Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Neurology examinations Dr Massud Wasel M.D D.O. N.D Registered osteopath P.G.C.A.P Fellow of Higher Education Academy General rules Explain carefully to patient what you want them to do Ask patient to copy your action Compare one side with the other side Organize your examination into categories Mental state Cranial nerves Motor function Reflexes Coordination and gait sensation Equipments Pen torch Snellen eye chart Ophtalmoscope Tendon hammer Tunning forks 512 Hz and 128 Hz Cotton wool Neuropins Motor system Inspection: Body position :observe the patient’s body position during movement and at rest (hemiplegia in stroke) Involuntary movements :if present, observe location, quality, rate, rhythm, amplitude (tremor, fasciculations, tics, chorea) Size, shape of the limbs, asymmetry, deformity (joints muscles, bones), scars, colour of skin, T, texture, muscle wasting, fasciculation, hypertrophy and muscle myokimia Palpation of muscles look for tone, bulk (atrophy) Ensure that the patient is relaxed, and assess tone by alternately flexing and extending the elbow or wrist Muscle tone :assess resistance to passive stretch of arms and legs (spasticity, rigidity, flaccidity) Patient : to be warm and relaxed Avoid jerky movement and application of excessive force – pain, induction of spasm Compare both sides Start :proximal to distal or distally to proximal UEX C4 – T1 LEX L1 – S2 Hand shaking, flexion, extension, compare Standing: forearm flapping, compare Shaking of elbow, GH joint Supine: elevation of elbow, GH joint Muscle strength :test and grade the major muscle groups If a pyramidal weakness is suspected (i.e. a weakness arising from damage to the motor cortex or descending motor tracts Ask the patient to hold arms outstretched with the hand supinated for up to one minute. The eyes are closed (otherwise visual compensation occurs) The weak arm gradually pronates and drifts downwards With nerve root (LMN) essential to test individual muscle groups to localise the lesion When testing muscle groups, think of root and nerve supply Muscle strength Grades: 0 – No muscular contraction detected 1 – A barely detectable trace of contraction 2 – Active movement with gravity eliminated 3 – Active movement against gravity 4 – Active movement against gravity and some resistance 5 – Active movement against full resistance Upper limbs Test for Serratus anterior C5, C6, C7 long thoracic nerve Patient presses arms against the wall Look for winging of scapula Shoulder abduction : C5, C6 roots Axillary nerve Arm abducts against resistance Elbow flexion biceps C5, C6 roots Musculocutaneous nerve Arm flexed against resistance with the hand fully supinated Brachioradialis : C5, C6 Radial nerve Arm flexed against resistance with hand in semi position Elbow extension triceps C6, C7, C8 roots Radial nerve patient extends arm against resistance Finger extension extensor digitorum C7, C8 roots posterior interosseous nerve patient extends fingers against resistance Thumb extension—terminal phalanx extensor pollicis longus and brevis C7, C8 roots posterior interosseous nerve thumb is extended against resistance Finger flexion—terminal phalanx flexor digitorum profundus I and II: C7, C8 roots flexor digitorum profundus III and IV: C7, C8 roots ulnar nerve (examiner tries to extend patient’s flexed terminal phalanges Thumb opposition opponens pollicis: C8, T1 roots median nerve patient tries to touch the base of the 5th finger with thumb against resistance Finger abduction 1st dorsal interosseous: C8, T1 roots ulnar nerve abductor digiti minimi C8, T1 roots ulnar nerve Sensation PAIN: Pin prick with a sterile pin provides a simple method of testing this important modality Firstly, check that the patient detects the pin as ‘ sharp’ then rapidly test each dermatome in turn C7 extends down the middle finger If pin prick is impaired, then more carefully map out the extent of the abnormality, moving from the abnormal to the normal areas Light touch This is tested in a similar manner, using a wisp of cotton wool Temperature For additional information Use a cold object or hot and cold test tubes Joint position sense Hold the sides of the patient’s finger or thumb and demonstrate ‘up and down’ movements Repeat with patient’s eyes closed ask patient to specify the direction of movement Vibration Tunning fork 128 Hz Bony prominence If ipaired move more proximally and repeat Vibration testing is of value in the early detection of demyelinating disease and peripheral neuropathy, but otherwise is of limited benifit IF THE ABOVE SENSORY FUNCTIONS ARE NORMAL AND A CORTICAL LESION IS SUSPECTED, IT IS USEFUL TO TEST FOR THE FOLLOWING: Two point discrimination The ability to discriminate two points when simultaneously applied to the finger, 5 mm apart Sensory inattention The ability to detect stimuli (pin prick or touch) in both limbs , when applied to both simultaneously The ability to recognise objess placed in the hands STEREOGNOSIS The ability to recognise numbers or letters traced out on the palm GRAPHAESTHESIA Reflexes Biceps jerk C5, C6 roots . Musculocutaneous nerve Ensure patient’s arm is relaxed and slightly flexed. PALPATE THE BICEPS TENDON WITH THE THUMB AND STRIKE WITH TENDON HAMMER. Look for elbow flexion and biceps contraction. Supinator jerk C6,C7 roots. Radial Nerve Strike the lower end of the radius with the hammer and watch for elbow and finger flexion. Triceps jerk C6, C7, C8 roots. Radial nerve. Strike the patient’s elbow a few inches above the olecranon process. Look for elbow extension and triceps contraction. Hoffman reflex C7, C8 Flick the patient’s terminal phalanx, suddenly stretching the flexor tendon on release. Thumb flexion indicates hyperreflexia. ( May be present in normal subjects with brisk tendon reflexes). Reflex enhancement When reflexes are difficult to elicit, enhancement occurs if the patient is asked to ‘clench the teeth’ Scale for grading reflexes 4+ Very brisk, hyperactive, with clonus (rhythmic oscillations between flexion and extension) 3+ Brisk than average; possibly but not necessarily indicative of disease 2+ Average; normal 1+ Somewhat diminished; low normal 0 No response Co- ordination Inco-ordination (ataxia) is often a prominent feature of cerebellar disease. Prior to testing, ensure that power and proprioception are normal. Inco-ordination video Finger-nose testing Ask patient to touch his nose with finger (eyes open) Look for jerky movements- DYSMETRIA or an INTENTION TREMOR ( tremor only occurring on voluntary movement). Ask patient to alternately touch his own nose then the examiner’s finger as fast as he can. This may exaggerate the intention tremor and may demonstrate DYSDIADOCHOKINESIA- an inability to perform rapidly alternating movements. This may also be shown by asking the patient to rapidly supinate and pronate the forearms or to perform rapid and repeated tapping movements. video Arm bounce Downward pressure and sudden release of the patient’s outstretched arm causes excessive swinging. Rebound phenomenon Ask the patient to flex elbow against resistance. Sudden release may cause the face to strike the face due to delay in triceps contraction. Examination-TRUNK Test pin prick and light touch in dermatome Levels to remember: T5—at nipple T 10—at umbilicus T 12—at inguinal ligament Abdominal reflexes T 7-T12 roots Stroke or lightly scratch the skin towards the umbilicus in each quadrant in turn Look for abdominal muscle contraction and note if absent or impaired Reflexes may normally be absent in obesity, after pregnancy, or after abdominal operations Cremasteric reflexes L1, L2 root. Scratch inner thigh. Observe contraction cremasteric muscle causing testicular elevation. Sphincters Examine abdomen for distended bladder. Note evidence of urinary or faecal incontinence. Note tone of anal sphincter during rectal examination. Anal reflex S4, S5 root. A scratch on the skin beside the anus causes a reflex contraction of the anal sphincter. EXAMINATION – LOWER LIMBS MOTOR SYSTEM Appearance: Note: - asymmetry or deformity - muscle wasting - muscle hypertrophy - muscle fasciculation - muscle myokimia Tone Try to relax the patient and alternately flex and extend the knee joint. Note the resistance. Roll the patient’s legs from side to side. Suddenly lift the thigh and note the response in the lower leg. With increased tone the leg kicks upwards. Clonus Ensure that the patient is relaxed. Apply sudden and sustained flexion to the ankle. A few oscillatory beats may occur in the normal subject, but when this persists it indicates increased tone. Power When testing each muscle group, think of root and nerve supply. Hip flexion Ilio-psoas: L1, L2, L3 roots. Femoral nerve Hip flexed against resistance Hip extension Gluteus maximus: L5, S1, S2 roots. Inferior gluteal nerve Patient attempts to keep heel on bed against resistance Hip abduction Gluteus medius and minimus and tensor fasciae latae: L4, L5, S1 roots. Superior gluteal nerve Patient lying on back tries to abduct the leg against resistance Hip adduction Adductors: L2, L3, L4 roots. Obturator nerve Patient lying on back tries to pull Knees together against resistance Knee flexion Hamstrings L5, S1, S2 roots. Sciatic nerve Patient pulls heel towards the buttock and tries to maintain this position against resistance Knee extension Quadriceps: L2, L3, L4 roots. Femoral nerve Patient tries to extend knee against resistance Dorsiflexion Tibialis anterior: L4, L5 roots. Deep peroneal nerve Patient dorsiflexes the ankle against resistance. May have difficulty in walking on heels. Plantarflexion Gastrocnemius, soleus: S1, S2 roots. Tibial nerve Patient plantarflexes the ankle against resistance. May have difficulty in walking on toes before weakness can be directly detected Toe extension Extensor hallucis longus, extensor digitorum longus: L5, S1 roots. Deep peroneal nerve Patient dorsiflexes the toes against resistance Inversion Tibialis posterior: L4, L5 root. Tibial nerve Patient inverts foot against resistance Eversion Peroneus longus and brevis: L5, S1 roots. Superficial peroneal nerve Patient everts foot against resistance Sensation Dermatome distribution(?) Test: Pain Light touch (Temperature) Follow the dermatome distribution as in the upper limb Joint position sense Firstly, demonstrate flexion and extension movements of the big toe. Then ask the patient to specify the direction with the eyes closed. If deficient, test ankle joint sense in the same way. Vibration Test vibration perception by placing a tuning fork on the malleolus. If deficient, move up to the head of the fibula or to the anterior superior iliac spine REFLEXES Knee jerk: L2, L3, L4 roots. Ensure that the patient’s leg is relaxed by resting it over examiner’s arm or by hanging it over the edge of the bed. Tap the patellar tendon with the hammer and observe quadriceps contraction. Note impairment or exaggeration. Ankle jerk S1, S2 roots. Externally rotate the patient’s leg. Hold the foot in slight dorsiflexion. Ensure the foot is relaxed by palpating the tendon of tibialis anterior. If this is taut, then no ankle jerk will be elicited. Tap the Achilles tendon and watch for calf muscle contraction and plantarflexion. Reflex enhancement When reflexes are difficult to elicit, they may be enhanced by asking the patient to clench the teeth or to try to pull clasped hands apart (Jendressik’s manoeuvre) Plantar response Check that the big toe is relaxed. Stroke the lateral aspect of the sole and across the ball of the foot.Note the first movement of the big toe. Flexion should occur. Extension due to contraction of extensor hallucis longus (a “Babinski” reflex) indicates an upper motor neuron lesion. This is usually accompanied by synchronous contraction of the knee flexors and tensor fasciae latae. continued Elicit Chaddock’s sign by stimulating the lateral border of the foot. The big toe extends with upper motor neuron lesions. To avoid ambiguity do not touch the innermost aspect of the sole or the toes themselves. Coordination Coordination of muscle movement requires that four areas of the nervous system function in an integrated way: The motor system, for muscle strenght The cerebellar system, for rhythmic movement and steady posture The vestibular system, for balance and for coordinating eye, head, and body movements The sensory system for position sense To assess coordination, observe the patient’s performance in: Rapid alternating movements Point-to-point movements Gait and other related body movements Standing in specified ways Rapid Alternating Movements Arms: strike one hand on the thigh Raise the hand turn it over and then strike Observe the speed, rhythm and smoothness of the movement In cerebellar disease one movement cannot be followed quickly by its opposite and movements are slow, irregular and clumsy. This called dysdiadochokinesis Show the patient how The nondominant side to tap the distal joint of the thumb with the tip of the index finger Again as rapidly as possible Observe the speed, rhythm and smoothness often performs less well Legs: Ask the patient to tap your hand as quickly as possible with the ball of each foot in turn Note any slowness or awkwardness The feet normally perform less well than the hands Dysdiadochokinesis (difficulty with rapidly alternating movement) in cerebellar disease Cerebellar disease causes incoordination may get worse with eyes closed. Point-to-Point Movements Arms; Ask patient to touch your index and then his nose alternately several times Change the directions Observe accuracy and smoothness Watch for tremor In cerebellar disease movements are clumsy, unsteady and inappropriately varying in their speed, force and direction The finger may initially overshoot its mark but finally reaches it fairly well, such movements are termed dysmetria Legs; Ask patient to place one heel on the opposite knee, and then run it down the shin to the big toe Note the smoothness and accuracy of the movements Repeat with patient’s ‘closed eyes’ In cerebellar disease the heel may overshoot the knee and there oscillate from side to side down the shin When position sense is lost the heel is lifted too high and patient tries to look With eyes closed performance is poor EXAMINATION POSTURE AND GAIT CO-ORDINATION Ask patient to repeatedly run the heel from the opposite knee down the shin to the big toe. Look for ATAXIA (inco-ordination). Ask patient to repeatedly tap the floor with the foot. Note any DYSDIADOCHOKINESIA (difficulty with rapidly alternating movement). GAIT Note: - Length of step and width of base - Abnormal leg movements (e.g. Excessively high step) - Instability (gait ataxia) - Associated postural movements (e.g. Pelvic swinging) If normal, repeat with tandem walking, i.e. Heel to toe. This will exaggerate any instability. Gait Ask the patient to: Abnormality of gait – Walk across the room falls A gait that lacks coordination with reeling and instability is called ataxia Causes of ataxia: cerebellar disease, loss of position sense, or intoxication then turn and come back Observe posture, balance, swinging of the arms, and movements of the legs Normally balance is easy The arms swing at the sides and turns are accomplished smoothly Walk heel-to-toe in a straight line-a pattern called tandem walking Walk on the toes then on the heels-sensitive tests, respectively for plantar flexion and dorsiflexion of the ankles, as well as for balance Tandem walking may reveal an ataxia Walking on toes and heels may reveal distal muscular weakness in the legs. Inability to heel-walk is a sensitive test for corticospinal tract weakness Hop in place on each foot in turn Hopping involves the proximal muscles of the legs as well as the distal ones and requires both good position sense and normal cerebellar function Difficulty with hopping may be due to weakness, lack of position sense or cerebellar dysfunction Do a shallow knee bend first on one leg, then on the other Support the patient’s elbow if the patient is danger of falling Difficulty here suggests proximal weakness (extensor of the hip), weakness of the quadriceps (knee extensor) or both Rising from a sitting position without arm support and stepping up on a sturdy stool are more suitable tests than hopping or knee bends when patients are old Proximal muscle weakness involving the pelvic girdle and legs causes difficulty with both of these activities Stance The following two tests can often be performed concurrently In each case stand close enough to the patient to prevent a fall Romberg’s test Ask patient to stand with the heels together, first with the eyes open, then with the eyes closed.(20-30 seconds) Note any excessive postural swaying or loss of balance -Present when eyes open or closed=cerebellar deficit (cerebellar ataxia) -Present only when eyes are closed (‘positive’ Romberg’s) = proprioceptive deficit (sensory ataxia). Romberg’s test In ataxia due to loss of position sense vision compensates for the sensory loss The patient stands fairly well with eyes open but loses balance when they are closed a positive Romberg sign In cerebellar ataxia the patient has difficulty standing with feet together whether the eyes are open or closed Test for pronator drift Patient should stand for 20-30 seconds with both arms straight forward, palms up eyes closed Who can not stand may be tested for a pronator drift in the sitting position In either case a normal person can hold this arm position well Test for pronator drift The pronation of one forearm suggest a contralateral lesion in the corticospinal tract; downward drift of the arm with flexion of fingers and elbow may also occur These movements are called pronator drift Test for pronator drift Instructing the patient A weak arm is easily to keep arms up and eyes shut tap the arm briskly downward The arm normally return smoothly This response requires muscular strength, coordination and a good sense of position displaced and remains so A patient lacking position sense may not recognize the displacement In cerebellar incoordination the arm returns to its position but overshoots and bounces