Presentation Transcript

1. Neurological Examination Indiana University Department of Neurology

2. OverviewLearn / do in organized sequence • General • Vital signs: wt, pulse , BP, temp ( respirations) • Skin for café au lait, meningococcal purpura, splinter hemorrhages • Measure OFC ( head size) in kids • Listen for bruits in neck ( carotid or vertebral arteries) • Neurological exam • Mental status • Cranial nerves • Motor exam • Cerebellar • Sensory • Station & Gait

3. Mental Status • Level of consciousness • Alert • Sleepy but awakens to verbal prompting ( Lethargic) • Unresponsive to painful stimuli ( Comatose) • Orientation • To person, place, time, situation • Speech & Language • Normal • Dysarthric (slurred, nasal) • Use of language in symbolic sense • Fluency, comprehension, repetition • Aphasia: expressive (Broca)/ receptive (Wernicke)

4. Mental Status • Parietal Functions • Spatial orientation ( R /L) • Construction • Calculation • Stereognosis • Gnosis (awareness) agnosagnosia

5. CN I Olfactory nerve • Check each nostril individually with patient’s eyes closed • Use coffee, mint, vanilla, clove • Not ammonia (checks V2) • Anosmia in • head trauma • frontal lobe tumor • Parkinson’s & Alzheimer’s

6. Optic System: Overview Functions: • Data acquisition & transmission • Camera control • Eye lids • Eye movements • Focus

7. CN II Optic nerve • Visual acuity • Visual fields • Pupillary light reflex • CN 2 Afferent • CN 3 Efferent • Funduscopic exam

8. Visual acuity • Visual acuity • Corrected (with glasses) • OS left • OD right • Ask patient to start at top read down the chart • VA is last line read correctly

9. Visual fields • Pt looks at your forehead • Check each eye alone • Keep equidistance between you and patient • Count fingers in the 4 visual field quadrants • Bring in your finger inward from beyond your periphery to define pts field

10. Pupillary light reflex • Direct and consensual • Observe pupil size ( mm) • Shine light into eye from off center • Observe for pupillary constriction in stimulated & opposite eye Accomodation • As pt looks at close target; eyes converge and pupils constrict • Relative afferent pupillary defect (RAPD) • Light in abnl eye after good eye shows pupil dilation rather than constriction • Present with optic nerve lesions

11. Relative afferent pupillary defect

12. Fundoscopy (ophthalmoscope) • Optic disk ( optic nerve head) • Retinal vessels • Retina

13. CN II Optic Nerve Normal Papilledema

14. CN III (oculomotor), IV (trochlear), VI (abducens) • Are the eyes conjugate • Puplliary function • Evaluate motility • Horizontal • Vertical • Oblique • Disorders • Nerve ( nucleus) • Intra-nuclear • Supra-nuclear

15. Extraocular muscles and their actions • CN III (Oculomotor nerve) • Superior rectus: • elevation when the eye is aBducted • Inferior rectus: • depression when the eye is aBducted • Medial rectus: aDduction • Inferior oblique: • elevation when the eye is aDducted • CN IV (Trochlear nerve) • Superior oblique: • depression when the eye is aDducted • CN VI (Abducens nerve) • Lateral rectus: aBduction

16. CN III—lesion causes eye motility problems, ptosis and mydriasis (enlarged pupil) • Third nerve palsy • Eye is “down and out” • Pupil abnormal Compression by uncal herniation or P-com aneurysm • Pupil normal Nerve infarction

17. Left IV nerve palsy • Left hypertropia • Right head tilt….What about the doll’s eyes?

18. INO (Internuclear ophthalmoplegia) Medial Longitudinal Fasciculus ( MLF) Lesion

19. CN V Trigeminal • Sensory to face and anterior scalp • Blink reflex • Motor to muscles of mastication (masseter/temporalis) • Test 3 divisions with cotton & pin • Jaw jerk reflex

20. CN VII -Facial nerve • Squeeze eyelids closed (like soap in eyes) • Raise eyebrows • Smile / pucker • Sneer (platysma) • Taste

21. Facial Nerve VII relaxed

22. Facial Nerve VII contraction

23. Corneal reflex afferent 5; efferent 7

24. CN VIII Vestibulo-cochlear Two divisions: • Vestibular: head motion sensing • Vertigo / nystagmus / veering gait • Cochlear: • Auditory acuity finger rustle / ticking watch • Rinne test: use tuning fork & compare perception of sound via bone and air. In a normal ear air conduction > than bone conduction. • Weber test: tuning fork on the patients forehead. Normal: patient hears sound equally in both ears. .

25. CN IX Glossopharyngeal& X Vagus • Palatal elevation • Gag reflex (sensory & motor) • Laryngeal function

26. CN XI -- Spinal Accessory • SCM--Right SCM turns head to the left • Trapezius Raise shoulders

27. CN XII Hypoglossal • Inspect bulk of tongue • Protrude tongue • midline vs deviation to one side • Ask to press tongue against inside of cheek • Tongue deviates to the weak side

28. Motor Exam • Inspection • atrophy, hypertrophy, fasciculation • Involuntary movements • tremor, chorea, dystonia, myoclonus, myotonia • Muscle Tone (resistance to passive movement) • Hypotonia (floppy) • Hypertonia • Spasticity Clasp-knife • Rigidity (Lead pipe) • Strength (grade 0 to 5) • 0/5 no contraction, 3/5 overcomes gravity, 5/5 normal • Muscle stretch reflexes (0-4+) r” • Plantar response: flexor or extensor (Babinski)

29. Upper versus Lower motor neuron lesions Sign UMN LMN Atrophy +/- yes Weakness yes yes Fasciculations no yes Muscle tone inc dec Reflexes inc dec

30. Motor Exam Atrophy of intrinsic hand muscles Calf muscle hypertrophy

31. Check strength proximal to distal • shoulder abduction (deltoid) • elbow flexion/extension • wrist flexion/extension • finger flexion/extension • finger abduction/adduction • hip flexion, abduction/adduction • knee extension/flexion • ankle extension (dorsiflexion) / plantar flexion • toe extensors / flexors/ abductors

32. Muscle stretch reflexes Reflex Nerve root Biceps C5 & 6 Brachioradialis C5 Triceps C7 Knee ( quadriceps) L3 & 4 Ankle ( gastroc/soleus) S1 Masseter CN V

33. Muscle stretch reflexes (MSR) Usually graded 0 to 4 + 0 no response 1+ present but slight in magnitude 2+ present, easily observable 3+ present, “don’t stand in front of pt” 4+ present, recurrent contractions (clonus)

34. Testing for ankle clonus (4+)

35. Plantar reflex Toe flexion is normal. Toe extension is abnormal ( Babinski sign)

36. Superficial Abdominal Reflex Stroke anterior abdominal skin toward umbilicus Rectus muscles Contract in quadrant stimulated Other superficial reflexes

37. Tremor types • Resting tremor : present when limb is relaxed or not in active use • Parkinson’s & related disorders • Action / postural tremor :present when body part is in sustained posture ( holding phone, newspaper) • Physiological, familial • Intention tremor: present when limb actively / quickly being moved (eating, pointing, applying makeup) • Cerebellar lesions

38. Cerebellar Functions • Nystagmus (jerky eye movments) • Dysarthria (scanning / ataxic speech) • Finger-nose-finger • Rapid alternating movements (hands) • Heel -knee -shin • Tandem gait ( heel to toe walking) • Cerebellar testing requires cooperative patient

39. Cerebellar: finger-nose finger • Patient extends finger out to your finger • Then moves finger back to nose • The back to your finger • Repeat with your finger in different position

40. Cerebellar: finger to nose Pattern of dysfunction: • Actions break into jerky steps • Target may be missed (dysmetria) Guy in movie Airplane with the “drinking problem”

41. Cerebellar: heel to shin testing • Patient flexes hip to place heel to knee • Runs heel smoothly down the crest of tibial ( shin) to ankle • Abnormal: heel oscillates above knee & slips off shin

42. Sensory Examination Sensory Modalities: • Light touch* • Vibration* (dorsal column) • Pin* (spinothalamic) • Temperature (spinothalamic) • Position (dorsal column) * = most commonly performed in routine examinations

43. Sensory Examination Light touch • Use cotton ball • Patient closes eyes • Present stimulus & ask for response • Move from abnormal area to normal

44. Sensory Examination Vibration • Tuning fork ( 128 Hz preferred) • Apply stimulus to toe or finger • Yes / No response or have patient tell when vibration stops • If abnormal distally move proximally: ankle knee wrist elbow • Significance of deficits which split the forehead or chest

45. Sensory Examination Pin ( pain) sensation • Use safety pin or broken cotton swap stick • Ask patient to distinguish pin from opposite end of safety pin ( or your finger tip) • Identify abnormal areas and then find normal ones: distal / proximal vs dermatomal

46. Sensory Examination Position Sense • Use toes & fingers • Patient closes eyes • Move part from straight (neutral) position into either flexion (down) or extension ( up) • Patient reports direction of movement

47. Sensory Examination Temperature Sensation • Hot vs Cold Cold used more often • Tuning fork often used for this vs tube of cool water • Limb must be warm to properly test • Start distally & move proximally • Good for finding “spinal level” in cord lesions

48. Gait & Station Testing Causal walking & then heel to toe ( tandem) Observe: • Stride length • Smoothness of movement • Symmetry • Steadiness during turning

49. Gait & Station Standing (station) • Normal foot spread vs wide vs narrow normal width is feet directly under hips • Steady vs unsteady • Have patient move feet close together • Have patient close eyes • Worsening with eye closure is Rhomberg’s sign (sensory deficit)

50. Common Patterns of Abnormality • Foot slap: peroneal palsy / L5 radiculopathy • Spastic/scissoring: corticospinal tract lesion • Waddling: hip girdle weakness muscle diseases / dystrophy • Broad based: sensory or cerebellar • Short stepped with reduced arm swing: basal ganglia (parkinsons) • Non-organic patterns