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SLCM Class 2014First Block Neuroscience I

Neurologic History Taking and Physical Examination – H.

Ludwig D.(16.06.10)

Transcribed byPOBLETE

CEREBRAL CORTEX Awareness – brainstem and cortices

o Reticular formation: excitatory-activating system of the brain

Has excitatory and inhibitory area Two lesions involved in coma:

o Brainstem lesiono Lesion on both sides of cortex

Functional areas of human cerebral cortexo Determined by electrical stimulation of cortex

Primary areas: direct connections with receptors Secondary areas: make sense of functions of primary

areas (motor patterns) Association areas: receive and analyze signals from

multiple regionso Parieto-occipito-temporal

Continuous analysis of coordinates of body and surroundings

Language comprehension Visual processing of words naming

o Prefrontal Plan complex patterns and

sequences of movementso Limbic

Behavior, motivation, emotions Special emphasis for Wernicke’s and Broca’s areas

for language comprehension and speech production, 95% of all persons are located in the left hemisphere

o Wernicke’s: organizationof somatic, auditory and visual association areas into a general mechanism for interpretation of sensory experience

Frontal: motoro Inferior part: smello Left: speech problem

Temporal: languageo Limbic lobe underneath where emotions,

memory loss, behavior are controlled Occipital: mostly visual Frontal lobe diseases: Please refer to power point for

detailed explanation. I will only mention the important ones.

o Tactile anosognosia/bimanual astereognosis: inability to know certain tactile stimuli

o Anosognosia: you don’t know anythingo Apraxia: you don’t know how (or you are

confused) to do a certain procedure Temporal lobe diseases: Again, refer to power point.

o Wernicke’s aphasiao Hypermetamorphopsiao Kluver-Bucy syndrome

Occipital lobe: mostly visual defectsCRANIAL NERVES

CN IV – only one coming from the back Midbrain: CN III Between midbrain and pons: CN IV Pons: CN V (sensory part goes down up to spinal

cord), VI Between pons and medulla: CN VII, VIII Medulla: CN IX-XII Branchial motors: skeletal muscle of face and neck Visceral motor: autonomic Refer to table.

MOTOR FUNCTION Review homunculus.

o Shows degree of representation of different muscles of the body in the motor cortex.

Pyramidal tract: corona radiata posterior limb of internal capsule midbrain pons pyramid of medulla decussate 85% lateral white columns/15% anterior white column anterior horn cells motor root motor nerve muscle

Anterior corticospinal tract: 15%, mostly spinal muscles

Lateral corticospinal tract: mostly arms and legs Lesions of motor system:

o Weakness (-)o Cramps (+)o Fasciculations (+)o Abnormal posture

Lesions of pyramidal tract:o Upper motor neuron signs (UMN)

Increased tone (also seen in basal ganglia lesion)

Hyperreflexia Abnormal signs – Babinski,

Hoffman UMN weakness pattern

Lesions above decussation: contralateral weakness Lesions below decussation: ipsilateral weakness Bilateral represented muscles may not appear weak

with unilateral lesionso These muscles are innervated ipsilaterally

and contralaterally: muscles of mastication, tongue, SCM/trapezius, laryngeal/pharyngeal muscles, upper ½ of face, diaphragm)

More distal muscles tend to exhibit more weaknessSENSORY FUNCTION

Dermatomes: only look for this when motor root is affected

Dorsal column lemniscal system: dorsal root ganglion fasciculus gracilis/cuneatus nuclei gracilis and cuneatus internal arcuate fibers decussate medial lemniscus ventroposterolateral nucleus of the thalamus posterior limb of internal capsule corona radiata post-central gyrus

o Touch requiring high localization and transmission of fine gradations of intensity

o Phasic (vibratory) sensationso Sensations that signal movement against the

skino Positiono Pressure requiring fine degrees of judgment

of intensity Anterolateral system: posterior root ganglion

substantia gelatinosa cross to opposite side ventroposterolateral nucleus of the thalamus posterior limb of internal capsule corona radiata post-central gyrus

o Paino Thermal sensation (hot and cold)o Crude touch and pressure discriminationo Crossing: immediately at that level

Lesions of the sensory system:o Numbness (-): to different modalities

Hypoesthesia: partial cut, some sensation

Anesthesia: total cut, no sensationo Dysesthesias (+): general term for pain, pins

and needleso Allodynia (+): when you touch something not

painful, you feel paino Hyperpathia (+): painful stimulus feels more

painfulMYOTACTIC REFLEX OR MUSCLE STRETCH REFLEX

Neuronal circuit of stretch reflex: muscle spindle proprioceptor nerve (interneurons) motor nerve muscle

Intrafusal fiber: contains muscle spindles which have sensory structures that are capable of sending signals to the proprioceptor nerve which then sends it to the motor nerve and tells the muscle to contract

Extrafusal fiber: normal fiberCEREBELLUM

Found in posterior fossa, dorsal part of brainstem Contains 3 lobes: posterior, anterior, flocculonodular

Neuroscience I – Neurologic History Taking and Physical Examination

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SLCM Class 2014First Block Neuroscience I

Neurologic History Taking and Physical Examination – H.

Ludwig D.(16.06.10)

Transcribed byPOBLETE

Somatic sensory projection areas in cerebellar cortex: body is in the middle (vermis area) and extremities are on the sides

Cerebellar tracts cross the brain twice so if left side is affected, the other side is also affected

Alcoholics: atrophied vermis Spinocerebellar tracts

o Has connection with other areaso Review main tracts.

Ventral spinocerebellar tract Dorsal spinocerebellar tract

Lesions of the cerebellumo Nystagmuso Action tremoro Dysmmetria: trouble localizing thingso Dysdiadokokinesia: inability to do rapid

alternating thingso Ataxia: inability to control gait and stanceo Titubation: midline is affected (neck and

body)o Overshoot: if one extremity is pushed, the

tendency is to overshoot What happens if cerebellum is stimulated?

o Nothing happens!o It only coordinates information from different

areas, not the primary ‘mover’.BASAL GANGLIA

Helpers of the pyramidal tract Globus pallidus + caudate nucleus = corpus striatum

(due to striae) Globus pallidus + putamen = lentiform nucleus Has relation to all parts of the brain Exerts influence on lower motor neuron by way of the

cortex Modulates motor activity of the cortical region Concerned with coarse stereotyped movements Principal influence is over the proximal muscles Responsible for the associated movements that

support voluntary activity Role in proper tone and postural adjustment Lesions of basal ganglia

o If there are lesions in the basal ganglia, there are generally involuntary movements

o Altered muscle tone – rigid/dystonico Loss of associated movementso Appearance of adventitial movement

Tremors (as in parkinsonism) Chorea: brief, irregular twitchi Athetosis: moves like a snake

(Michael Jackson) Hemiballismus

o Masked expressiono Paucity of movemento Gait instability

HISTORY TAKING Genereal data Chief complaint History of present illness

o Diagnosis Anatomic localization Disease

Put all relevant information in chronological order (oldest to latest)

Significant (+) and (-) By the end of the history of present

illness, you should have diagnosis Past medical history Surgical history Family history Medications Social history

PHYSICAL EXAMINATION Top to bottom

o Mental statuso Cranial nerveso Motor systemo Reflexo Sensory systemo Cerebellar functiono Others

Irritating tests should be done last. See succeeding pages for detailed PE.

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SLCM Class 2014First Block Neuroscience I

Neurologic History Taking and Physical Examination – H.

Ludwig D.(16.06.10)

Transcribed byPOBLETE

Nerve # Somatic Motor

Branchial Motor

Visceral Motor

Visceral Sensory

General Sensory

Special Sensory

Function

Olfactory I ü Sense of smellOptic II ü VisionOculomotor III ü Motor to all extraocular

muscles except superior oblique and lateral rectus

ü Parasympathetic supply to ciliary and pupillary constrictor muscles

Trochlear IV ü Motor to superior obliqueTrigeminal V ü Motor to muscles of

mastication, etc. (V3) ü Sensory from surface of head

and neck, sinuses, meninges, and tympanic membrane (external surface)

Abducens VI ü Motor to lateral rectus muscleFacial VII ü Motor to muscles of facial

expression, etc.ü Parasympathetic supply to all

glands of the head except the parotid and integumentary glands

ü General sensation from a small area around the external ear, tympanic membrane (external surface)

ü Taste, anterior two-thirds of the tongue

Vestibulo-cochlear

VIII ü Balanceü Hearing

Glosso-pharyngeal

IX ü Motor to stylopharyngeaus muscle

ü Parasympathetic supply to parotid gland

Vagus X ü Motor to pharynx and larynxü Parasympathetic supply to

pharynx, larynx, thoracic and abdominal viscera

ü Visceral sensory from pharynx, larynx and viscera

ü General sensation from a small area around the external ear

Accessory XI ü Motor to sternomastoid and trapezius muscle

Hypoglossal XII ü Motor to intrinsic and extrinsic muscles of the tongue except palatoglossus

NEUROLOGICAL EXAMINATION Definition Procedure Normal Abnormal

Mental Status        

General Behavior & Appearance   Observation     

Stream of Talk Tests Wernicke and Broca’s Areas 

ConversationObservation

   

Mood and Affective Responses   ConversationObservation

   

Content of Thought   ConversationObservation

   

Intellectual Capacity   ConversationObservation

   

Sensorium        

Consciousness   Observe  Alert Not conscious

Attention Span   Serial 7 Test

You flick two fingers repeatedly but person notices only one side

Attentive  Can’t finish serial 7 test

Sensory Inattention

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SLCM Class 2014First Block Neuroscience I

Neurologic History Taking and Physical Examination – H.

Ludwig D.(16.06.10)

Transcribed byPOBLETE

Orientation  Ask about awareness of present location, time and awareness of self

   

Time     Not Aware 

Place     Not Aware

Person     Not Aware

Memory        

Recent   Remembering 3 words you give after 5 minutes;Ask about last night

  Amnesia

Remote   Ask personal events about 5-10 years ago

  Amnesia

Fund of Information    Ask about TRIVIA  

Insight    Ask for opinion  

Judgment   Give situation, see what person will most likely do

 

Planning    Let person tell you the things he has to do to complete a given task

  Can’t plan

Calculation    Give a simple mathematical problem

  Can’t process problem

Language        

Naming    Ask person to name the object you are pointing to

  Can’t name 

Comprehension    Ask person to do multi-step tasks

  Can’t understand

Fluency    Conversational How do you do’s

  Can’t finish sentence or thought

Repetition    Ask patient to repeat what you say

  Can’t repeat 

Writing    Ask patient to write   Can’t write legibly (for literate people)

         

Higher Cerebral Function        

Sensory Agnosia Do not know things      

Graphesthesia Ability to determine what is written on palm/skin

Trace a figure on the palm of patient who has his eyes closedAsk if he can identify what you wrote 

  Can’t identify figure

Stereognosia Tests ability to identify 3D shapes

    Can’t identify shape

Tactile Inattention Tests the ability to feel touch

 Lightly touch limbs, etc   Can’t feel touch

Astatognosia Tests position sense   

Anosognosia Tests things a person suddenly don’t know

     

Atopognosia Tests ability to localize touch 

     

Apraxia  Cannot do things      

Ideomotor Apraxia        

Ideational Apraxia  More severe than ideomotor apraxia

     

Constructional Apraxia Ask person to copy block structures (Lego, etc)Observe

  Cannot copy given block structure

Dressing Apraxia   Ask person to do movements associated  with dressing up

  Cannot dress

         

Cranial Nerves        

CN I (Olfactory) Least checked Use smelling salts and ask patient to identify scent

Can detect odor Can’t detect or wrongly identifies scent 

CN II (Optic)      

Visual Acuity Use Snellen/Jaeger charts 

Let person read the smallest row of figures in the chart

 

Visual Fields Tests for hemianopsia, etc

Test vision in all visual fields

Finger movements seen in all fields

 Hemianopsia/Quadrantanopia

Neuroscience I – Neurologic History Taking and Physical Examination

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SLCM Class 2014First Block Neuroscience I

Neurologic History Taking and Physical Examination – H.

Ludwig D.(16.06.10)

Transcribed byPOBLETE

Pupillary Reflex      

Direct Shine light on one eyeObserve same eye 

Ipsilateral dilation is a grade 2 or 3

Amedriasis (no response) or over-dilation

Consensual   Shine light on one eyeObserve opposite eye

Symmetric dilation of contralateral pupil

Amedriasis in contralateral pupil

Fundoscopy        

CN III (Oculomotor) Tests extraocular muscles, ability to accommodate, conjugate eye movement

Let patient follow your finger in all the major directions of eye movement East, West, NE, NW, SE & SW

Smooth pursuit 

Can’t follow  CN IV (Trochlear)

CN VI (Abducens)

CN V (Trigeminal)        

Sensory   Graze face, arms and legs on both sides and ask person to compare sensation

Similar Feeling is greater on one side

Motor Checks integrity of the cranial nerve and muscles of mastication

Put one finger at the masseter and another at the temporalis muscle then open and close jaw 

Both muscles will move

No/abnormal movement

Corneal Blink Reflex    Touch corneas with clean, light fabric when the patient is looking away from you

Blink present  Blink absent

Jaw Jerk    Hit mental symphysis with hammer

Negative Jaw closes 

CN VII (Facial)        

Motor    Let person say “mamama” Check orbicularis oculiAsk person to smile

Symmetric movement of muscles of the face

Palsy in one side

Taste        

CN VIII (Auditory/Vestibular)        

Weber Tests lateralization of sound

Place tuning fork at the skull’s midline (intersection of sagittal and coronal suture)

Same duration Lateralization noted (sound longer in one ear) 

Rinne Tests air-bone conduction

 Place tuning fork at the mastoid process and just near ear

Bone conduction is shorter than air conduction

Converse is true

Schwabach Tests air conduction Compare person’s air conduction against yours (if he hears the sound longer or shorter than you)

 Same duration Longer in patient/ can’t hear sound 

CN IX (Glossopharyngeal) Tests presence of gag reflex

Stimulate soft palate or posterior pharynx to elicit gag reflex

 Gagging Areflexia (but gag reflex is normally absent in 10% of people)

CN X (Vagus)  Tests palatal elevation and partly gag reflex

Ask person to say “Ah” and look at the symmetry of the palate 

Symmetrical elevation of palate 

Asymmetrical elevation (uvula deviates toward strong side)

CN XI (Accessory) Tests motor innervations of sternocleidomastoid and trapezius

Push SCM down while telling the person to resist you

Head rotation

Maximum resistance

SCM bulging

 Little or No resistance

No bulging CN XII (Hypoglossal) Tests tongue movement Ask person to say “lalala”

Ask person to protrude tongue

Normal movement

Midline protrusion

Can’t say lalala properly

Deviation of tongue to one side 

         

Sensory Tests integrity of spinal lemniscus

     

Pain & Temperature Tests integrity of lateral spinothalamic tract

Touch a part of skin (on the left and right side)

Positive No sensation/ hypoesthesia/

Neuroscience I – Neurologic History Taking and Physical Examination

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SLCM Class 2014First Block Neuroscience I

Neurologic History Taking and Physical Examination – H.

Ludwig D.(16.06.10)

Transcribed byPOBLETE

with a pin or needle anesthesia Vibration & Proprioception Tests position and

vibration sense (integrity of dorsal lemniscal tract/ posterior white columns)

Vibration:Ask if the person feels the vibrations of the tuning fork on his back, etc

Proprioception:Ask patient to close his eyes then move one finger up and down

Ask person to identify position of finger as you move it

Positive Can’t feel vibration/Can’t tell position of finger correctly

Light Touch Tests light touch sense (integrity of spinothalamic tract) 

Pass cotton swab lightly on both hands, arms, feet and legs Ask if equal degree of sensation

Positive  Can’t feel

         

Motor      

Bulk   Observe before inspectionLook then lightly squeeze muscles

Symmetric, good bulk

Atrophied muscles 

Tone   Get a relaxed limb and lightly wiggle it around (repeatedly flex or extend arms and knees)

No tension, rigidity nor spascticity

Presence of tension, rigidity and spasticity

Strength   Ask person to oppose your strength as youbear down on each of his shoulders

Grading 5 Max resistance

 Grading 3 below

0 - no movement        

1 - minimal twitch        

2 - without gravity        

3 - against gravity        

4 - minimal resistance        

5 - maximal resistance    

         

Reflexes        

Superficial        

Cremasteric Reflex   Lightly graze medial surface of one thigh

Brisk and brief elevation of ipsilateral testis 

areflexia

Superficial Abdominal Reflex   Lightly stroke abdominal area toward the umbilicus

Abdominal muscles tighten

 areflexia

Deep Tendon   ++ normal 0 areflexia+ hyporeflexia+++ hyper-++++ clonus

Most Commonly Tested        

Biceps tests musculocutaneous nerve (C5-C6)

Tap corresponding tendon with neuro hammer (but for knee jerk, ask person to cross one leg over the other before tapping)

Observe reflex

 Flick of biceps  See above

Triceps Tests radial nerve (C6-C7)

Flick of triceps  See above

Brachioradialis Tests radial nerve (C5-C6)

Flick of brachioradialis

 See above

Quadriceps/Knee Tests femoral nerve (L2-L3-L4)

Flick of knee  See above

Achilles/Ankle Tests tibial nerve (S1) Flick of ankle (ask person to kneel)

 See above

Pathologic (Frontal Release Signs)        

Babinski   Stroke dorsal surface of feet in inverted J pattern (lateral to medial) 

Negative Big toe moves upward and painful spread of toes

Clonus   Plantar flex the person’s foot and see how it goes

 Negative  Foot/arm experiences

Neuroscience I – Neurologic History Taking and Physical Examination

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SLCM Class 2014First Block Neuroscience I

Neurologic History Taking and Physical Examination – H.

Ludwig D.(16.06.10)

Transcribed byPOBLETE

back to position

Palmar flex the person’s hand and see how it goes back to position

clonus of feet and arm

Hoffmans   Raise middle finger from hand and flick it

 Negative Other fingers will curl (but in 10% of people, this may be normal)

Palmomental   Lightly graze palm of outstretched, pronated arm

 Negative Mental muscle twitches 

Grasp   Lightly graze palm  Negative Fingers curl or close over palm 

Snout/Rooting   Tap lips  Negative Lips pucker

Glabellar Tap   Continuously tap glabella Person blinks once or twice

Person blinks continuously 

         

Cerebellum        

Coordination        

Finger-to-nose test Tests for presence of dysmetria and intention tremors

Place your forefinger a distance from the person’s nose

Ask person to touch his nose with his forefinger first before touching your finger

Repeat above but this time, move your finger 

Person’s finger is always on point to yours

Smooth movements (smooth pursuit)

Can’t touch your finger directly

Saccadic movements of finger

Heel-to-shin test Tests for fine motor movement

Ask person to place the heel of one foot to the shin of the opposite leg

Ask him to move his heel parallel to the direction of shin

Smooth movement

Can’t  smoothly move his heel

Rapid alternating movements  Tests for fine motor movement

Ask person to rapidly alternate both his hands between pronation & supination

Ask person to rapidly ann repeatedly touch his forefingers to thumbs in both hands

Can accomplish rapid, alternating movements

Cannot rapidly alternate movements

Overshoots Tests for fine motor movement 

Ask person to close his eyes, raise his pronated arms forwardPush one arm down and ask the person to put his arm back to its original level

Can raise his arm back to original position 

Overshoots original level 

Nystagmus (optokinetic movement)

   Ask person to follow a long sheet of paper with alternating columns of two colors

Both eyes have synchronized saccadic movement

One eye doesn’t move in sync with the other

         

Gait and Balance Tests for Basal Ganglia function

Do not forget to check associated movements such as swinging of the arms and a nice stance 

 

Tandem Gait Ask person to walk back and forth following a straight line 

Takes only one step to turn back 

Takes slowly and a lot of steps to turn 

Shuffling gait Heel and Toe Walk   Ask person to follow a

straight line but walk heel-to-toe

Smooth movement

Can’t walk straight, loses balance

Romberg's Sign   Let person close eyes and raise his arms

Will not lean or fall or lose

Will lean toward one side and/or

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SLCM Class 2014First Block Neuroscience I

Neurologic History Taking and Physical Examination – H.

Ludwig D.(16.06.10)

Transcribed byPOBLETE

forward

Let him open his eyes

balance upon opening eyes

lose balance upon opening eyes

  Pronator Dip   Let patient close his eyes with his arms raised forward

Arms will not fall  One/Both arms will fall

Meningeal Signs Assesses condition of the meninges (great for looking for inflammation, etc)

Let patient lie down supine position

   

Brudzinski   Bend person’s neck and observe knee movements

Negative Knees will reflexively bend

Kernigs   Bend person’s knee Negative Reflexive extension of leg occurs

         

Special Examinations        

Straight-Leg Test (Lasegue's Test) Tests for presence of pinched nerve

In supine position, straighten leg and raise it without bending the knee

Negative Pain/electricity shoots down the leg

Reverse Straight Leg Raising Test        

Crossed Straight Leg Raising Test        

Tinel's Sign   Hit pronated midwrist with hammer

Negative Numbness in hand 

Phalen's Maneuver Tests for carpal tunnel syndrome

Put wrists together Negative  Numbness 

Neuroscience I – Neurologic History Taking and Physical Examination

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SLCM Class 2014First Block Neuroscience I

Neurologic History Taking and Physical Examination – H.

Ludwig D.(16.06.10)

Transcribed byPOBLETE

Neuroscience I – Neurologic History Taking and Physical Examination