerks)UL

• BICEPS • BRACHIORADIALIS• TRICEPS

LL• KNEE + clonus• ANKLE + clonus

Reflexes & clonusSuperficial reflexes

• Corneal• Grasp• Gag (palatal)• Planter• Abdominal• Cremastric• Anal

C5,6

C6,7

L2,3,4S1,2

S1,2

T6-12L1

S3,4,5

Abnormal Deep reflexes• Jaw jerk• Wartenberg• Finger jerk• Hofman• Patelal jerk• Adductor jerk

TechniqueBabiniski Scratsh From below up- lat to medialChaddock The skin under and around the lateral malleolus

is stroked in a circular fashion.

Gonda’s Flex 3rd & 4th toes 7 release suddenlyOppenheim press to the anterior surface of the tibia,

stroking down to the ankle.

Gordon Compressing the calf musclesSchaefer Pinching the Achilles tendon enough to cause

pain.

Sure signs of ∆????

EXAMINATION – REFLEXES: SCALE FOR GRADING

Reflexes are usually graded on a 0 to 4+ scale

4+ Very brisk, hyperactive, with clonus

3+ Brisker than average; possibly but not necessarily indicative of disease (no clonus)

2+ Average; normal

1+ Somewhat diminished; low normal

0 No response

Sensory

• Superficial: Pain, Temp, Touch (one ⅟2, Rt & Lt, derm)

• Deep: Position, Mov., Vibr., N & M• Cortical: Steriog, T. loc & discr., Graph.

If +ve : pattern• Sensory level• hemihypoth• Glove & stock• Jacket loss

Patient e PN (glove & stock) how to confirm presence or absence of post column lesion?

PN only: vib. Not felt at ankle but felt at iliac crestPC: vib not felt at ankle , knee or iliac crest but felt at vertebr column

Can u perform cortical sensation examination if impaired superficial or deep sensation?

If impaired deep = PC affection w carry both deep s & fine touchIf impaired superficial = ST affection but intact PC

Cranial n

• ① - smell• ② - Acuity: ( Snellen chart, Counting finger, Hand

mov., Light perception)- Fields ( confrontation)- Fundus- Colour vision

• ③,④,⑥- Ocular mov. - Ptosis, Myosis or Mydriasis

- Reflexes: • Light: (direct & consensual)• Accomodation• Ciliospinal

Partial ptosis+Miosis+

Anhdrosis+Enophthalm

=??

Complete ptosis+Mydriasis+

Diverg squint=??

Cranial n

• ⑤ - Sensory: (ophth., maxillary, mandibular)- Motor: (massiter, temporalis, tregoid)- Reflexes:

• Corneal• Jaw : if +ve = bilateral ∆ lesion above pons (above ⑤ nc.)

• ⑦ - Sensory: (Tast ant ⅔ of tounge)- Motor: (frontalis, orbic occul., buccinator,

retractor angulii, orbic oris)- Reflexes:

• glabellar

• ⑧ - Nystagmus- Hearing

⑤→⑦

⑤→⑤

⑦→⑦

Rapid phase toward

H pendular occular

H fix i.e. (lesion) cerebel

H Away from (norm) vestib

V vertical stem

Cranial n

• ⑨,⑩ -Say AHH = palatal movement ⑩

Move up = normal deviate to healthy =LMNL

Move No movement

-Palat reflex-Pharyn reflex

⑤→⑩

⑨→⑩

Exag bilat=Bilateral UMNL

Lost bilateral=Bilateral LMNL

Cranial n

• ⑪ - Shoulder elev (trapezius)- Neck side mov (sternomastoid)

• ⑫ - Observation ( atrophy, fascic)- Midline protrusion (Deviation, invol. movem )- Power

Sphincters

↑ ICT

Gait

Other systems affection

Classical Patterns of Abnormal Gait• Parkinsonism Gait• Hemiparetic Gait• Ataxia Gait• Waddling Gait (Hip Girdle Weakness)

• High Stepping Gait