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Neurological
Examination
Physical Diagnosis
Learning Objectives
• Select appropriate questions to elicit from the
patient with a neurological complaint during a
patient interview
• Differentiate “normal” from “abnormal” findings
on neurological examination
• Identify common causes of various cranial nerve
palsies
• Differentiate conductive hearing loss from
sensorineural hearing loss
• Determine location of neurological lesion
• Differentiate amongst the various movement
disorders
Learning Objectives
• Differentiate atrophy, hypertrophy, and
pseudohypertrophy.
• Differentiate between spasticity, rigidity, and flaccidity,
and identify common causes of each.
• Differentiate upper motor neuron lesions from lower
motor neuron lesions.
• Differentiate CNS disorders from PNS disorders, and
identify location of the lesion & common causes.
• Compare and contrast the five clinical levels of
consciousness.
• Given a case study perform the appropriate focused
history and physical examination and formulate a
differential diagnosis
Purpose
• Determine if there is a neurological deficit
– Sensory
– Motor
– Behavioral
– Coordinative
• Localize the site of the problem
• Determine the etiology of the problem
Terminology
• Paresis – slight or incomplete paralysis
• Paralysis (plegia) – loss or impairment of
motor function
• Hemiparesis
• Hemiplegia
• Paraplegia
• Quadriplegia
Terminology
• Atrophy – a decrease in size
• Hypertrophy
– enlargement of an organ or part due to an increase in size
of its constituent cells
• Pseudohypertrophy
– increase in size without true hypertrophy
• Spasticity – hypertonicity with increased DTRs
• Rigidity – stiffness or inflexibility
• Flaccidity – loss of tone with diminished DTRs
Focuses
• Mental status
• Cranial nerves
• Motor function
• Reflexes
• Sensory status
• Coordination and balance
History
•
•
•
•
•
•
•
•
•
Chief complaint
PQRST
Headache?
Vertigo?
Visual disturbance?
Tremors or dyskinesias?
Weakness?
Dysesthesias/Paresthesias?
Loss of consciousness?
Key components of H&P
Complaint
Hx
P.E.
Altered mental
status
Vertigo
Associated seizure activity;
recent trauma or infection; illicit
drug use; exposure to toxic
substances
Mental status exam; pupillary
reaction; corneal reflexes; gag
reflexes; posturing/motor
asymmetry; Babinski
Differentiate between true
vertigo and lightheadedness!
Present at rest; affected by
positional changes
CN VIII function; Dix-Hallpike
maneuver; nystagmus
Headache
Thorough hx; “worst headache
ever?”; associated sx’s; neck
pain/stiffness
CN function; pupillary reaction;
fundoscopic exam; palpate
temporal artery; Marcus-Gunn
Seizures
Previous hx; frequency; motor
activity; aura; LOC; post-ictal
confusion; external etiology
Search for focal deficits; signs of
trauma; hyperreflexia
Weakness
Generalized or focal; loss of
strength; pain; progressive or
recurrent fatigue
Asymmetry7; atrophy; sensory
deficits; fasciculations; DTRs
Mental Status
• Alertness
• Attention
• Orientation
– Person, Place, Time, & Situation
• Cognitive function
• Perception
– Illusions = misinterpretations of real external stimuli
– Hallucinations = subjective sensory perceptions in the absence of stimuli
• Judgment
• Memory
– Short-term & long-term
• Speech
–
–
–
–
Rate & rhythm
Spontaneity
Fluency
Simple vs. complex
Levels of Consciousness
• Alert and Oriented
• Disoriented
• Obtunded
– Drowsy/somnolent
– Clouded consciousness
– Slow thought, movement, and speech
• Stuporous
– Marked reduction in mental and physical activity
– Vigorous stimuli needed to provoke a response
• Comatose
–
–
–
–
Completely unconscious
Cannot be aroused by painful stimuli
Absence of voluntary movement
+/- reflexes
Glasgow Coma Scale
Malingering (Nonorganic)
• Hand drop
• Blindness
– EOM/I
• Unilateral diplopia
• Ammonia reaction (CN V vs. CN I)
• Absence of pain or weakness in different
positions
The “Difficult” Patient
•
•
•
•
Observation is key!
Use ingenuity!
Be patient!
Agitated
– May be threatening or violent
• Unresponsive
– Fail to participate
• Unreliable
– Inattentive, preoccupied, inconsistent information
• Hysterical
– Uncooperative
Testing Cognitive Function
• Information & vocabulary
– Common
• Calculating
– Simple math
– Word problems
• Abstract thinking
– Proverbs
– Similarities/differences
• Construction
– Copy figures of increasing difficulty (i.e. circle, clock)
Abnormalities of Thought Processes
Circumstaniality
Indirection and delay in reaching a point because of unnecessary detail.
Loose Associations
Person shifts from one unrelated subject to another.
Flight of Ideas
Almost continuous flow of accelerated speech with abrupt topic changes.
Incoherence
Incomprehensible because of illogic, lack of meaningful connections,
abrupt topic changes, or disordered word use/grammar.
Confabulation
Fabrication of facts or events to fill in gaps in impaired memory.
Perseveration
Persistent repetition of words or ideas.
Echolalia
Repetition of the words or phrases of others.
Neologisms
Invented or distorted words.
Blocking
Sudden interruption in mid-sentence or before completion of an idea.
Clanging
Person chooses a word based on sound instead of meaning.
Abnormalities of Thought Content
Obsessions
Recurrent, uncontrollable thoughts, images, or impulses that a
persons considers unacceptable or strange
Compulsions
Repetitive acts that a person feels driven to perform to prevent or
produce some unrealistic future state of affairs.
Delusions
False, fixed, personal beliefs that are not shared by other
members of the person’s culture.
Phobias
Persistent, irrational fears; accompanied by a compelling desire
to avoid the stimulus.
Anxieties
Apprehensions, fears, or tensions that may be free-floating or
focused (i.e. phobia).
Feelings of Unreality
A sense that things in the environment are strange, unreal, or
remote.
Feelings of
Depersonalization
A sense that one’s self is different, changed, or unreal. Identity is
lost.
Delirium vs. Dementia
•
•
Although confusion and/or disorientation are signs of both Delirium and
Dementia, they are different
Delirium is an acute confusional state
– It is potentially reversible
– Delirium usually occurs over a period of days to months
•
Dementia is slow and insidious
– It progresses slowly over months to years
– Dementia is not reversible
Condition
Onset
Pattern
Orientation
Attention
Memory
Duration
Acute
Fluctuating
Usually
impaired
Impaired/
Fluctuating
Impaired
Hours or
days
Dementia
Insidious
Progressive
Normal or
impaired
~Normal
Impaired
Months or
years
Psychosis
Variable
Variable
~Normal
Normal or
impaired
Normal or
impaired
Variable
Delirium
Visual disturbance
•
•
•
•
•
•
•
Onset?
Progression?
TIA = brief, intermittent visual loss
Migraine = “wavy”
Retinal detachment = “drawn curtain”
Acute glaucoma = “rainbows” or “halos”
Digitalis toxicity = yellow hue
Vertigo
• A sense of spinning
– Person
– Environment
• Suggests dysfunction of
– Vestibular apparatus
– Vestibular nerve
• Differentiate from “lightheadedness” and
“faintness”
– Results from impairment of brain oxygenation
Dix-Hallpike maneuver
Testing for Aphasia
Word
Comprehension
Comprehension of spoken language through recognition (“point to your nose”) or
understanding (“Can dogs fly?”).
Repetition
Repeat items of increasing complexity. Note the fluency and accuracy of the
responses.
Naming
Name a series of objects or colors. Gradually increase difficulty. Note the fluency
and accuracy of the responses.
Reading
Comprehension
Have the patient follow several simple written commands.
Writing
Ask the patient to make up and write a sentence.
Localization
• CNS vs. PNS
– Brain/Brain stem
– Spinal cord
– Peripheral nerves
• Difficult when evaluating:
– Radicular pain
– Dysesthesia/paresthesia
– Tremors
– Incoordination
Localization
• Cerebrum
– Impaired intellect, memory, higher brain function
• Brain stem
– unconsciousness
• LMN
– paralysis with loss of DTRs
– muscle atrophy with fasciculation
• LMN + anesthesia
– peripheral nerve or spinal root
• UMN
–
–
–
–
involves whole muscle groups
increased or spastic muscle tone
+/- paralysis with DTR accentuation
Positive Babinski
Organic Disease
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•
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Asymmetric pupillary light reflex
Abnormal fundus
Ocular divergence
Nystagmus
Muscular atrophy
Fasciculations
Multiple complex signs/symptoms
explained by a single lesion
Headache
• 5th most common reason for OP visit
• Symptom! (not a disease)
• Most important diagnostic clue is a steady,
bilateral, nonthrobbing pain that is worse
in the a.m.
– May awaken patient
– Worse with VALSALVA
Types of Headaches
• Tension
• Sinus
• Migraine
– Classic
– Common
– Complicated
– Cluster
• Post-traumatic
• Post-LP
Types of Headaches
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•
•
Temporal Arteritis
ICP
Subarachnoid hemorrhage
Infection
Ocular
Trigeminal neuralgia (Tic doloureaux)
TMJ syndrome
Toxic
Headache History
• Location
–
–
–
–
Unilateral ~ migraine
Periorbital ~ glaucoma/uveitis
Parietal/Occipital ~ tension
Neck ~ meningitis or Subarachnoid hemorrhage
• Quality
– “Throbbing” ~ vascular
– “Intermittent jabbing” ~ Trigeminal neuralgia
– “Pressure” ~ sinus
• Radiation?
• Severity
• Timing
– Constant vs. intermittent
– Worse in a.m. or p.m.
• Worst headache ever?????
Headache History
• Associated Sx’s
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–
–
–
–
•
•
•
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Visual disturbance
Vertigo
N/V
Dysesthesias
Aura
Past medical history
Family history
Current medication/drug use
Suspect an extracranial etiology if pain is the
only symptom
Physical Examination
• Appearance
• Behavior/Mannerisms
– Gait and Posture
– Motor behavior
– Facial expressions
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•
•
•
Mood vs. Affect
MMSE
Test Cranial Nerves II through XII
Fundoscopic examination
Physical Examination
• Test motor nerve function
– Grip/SAR (Grade 0-5)
– Station and gait – ambulate, turn, toes, heels, heel-to-toe, knee bend
– Romberg
• Test sensory nerve function
– Pain +/- Light touch
– Two point discrimination (normally <5mm)
– Proprioception/Stereognosis/Vibration
• Test deep tendon reflexes (0-4+)
• Test for meningeal irritation - Kernig’s & Brudzinski’s signs
• Straight leg raise
– Used to identify potential discogenic injury and nerve root injury
• Test Coordination
– Finger-to-nose
– Rapid alternating movements of hands & feet
Reflexes
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Corneal
Pharyngeal
Biceps
Triceps
Brachioradialis
Abdominal
Patellar (knee jerk)
Achilles (ankle jerk)
Babinski
– Positive suggests UMN lesion
Cranial Nerves
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I
II
III
IV
V
VI
VII
VIII
IX
X
XI
XII
- Olfactory
- Optic
- Oculomotor
- Trochlear
- Trigeminal
- Abducens
- Facial
- Vestibulocochlear (Acoustic)
- Glossopharyngeal
- Vagus
- Accessory
- Hypoglossal
Cranial Nerve I
• Responsible for sense of smell
• Receptors located in the upper 1/3 of the
nasal septum.
• Test each nostril separately.
• Identify familiar odors.
• Avoid noxious substances
• Unilateral lesion = ipsilateral anosmia
Cranial Nerve II
• Responsible for vision
• Test visual acuity!!!!
• Pupillary size
– Swinging-flashlight test
• Visual fields
– Peripheral vision
– Test by confrontation
• Fundoscopic examination
– Papilledema
Cranial Nerves III, IV, VI
• CN III involved in:
– Pupillary reflex
– Opening of the eyelids
– Most extraocular movements
• CN IV
– provides downward/inward eye movement
• CN VI
– provides lateral eye movement
Cranial Nerves III, IV, VI
• Check pupillary reaction/reflex
– Direct & consensual
• Check eye movement through all six Cardinal fields
– Unilateral complete paralysis is usually caused by increased ICP
or an aneurysm
– Neither eye can move to the contralateral side
• Eyes “look toward the lesion”
– Injury may occur secondary to:
•
•
•
•
•
Infection
Orbital fracture
Internal carotid aneurysm
Mastoiditis
Increased ICP
• Look for nystagmus*
Pupil Abnormalities
• Adie’s (Tonic) pupil
– sluggish response
• Argyll Robertson pupil
– irregular/unequal pupils
– weak/absent reaction to light
– exaggerated contraction to accommodation
• Marcus-Gunn pupil
– results from reduced afferent input in the affected eye**
– pupil fails to constrict fully
– rapidly stimulate each eye in succession and observe the direct
and consensual light response in each
• stimulation of the normal eye produces full constriction in both
pupils.
• immediate subsequent stimulus of the affected eye produces an
apparent dilation in both pupils since the stimulus carried through
that optic nerve is weaker
Pupil Abnormalities
• Asymmetry of pupil size of >1mm suggests CN
III compression
• Bilateral dilation suggests anoxia or drug affect
• Unilateral constriction is seen with sympathetic
dysfunction (Horner syndrome) or carotid artery
dissection
• Bilateral constriction is seen with:
– Pontine hemorrhage
– Drugs (opiates, Clonidine)
– Toxins (organophosphates)
Cranial Nerve V
• Sensory
– Ophthalmic branch (sensory)
• Cornea, conjunctiva, ciliary body, nasal cavity, sinuses, skin
of eyebrows/forehead/nose
– Maxillary branch (sensory)
• Side of nose, lower eyelid, upper lip
– Mandibular branch (mixed)
• Sensory – skin of temporal region, auricles, lower lip/face,
anterior 2/3 of tongue, mandibular gums/teeth
• Motor - innervates the muscles of mastication
• Cerebral lesion causes contralateral paresthesia
• Most lesions affect all 3 branches
Cranial Nerve V Testing
• Inspect for tremor of the lips, involuntary
chewing movements, and trismus
• Compare muscle tension bilaterally with
teeth clenched
• Test tactile perception
• Test sharp-dull discrimination
• Test temperature perception
• Test corneal reflex
– Tests V & VII directly and VII consensually
Cranial Nerve VII
• Motor
– Muscles of the face, scalp, and ears
• Autonomic
– Vasodilation
– Secretion of submaxillary/sublingual glands
• Sensory
– Taste in anterior 2/3 of tongue
– Ear canal/postauricular
• Palsies can occur secondary to:
– Polio, ALS, MS, tumors, syphilis, Lyme disease,
Guillain-Barré Syndrome
Cranial Nerve VII
• Inspect for flaccid paralysis
• Differentiate UMN vs. LMN
– Elevate eyebrows
– Close eyes
– Show teeth
– Whistle
– Smile
• **Central lesions causes contralateral
paralysis to lower half of face (below the
eyes)
Cranial Nerve VIII
•
•
•
•
Responsible for sense of hearing and balance
Composed of the cochlear and vestibular nerves
Sensory
Test hearing
Conductive loss
Sensorineural loss
Distortion of sound
Minor
Present with loss of upper tones
Noisy environment
Hearing may seem to improve
Hearing typically worsens
Patient’s voice
Generally normal*
Loud
Ear canal/TM
Visible abnormality
Normal
Weber
Lateralizes to the impaired ear
Lateralizes to the normal ear
Rinne
BC > AC
AC > BC
Cranial Nerve VIII
• Look for spontaneous nystagmus
• Romberg test/sign
– Functional test of position sense
• Stand with feet together
• Close eyes and maintain for 20-30 seconds
– Usually combined with a check for pronator drift
•
•
•
•
As above
Extend arms forward in supinated position
Briskly move arms downward (separately)
Arms should return smoothly to original position
• Lesion causes
– Unilateral deafness
– Imbalance
Cranial Nerve IX
• Motor
– Muscles of the pharynx
• Autonomic
– Vasodilation
• Sensory
– Taste in posterior 1/3 of tongue
– Pharynx, tonsils, fauces, TM, posterior ear canal
• Test for
– Elevation of the uvula
– Gag reflex
– Mucosal anesthesia
Cranial Nerve X
• Motor, autonomic, and sensory functions
– Palate, pharynx, larynx, neck, thorax, and abdomen
• Branches to:
–
–
–
–
–
–
–
–
Pharynx
Larynx
Esophagus
Heart
Bronchioles
Stomach
Liver
Celiac
• Perform indirect examination of the vocal cords
• Lesion cause:
– Hoarseness/aphonia
– Dyspnea/stridor
Cranial Nerve XI
• Provides motor to
– SCM
– upper Trapezius
• Testing:
– Have patient shrug against resistance
– Head rotation and movement against
resistance
Cranial Nerve XII
• Motor to tongue
• Testing:
– Tongue movement
• Midline
• Tremors
• Involuntary
– Atrophy
– Lingual speech
• Paralysis causes deviation to the weak
side
Motor Function
• UMNs
– Transmit impulses from cortical nerve bodies
to:
• motor nuclei in brainstem (CNs)
• Anterior horn cells of spinal cord
• LMNs
– Transmit impulses from anterior horn cells
through anterior root into peripheral nerves
– Terminate at the neuromuscular junction
Motor Function
• Inspection
– Symmetry
– Muscle bulk; size and contours; flat or concave; unilateral or bilateral;
proximal or distal
– Atrophy
• Palpation
– Muscle tone
• Percussion
– ? Fasciculations
• Check motor strength
• Body position (during movement and at rest)
• Involuntary movements
– Location, quality, rate, rhythm, amplitude and relation to posture,
activity, fatigue, or emotions
• If an abnormality exists:
– Identify muscle(s) involved
– Central vs. peripheral?
– Learn muscle innervations
Motor Function
• Muscle tone
– Slight residual tension in normal relaxed muscle
– Feel muscle’s resistance to passive stretch
• Muscle strength
–
–
–
–
Wide variance - stronger dominant side
Test by asking patient to actively resist movement
If muscles too weak - test against gravity only or eliminate gravity
If patient fails to move, watch or feel for weak contraction
• Suspect decreased resistance?
– Hold forearm and shake hand loosely
• Resistance increased?
– Varies or persists throughout movement
Function and Innervations
Muscle(s)
Function
Primary Nerve Origin
DELTOID
Shoulder abduction
Axillary
C5-C6
BICEPS
Elbow flexion
Musculocutaneous
C5, C6
TRICEPS
Elbow extension
Radial
C6, C7, C8
WRIST EXTENSORS
Radial
C6, C7, C8
WRIST FLEXION
Median
C6, C7
Median
C7, C8, T1
FINGER ADDUCTION
Median
C7-T1
FINGER ABDUCTION
Ulnar
C8, T1
THUMB OPPOSITION
Median
C8, T1
HIP FLEXION
Iliopsoas
L2, L3, L4
HIP EXTENSION
Gluteus maximus
S1
HAND GRIP
Grasp Fingers
Function and Innervations
Primary Nerve Origin
Motor Function
Muscles
KNEE EXTENSION
Quadriceps
L2, L3, L4
KNEE FLEXION
Hamstrings
L4, L5, S1, S2
FOOT DORSIFLEXION
Tibialis Anterior
ANKLE PLANTAR
FLEXION
Gastrocnemius
mainly S1
EXTENSION OF GREAT
TOE
Extensor
hallicus
longus
L5
Deep peroneal
L4, L5
Motor function
• Always compare symmetry
• Note any atrophy
• Check muscle tone against resistance
– Cogwheel rigidity = jerky, released in degrees
– UMN paralysis = spasticity (increased tone)
– LMN paralysis = hypotonia
• Test muscle strength
– Grade 0 to 5
Grading Muscular Response
Grade
Muscular Response
0
No contraction detected
1
Barely detectable flicker or 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 resistance without
evident fatigue - “Normal”
Sensory Function
• Fatigues quickly
– Efficiency
– Special attention to areas of:
• Symptomology
• Motor or reflex abnormalities
• Trophic changes
– Confirm with repeat testing!!
• Patterns of testing:
– Symmetrical
– Distal vs. proximal: scattered stimuli
– Vary pace
Sensory Function Testing
• Look for abnormality
– map out boundaries in detail
• Source of lesion
• Distribution of sensory abnormalities
and kinds of sensations affected
• +/- motor/reflex abnormality
• Demonstrate to patient before testing
Spinothalamic Tract
• Pain and temperature
• Crude touch (light
touch without
localization)
• Fibers cross & pass
upward into thalamus
Pain Sensation
• Sharp safety pin or other tool
• Demonstrate sharp & dull
• Test by:
– Alternating sharp & dull w/ pt’s eyes closed
• Ask patient:
– Sharp or dull?
– Does this feel same as this?
– Lightest pressure needed - do not draw blood
Temperature
• Often omitted if pain sensation normal
• Two test tubes
– filled with hot & cold water
– or tuning fork heated or cooled by water
Light Touch
• Wisp of cotton
• Touch lightly avoid pressure
• Ask patient:
– To respond
when touch is
felt
– Compare one
area with
another
Posterior Columns
• Position and
vibration
• Fine touch
• Synapse in
medulla,
cross &
continue on
to thalamus
Vibratory Sense
• 128 or 256
Hz Tuning
fork
• If impaired,
proceed
proximally
Proprioception
Grasp toe by
sides - pull
away from
other toes
Demonstrate
“up” &
“down”
Tactile Localization
• Have pt close
eyes
• Touch pt on R
cheek & L arm
• Ask patient
where touch
was felt
Discriminative Sensations
• Stereognosis, graphesthesia, two-point
discrimination
• Test ability of sensory cortex to correlate,
analyze, & interpret sensations
• Dependent on touch & position sense
• Screen first with stereognosis - proceed to
other methods if indicated
Stereognosis
• Ability to identify an
object by feeling it
• Place familiar object in
patient’s hand & ask
patient to identify it
• Normally patient
manipulates it skillfully
& identifies it correctly
Graphesthesia
• Perform if inability
to manipulate
object
• Ability to identify
numbers written
in hand
• Use patient’s
orientation
Two-Point Discrimination
• Touch two places
simultaneously
• Alternate stimuli
• Avoid pain
• Determine distance
Spinal Reflexes: DTRs
• Segmental levels of DTRs:
– Supinator reflex
– Biceps reflex
– Triceps reflex
– Abdominal reflexes - upper
–
- lower
– Knee (Patellar)
– Plantar responses
– Achilles reflex
C5, 6
C5, 6
C6, 7
T8, 9, 10
T 10, 11, 12
L2, 3, 4
L5, S1
S1 primarily
Deep Tendon Reflexes: Grading
Grade
DTR Response
4+
Very brisk, hyperactive, with
clonus
Brisker than average, slightly
hyperreflexic
Average, expected response;
normal
Somewhat diminished, low
normal
No response, absent
3+
2+
1+
0
Reflex Hammer - Incorrect Usage
Jendrassik’s Maneuver
• Reinforcement
technique
• Upper extremities
– clench teeth
– squeeze thigh
• Lower extremities
– lock fingers and
pull one against the
other
Biceps Reflex
C5,C6
Elbow Flexion
Triceps Reflex
C6, C7, C8
Elbow Extension
Brachioradialis Reflex
C5, C6
Forearm semiflexion/semipronation
(NO wrist/hand flexion)
Patellar Reflex
L2, L3, L4
Knee Extension
Achilles Reflex
S1, S2
Ankle Plantar Flexion
Plantar Reflex
L5, S1, S2
Babinski Sign
Abdominal Reflexes
T8, T9, T10:
ABOVE umbilicus
T10, T11, T12:
BELOW umbilicus
Anal Reflex
• Superficial reflex
• Loss of anal reflex suggests lesion of
S2,3,4 reflex arc
• Possible lesion of cauda equina
Clonus
• Rhythmic Oscillation
• Flexion/Extension
• UMN Lesion
Cerebellar Function
• Requires
integration of:
– Motor system
– Cerebellar
system
– Vestibular
system
– Sensory system
• Assessed by:
– Rapid alternating
movements
– Finger-to-Nose /
Heel-to-Knee
Test
– Romberg’s Test
– Gait
Finger-to-Nose Test
• Finger-to-nose
with moving
target
• Stationary
finger-to-nose
with eyes
closed
Heel-to-Knee Test
Rapid Alternating Movements
•
•
•
•
First with hands
Repeat with feet
Diadochokinesia = ability to perform RAM
Dysdiadochokinesis = slow, irregular, clumsy
movements
Station, Stance & Romberg’s Test
• Station & Stance
– Pt stand with feet together
– First, eyes open
• Romberg Test
– Then, close eyes
– If okay with eyes open, but
sways w/ eyes closed = +
Romberg
– Mainly tests position sense
• Vision can compensate for loss of
position sense
Pronator Drift
• Often performed in
conjunction with
Romberg test
• Pronator drift
– Muscular strength
– Coordination
– Position sense
Gait
• Walk across room, turn
and walk back
• Tandem walking
• Heel & toe walking
• Hop in place
• Shallow knee bend
• Rising from sitting position
or stepping up on stool
Meningeal Irritation
• Occur with meningitis & subarachnoid
hemorrhage
• Brudzinski’s Sign
– Flex the head
– Marked pain in the neck
– Patient flexes hip and BLE
• Kernig’s Sign
– Pain when raising a straightened LE
Lab/X-ray
•
•
•
•
•
CBC, CMP, U/A
Specific drug levels
Plain films of the spine
CT of the brain & head
MRI of the brain & spine
– Greater resolution then CT for soft tissue/plaques
•
•
•
•
•
Angiography
CSF exam
EEG
EMG & NCT
PET/SPECT
Spinal Studies
Normal Skull Anatomy
Normal
L-Spine
MRI
CSF
• Obtained through lumbar puncture
• Indications:
– Suspected CNS infection (i.e. syphilis)
– Suspected subarachnoid hemorrhage
• Contraindicated if cerebral mass/lesion is
suspected
• Measure opening pressure
• Obtain samples for cell counts, glucose,
protein level, and cultures
Computed Tomography
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Gives adequate information about brain anatomy
Used primarily to detect hemorrhage & tumors
Can be performed with/without contrast
Indications:
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Focal neurologic deficits
Altered mental status
Head trauma
New-onset seizure
Increased ICP
Suspected mass lesion
Suspected subarachnoid hemorrhage
(with contrast) Abscess, intracranial tumor
(with contrast) Chronic subdural hematoma, infarct, vascular
malformation
Review of Neurological Exam
• Six categories:
– Mental status & speech
– Cranial nerves
– Motor function
– Sensory function
– Reflexes
– Cerebellar function
• Carefully evaluate the hx of the CC
• CN assessment is essential!
Summary
• Select appropriate questions to elicit from the patient with a
neurological complaint during a patient interview
• Differentiate “normal” from “abnormal” findings on neurological
examination
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Identify common causes of various cranial nerve palsies
Differentiate conductive hearing loss from sensorineural hearing loss
Differentiate amongst the various movement disorders
Differentiate atrophy, hypertrophy, and pseudohypertrophy.
Differentiate between spasticity, rigidity, and flaccidity, and identify
common causes of each.
• Determine location of neurological lesion
– Differentiate upper motor neuron lesions from lower motor neuron
lesions
– Differentiate CNS disorders from PNS disorders, and identify location of
the lesion & common causes.
• Compare and contrast the five clinical levels of consciousness.