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Weakness & Sensory DeficitWeakness & Sensory Deficit
Describe unique findings in• Myopathy, NMJ disorder, neuropathy,
plexopathy, radiculopathy• Myelopathy, motor neuron disease• Brain stem and cortical lesions
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WeaknessWeakness
Pertinent parameters include:• Motor power pattern• Sensory findings• Deep tendon reflexes and muscle tone• Others
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Symptomatology of Motor DysfunctionSymptomatology of Motor Dysfunction
1.Muscle mass and contour• atrophy, hypertrophy, dystrophy• myopathy, myotonia2.Muscle tone• spasticity• rigidity• decorticate, decerebrate posture• hypotonia
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Symptomatology of Motor DysfunctionSymptomatology of Motor Dysfunction
3.Involuntary movement• tremor, myoclonus, chorea, athetosis,
ballism, dystonia, spasm, tics, clamps4.Weakness• paresis, paralysis, -plegia, palsy• mono-, para-, hemi-, quadri-
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Neurologic examinationNeurologic examination
1. Cerebral function2. Cranial function3. Motor function4. Sensory function5. Reflexes and muscle tone6. Coordination7. Gait and posture8. Meningeal irritation9. Funduscopic examination
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Motor PowerMotor Power
Grading system (British Medical Research Council)• V normal, full resistance to external force• IV partial resistance to external force• III against gravity, not to external force• II joint movement, not against gravity• I muscle contraction, no joint movement• 0 no muscle contraction
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Sensory FunctionsSensory Functions
1. Dorsal column system• proprioception, touch
2. Anterolateral system• pain (pinprick), temperature
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ReflexesReflexes
Deep tendon reflexes• 4+ pathological• 3+ normal, pathological• 2+ normal• 1+ normal, pathological• 0 pathological
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Etiology (VINDICATEN_HIM)Etiology (VINDICATEN_HIM)
V vascular
I infectious/inflammatoryN neoplasticD degenerativeI intoxicativeC congenital/hereditaryA autoimmuneT traumaticE endocrinopathicN neoplastic
H hematologic
I idiopathic
M metabolic & miscellaneous
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Where is the lesion?Where is the lesion?
Peripheral lesions• Myopathy• Neuromuscular junction• Peripheral nerve
× polyneuropathy× mononeuropathy (single, multiple)× plexopathy× radiculopathy
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Central lesions• Motor neuron• Spinal cord• Brainstem• Cerebral hemisphere• Others
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Lower Motor Neuron LesionsLower Motor Neuron Lesions
Muscle (myopathy)• hypokalemia• myositis, muscular dystrophy
NMJ• myasthenia gravis
Peripheral nerves (neuropathy)• Polyneuropathy• Mononeuropathy (single, multiple)
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Plexus (plexopathy)• diabetic plexopathy
Nerve root (radiculopathy)• Guillain-Barre Syndrome (AIDP), CIDP• herniated disk
Spinal cord (myelopathy)• motor neuron disease
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Symptoms/Signs of LMN LesionsSymptoms/Signs of LMN Lesions
Focal weakness• monoparesis, selective neuropathy weakness
Flaccid tone
Areflexia, hyporeflexia
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Upper Motor Neuron LesionsUpper Motor Neuron Lesions
Spinal cord• cord compression, myelitis
Brain stem, cerebral cortex, cerebellum and basal ganglia
• cerebrovascular disease, tumor, degenerative disease
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Symptoms/Signs of UMN LesionsSymptoms/Signs of UMN Lesions
Diffuse weakness• paraparesis, hemiparesis, quadriparesis
Spastic tone
Hyperreflexia
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Hypotonia - HyporeflexiaHypotonia - Hyporeflexia
Reflex arc dysfunction (any components)• receptor organs• afferent neurons• reflex center• efferent neurons• effector organs
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CST+
VST+
RST+RST -
DRG +CST+
VST+
RST+RST -
DRG +
CST+
VST+
RST+RST -
DRG +CST+
VST+
RST+RST -
DRG +
A
C
B
D
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SpasticitySpasticity
Hypertonia• unidirectional• velocity-dependent
Hyperreflexia
Seen in upper motor neuron lesion other than basal ganglia pathology
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RigidityRigidity
Hypertonia• bidirectional• velocity-independent• cog-wheeling
Normoreflexia
Seen in basal ganglia pathology• Parkisonism, Parkinsonism plus
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CoordinationCoordination
Equilibratory coordination• Romberg sign• Tandem walk
Non-equilibratory coordination• finger to nose, finger to finger, nose-finger-nose• dysdiadokokinesia• rebound• past-pointing
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Gait & PostureGait & Posture
• ataxic gait (proprioceptive, vestibular, cerebellar): wide base, high swing, sway
• festinating gait (Parkinsonism): short, slow, rigid and shuffling
• steppage gait (polyneuropathy): excessive hip flexion
• waddling gait (myopathy): body swaying from side to side like a duck
0% 50% 100%
RT. HEEL STRIKE LT. HEEL STRIKE RT. HEEL STRIKE
RIGHT STANCE RIGHT SWINGLEFT STANCELEFT SWING
RIGHT STRIDE LENGTH0% 50% 100%
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MotorP > DP/D with FD > PP/DP/Dfocal/diffusediffuse
Sensorynormalnormalimpairedimpairedimpairedimpairedimpaired
ReflexesN, DeN, De
DeDeDe
De, II
•Myopathy•NMJ•Peripheral nerve•Plexus•Root•Cord•Brain
P = proximal, D = distalN = normal, De = decreased, I = increased
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Sensory DeficitsSensory DeficitsSpinal sensory Pathways• Dorsal Column system
• Touch, proprioception, two-point discrimination, vibratory sense
• Anterolateral system• Pain (sharp and dull aching)• Temperature sense
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Sensory DeficitsSensory DeficitsCranial sensory pathways• CN I (olfaction)• CN II (vision)• CN V (pain and touch)• CN VII, IX, X (gustatory, etc)• CN VIII (hearing and vestibular sense)
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Diabetic neuropathyDiabetic neuropathy
Clinical features- Initial tingling paresthesia- Pain- Dysesthesia- Loss of feeling distally
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Diabetic neuropathyDiabetic neuropathyDistal sensory impairment ascends
symmetrically in legs and armsPhysical exam:• Glove and stocking pattern• Hyperalgesia • Numbness or lack of sensation
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• http://www.metadon.net/• students• neurologic-examination.pdf
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