Download Dr Jon Stone

Neurological Examination
RCPsych 2012 Liverpool
Jon Stone
Consultant Neurologist and
Honorary Senior Lecturer
Dept of Clinical Neurosciences
University of Edinburgh
Neurological Examination
 Myths about the Neurological Examination
 The Neurological Examination
– In 10 seconds
– In 1 minute
– In 2 minutes
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Special Situations
Things that are fairly useless
Pattern Recognition
Neuroanatomy ( a tiny bit)
The Seven Sins of Neurological Examination
The neurologist………
 “……a brilliant and
forgetful man with a
bulging cranium, a loud
bow tie, who reads
Cicero in Latin for
pleasure, hums Haydn
sonatas, talks with ease
about bits of the brain
you’d forgotten existed,
and - most importantly never bothers about
treatment”
 Richard Smith, BMJ
Editor, 1999
Myths about the neurological
examination
 MYTH 1 – Neurological Diagnosis is all
about Examination
Relative importance of History,
Examination and Tests in Neurology
History
Examination
Investigations
Blackouts
95%
2%
3%
Headache
95%
2%
3%
Paralysis
40%
30%
30%
Movement
Disorder
50%
40%
10%
I made these figures up!
What do neurologists do all day?
Diagnoses
% of new
outpatients
Headache
19%
All ‘psychological’ diagnoses
- Conversion Symptoms
16%
- 6%
Epilepsy
14%
Peripheral Nerve Disorders
11%
Multiple Sclerosis
7%
Movement Disorder
6%
Spinal Disorder
6%
Syncope
4%
Stroke
3%
(n=3781. Scottish Neurological Symptoms Study)
What do neurologists do all day?
Diagnoses
% of new
outpatients
History
Examination
Headache
19%
+++
0
All ‘psychological’ diagnoses
- Conversion Symptoms
16%
- 6%
++
+
Epilepsy
14%
+++
0
Peripheral Nerve Disorders
11%
++
+
Multiple Sclerosis
7%
++
+
Movement Disorder
6%
+
++
Spinal Disorder
6%
++
+
Syncope
4%
+++
0
Stroke
3%
++
+
(n=3781. Scottish Neurological Symptoms Study)
Relative Importance
Myths about the neurological
examination
 MYTH 1 – Neurological Diagnosis is all
about Examination
 MYTH 2 – You need to know a lot of
neuroanatomy
MYTH 2 – You need
to know a lot of
neuroanatomy
Myths about the neurological
examination
 MYTH 1 – Neurological Diagnosis is all
about Examination
 MYTH 2 – You need to know a lot of
neuroanatomy
 MYTH 3 – The neurological examination is
complicated
Myths about the neurological
examination
 MYTH 1 – Neurological Diagnosis is all
about Examination
 MYTH 2 – You need to know a lot of
neuroanatomy
 MYTH 3 – The neurological examination is
complicated
 MYTH 4 – I feel a bit of a fraud doing a
neurological examination because I’m a
psychiatrist
How useful is the neurological
examination?
• False positive and negative findings
• Poor inter-observer agreement (even
“experts”)
• Compressed neuro exam likely to amplify
all this
• Much neurological disease with normal
exam
The neurological examination
The 10 second neurological
exam
 Stand up, shut your
eyes, play the
piano, stand on
one leg
The 1 minute neurological exam
 Watch/listen during history
- Speech
- Abnormal movements
 Examination
- Pupils
- Fields – both eyes open
- Eye Movements
- ‘Show me your teeth’
- ‘Stick out your tongue’
- ‘Play the piano’
- Walk – normally and then heel to toe
2 minute neuro exam
 Test power in arms and legs
– Is it pyramidal, proximal, distal?
 Rapid Alternating Movements of the hands
 Knee Reflexes, Ankle Jerks, Plantars
 Confirmation of any sensory disturbance
given in history + tuning fork at both toes
Special Situations - Tremor / Slowness
 Tremor – hands on knees, action, postural
 Bradykinesia
–
–
–
–
–
–
Open and shut thumb and index finger
Facial expression
Tap your foot
Gait – pay attention to starting, turning and arm swing
Swing trunk in standing position
Postural reflexes
 Rigidity
Examining the unco-operative
patient
 Pupils
 ‘Menace’ to test fields
 Eye Movements - Wave hands / or move your own
face
 Look at face / tongue
 Pull arms (like arm wrestling) – then push
 OK to examine leg power in the sitting position
Special Situations - Other
 Speech - ‘Say P,P,P….L.L.L……K.K.K.K’ ‘Baby
hippopotamus’
 Motor Neurone Disease
–
–
–
–
Palmomental reflex
Tongue
Look carefully for fasciculations
Think of this in someone with frontotemporal dementia
 Myasthenia Gravis
– Weird eye movement problem with ptosis
– Repeated shoulder abduction
Special Situations - Other
 Back pain
– Pain on
- simulated rotation
- pressure on head
- During straight leg raising but not sitting on bed with legs
outstretched may indicate a ‘somatoform flavour’
 Both legs weak
– Look for a sensory level
 Proximal Weakness
– Fold your arms and stand up
– Standing from crouching
– Sitting from lying with arms folded
Less useful…
 Visual fields for individual eyes
 Rinne/Webers
- But do look in the ear!
 Romberg’s test
 Gag reflex
 A lot of sensory examination
Looking for patterns of weakness
 Pyramidal = UMN =
Corticospinal
 Extensors weakest in arms,
flexors weakest in legs
 e.g. Cerebral Palsy / Stroke
Looking for patterns of weakness
UMN
Pyramidal
Anterior Horn Wasting, fasciculation
Cell
Root
Root pattern
LMN
Muscle
Plexus
Plexus pattern
Nerve
Distal
Neuromuscular
Junction
Proximal
Proximal
Oh yes…Neuroanatomy
 Reflexes – count from 1 to 8.
– S1/2 (ankle), L3/4 (knee), C5/6 (biceps), C7/8 (triceps)
 Median / Ulnar nerve distribution
 Face involved or not – just mouth or whole face?
 Vibration sense and Proprioception go together
Seven Sins of Neurological Examination
 Just writing ‘Left side weak’
 Writing “CNS – NAD”
 Using ‘Neurolingo’ when a common sense
description would be better – eg shaking instead
of ‘tonic clonic’
 Having unrealistic expectations of what a
neurologist / neurological examination can
accomplish in depression / psychosis / dementia
 Finding an upgoing plantar / positive Romberg /
nystagmus
 Not owning / having access to a tendon hammer
and ophthalmoscope
 Doing too much examination when the history
doesn’t warrant it
Top 5 referrals from Psychiatry
Top 5 avoidable referrals:
at number 5
 “Please see this man with”
 Diagnosis : Syncope
Top 5 avoidable referrals:
at number 4
 “Please see this man who has
developed some numbness in a
patch on his thigh”
 Diagnosis : Meralgia Paraesthetica
Functional Hemiparesis
Top 5 avoidable referrals:
at number 3
 “Please see this 70 year old man with
a tremor which is worse when he
does things. There is a family history
but I’m worried about Parkinson’s
disease (and wondered if you would
suggest any treatment)”
 Diagnosis : Essential Tremor
Top 5 avoidable referrals:
at number 2
 “This patient has tingling in their 4th
and 5th finger with no weakness –
presumably due to ulnar neuropathy”
 Diagnosis: Ulnar Neuropathy
 Treatment : Stop leaning on elbows
Top 5 avoidable referrals:
at number 1
 “This patient has tingling in their
hands which wakes them up at night
and is worse when driving. Cervical
spine xr normal. Please see”
 Diagnosis: Carpal Tunnel Syndrome
Treatment : Wrist Splints at night and
wait