Neurologic Examination-KABERA Rene

8/8/2019 Neurologic Examination-KABERA Rene

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KABERA Ren,MDPG Y III ResidentFamily and Community MedicineNational University of Rwanda

October 2010


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Initial approachMental StatusCranial NervesMotor ExamReflexes

Coordination and GaitSensory ExamReferences


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The Neurologic History

Temporal course of the illness Patients' descriptions of the complaint. Corroboration of the history by others

Family history Medical illnesses Drug use and abuse and toxin exposure. Formulating an impression of the patient.


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1.Level of consciousness, attention and comprehension

AVPU-GCSAwake and alertAgitatedLethargicComatoseTest attention by seeing if the patient can remain focused on a simpletask, such as spelling a short word forward and backward (R-W-A-N-D-A/A-D-N-A-W-R) is a standard.

Comprehension: Can the patient understand simple questions andcommands? Comprehension of grammatical structure should be testedas well


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2.Speech and Language

Spontaneous speech : Note the patient's fluency, including phrase length,rate, and abundance of spontaneous speech. Also noteTonal modulation and whether paraphasic errors (inappropriately

substituted words or syllables), neologisms (nonexistent words), errors ingrammar are present, Aphasia or dysarthria Naming : Ask the patient to name some easy (pen, watch, tie, etc.) andsome more difficult (fingernail, belt buckle, stethoscope, etc.) objectsRepetition : Can the patient repeat single words and sentences (astandard is "no ifs ands or buts")?Reading : Ask the patient to read single words, a brief passage, and thefront page of the newspaper aloud and test for comprehension.Writing: Ask the patient to write their name and write a sentence.


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3.Memory

Immediate memory :say a list of 3 objects at 0/3/5 minutesshort-term memory :ask the patient to recall the same three items 5 and15 min later

long-term memory: Ask the patient about historical or verifiable personalevents.If immediate recall is intact, then difficulty with recall after about 1 to 5minutes usually signifies damage to the limbic memory structureslocated in the medial temporal lobes and medial diencephalon.


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4.Orientation :person, place, time5. Calculations and right/left orientation, finger agnosia , and agraphia .6. Apraxia7. Constructions and neglect8. Logic and abstractions(preoccupation)

9. Sequencing tasks and frontal release signs10. Delusions and Hallucinations11. Mood


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I - OlfactoryWith eyes closed, ask the patient to sniff a mild stimulus such astoothpaste or coffee and identify the odorant.Testing is usually omitted unless there is suspicion for inferior frontal lobedisease.

II - OpticVisual Acuity (test with hand card)Color Vision (loss of color vision especially red is an important symptomof optic neuritis)Visual Fields (can be tested at the bedside by counting fingers in eachquadrant)Visual Extinction (to detect visual neglect)Funduscopic Examination


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II and III Optic/Oculomotor

The size and shape of the pupil should be recorded at rest. Under normalconditions, the pupil constricts in response to light.Note the direct response, meaning constriction of the illuminated pupil,as well as the consensual response, meaning constriction of the oppositepupil.Test the pupillary response to accommodation. Normally, the pupilsconstrict while fixating on an object being moved from far away to nearthe eyes.


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III/IV/VI-Oculomotor/Trochlear/Abducens

Observe the eyes at rest to see if there are any abnormalities such asspontaneous nystagmus or dysconjugate gaze (eyes not both fixated onthe same point) resulting in diplopia (double vision).Test smooth pursuit by having the patient follow an object moved across

their full range of horizontal and vertical eye movements.Test convergence movements by having the patient fixate on an objectas it is moved slowly towards a point right between the patient's eyes.In comatose or severely lethargic patients, the vestibulo-ocular reflex can

be used to test whether brainstem eye movement pathways are intact.The oculocephalic reflex, a form of the vestibulo-ocular reflex, is testedby holding the eyes open and rotating the head from side to side or upand down.Pupillary response, eye movements,9 cardinal positions, observe lids forptosis.


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V Trigeminal

Three branches : Ophthalmic, maxillary, mandibular.Facial sensation and muscles of mastication.Test facial sensation using a cotton wisp and a sharp object. Also test for

tactile extinction using double simultaneous stimulation.The corneal reflex, which involves both CN 5 and CN 7, is tested bytouching each cornea gently with a cotton wisp and observing anyasymmetries in the blink response.Feel the masseter muscles during jaw clench. Test for a jaw jerk reflex bygently tapping on the jaw with the mouth slightly open.


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VII Facial

Muscles of Facial Expression and Taste.Look for asymmetry in facial shape or in depth of furrows such as thenasolabial fold. Also look for asymmetries in spontaneous facial

expressions and blinking.Ask patient to smile, puff out their cheeks, clench their eyes tight,wrinkle their brow, and so on. Old photographs of the patient can oftenaid your recognition of subtle changes.Check taste with sugar, salt, or lemon juice on cotton swabs applied tothe lateral aspect of each side of the tongue.Like olfaction, taste is often tested only when specific pathology issuspected, such as in lesions of the facial nerve, or in lesions of thegustatory nucleus.


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VIII Acoustic

Mediates Hearing and vestibular functionTest to see can the patient hear fingers rubbed together or wordswhispered just outside of the auditory canal and identify which ear hears

the sound?A tuning fork can be used to perform the Weber and Rinnes test toevaluate sensorineural and conductive hearing loss respectively.Vestibular : Evaluate the dizziness.


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Weber's test

the stem of a vibrating tuning fork is placed on the midline of the headand the patient indicates in which ear the tone is heard louder.A patient with a unilateral conductive hearing loss hears the tone louder

in the ear with the conductive hearing loss, or reasons that are unclear.In contrast, a patient with a unilateral sensorineural hearing loss hearsthe tone louder in the normal ear because the tuning fork stimulatesboth inner ears equally and the patient perceives the stimulus with themore sensitive, unaffected end organ and nerve.


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Rinne's test

It compares hearing by air conduction with that by bone conduction.The stem of a vibrating tuning fork is placed in contact with the mastoidprocess (for bone conduction); then the tines of the still vibrating fork areheld near the pinna (for air conduction), and the patient is asked to

indicate which stimulus is louder.Normally, the stimulus is heard louder by air conduction (AC) than bybone conduction (BC), so the relationship is AC > BC.With a conductive hearing loss, the relationship is reversed; the boneconduction stimulus is perceived louder than the air conduction stimulus

(BC > AC).With a sensorineural hearing loss, both air and bone conductionperceptions are reduced, but the ratio remains the same as that fornormal hearing (AC > BC).


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IX/X - Glossopharyngeal/Vagus

Mediate sensory and motor functions of palate ,pharynx, larynx.Palatal Elevation and Gag ReflexDoes the palate elevate symmetrically when the patient says, "Aah"?Does the patient gag when the posterior pharynx is brushed?The gag reflex needs to be tested only in patients with suspectedbrainstem pathology, impaired consciousness, or impaired swallowing.Palate elevation and the gag reflex are impaired in lesions involving CN 9,CN 10, the neuromuscular junction, or the pharyngeal muscles.


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XI- Spinal accessory

Ask the patient to shrug their shoulders, turn their head in bothdirections, and raise their head from the bed, flexing forward against theforce of your hands.Sternocleidomastoid muscle, Trapezius muscle.

XII Hypoglossal

Note any atrophy or fasciculation (spontaneous quivering movementscaused by firing of muscle motor units) of the tongue while it is resting

on the floor of the mouth.Ask the patient to stick their tongue straight out and note whether itcurves to one side or the other.Ask the patient to move their tongue from side to side and push itforcefully against the inside of each cheek.


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Look for any twitches, tremors, abnormal movements or postures.

Look carefully for hypokinesia, decreased eye blinking or staring whichcould be indicative or an extrapyramidal disorder such as Parkinsonsdisease.In suspected lower motor neuron disorders, look for muscle wasting orfasciculation.Palpate muscles in cases of suspected myopathy to check for muscletenderness.Passively move each limb to check muscle tone. Ask the patient to relaxbefore beginning.

Then check individual muscles for strength using the MRC scale to ratestrength.


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MRC(Medical Research Council) scale

0 No contraction1 Flicker or trace contraction2 Active movement with gravity eliminated3 Active movement against gravity4 Active movement against gravity and resistance5 Normal power


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Romberg test

With the eyes open, three sensory systems provide input to thecerebellum to maintain truncal stability. These are vision, proprioception,and vestibular sense.

If there is a mild lesion in the vestibular or proprioception systems, thepatient is usually able to compensate with the eyes open.When the patient closes their eyes, however, visual input is removed andinstability can be brought out.

If there is a more severe proprioceptive or vestibular lesion, or if there isa midline cerebellar lesion causing truncal instability, the patient will beunable to maintain this position even with their eyes open.


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Gait It involves multiple sensory and motor systems. These include vision,proprioception, lower motor neurons, upper motor neurons, basal ganglia,the cerebellum, and higher-order motor planning systems in theassociation cortex

Observe :

Stance, how far apart are the feet, posture, stability, how high the feet areraised off the floor.Trajectory of leg swing and whether there is circumduction (an arcedtrajectory in the medial to lateral direction).Leg stiffness and degree of knee bending, arm swing, tendency to fall orswerve in any particular direction, rate and speed.Difficulty initiating or stopping gait, and any involuntary movements thatare brought out by walking, turnsThe patient's ability to rise from a chair with or without assistance should

also be recorded.


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Reflexes are graded according to the following scale

0 : absent reflex1+ : trace, or seen only with reinforcement2+ : normal3+ : brisk4+ : no sustained clonus (i.e., repetitive vibratory movements)5+ : sustained clonus


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Muscle Stretch ReflexesPectoral C5

Jaw Jerk Trigeminal, Facial Biceps C5,C6Triceps C6,C7Brachioradialis C7Patellar L3,L4Achilles Tendon S1

Cutaneous ReflexesAbdominal reflexes T9-T12

Cremasteric L1-L2Anal S1-S3-S4Extensor plantar response or Babinski sign

Primitive ReflexesGrasp, suck, palmomental


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Primary sensation

Light TouchPinprickVibrationJoint PositionTemperatureTwo point discriminationThe pattern of sensory loss can provide important information that helpslocalize lesions to particular nerves, nerve roots, and regions of the spinal

cord, brainstem, thalamus, or cortex.


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Cortical sensation

Graphesthesia, Stereognosis, Double Simultaneous StimulationIntact primary sensation with deficits in cortical sensation such asagraphesthesia or astereognosis suggests a lesion in the contralateralsensory cortex.Severe cortical lesions can cause deficits in primary sensation as well.Extinction with intact primary sensation is a form of hemineglect that ismost commonly associated with lesions of the right parietal lobe.Extinction can also be seen in right frontal or subcortical lesions, or

sometimes in left hemisphere lesions causing mild right hemineglect.


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www.neuroexam.com Harrisons Principles of Internal Medicine ,17 th EdRudolphs Paediatrics,21 st EdThe Merck manual of diagn0sis and therapy,18th EdFamily medicine: Principles and Practice,6th Ed


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Neurologic Examination-KABERA Rene