Transcript Neurological Examination - Luton & Dunstable Hospital

Neurological Examination
Dr Andrew Gale
23 Feb 2010
What do I need to do?
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Systematic neurological examination
Selective examination
“3-minute examination”
None
During History
OLAT
• Observe
– Gait
– General demeanour
– Facial mobility, blink rate
• Listen
– Speech quality and content
• Assess
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Mental state
Memory
Reliability
Consistency
• Think
– Provisional diagnosis
– What do I want to know?
Systematic Neurological
Examination
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6.
Mental state and higher function
Gait, posture and movement
Cranial nerves
Motor function
Coordination
Sensory function
1. Mental state and higher function
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Mental state
Cognitive function
Speech
Higher function deficit
2. Gait, posture and movement
• Gait
– Observe, particularly steps and arm swing
and tremor
– Heels and toes
– Heel to toe
– Romberg
• Rise from crouching
3. Cranial Nerves
• Vision
– VA, VF
• Fundi
• Ptosis,
• Proptosis, Pupils, Eye movts, nystagmus
• Facial sensation and corneal reflexes
• Facial weakness
• Hearing
• Tongue
Diagnosis of weakness
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Localisation depends on
pattern of involvement and
associated sensory impairment
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Cortex
Internal capsule
Spinal cord
Anterior horn cell
Nerve root/Peripheral nerve
Neuromuscular junction
Muscle
Pathology
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What lesions occur at that
site?
Time course of illness
Acute limb weakness
Common causes
Localisation
Pattern
Common causes
Brain
Mono- or hemi-paresis
Stroke, MS, tumour
Brainstem
Hemi-, quadri- or para- Stroke, MS
paresis
Quadri-, para- or occ
Compression, MS
mono-paresis
Segmental
Disc, tumour
Cord
Nerve root
Periph nerve
N-M Junction
Muscle
Distal
Single nerve
Proximal but variable
and fatiguable
Proximal
Periph neuropathy
Mononeuropathy
Myasthenia
Myopathy
4. Motor function
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Posture
Rapid repetitive movts fingers
Finger-nose coordination
Symptomatic muscles
– Wasting, fasciculation, tone, power
• Reflexes
• Plantars
5. Coordination
• Finger-nose
• Heel-shin
6. Sensory function
• Only test when relevant
• Focus on question that needs answering
• Unexpectedly finding loss of touch or
reduction of pin-prick not likely to be
relevant
• VS loss commonly asymptomatic
• Joint position loss most significant
– Especially in ataxia or loss of balance without
dizziness
Common neurological complaints
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Headaches
Blackouts
Dizziness (Vertigo)
Weakness
Numbness
Tremor
Loss of balance
Memory loss
Pain
During History
• Observe
– Gait
– General demeanour
– Facial mobility, blink rate
• Listen
– Speech quality and content
• Assess
–
–
–
–
Mental state
Memory
Reliability
Consistency
• Think
– Provisional diagnosis
– What do I want to know?
Examination in Headaches
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BP
Visual fields
Fundi
Reflexes
Plantars
Examination in Blackouts
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BP, heart
Visual fields
Fundi
Reflexes
Plantars
Examination in Vertigo
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Gait, Tandem walking
Fundi
Corneal reflexes
Nystagmus
Facial weakness
Hearing
Reflexes
Plantars
Ataxia
Hallpike’s test (vertigo)
Examination in Weakness
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Wasting and fasciculation
Tone
Power
Reflexes
Plantars
Examination in Numbness
• Motor
• Sensory Modality
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LT
VS
JPS
PP ( & Temp)
Dissociated
• Pattern of sensory loss to LT & PP
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Peripheral nerve
Nerve root - dermatomal
Spinal - sensory level
Hemisensory
Examination in Tremor
• Observation of tremor at rest, walking,
posture, action and activities
• Gait
• Facial movement
• Dexterity
• Muscle tone
• Coordination
Examination in Memory Loss
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Corroborative history
MMSE
Parkinsonian features
Motor signs
Sphincter disturbance
Examination in pain
• Anatomical localisation
• Appropriate exam for concomitant motor
or sensory impairment
During History
OLAT
• Observe
– Gait
– General demeanour
– Facial mobility, blink rate
• Listen
– Speech quality and content
• Assess
–
–
–
–
Mental state
Memory
Reliability
Consistency
• Think
– Provisional diagnosis
– What do I want to know?
“3 min exam”
1. Facial mobility & movt e.g. ptosis, facial
weakness, Parkinson’s
2. Speech
3. Gait, H-T, walk on heels & toes, Rombergs
4. VF, eye movements, pupils
5. Face and tongue
6. Outstretched arms, tremor, pronator drift
7. Rapid finger movts
8. Reflexes and plantars
9. Fundoscopy