The Neurological Examination Robin Meek, M.D. Introduction to the Medical Profession March 22, 2006

The Neurological The Neurological ExaminationExamination

Robin Meek, M.D.Robin Meek, M.D.

Introduction to the Medical Profession Introduction to the Medical Profession

March 22, 2006March 22, 2006

Objectives:Objectives:

1. List and discuss the 3 essential questions 1. List and discuss the 3 essential questions to consider when assessing neurological to consider when assessing neurological function.function.

2. Describe the 6 components of the 2. Describe the 6 components of the neurological exam.neurological exam.

Three Key QuestionsThree Key Questions

1.1. Is there evidence of nervous system Is there evidence of nervous system disease or dysfunction?disease or dysfunction?

2.2. Where is the problem located?Where is the problem located?

3.3. What is the nature of the problem?What is the nature of the problem?

1. Is there evidence of nervous 1. Is there evidence of nervous system disease or dysfunction ?system disease or dysfunction ?

Focal – strokeFocal – stroke

Diffuse – multiple sclerosisDiffuse – multiple sclerosis

Systemic –peripheral neuropathySystemic –peripheral neuropathy

2. Where is the problem?2. Where is the problem?

CNS vs. PNSCNS vs. PNS

Tracts vs. neuronsTracts vs. neurons

UMN vs. LMNUMN vs. LMN

Cortical vs. subcorticalCortical vs. subcortical

Peripheral vs. CentralPeripheral vs. Central

PeripheralPeripheral- Muscle- Muscle

- Neuromuscular junction- Neuromuscular junction

- Spinal or cranial nerves- Spinal or cranial nerves

- Plexus- Plexus

- Nerve roots- Nerve roots

CNSCNS- Spinal cordSpinal cord- BrainstemBrainstem- CerebellumCerebellum- CerebrumCerebrum

- Right vs. leftRight vs. left- Cortex vs. subcorticalCortex vs. subcortical

3. What is the nature of the 3. What is the nature of the problem?problem?

PIT VET 3-DPIT VET 3-D

PIT VET 3 - DPIT VET 3 - D

PITPIT- - pressurepressure

- infection- infection- toxic or metabolic- toxic or metabolic

VETVET- vascular- vascular- epilepsy- epilepsy- trauma- trauma

3 - D3 - D- - demyelinatingdemyelinating

- degenerative- degenerative- developmental- developmental

Six ComponentsSix Components

1. Mental status1. Mental status

2. Cranial nerves2. Cranial nerves

3. Motor3. Motor

4. Sensory4. Sensory

5. Reflexes5. Reflexes

6. Coordination6. Coordination


1. Mental status1. Mental status2. Cranial nerves2. Cranial nerves

3. Motor3. Motor



6.Coordination6.Coordination

Mental StatusMental Status

Alertness or awarenessAlertness or awareness

OrientationOrientation



2. Cranial nerves2. Cranial nerves3. Motor3. Motor




The Cranial NervesThe Cranial Nerves

II OlfactoryOlfactory

IIII OpticOptic

IIIIII OculomotorOculomotor

IVIV TrochlearTrochlear

VV TrigeminalTrigeminal

VIVI AbducensAbducens

VIIVII FacialFacial

VIIIVIII AcousticAcoustic

IXIXGlossopharyngealGlossopharyngeal

XX VagusVagus

XIXI Spinal Spinal accessoryaccessory

XIIXII Hypoglossal Hypoglossal

Olfaction (CN I)Olfaction (CN I)

Almost never testedAlmost never testedSmellSmellCoffee, mint, essence of orangeCoffee, mint, essence of orange Impaired olfaction:Impaired olfaction:

Inflammation (allergies or colds)Inflammation (allergies or colds)SmokingSmokingAgingAging

AnosmiaAnosmia

CN II - VisionCN II - Vision

Three steps:Three steps:

1.Visual fields by confrontation1.Visual fields by confrontation

2. Visual acuity testing – patient should wear 2. Visual acuity testing – patient should wear their usual corrective lensestheir usual corrective lenses

3. Funduscopic examination –red reflex, optic 3. Funduscopic examination –red reflex, optic disc, retinal vesselsdisc, retinal vessels

Pupillary Light Reflex (CN II,III)Pupillary Light Reflex (CN II,III)

Check pupil symmetryCheck pupil symmetrySwinging penlight– pupils should remain Swinging penlight– pupils should remain

equally constrictedequally constrictedAnisocoria – one pupil is larger than the Anisocoria – one pupil is larger than the

otherother- Normal variant- Normal variant

- Sympathetic vs. parasympathetic- Sympathetic vs. parasympathetic

Sympathetic – responsible for dilationSympathetic – responsible for dilation

- asymmetry greatest in the dark - asymmetry greatest in the dark

Parasympathetic – responsible for Parasympathetic – responsible for constrictionconstriction

- asymmetry greatest in the light- asymmetry greatest in the light

IV TrochlearIV Trochlear

Downward and inward movement of the Downward and inward movement of the eyeeye

Innervates the superior obliqueInnervates the superior oblique

VI AbducensVI Abducens

Lateral deviation of the eyeLateral deviation of the eye

Innervates the lateral rectusInnervates the lateral rectus

NystagmusNystagmus

Experiment on your buddy!Experiment on your buddy!

V TrigeminalV Trigeminal

Mixed nerve – somatic sensory and Mixed nerve – somatic sensory and somatic motorsomatic motor

Sensory nucleus – pons and medulla, Sensory nucleus – pons and medulla, becoming continuous with the posterior becoming continuous with the posterior horn of the spinal cordhorn of the spinal cord

Motor nucleus – confined to the ponsMotor nucleus – confined to the pons

Trigeminal - SensoryTrigeminal - Sensory

Three branches: opthalmic, maxillary, Three branches: opthalmic, maxillary, mandibularmandibular

Sensory input from the face and mucus Sensory input from the face and mucus membranes (ocular, nasal, and oral) membranes (ocular, nasal, and oral) excluding the external ear and the excluding the external ear and the posterior head, via the trigeminal ganglionposterior head, via the trigeminal ganglion

Trigeminal - MotorTrigeminal - Motor

Supplies the muscles of mastication Supplies the muscles of mastication (masseter, temporal, internal and external (masseter, temporal, internal and external pterygoid) muscles and other minor pterygoid) muscles and other minor pharyngeal muscles pharyngeal muscles

Trigeminal ExaminationTrigeminal Examination

1.1. Pinprick and fine touch sensation in Pinprick and fine touch sensation in forehead, cheek, and mandible bilaterallyforehead, cheek, and mandible bilaterally

2.2. Corneal reflexCorneal reflex

3.3. Jaw movements and jaw reflexJaw movements and jaw reflex

4.4. Palpation of jaw muscles for tone and Palpation of jaw muscles for tone and strength with teeth clenchedstrength with teeth clenched

VII FacialVII Facial

Mixed nerveMixed nerve

Motor – facial musculature except for Motor – facial musculature except for levator palpebrae (CN III)levator palpebrae (CN III)

Superior salivatory nucleus – Superior salivatory nucleus – submandibular and sublingual glandssubmandibular and sublingual glands

VII Facial SensoryVII Facial Sensory

Nucleus solitarius – taste from anterior 2/3 Nucleus solitarius – taste from anterior 2/3 of the tongue ( sweet and salty)of the tongue ( sweet and salty)

Sensory nucleus 5 – sensation from the Sensory nucleus 5 – sensation from the external ear external ear

VII – Three StepsVII – Three Steps

1.1. Inspection at rest and with facial Inspection at rest and with facial expressionexpression

2.2. Wrinkling the forehead – differentiates Wrinkling the forehead – differentiates central from peripheral lesioncentral from peripheral lesion

3.3. Identifying sweet and salty tastes on both Identifying sweet and salty tastes on both sides of the tonguesides of the tongue

Try it out!Try it out!

VIII AcousticVIII Acoustic

Hearing - cochlear divisionHearing - cochlear division

Balance – vestibular divisionBalance – vestibular division

- seldom tested in basic neuro. exam- seldom tested in basic neuro. exam

VIII – Two StepsVIII – Two Steps

1.1. Assess hearing, covering opposite ear:Assess hearing, covering opposite ear:

whispered wordswhispered words

rubbing your fingersrubbing your fingers

ticking watchticking watch

2.2. Rinne test – bone and air conductionRinne test – bone and air conduction

IX GlossopharyngealIX Glossopharyngeal

Mixed nerveMixed nerve

Motor – pharynxMotor – pharynx

Sensory – posterior portions of the Sensory – posterior portions of the eardrum and ear canal, the pharynx, and eardrum and ear canal, the pharynx, and the posterior tongue (salty, sweet, sour, the posterior tongue (salty, sweet, sour, and bitter)and bitter)

X VagusX Vagus

MixedMixed

Motor – palate, pharynx, and larynxMotor – palate, pharynx, and larynx

Sensory – pharynx and larynxSensory – pharynx and larynx

Testing IX and XTesting IX and X

Listen to the patient’s voice – is it hoarse Listen to the patient’s voice – is it hoarse or does it have a nasal quality?or does it have a nasal quality?

Say “ah” – look at the soft palate and the Say “ah” – look at the soft palate and the pharynx. pharynx.

Gag reflex – stimulate both sides of the Gag reflex – stimulate both sides of the back of the throat and note the gag back of the throat and note the gag response (warn the patient)response (warn the patient)

XI Spinal accessoryXI Spinal accessory

Shoulder and neck movementsShoulder and neck movements

Look for atrophy or fasiculations in the Look for atrophy or fasiculations in the trapezius muscles, compare one side to trapezius muscles, compare one side to the otherthe other

Shrug shouldersShrug shoulders

Turn head against your handTurn head against your hand

XII HypoglossalXII Hypoglossal

Somatic motor – muscles of the tongueSomatic motor – muscles of the tongue

Observe the tongue for muscle atrophy or Observe the tongue for muscle atrophy or fasiculationsfasiculations

Ask patient to protrude tongue and move it Ask patient to protrude tongue and move it from side to side – ? symmetry, deviation from side to side – ? symmetry, deviation from the midlinefrom the midline

Your turn!Your turn!




3. Motor3. Motor4. Sensory4. Sensory



Motor ExamMotor Exam

Body position – abnormal positions alert Body position – abnormal positions alert you to deficits such as paralysisyou to deficits such as paralysis

Involuntary movements – tremors, tics, or Involuntary movements – tremors, tics, or fasiculationsfasiculations

Muscle bulk – atrophic, symmetric or Muscle bulk – atrophic, symmetric or asymmetric? Especially shoulders, hands, asymmetric? Especially shoulders, hands, thighsthighs

Tone and strengthTone and strength

Muscle StrengthMuscle Strength

Grade 5 - full strengthGrade 5 - full strength

Grade 4 - weak against resistanceGrade 4 - weak against resistance

Grade 3 - movement against gravityGrade 3 - movement against gravity

Grade 2 – movement with gravity Grade 2 – movement with gravity eliminatedeliminated

Grade 1 – minimal contractionGrade 1 – minimal contraction

Grade 0 – no contractionGrade 0 – no contraction

Muscle ToneMuscle Tone

flaccid – a decrease in toneflaccid – a decrease in tone normal – slight resistance to passive normal – slight resistance to passive

movement movement spastic – increased tone that varies, spastic – increased tone that varies,

often worse at the extremes of often worse at the extremes of the the rangerange rigid – resistance that persists throughout rigid – resistance that persists throughout

the range of motion and in both the range of motion and in both directionsdirections

Lower Motor NeuronsLower Motor Neurons Corticospinal tract or pyramidal system – Corticospinal tract or pyramidal system –

- mediates voluntary movements- mediates voluntary movements- crosses over at the junction of the - crosses over at the junction of the

brainstem and the spinal cordbrainstem and the spinal cord Reticulospinal or rubrospinal tracts – Reticulospinal or rubrospinal tracts –

- extrapyramidal system- extrapyramidal system- connects basal ganglia with the LMN- connects basal ganglia with the LMN- integrate motor activity and posture- integrate motor activity and posture

UMN vs. LMNUMN vs. LMN

UMNUMN LMNLMN

ParalysisParalysis spasticspastic flaccidflaccid

Muscle atrophyMuscle atrophy nono yesyes

FasiculationsFasiculations nono yesyes

ReflexesReflexes Hyper-reflexicHyper-reflexic Hypo-reflexicHypo-reflexic

Babinski signBabinski sign May be presentMay be present Not presentNot present

Upper extremity nerve roots

Lower extremity nerve roots

DemonstrationDemonstration

Symmetric weakness of the proximal Symmetric weakness of the proximal muscles – myopathy or a muscle disordermuscles – myopathy or a muscle disorder

Symmetric weakness of the distal muscles Symmetric weakness of the distal muscles suggests a polyneuropathy or a disorder of suggests a polyneuropathy or a disorder of the peripheral nervesthe peripheral nerves




3. Motor3. Motor

4. Sensory4. Sensory5. Reflexes5. Reflexes


Sensory ExaminationSensory Examination

1.1. Superficial pain and touchSuperficial pain and touch

2.2. TemperatureTemperature

3.3. Deep pain or pressureDeep pain or pressure

4.4. VibrationVibration

5.5. PositionPosition

6.6. Discriminative functionsDiscriminative functions

Ascending TractsAscending Tracts

Lateral spinothalamic – superficial pain Lateral spinothalamic – superficial pain and temperatureand temperature

Posterior columns – vibration, deep Posterior columns – vibration, deep pressure, position sense, point location, pressure, position sense, point location, stereognosis, and two-point discriminationstereognosis, and two-point discrimination

Spinocerebellar – proprioceptionSpinocerebellar – proprioceptionVentral spinothalamic – superficial touch Ventral spinothalamic – superficial touch

and deep pressureand deep pressure

Superficial pain – pinprick , “sharp or dull”Superficial pain – pinprick , “sharp or dull”

Light touch – fingertips or wisp of cottonLight touch – fingertips or wisp of cotton

(Temperature – ice and warm water in test (Temperature – ice and warm water in test tubes)tubes)

Deep pain – squeezing the calf or biceps Deep pain – squeezing the calf or biceps musclemuscle

Vibration sense – vibrating tuning fork Vibration sense – vibrating tuning fork against bony prominences with patient’s against bony prominences with patient’s eyes closed, “When does it stop?”eyes closed, “When does it stop?”

Position sense – holding a distal joint of Position sense – holding a distal joint of the fingers and toes and moving up or the fingers and toes and moving up or downdown

Discriminative FunctionDiscriminative Function

Reflects the ability of the sensory cortex to Reflects the ability of the sensory cortex to correlate, analyze, and interpret correlate, analyze, and interpret sensationssensations

Sterognosis – identify an object (coin)Sterognosis – identify an object (coin)

Two-point discrimination - find the distance Two-point discrimination - find the distance where the patient no longer perceives two where the patient no longer perceives two stimulistimuli

Graphesthesia – recognize numbers or Graphesthesia – recognize numbers or letters drawn on skinletters drawn on skin

Extinction – touch both sides of the body Extinction – touch both sides of the body simultaneously with closed eyessimultaneously with closed eyes

Point location – with the patient’s eyes Point location – with the patient’s eyes closed, touch an area on the body, closed, touch an area on the body, withdraw the stimulus, and then ask the withdraw the stimulus, and then ask the patient to point to the area touchedpatient to point to the area touched




3. Motor3. Motor


5. Reflexes5. Reflexes6.Coordination6.Coordination

ReflexesReflexes

Superficial reflexes:Superficial reflexes:

- abdominal reflex – contraction toward the - abdominal reflex – contraction toward the stimulusstimulus

- cremasteric reflex – elevation of the - cremasteric reflex – elevation of the ipsilateral scrotum and testicle by touching ipsilateral scrotum and testicle by touching the thighthe thigh

Deep Tendon ReflexesDeep Tendon Reflexes

00 AbsentAbsent

1+ Hyporeflexic1+ Hyporeflexic

2+ Normal2+ Normal

3+ Hyperreflexic3+ Hyperreflexic

4+ Clonus4+ Clonus

Eliciting ReflexesEliciting Reflexes

1.1. Biceps (C5, C6)Biceps (C5, C6)

2.2. Brachioradialis (C5, C6)Brachioradialis (C5, C6)

3.3. Triceps (C6, C7)Triceps (C6, C7)

4.4. Patellar (L2, L3, L4)Patellar (L2, L3, L4)

5.5. Achilles (ankle – S1)Achilles (ankle – S1)

6.6. Plantar (L5, S1)Plantar (L5, S1)

7.7. Clonus – indicates CNS diseaseClonus – indicates CNS disease

DemonstrationDemonstration

Babinski signBabinski sign




3. Motor3. Motor




CoordinationCoordination

Four areas that need to work together:Four areas that need to work together:

1. Motor system1. Motor system

2. Cerebellum – for rhythmic movement 2. Cerebellum – for rhythmic movement and steady postureand steady posture

3. Vestibular system – for balance & for 3. Vestibular system – for balance & for coordinating eye, head, and body coordinating eye, head, and body movementsmovements

4.Sensory system – for position sense4.Sensory system – for position sense

CoordinationCoordination

Rapid alternating movements Rapid alternating movements

Point to point movementsPoint to point movements

Gait – walk down the hall, heel to toe, walk Gait – walk down the hall, heel to toe, walk on toes, and then on heelson toes, and then on heels

Standing – Romberg testStanding – Romberg test

Pronator DriftPronator Drift

Changes With AgingChanges With Aging

Motor system – move and react with less Motor system – move and react with less speed and agility, muscle mass decreasesspeed and agility, muscle mass decreases

Benign essential tremorBenign essential tremorVibration sense decreased or lost in feet Vibration sense decreased or lost in feet

or anklesor anklesReflexes – gag, ankle reflexes decreasedReflexes – gag, ankle reflexes decreased ““Benign forgetfulness”Benign forgetfulness”

DemoDemo




3. Motor3. Motor




Documents

The Neurological Examination Robin Meek, M.D. Introduction to the Medical Profession March 22, 2006