Neurological Examination Charles University in Prague 1st Medical Faculty and General University Hospital
Neurological examination: Why important? clinical history taking and bedside examination: classical core features of neurology remain key aspects of making a diagnosis, despite recent availability of many ancillary tests (CT, MRI, ultrasound, specific laboratory tests including searching for specific autoantibodies and gene mutations) the indication and appropriate selection for many of these ancillary tests depends on a clinical working hypothesis... that risks to be wrong without a proper previous examination
Clinical history the first step in virtually every clinical encounter allows the clinician to define the patient's problem and to proceed with a more effective physical examination history of the presenting illness or chief complaint Onset of symptoms (eg, acute, subacute, chronic, insidious) Duration Course (eg, static, progressive, transient, or relapsing and remitting) Associated symptoms (eg, pain, headache, nausea, vomiting, vertigo, numbness, weakness, seizures) Precipitating factors (stress, periods, allergens, sleep deprivation, etc) Relieving factors (sleep, stress management, etc) Diurnal or seasonal variation
Clinical history the first step in virtually every clinical encounter allows the clinician to define the patient's problem and to proceed with a more effective physical examination history of the presenting illness or chief complaint Onset of symptoms (eg, acute, subacute, chronic, insidious) Duration Course (eg, static, progressive, transient, or relapsing and remitting) Associated symptoms (eg, pain, headache, nausea, vomiting, vertigo, numbness, weakness, seizures) Precipitating factors (stress, periods, allergens, sleep deprivation, etc) Relieving factors (sleep, stress management, etc) Diurnal or seasonal variation
Clinical history Previous medical interventions Results of previous attempts to diagnose the condition Any previous therapeutic interventions and response to them General medical history focus on relevant information regular medication alcohol, substance abuse etc. Family history focus on relevant information
Clinical exam: Two ways of approaching the patient hypothesis-driven focused neurological examination experienced neurologist in a busy practice the more experienced examiner, the more selective and hypothesis-driven the examination may be general screening neurological examination more time consuming, but unbiased should be preferred by students and young residents much time can be saved and costly or even invasive procedures may be avoided if the diagnostic hypothesis is generated in a logical way following an unbiased exam
Screening neurological examination: 22 items patient position: sitting 1. Consciousness, orientation, memory and behavior 2. Speech and articulation 3. Visual field 4. Eye movements and pupillary reaction 5. Facial movements 6. Tongue movements 7. Upper limb muscle tone 8. Upper limb muscle strength 9. Bicipital reflex (C5) 10. Tricipital reflex (C7) 11. Pronator sign 12. Finger-to-nose test
Screening neurological examination: 22 items patient position: supine 13. Lower limb muscle tone 14. Lower limb muscle strength 15. Patellar reflex 16. Achilles tendon reflex 17. Mingazzini sign 18. Babinski sign (plantar response) 19. Heel-to-knee test 20. Sensory testing patient position: standing 21. Romberg sign 22. Gait
Consciousness, Orientation, Memory, and Behavior Brief assessment of vigilance, attention, orientation to person, time and place. 1) What is today s date? What day of the week is it? 2) Where are you? 3) How old are you? 4) Where do you live? Assess memory and behavior.
Brief assessment: Speech and Articulation Language, possible aphasia (fluency, verbal content, word selection, phrase length, comprehension). Speech (volume, phonation, articulation, intelligibility, melody).
Visual Field Testing Sit or stand about 1 meter away from and opposite to the patient and have him/her fixate your nose consistently. Stretch out your arms sideways half way between you and the patient in the upper quadrant fields to a position where you can still see your fingers well. Then move your fingers slowly on one and the other side and on both sides simultaneously and have the patient name the side of movement. Your own visual field is the control. Then repeat the exam in the lower quadrant fields.
Eye Movements Instruct the patient to follow a moving object (finger, hammer) at 1m distance in both horizontal and vertical directions ( cross ) without moving the head (ask the patient to put one finger on his chin). Observe potential nystagmus, assess range and speed of the eye movements. Ask about diplopia. Assess pupillary width, symmetry and reactivity to light.
Facial Movements Facial expression and symmetry. Movements of muscles in the upper and lower branch of facial nerve: Ask the patient to look up or wrinkle his forehead; inspect for asymmetry. Ask him to close his eyes tightly. Look for incomplete closure or incomplete closure of eyelashes on the affected side. Ask the patient to smile, show his teeth, or pull back the corners of the mouth. Look for asymmetry about the mouth.
Tongue Movements (CN XII) Tongue at rest. Protruding tongue. Assess atrophy and fasciculation.
Upper Limb Muscle Tone Resistance to passive movement in both the wrist and elbow. Rigidity: Slowly move the joint in both directions. Spasticity: Fast flexion or extension of a selected joint (e.g. elbow or knee) to elicit a sudden increase in tone.
Upper Limb Muscle Strength Test proximal and distal muscle groups: 1. Have the patient flex at the elbow. Provide resistance as he tries to elevate abduct his arms. 2. Ask the patient to make a fist, squeezing his hand around two of your fingers. Test both hands simultaneously. Ask him to apply maximum strength. Assess power and symmetry.
Deep Tendon Reflexes Biceps reflex(c5) Semi-flexed elbow, forearm supported, patient s muscles relaxed. Tap the biceps tendon with reflex hammer. Assess elbow flexion response and symmetry.
Deep Tendon Reflexes Triceps reflex (C7) Passive abduction in shoulder and semi-flexed elbow, muscles relaxed. Tap the triceps tendon above the olecranon ulnae. Assess forearm extension response and symmetry.
Upper Motor Neuron Weakness Signs Pronation (Dufour) Sign Both arms stretched forward, forearms in supine position, eyes closed. Observe forearm pronation and/or arm decline.
Cerebellar Ataxia Signs Finger-to-Nose Test Instruct the patient to point with his finger to his nose and to your finger. Note precision and continuity of movement.
Lower Limb Muscle Tone Resistance to passive movement in the ankle and knee. Rigidity slow movement. Spasticity swift movement.
Lower Limb Muscle Strength Test proximal and distal muscle groups. 1) Hip flexion the patient is seated and instructed to elevate one leg. 2) Ankle dorsal and plantar flexion. Patient applies maximum strength against resistance. Assess power and symmetry.
Deep Tendon Reflexes Patellar Reflex (L2 - L4) Have the patient s knee flexed and quadriceps muscle relaxed, support the back of his thigh. Tap the patellar tendon just below the patella. Assess knee extension response and symmetry.
Achilles Tendon (L5 - S2) (Deep Tendon Reflex) Have patient with semi-flexed lower limbs, hold his foot with your hand at a 90⁰ angle. Tap the Achilles tendon. Assess plantar flexion response and symmetry.
Upper Motor Neuron Weakness Signs Mingazzini Sign Patient s thighs are bent 90 degrees, calves held horizontal, limbs not touching each other. Observe any decline of the limb.
Upper Motor Signs Babinski Sign Scratch the lateral border of the patient s sole, by starting near the heel and moving up above the metatarsal heads towards the big toe. Use a pointed but not-too-sharp object (eg. a wooden stick). Look for extension of the big toe.
Cerebellar Ataxia Signs Heel-Knee-Shin Test Eyes closed and legs stretched, the patient is instructed to place the heel of one foot on the other knee and run it straight down his shin to the ankle. Note precision and continuity of movement.
Sensory Testing Touch the face, dorsal forearm and hand, thigh and shin, left and right side. Ask the patient to refer feeling a/symmetry.
Stance and Romberg Sign Assess normal stance (I). Then ask the patient to stand with feet together (II), and then to close his eyes (III). Observe instability in 20 sec after closing the eyes. Note wider base and/or any side steps. Minor instability and oscillations with no side steps is normal.
Gait Evaluate the patient walking over at least 3 m, then ask him to turn and come back. Assess the body posture, base width, step length, speed, symmetry, arm swing, turning (instability, freezing).
Basic terms symptom: any subjective evidence of disease = taken from history sign: any objective evidence of disease = resulting from clinical neurological examination syndrome: a combination of symptoms and signs that characterize a particular condition (nervous system lesion location, a particular disease)
Feature Deep tendon reflexes Muscle tone Lower motor neurone Upper motor neurone Muscle weakness + + Plantar response (Babinski) - + Sensory loss + + Muscle wasting + - (late, inactivity) Fasciculations + -
That s all for today Tomorrow you will examine your first patient with your own reflex hammer (hopefully) ENJOY NEUROLOGY