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    Erman Fandialan M.D. Department of Clinical Neurosciences Uermmmc

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    lovelots1234
    This document provides guidance on performing a neurological examination. It outlines the typical sequence of a neurological interview, including components like chief complaint and past medical history. It then describes the necessary and recommended equipment for examinations. The rest of the document details how to perform different parts of the neurological exam in a systematic manner, including mental status, cranial nerves, motor function, reflexes, and coordination. Special tests are also explained to localize neurological deficits.

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    Erman Fandialan M.D. Department of Clinical Neurosciences Uermmmc

    Uploaded by

    lovelots1234
    150 views48 pages
    This document provides guidance on performing a neurological examination. It outlines the typical sequence of a neurological interview, including components like chief complaint and past medical history. It then describes the necessary and recommended equipment for examinations. The rest of the document details how to perform different parts of the neurological exam in a systematic manner, including mental status, cranial nerves, motor function, reflexes, and coordination. Special tests are also explained to localize neurological deficits.

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    Neurologic Examination

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    This document provides guidance on performing a neurological examination. It outlines the typical sequence of a neurological interview, including components like chief complaint and past medical history. It then describes the necessary and recommended equipment for examinations. The rest of the document details how to perform different parts of the neurological exam in a systematic manner, including mental status, cranial nerves, motor function, reflexes, and coordination. Special tests are also explained to localize neurological deficits.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    150 views48 pages

    Erman Fandialan M.D. Department of Clinical Neurosciences Uermmmc

    Uploaded by

    lovelots1234
    This document provides guidance on performing a neurological examination. It outlines the typical sequence of a neurological interview, including components like chief complaint and past medical history. It then describes the necessary and recommended equipment for examinations. The rest of the document details how to perform different parts of the neurological exam in a systematic manner, including mental status, cranial nerves, motor function, reflexes, and coordination. Special tests are also explained to localize neurological deficits.

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    Erman Fandialan M.D.

    Department of Clinical
    Neurosciences
    UERMMMC

    To review the different parts of the


    neurologic examination.
    To review techniques of eliciting the
    abnormalities.

    Facilitates communication
    Provides baseline
    Directs testing
    Localizes the lesion

    The customary sequence of information


    collection in the neurological interview is
    outlined below:

    Chief Complaint
    History of Present Illness
    Past Medical History
    Review of Systems or Functional Inquiry
    Family History
    Social History

    Accurate history often suggest correct


    diagnosis
    Chronological order and systematic
    manner
    Symptoms characterized in terms of:
    severity, location, temporal profile,
    aggravating and ameliorating factors

    Includes complete general physical


    examination + neurologic examination
    Emphasis on:

    Vital Signs
    Head: Evidence of Trauma
    Neck: Bruits
    Heart: Murmurs, rhythm
    Abdomen: Masses / Distention
    Skin / Scalp: Lesions / Tenderness

    MUST HAVES:

    Neurological
    hammer
    Pen light
    Pin / cotton
    Tongue depressor
    Stethoscope
    BP apparatus

    NICE TO HAVE:

    Ophthalmoscope
    Tuning Fork
    Pocket Snellen

    1.
    2.
    3.
    4.
    5.
    6.
    7.

    Mental Status Exam


    Cranial Nerves
    Motor Exam
    Sensory Exam
    Reflexes
    Cerebellar Exam
    Meninges

    Do the neurological examination in an


    orderly fashion.
    Finish the examination for one system
    before starting another.
    Always examine the left and the right
    side of the body and compare.
    Compare proximal against distal
    findings.

    1. Level of Alertness, Attention


    and Cooperation
    Awake, drowsy, stuporous, comatose
    Best response
    Spelling a short word forward and
    backward (W-O-R-L-D / D-L-R-O-W is a
    standard or naming the 12 months forward
    and backward )

    2. Orientation
    Person
    Place
    Time

    3. Memory
    Immediate
    recall
    Recent Memory
    Remote
    Memory

    4. Language
    Spontaneous speech
    Comprehension
    Naming
    Repetition
    Reading
    Apahasia

    Brocas
    Transcortical
    Wernickes
    Global
    Conduction

    5. Calculations, RightLeft Confusion, Finger


    Agnosia, Agraphia*
    Addition, subtraction,
    multiplication, division
    exercises
    Identify right and left body
    parts
    Name and identify each
    digit
    Write the name and a
    sentence

    * Gerstmann's syndrome
    dominant parietal lobe

    6. Apraxia
    Inability to follow a
    motor command that
    is not due to a primary
    motor deficit or a
    language impairment
    Ideomotor apraxia
    left inferior parietal
    lobe lesion
    Constructional Apraxia
    non-dominant
    parietal lobe lesion
    Dressing Apraxia

    7. Neglect and
    Constructions
    Hemineglect
    Extinction on double
    simultaneous
    stimulation
    Construction tasks
    involving drawing
    complex figures or
    manipulating blocks
    Anosognosia inability
    to recognize ones body
    part (non-dominant
    parietal lobe lesion)

    8. Sequencing
    Tasks and Frontal
    Release Signs
    Continue drawing a
    silhouette pattern of
    alternating triangles
    and squares
    Frontal release signs:
    the grasp, root, and
    suck reflexes
    Abulia

    9. Logic and
    Abstract thinking
    Simple problem
    solving
    Proverb
    interpretation
    Similarity
    comprehension
    e.g. how are a car
    and an airplane
    alike?

    FRONTAL LOBE:
    Abstract thinking and
    logic
    Speech - Brocas area
    Sequencing Tasks and
    Frontal Release Signs
    Concentration
    Emotional expression
    (abulia, apathy)

    TEMPORAL LOBE:
    DOMINANT:
    Wernickes area
    Memory,learning, orientation,
    hearing
    NON-DOMINANT:
    Prosopagnosia (recognizes
    persons by pictures)
    Music, hearing

    PARIETAL LOBE
    DOMINANT :
    Calculations, Right-Left Confusion,
    Finger Agnosia, Agraphia
    Naming,reading,stereognosis,
    graphesthesia, somatognosia
    NON-DOMINANT :
    Apraxia, neglect, constructions
    Stereognosis, graphesthesia

    OCCIPITAL
    LOBE:
    Identify
    objects and
    colors

    Use at least 3 substances


    Do not use alcohol or
    perfume
    Cover one nostril
    Ask the px to close his/her
    eyes
    While occluding each nostril,
    patient is asked to sniff and
    identify various odorants
    Unilateral anosmia
    hippocampus problem

    A. Visual Acuity

    Snellens or Jaeger
    chart
    Pinhole

    B. Visual Fields

    Confrontation test

    C. Funduscopy

    Red orange reflex


    Media clear, hazy
    Disc borders distinct, blurred
    Cup disc ratio = 0.4 0.5
    Arteriole/Venule ratio (AVR) =
    2:3

    Hemorrhages, Exudates

    Papilledema

    D. Pupillary Reflex

    Afferent arm :optic nerve


    Efferent arm: oculomotor
    nerve
    effector organ: pupillary
    constrictor muscle
    direct & consensual

    CN III: MR, SR, IR, IO, levator palpebrae


    CN IV: Superior oblique
    CN VI: Lateral rectus

    Mixed nerve
    Sensory: corneal reflexes

    Stimulate the corneoscleral junction


    Afferent arm CN V
    Efferent CN VII
    Effector ms orbicularis oculi

    Sensory V1, V2, V3


    Test pain, temperature, vibration,
    light touch
    Compare areas
    Report in %

    Motor: jaw strength and muscle


    bulk (masseter, temporalis)

    Mixed nerve, predominantly


    motor
    Sensory: Taste anterior 2/3 of
    tongue
    Motor

    Smile
    Bury eyelashes
    Nasolabial fold
    Forehead has bihemispheric
    innervation centrally

    Central Vs Peripheral facial palsy

    CENTRAL FACIAL PALSY

    PERIPHERAL FACIAL PALSY

    Gross hearing
    Weber
    No lateralization

    Rinne
    Compare air conduction
    and bone conduction length
    AC>BC
    Normal
    Sensorineural hearing loss
    both are decreased

    BC>AC
    Conductive hearing loss

    Taste / sensation
    posterior pharynx
    Swallow
    Gag reflex
    Without gag but
    can swallow
    normal CN IX & X

    Sternocleidomas
    toid - chin to the
    opposite side

    Trapezius raise
    shoulder

    Tongue
    Stick out tongue
    Tongue receives
    bilateral innervation
    from R and L CN XII
    Tongue deviated
    towards R - problem
    on R CN XII
    Check for atrophy and
    fasciculations

    Inspection: bulk, fasciculations


    Palpation: tenderness
    Tone
    Hypertonia: subacute or chronic corticospinal lesion
    Hypotonia: LMN lesion or acute UMN
    Rigidity: basal ganglia disease

    Muscle testing
    Primary concern: can patient breathe
    Key test: drift of extremity
    Check both distal and proximal muscles

    Grading:

    0 - No muscle contraction is detected


    1 - A trace contraction is noted in the muscle by
    palpating the muscle while the patient attempts to
    contract it.
    2 - The patient is able to actively move the muscle when
    gravity is eliminated.
    3 - The patient may move the muscle against gravity but
    not against resistance from the examiner.
    4 - The patient may move the muscle group against
    some resistance from the examiner.
    5 - The patient moves the muscle group and overcomes
    the resistance of the examiner. This is normal muscle
    strength

    Deltoid

    Biceps

    Wrist flexors

    Finger flexors

    Triceps

    Thumb add.

    Finger abd.

    Dorsiflexors

    Hip flexors
    Hip abductors

    Plantarflexors

    Hip extensors

    Hip adductors

    Knee flexors

    Toe extensor

    Pain, Temperature: Lateral spinothalamic tract


    Light touch, Pressure: Anterior spinothalamic tract
    Vibration, joint position sense: Dorsal column
    Medial lemniscal system

    Cortical sensation

    Graphesthesia

    2 point Discrimination:
    2-4 mm fingertips
    4-6 mm dorsum of fingers
    8-12 mm palm
    20-30 mm dorsum of hand

    Stereognosis

    Tactile Extinction

    REFLEXES GRADING
    4+ Very brisk, hyperreflexive, with clonus
    3+ Brisker or more reflexive than normally.
    2+ Normal
    1+ Low normal, diminished
    0
    No response

    Biceps
    brachii
    tendon
    reflex

    C5-6

    Triceps
    tendon
    reflex

    C6-8

    Brachioradia
    lis tendon
    reflex

    C5-7

    Patellar
    tendon
    reflex

    L2-4

    Corneal CN V, CN VII
    Pharyngeal CN IX, X
    Abdominal - T6-9, T10-12
    Beevors sign

    Anal S2-4
    Cremasteric L1-2
    Bulbocavernosus S3-4

    Babinski
    Chaddock
    Oppenheim
    Gordon
    Schaefer
    Hoffman
    Myersons sign

    Requires integration of cerebellar, motor, and


    sensory functions
    1. Appendicular Coordination
    Rapid alternate pronation & supination

    Dysdiadochokinesia

    Ask patient to tap distal joint of thumb with tip of index


    finger
    Ask patient to tap your hand quickly with the ball of each
    foot in turn

    2. Point-to-point movements
    Finger-to-nose pointing
    Dysmetria

    Heel-to-shin movement

    3. Stance
    With feet apart, then closed together
    With eyes open, then eyes closed

    4. Gait
    Ask patient to walk across the room then turn and come
    back
    Ataxia when gait lacks coordination and unstable

    Tandem Walking
    Walk Heel-to-toe in a straight line
    Walk on toes, then on heels

    5. Nystagmus
    Refers to involuntary rhythmic movements of
    the eyes
    Reflects an imbalance in one or more of the systems
    that maintain stability of gaze:
    Cerebellum and vestibular system

    Supple or rigid neck


    Kernigs
    Brundzinskis

    Not getting a complete history utilizing


    family or observers
    Not performing a systematic exam
    Jumping to conclusions before gathering all
    the data
    Misinterpreting old lesions for new
    Misinterpreting limitations from pain as
    neurologic deficits

    Lesions of the cerebral cortex and internal capsule


    (supratentorial) sensory and motor defects confined to the
    contralateral side of the body

    Brain stem and spinal cord lesions ipsilateral as well as


    contralateral defects due to varying patterns of crossover

    Unilateral pain syndromes without motor deficits thalamic


    pathology

    A careful exam of CN II, III, IV and V is indicated in patients with


    headache or suspected processes that cause increased ICP

    Testing for pronator drift is the best screen for muscle weakness
    of central origin

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