Neurological Examination Handout Jan 2008

8/12/2019 Neurological Examination Handout Jan 2008

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Neurological Examination

www.metadon.net


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Objectives

Demonstrate how to perform complete neurological

examination in normal individuals

Demonstrate how to perform complete neurologicalexamination in comatose patients


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Outline of Neurolgical Examination

1. Cortical functions

2. Brainstem functions3. Spinal functions

4. Reflexes and muscle tone5. Coordination

6. Gait and posture

7. Meningeal irritation

8. Funduscopic examination9. Autonomic examination

10. Intelligence examination


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Outline of Neurolgical Examination


2. Cranial functions

3. Motor functions

4. Sensory functions5. Reflexes and muscle tone

6. Coordination

7. Gait and posture8. Meningeal irritation

9. Funduscopic examination


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Neurolgical Examination


A. Consciousness

B. Cognitive functions

1) Language functions

2) Memory

3) Stereognosis

4) Sensory localization5) Abstract thinking

6) Etc.


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A. Consciousness: 2 components

1) Wakefulness (arousal)

2) Awareness (content)

B. Awareness depends on wakefulness

A. Patients may be awake but not aware

B. Patients may be aware if and only if they are awake


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Levels of consciousness

1) Normal/alert/awake-aware: spontaneous eye opening

and responding to command

2) Drowsy: awake in response to stimulti (loud noise or

deep pain stimuli), answering to simple questions,

falling asleep if not stimulated

3) Stuporous: eye opening in response to deep pain,answering simple questions with yes or no

4) Comatose: no eye-opening in response to pain


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Content of consciousness (awareness)

Orientation is the sign of normal awareness

1) Time (year, month, day, hour)

2) Space (the current location of the patient)

3) Person (people around the patient)

Impairment of any of the three signifies disorientation.


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Rancho Los Amigos Scale (RLAS)LevelI

-No response to any stimuli

-indicates coma

LevelII - Generalized response, i.e. patient reacts inconsistently and nonpurposefully to stimuli in a non-specific manner,such as eye blinking, changes in breathing rate, gross body movement, and vocalization - indicates coma

LevelIII -Localized response, i.e. patient reacts specifically but inconsistently to stimuli, such as turning head toward a soundor focusing on an object presented and following simple commands in an inconsistent, delayed manner -notconsidered coma, but stimulation techniques appropriate through Levels III.

LevelIV- Confused-Agitated, i.e. patient is in a heightened state of activity with severely decreased ability to processinformation. The patient is detached from the present and responds primarily to his/her own internal confusion.

Behavior is often bizarre.LevelV-Confused, Inappropriate, Non-Agitated, i.e. patient appears alert and is able to respond to simple commands fairly

consistently, but responds to more complex commands in a non-purposeful, random manner and is agitated byexternal stimuli

LevelVI - Confused-Appropriate, i.e. the patient shows goal-directed behavior, but is dependent on external input fordirection. He/she follows simple directions and shows carryover for tasks that have been relearned, such as self-careactivities. Responses may be incorrect due to memory problems, but they are appropriate to the situation.

LevelVII -Automatic-Appropriate, i.e. the patient appears appropriate and oriented, but goes through daily routinesautomatically, and has shallow recall of what he/she has been doing. The patient shows increased, but superficialawareness of self and other people, demonstrates decreased judgement and problem

-solving abilities, lacks realistic

planning for the future, and requires at least minimal supervision for learning and safety purposes . Judgment and otherhigher level cognitive abilities remain compromised.

LevelVIII- Purposeful and Appropriate, i.e. the patient is alert and oriented able to recall and integrate past and recentevents, is aware of and responsive to the environment, and needs no supervision once learning has occurred. He/shemay continue to show decreased reasoning, tolerance for stress, judgment in emergencies or unusual circumstances,and decreased social, emotional, and intellectual capacities.


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Test of language functions

1. Naming: watch, pen, cup, etc.

2. Comprehension: simple commands, e.g., 3. Repetition

4. Fluency: sing a song, etc.


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Aphasia

= impaired ability to produce/comprehend language.

Type Naming Comp. Repet. Fluency

Motor

Sensory

Global

Conduction

N = normal, Imp = impaired

N Imp.N Imp.

N Imp.Imp. N

Imp.

Imp.

Imp.

N

N Imp.N N


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Memory

1) Short-term (3-item test)

a) Registration

b) Recall

2) Long-term

No localizing significance: limbic system, temporal lobe?


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Stereognosis

ability to perceive the form of an object using the

sense of touch

- US coins: 1, 5, 10

- Thai coins: 1, 2, 5, 10


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Stereognosis


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Sensory localization

A. Two point discrimination (caliper)

B. Left-right discrimination (cotton bud)


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Abstract thinking

A. banana:orange = cat:dog

B. Strike while the iron is hot. (Hit the iron while it is still

hot)


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2. Brainstem functions

A. Motor functions: III, IV, VI, V, VII, IX, X, XI, XII

A. Eye movements (III, IV, VI) (do flash)

B. Muscle of mastication (V)

C. Facial expression (VII) (do facial palsy)

D. Uvular movement (X)

E. Neck rotation (XI)

F. Tongue movement (XII)


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B. Sensory functions: I, II, V, VII, VIII, IX, XA. Touch

B. Pain and temperatureA. Pin prick

B. Deep pain: supraorbital nerve

C. Light (vision)

D. Chemical (smell and taste)

E. Sound (auditory function) (do tuning fork and audiometry)

F. Vestibular (head movement)

G. Movement (proprioception)


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B. Vision

A. Visual acuity (Snellen)

B. Perimetry (confrontation)


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http://upload.wikimedia.org/wikipedia/commons/e/e7/Snellen06.png


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C. Reflex functions: e.g.,

1) Light reflex: II > III

2) Corneal reflex: V > VI

3) Jaw jerk: V > V

4) Gag reflex: IX > X

5) Etc.


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2. Brainstem functionsA. Motor functions: III, IV, VI, V, VII, IX, X, XI, XII

A. Eye movements (III, IV, VI)

B. Muscle of mastication (V)

C. Facial expression (VI)

D. Neck rotationE. Tongue movement

B. Sensory functions: I, II, V, VII, VIII, IX, X Touch, pain, chemical, sound, light and movement

C. Reflex functions: e.g.,1) Light reflex: II > III

2) Corneal reflex: V > VI3) Jaw jerk: V > V

4) Gag reflex: IX > X5) Etc.


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Gilden D. N Engl J Med 2004;351:1323-1331

Central and Peripheral Facial Weakness


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Gilden D and Tyler K. N Engl J Med 2007;357:1653-1655

A Patient with Bell's Palsy Who Has Been Asked to Close His Eyes

Bells

phenomenon


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Gilden D. N Engl J Med 2004;351:1323-1331

Functional Anatomy of the Facial Nerve and Diagnosis of Peripheral Facial Weakness


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3. Spinal functions

A. Motor functions

A. Muscle tone (resistance against passive movement)

B. Motor power

0/5: no contraction

1/5: muscle contraction, but no movement

2/5: movement possible, but not against gravity

3/5: movement possible against gravity, but not resistance

4/5: movement possible against some resistance

5/5: normal strength


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3. Spinal functions

A. Motor functions

Some specific nerves

A. Long thoracic nerve to serratus anterior (C5-6-7)(winged scapula)


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3. Spinal functions

B. Sensory functions

A. Posterior column pathway

1) Proprioception: joint position sense

B. Anterolateral pathway

1) Pain: superficial pain (pin prick) and deep pain

2) temperature


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http://images.google.com/imgres?imgurl=http://www.surgicalsindia.com/gifs/hypodermic-needles.jpg&imgrefurl=http://www.surgicalsindia.com/hypodermic-needles.html&h=221&w=175&sz=11&hl=en&start=7&tbnid=cTWNSXl5LxirHM:&tbnh=107&tbnw=85&prev=/images%3Fq%3Ddisposable%2Bneedle%26gbv%3D2%26svnum%3D10%26hl%3Denhttp://images.google.co.th/imgres?imgurl=http://www.patientmedia.com/previewproducts/reports/images/safetypin.jpg&imgrefurl=http://www.patientmedia.com/previewproducts/reports/safetypin.htm&h=350&w=272&sz=9&tbnid=8KqM4nlibJNouM:&tbnh=120&tbnw=93&prev=/images%3Fq%3Dsafety%2Bpin%26um%3D1&start=3&sa=X&oi=images&ct=image&cd=3


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3. Spinal functions

C. Reflex functions

1) Deep tendon reflexes: biceps (C5-6), triceps (C7-8),

quadriceps (L2-4)2) Superficial reflexes: abdominal

3) Pathological reflexes: palmomental


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http://images.google.com/imgres?imgurl=http://www.metrouniforms.com/images/P/24_300.jpg&imgrefurl=http://www.metrouniforms.com/products/24-BABINSKI-TELESCOPING-REFLEX-HAMMER.html&h=300&w=300&sz=9&hl=en&start=26&tbnid=aMofsIx8rSlXLM:&tbnh=116&tbnw=116&prev=/images%3Fq%3Dreflex%2Bhammer%26start%3D18%26gbv%3D2%26ndsp%3D18%26svnum%3D10%26hl%3Den%26sa%3DNhttp://images.google.com/imgres?imgurl=http://www.medshop.dk/images/reflekshamre/GF05E.jpg&imgrefurl=http://www.medshop.dk/index.php%3FcPath%3D25%26language%3Dse&h=419&w=419&sz=5&hl=en&start=24&tbnid=Cv2hmVYKv7RD2M:&tbnh=125&tbnw=125&prev=/images%3Fq%3Dreflex%2Bhammer%26start%3D18%26gbv%3D2%26ndsp%3D18%26svnum%3D10%26hl%3Den%26sa%3DNhttp://images.google.com/imgres?imgurl=http://grxmedical.com/images%252Fproducts%252FGRx%252FAccessories%252FRFH_25.jpg&imgrefurl=http://grxmedical.com/item.asp%3FPID%3D24&h=291&w=407&sz=16&hl=en&start=2&tbnid=N9IuKz1bnbi4GM:&tbnh=89&tbnw=125&prev=/images%3Fq%3Dreflex%2Bhammer%26gbv%3D2%26svnum%3D10%26hl%3Denhttp://images.google.com/imgres?imgurl=http://www.4imprint.com/imageserver/productimages/4imprint/detailed/8130.jpg&imgrefurl=http://www.4imprint.com/Taylor-Reflex-Hammer/EXEC/DETAIL/~BSID39/~SKU008130/~CA8130.htm&h=250&w=220&sz=11&hl=en&start=3&tbnid=UJZFtk3Pf2gmhM:&tbnh=111&tbnw=98&prev=/images%3Fq%3Dreflex%2Bhammer%26gbv%3D2%26svnum%3D10%26hl%3Den


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4. Coordination

A. Equilibratory coordination

A. Romberg

B. Tandem walk

B. Non-equilibratory

A. Finger to nose, finger to finger, finger to nose to finger

B. Rapid alternating movementC. Heel to knee to shin/toe


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A word on ataxia or in-coordination

Causes due to

A. Weakness

B. Proprioceptive impairment

C. Cerebellar pathways

Not all ataxia cases are caused by cerebellar lesion.


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5. Gait and posture

A. Parkinsons gait


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6. Meningeal irritation

A. Neck stiffness, stiffed neck, stiffness of neck


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7. Funduscopic examination

A. Normal fundus

B. Unilateral papilledema

C. Various degree of papilledema


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Unilateral Papilledema


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Moderate hypertensive retinopathy

is characterized by thinned, straight

arteries; increased venous caliber;

intraretinal hemorrhages; and hard

exudates (top). Cotton-wool spots

(bottom) are an additional feature of

moderate hypertensive retinopathy.

They are caused by focal axonal

swelling of the retinal nerve fiber

layer as a result of small vesselocclusion


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Thickening and opacification of arteriolar walls (copper wiring)

caused by hypertensive arteriosclerosis. Image also shows macularedema.


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Wong T and Mitchell P. N Engl J Med 2004;351:2310-2317

Examples of Mild Hypertensive Retinopathy

Figure 1.

Examples of Mild Hypertensive Retinopathy.

Panel A shows arterio-venous nicking (black arrow)

and focal narrowing (white arrow).

Panel B shows arterio-venous nicking (black

arrows) and widening or accentuation ("copper

wiring") of the central light reflex of the arterioles

(white arrows).


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Examples of Moderate Hypertensive Retinopathy

Figure2.

Examples of Moderate Hypertensive

Retinopathy.

Panel A shows retinal hemorrhages (black

arrows) and a cotton-wool spot (white arrow).

Panel B shows cotton-wool spots (white arrows)

and arterio-venous nicking (black arrows).


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Example of Malignant Hypertensive Retinopathy

Figure 3.

Example of Malignant HypertensiveRetinopathy.

Multiple cotton-wool spots (white arrows),

retinal hemorrhages (black arrows), and

swelling of the optic disk are visible.


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Classification of Hypertensive Retinopathy on the Basis of Recent Population-Based Data


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Eye Movements

5 types of eye movements

http://www.physpharm.fmd.uwo.ca/undergrad/sensesweb/L11EyeMovements/L11EyeMovements.swf

1. Smooth pursuit

2. Saccade

3. Optokinetics

4. Vergence5. Vestibulo-ocular reflex
http://www.physpharm.fmd.uwo.ca/undergrad/sensesweb/L11EyeMovements/L11EyeMovements.swfhttp://www.physpharm.fmd.uwo.ca/undergrad/sensesweb/L11EyeMovements/L11EyeMovements.swfhttp://www.physpharm.fmd.uwo.ca/undergrad/sensesweb/L11EyeMovements/L11EyeMovements.swfhttp://www.physpharm.fmd.uwo.ca/undergrad/sensesweb/L11EyeMovements/L11EyeMovements.swfhttp://www.physpharm.fmd.uwo.ca/undergrad/sensesweb/L11EyeMovements/L11EyeMovements.swfhttp://www.physpharm.fmd.uwo.ca/undergrad/sensesweb/L11EyeMovements/L11EyeMovements.swf

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Neurological Examination Handout Jan 2008