Neurological examination two pdf - عملي

The Basic Neurologic

Examination

Sally De Castro Tilsen, P.A.-C, MSCS
Hoag Neuroscience Center and
MS Center of Southern California
Newport Beach, California

OBJECTIVES:

Understanding the importance of the basic

neurologic history and examination

• To Teach How to Conduct a Basic Neurologic

Examination

• Review the Use of Instruments Needed for a Complete

• Review Specific Clinical Testing and Techniques
• Discuss Abnormal Findings
• Learn How to Conduct Specific Tests for the Following

Disorders:

Dementia
Multiple Sclerosis
Parkinson’s Disease

A mechanic does not need to use every tool on every project

Tools of the Trade

•

Steel measuring tape

•

Stethoscope

•

Flashlight

•

Ophthalmoscope

•

Tongue blades

•

Vials of coffee, salt, sugar

•

Cotton wisp

•

Two stopped tubes

•

Disposable straight pins

•

Reflex hammer

•

Penny, nickel, dime, key

•

Blood pressure cuff

•

Forms for various tests

http://www.cbu.edu/~mcondren/IRM/Stop-Look-Listen-sign-IRM-7-7-07.jpg

Take a Good HISTORY

• Much of the NE comes from the History
• Assess the Pts. word articulation, content of speech,

and overall mental status.

• Inspect facial features.
• Inspect eye movements, facial movements and any

asymmetry.

• Observe how a Pt. swallows saliva and breathes.
• Inspect the posture, look for tremors
• The history and observation can help you focus on

specific systems: motor, sensory, cranial nerves or
cerebral functions.

Neurologic Examination

• Mental Status Exam

• Cranial Nerve Examination

• Motor Examination

• Reflexes

• Sensory

• Coordination

• Gait

MENTAL STATUS

Outline of Mental Status

Examination

• General behavior and appearance

• Stream of talk

• Mood and affective responses

• Content of thought

• Intellectual capacity

• Sensorium

Level of Consciousness

• Awake and alert

• Agitated

• Lethargic

– Arousable with

• Voice

• Gentle stimulation

• Painful/vigorous stimulation

• Comatose

ORIENTATION

• PERSON

– NOT WHO THEY ARE BUT WHO YOU ARE

• PLACE

• TIME

LANGUAGE

• FLUENCY

• NAMING

• REPETITION

• READING

• WRITING

• COMPREHENSION

Aphasia vs. dysarthria

Mental Status Exam

• Family story of memory loss

• Orientation

• General Information

• Spelling &/or numbers

• Recognition of objects

Mental Status Exam

• When there is a history of cognitive decline

• What tests?

– Mini-mental State Examination

– Halstead-Reitan Performance Test

– Full Cognitive and Neuropsychological testing

CRANIAL NERVES

CRANIAL NERVE EXAM

• I - OLFACTORY

– DON’T USE A NOXIOUS STIMULUS

– COFFEE, LEMON EXTRACT

• II - OPTIC

– VISUAL ACUITY

– VISUAL FIELDS

– FUNDOSCOPIC EXAM

C.N. 1 (olfactory)

• Each nostril separately

– non-irritating substances : ideally coffee/aromatic oils;

practically soap/toothpaste

• Anosmia

(olfactory)

vs. Ageusia

(taste)

• First consider nasal disorders

C.N. II (optic)

• Ophthalmoscopy:

– Optic atrophy, papilledema

• Visual acuity

– Snellen chart or

– Hand-held card

Color Vision

C.N. II (optic)

• Visual fields

– Outline perimetry : misses relative defect or inattention

– Other confrontation

techniques(Beck):

Pupillary reflexes (CN 2 & 3)

• Eyes looking in the distance, bright light

• “ Swinging flashlight test “

– e.g. is there a relative afferent pup. defect?

– a sensitive test for optic neuropathy

• Horner syndrome (oculo-sympathetic)

– miosis, ptosis, anhydrosis

CRANIAL NERVE EXAM

• III/IV/VI OCULMOTOR, TROCHLEAR,

ABDUCENS

– PUPILLARY RESPONSE

– EYE MOVEMENTS

• 9 CARDINAL POSITIONS

– OBSERVE LIDS FOR PTOSIS

• V - TRIGEMINAL

– MOTOR - JAW STRENGTH

– SENS - ALL 3 DIVISIONS

CN 3, 4 , 6

• Parasympathetic (pupillo-constrictor) in CN 3

• CN 3,4,6 are under “central” control; Ex:

– Medial longitudinal fasciculus

Internuclear ophthalmoplegia: ipsilateral eye fails to adduct,
contra lateral eye shows nystagmus

– Frontal eye fields

Tend to direct gaze contra laterally : with a frontal lesion,

eyes are deviated ipsilaterally (“towards the lesion”)

Extraocular movements

C.N. 5 (trigeminal)

• Test light touch and/or pinprick in 3 divisions

• Corneal reflex

– cotton / kleenex on cornea (not conjunctiva)

– Avoid visual threat

• Palpate contracting masseter & temporalis m

• Jaw jerk

C .N. VII

Special visceral
efferent

frontalis, corrugator,
orbicul oris & ocul.
Buccin., platysma
stapedius

inspect facial muscles
> 8 maneuvers
e.g. raise eyebrows
smile, frown, etc.

General visceral
efferent

lacrimal gland
submandigular gland

inspect eye
Schirmer test

Special visceral
afferent

taste buds
anterior 2/3 tongue

test taste
salt, sugar, acetic a.
& quinine solutions

General somatic
afferent

external ear

test light touch
in post ext. ear canal

CRANIAL NERVES

• VII - FACIAL

– OBSERVE FOR FACIAL ASYMMETRY

– FOREHEAD WRINKLING, EYELID CLOSURE,

WHISTLE/PUCKER

• VIII - VESTIBULAR

– ACUITY

– RINNE, WEBER

Rinne test

CRANIAL NERVES

• IX/X - GLOSSOPHARYNGEAL, VAGUS

– GAG

• XI - SPINAL ACCESSORY

– STERNOCLEIDOMASTOID M.

– TRAPEZIUS MUSCLE

• XII - HYPOGLOSSAL

– TONGUE STRENGTH

– RIGHT XII THRUSTS TONGUE TO LEFT

C.N. 9 & 10

• Is there dysphonia?

• Assess palatal movement with phonation

• IF

there is dysarthria, dysphagia, dysphonia:

– Test gag reflex

C.N. 11 (spinal accessory)

• Two muscles:

– trapezius: shoulder shrug ; abduction of arm beyond

90 degrees

– sternocleidomastoid: turn chin to opp shoulder

C.N. 12 (hypoglossal)

• Inspect tongue at rest

– atrophy, fasciculations

• Tongue protrusion

– deviation towards paretic side

MOTOR EXAMINATION

Motor Examination

STRENGTH

• STRENGTH

– GRADED 0 - 5

– 0 - NO MOVEMENT

– 1 - FLICKER

– 2 - MOVEMENT WITH GRAVITY REMOVED

– 3 - MOVEMENT AGAINST GRAVITY

– 4 - MOVEMENT AGAINST RESISTANCE

– 5 - NORMAL STRENGTH

STRENGTH EXAM

• UPPER AND LOWER EXTREMITIES

• DISTAL AND PROXIMAL MUSCLES

• GRIP STRENGTH IS A POOR SCREENING

TOOL FOR STRENGTH

• SUBTLE WEAKNESS

– TOE WALK, HEEL WALK

– OUT OF CHAIR

– DEEP KNEE BEND

MUSCLE OBSERVATION

• ATROPHY

• FASCIULATIONS

TONE

• INCREASED, DECREASED, NORMAL

• COGWHEELING

• CLASP KNIFE

ABNORMAL MOVEMENTS

• TREMOR

– REST

– WITH ARMS OUTSTRETCHED

– INTENTION

• CHOREA

• ATHETOSIS

• ABNORMAL POSTURES

CEREBELLAR FUNCTION

• RAPID ALTERNATING MOVEMENTS

• FINGER TO FINGER TO NOSE TESTING

• HEEL TO SHIN

• GAIT

– TANDEM

Romberg Sign

• Stand with feet together - assure patient

stable - have them close eyes

• Romberg is positive if they do worse with

eyes closed

• Measures

– Cerebellar function

– Frequently poor balance with eyes open and

closed

– Proprioception

– Frequently do worse with eyes closed

– Vestibular system

Gait:

• Normal Walking

• Toe Walking

• Heel Walking

• Inversion Walking

• Eversion Walking

• Tandem Walking

• Romberg

Gait Evaluation

• Include walking and turning

• Examples of abnormal gait

– High steppage

– Waddling

– Hemiparetic

– Shuffling

– Turns en bloc

REFLEXES

MUSCLE STRETCH REFLEXES

(DEEP TENDON REFLEXES)

• GRADED 0 - 5

– 0 - ABSENT

– 1 - PRESENT WITH REINFORCEMENT

– 2 - NORMAL

– 3 - ENHANCED

– 4 - UNSUSTAINED CLONUS

– 5 - SUSTAINED CLONUS

MSR / DTR

• BICEPS

• BRACHIORADIALIS

• TRICEPS

• KNEE

• ANKLE

OTHER REFLEXES

• Upper motor neuron dysfunction

– BABINSKI

• present or absent

• toes downgoing/ flexor plantar response

– HOFMAN’S

– JAW JERK

• Frontal release signs

– GRASP

– SNOUT

– SUCK

– PALMOMENTAL

SENSORY EXAM

• VIBRATION

– 128 hz tuning fork

• JOINT POSITION SENSE

• PIN PRICK

• TEMPERATURE

Start distally and move proximally

HIGHER CORTICAL SENSATIONS

• GRAPHESTHESIA

• STEREOGNOSIS

• DOUBLE SIMULTANEOUS STIMULATION

• BAROSTHESIA

• TEXTURES

Mini-Mental State Examination

Halstead-Reitan Battery Test

Cognitive Impairment

Expanded Disability

Status Scale

Neurostatus scoring

For Multiple Sclerosis

EDSS:

Scoring to Quantify Impairment

Associated with Multiple Sclerosis

7. Kurtzke JF. Neurology. 1983;33:1444-1452.

0 = Normal neurologic exam

1.0-1.5 = No impairment

2.0-2.5 = Impairment is minimal

3.0-3.5 = Impairment is mild to moderate

4.0-4.5 = Impairment is relatively severe

5.0-5.5 = Increasing limitation in ability to walk

6.0-6.5 = Walking assistance is needed

7.0-7.5 = Confined to wheelchair

8.0-8.5 = Confined to bed/chair; self-care with help

9.0-9.5 = Completely dependent

10.0 = Death due to MS

Unified Parkinson’s

Disease Rating Scale

Comprehensive

Parkinson’s Disease Tool

References

• The Technique of the Neurologic Examination

by W. DeMyer, 2004, McGraw Hill, 5

edition

• Basic Clinical Neuroscience by P. Young, P.H.

Young, D. Tolber, 2008, Lippincott, Williams and
Wilkins

• Neurology for Dummies, 2008

• Neuroanatomy Through Clinical Cases, Hal

Blumenfeld, 2010