The Neurological examination. General frame Reduced your neurological differential diagnosis How the...
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Transcript of The Neurological examination. General frame Reduced your neurological differential diagnosis How the...
Reduced your neurological differential diagnosis
• How the symptoms started?• How they progressed over time?• What is the localization?
• Mental status, cognition & language• Signs of meningeal irritation.• Cranial nerves• Motor system• Sensory system • Cerebellar functions• Gait and balance
• Remember that normal range of findings dynamically changes with age.
• We all have some soft neurological signs – be symptoms oriented and try to look at the entire picture and not on a soft abnormal finding.
• Define the patient mental status - alert? Confused? Lethargic? comatose?
• Be sure your patient is oriented to time and place.
• If during conversation you suspect any language abnormality test spontaneous conversation (fluency, paraphasia), understanding commands, low and high frequency naming, repetition, reading, writing. Distinguished and define dysarthria.
CN II - OphthalmicTest each eye separately
Visual Acuity
Optic discs
Visual fields(confrontation)
Pupils(also CN III)
Use printed text, your fingers or
hand-palm, light. Do not remove glasses
Don't ask and we won't tell
Light from asideClose your eye and Move your finger fromOutside in (4 quarters)
CN II - OphthalmicVisual Acuity
Optic discs
Visual fields(confrontation)
Pupils(also CN III)
No difference frombaseline
Equal and responsiveVisual fields as good as yours
Sharp borders
CN III(Oculomotor) , IV(Trochlear) & VI (Abducens)
Distant large movements in 6 directions plus convergence
Full coordinated movements, no pathological nystagmus
CN IX & X – Glossopharyngeal and vagus
Look for deviation of the uvula, lowering of palatal arch or a coarse voice
CN XI - Accessory
Sternocleidomastoid – ask patient to turn head against resistance (contralateral to turning direction)
Trapezius - press shoulderagainst patient resistance
CN XII - HypoglossalLook for atrophy or fasciculationswhile mouth slightly open andtongue rests on the floor of the mouth
Ask patient to stick tongue out
No asymmetry, atrophy (hypertrophy) or fasciculations. No involuntary movements,
or abnormal posture.
Observe exposed limb / trunk
Biceps Triceps
Gastrocnemius Tibialis anteriorIliopsoas Quadriceps femoris
Deltoid Grip (many muscles)
Compare muscle force on both sides:
Hamstrings (opposite)
Deep Stretch reflexes
Muscle Nerve Root
Biceps Musculocutaneous C 5-6
Triceps Radial C 6-8
Brachioradialis Radial C 5-6
Quadriceps femoris Femoral L 2-4
Gastrocnemius Tibial S 1-2
Ask patient to stand, close eyes and stretch arms (Romberg test)
Remember you are testing proprioception (large diameter fibers, posterior spinal columns) and the integrative function of the vestibular system rather then cerebellar functions.
Smooth and regular movements(no dysdiadochokinesia)
Finger on target without significantcorrections (dysmetria) or tremor at the end of the movement (intentiontremor)
Alternating palm movements: Finger to nose test (slow):
Steps are regular and in normal length, base in narrow and postureis errect.
Patients younger than 65 years are expected to succeed
Natural walking: Tandem walking (heel to toe):
While patient is bared-foot (if possible):
Visual Acuity
Optic discs
Visual fields(confrontation)
Pupils(also CN III)
CN II - Ophthalmic
Finger counting?Hand movements?Light perception?
CN III(Oculomotor) , IV(Trochlear) & VI (Abducens)
CN VII - Facial
CN IX & X – Glossopharyngeal and vagus
CN XII - Hypoglossal
Decreased passive tone
ParatoniaRigiditySpasticity
Uniform throughout movement, not speed dependent, feels like ‘cogwheel’ or lead-pipe’, increases with movements of other limb
Not uniform throughout the range of movement , varied with speed of movement, ‘clasp knife’ phenomenon, more severe in upper limb pronators and knee extensors.
Increased passive tone
Patients does not relax, he increases his resistance proportionally with the force you apply. Patient continues repetitive movements after you stop
Lower motor neuron, acute upperMotor neuron or (cerebellar)
Upper motor neuron (corticospinal , pyramidel)
Basal ganglia (parkinsonian sign) Frontal release sign
Exam tone
What is the origin of muscle weakness?
Upper motor neuron Lower motor neuron
Atrophy (in chronic disease) Severe with fasiculations None or mild due to disuse
Tone Decreased Spastic in chronic stage, spastic or decreased in acute stage
Deep tendon reflexes Decreased Increased
Babinski sign Negative Positive
Remember – motor system is not just about weakness but also deals with abnormal involuntary movements, fine movements etc and possible localization is not just upper vs. lower motor neurons but also frontal lobes, basal ganglia and cerebellum.
CN I - OlfactoryApply a pleasant smell to each nostril separately when suspecting frontal space occupying lesion (or certain neurodegenerative disease)
CN II - OphthalmicIn case you suspect optic nerve injury:
Test relative afferent papillary defect (RAPD) using light swing test
Use red object to test for red saturation
CN V - TrigeminalSuspect weakness of jaw muscles? Test jaw muscle Force.
Suspect pyramidal involvement above the foramen magnum? Check jaw jerk reflex.
Suspect pathological increased reflexes or wish to better localize lesion?
Pectoral reflex
Supra-patellar reflexCross-adductors reflex
Hoffman Tromner
Ankle clonus:Abruptly dorso-flexed ankle.
Suspect frontal lesion? Neurodegenerative disease? Check frontal release signs.
Palmo-mental Grasp
Snout Glabellar tap
Suspect peripheral neuropathy, spinal posterior columns involvement or hemi-spinal syndrome? Use you tuning fork.
Test for extinction when you suspect non-dominant parietal involvement. You can apply the test while checking visual fields
Visual extinction Tactile extinction
Use pull test when patients gait is impaired or when falls are reported. Stand with a wall on your back!