Transcript 2b Neurological Exam

Neurological Exam
Muscle Strength
• Pair the testing of each muscle group
immediately with testing of its contralateral
counterpart to enhance detection of any
asymmetries.
• Have them flex, then extend, the chosen joint.
First the right, then the left.
• Have them flex and extend that joint again, but
this time, examiner pushes against the
movement, creating resistance.
• Proceed to the next joint.
Muscle Strength
• Upper Extremity
– Shoulder
– Elbow
– Wrist
• Lower Extremity
– Hip
– Knee
– Foot
0/5: no contraction
1/5: muscle flicker, but no movement
2/5: movement possible, but not against
gravity (test the joint in its horizontal
plane)
3/5: movement possible against gravity,
but not against resistance by the
examiner
4/5: movement possible against some
resistance by the examiner
5/5: normal strength
Upper Extremity Strength Video
Lower Extremity Strength Video
Reflexes
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Biceps (C5-6)
Triceps (C7)
Patellar (L4)
Ankle (S1)
Plantar
0: absent reflex
1+: trace
2+: normal
3+: brisk
4+: nonsustained clonus (i.e.,
repetitive vibratory movements)
5+: sustained clonus
– Babinski sign
Deep tendon reflexes are normal if they are 1+, 2+, or 3+ unless they are
asymmetric or there is a dramatic difference between the arms and the legs.
http://www.neuroexam.com/content.php?p=2
http://meded.ucsd.edu/clinicalmed/neuro3.htm
Reflexes Exam
• The limbs should be in a relaxed and symmetric position.
• The muscle group to be tested must be in a neutral position
(i.e. neither stretched nor contracted).
• Compare each reflex immediately with its contralateral
counterpart so that any asymmetries can be detected.
• If you cannot elicit a reflex, you can sometimes bring it out
by certain reinforcement procedures. For example, have
them forcefully contract a different muscle group when the
reflex is tested.
• Upper Extremity reflexes video
• Lower Extremity reflexes video
• Plantar Reflexes video
Biceps Reflex
• Have the patient’s elbow resting in your arm at a 90 degree
angle.
• Place your thumb over the antecubital fossa (inside of
elbow) of the patient.
• Ask the patient to flex their forearm (i.e. contract their
Biceps muscle) while you simultaneously palpate the fossa.
The Biceps tendon should become taut and thus readily
apparent.
• Place your thumb over the
tendon and tap the pointed
side of the reflex hammer onto
your thumb and observe the
reflex in their biceps.
Triceps Reflex
• Have the patient’s elbow resting in your arm at a
90 degree angle.
• Ask the patient to extend their forearm (i.e.
contract their Triceps muscle) while you
simultaneously palpate the tendon behind the
elbow.
• Place your thumb
over the tendon and
tap the pointed side
of the reflex hammer
onto your thumb and
observe the reflex in
their triceps.
Patellar Reflex
• Make sure the leg is
relaxed.
• Use the wide side of the
hammer.
• If no reaction, have patient
clasp fingers together and
pull while the test is
performed.
Achilles Tendon Reflex
• This is most easily done with the patient
seated, feet dangling over the edge of the
exam table.
•Use one hand to hold
the foot at a 90 degree
angle, and strike the
tendon with the wide
side of the hammer in
the other hand. Feel for
the foot plantarflexion.
Plantar Reflex
• Scrape an object across the sole of the foot
beginning from the heel, moving forward toward
the small toe, and then arcing medially toward
the big toe.
• The normal response is downward contraction of
the toes.
• The abnormal response,
called a positive Babinski's
sign, is characterized by a
dorsiflexed big toe and
fanning outward of the other
toes. This is normal in
children under 1 year of age,
but abnormal in adults.
Cerebellar Function
• Finger to Nose
– Patient is asked to alternately touch their nose and the
examiner's finger as quickly as possible, while the examiner's
finger is held at the extreme of the patient's reach, and the
examiner's finger is moved after each attempt.
• Heel to Shin
– Touch the heel of one foot to the opposite knee and then to
drag their heel in a straight line all the way down the front of
their shin and back up again. Do not touch the shin with the
toes.
• Rapid Alternating Movements
– Touch the thumb to each finger quickly.
– Can also wipe one palm alternately with the palm and dorsum
of the other hand
Station and Gait
Station = how far apart the feet are when standing. Normal is same
width as shoulders. Observe if they have a wide, narrow, or normal
station.
Gait = walking
• Tandem gait
– walk a straight line while touching the heel of one foot to the toe of
the other with each step. Tests cerebellar function.
• Hopping on one foot (not for feeble patients)
• Romberg
– Ask the patient to stand with their feet together (touching each other).
Then ask the patient to close their eyes. Remain close in case the
patient begins to sway or fall.
– With the eyes open, visual input helps to maintain stability. Closing the
eyes and having difficulty with the task suggests a mild lesion in the
vestibular system.
Cranial Nerves Exam
• CN I
• Smell test
Patient closes eyes
and plugs one nostril.
Hold an alcohol swab
a few inches away and
have them sniff.
Repeat with the other
nostril. Is the strength
of the smell the
same?
CN III, IV, and VI
• Instruct the patient to hold his head still and follow the
examiner’s finger with his eyes as the examiner
circumscribes a large "H" in front of the patient. Then
move the finger towards the patient’s nose. Weakness
in an eye muscle indicates cranial nerve damage.
• CN III also controls the pupillary reflex. Have the
patient look straight ahead, then shine a light into the
left eye once to see if the left pupil constricts. Remove
the light and shine it again at the left eye, but look at
the right eye to see if the right pupil constricts.
• Repeat this, shining the light twice in the right eye to
see if the right and left pupil constrict.
Extraocular Movements:
CN III (except as listed)
CN VI
CN IV
Look for Nystagmus
• Nystagmus is involuntary eye movement.
• http://en.wikipedia.org/wiki/Physiologic_nystagmus
• It is characterized by the eye flicking right to left when
the examiner pulls a nystagmus flag quickly through his
fingers. Nystagmus is normal.
• Pathological nystagmus (flicking without the flag) is the
result of damage to one or more components of the
vestibular system, including the semicircular canals,
otoliths, and the vestibulocerebellum.
• Many blind people have pathological nystagmus, which
is one reason that some wear dark glasses.
CN V
• Check sensation on the
upper, middle, and lower
part of the face.
CN VII
• Voluntary facial movements, such as wrinkling
the brow, showing teeth, frowning, closing the
eyes tightly, pursing the lips and puffing out
the cheeks, all test the facial nerve. There
should be no noticeable asymmetry.
• Check for ability to open and close mouth in a
chewing fashion.
• CN VII also supplies taste to the anterior 1/3
of tongue.
CN VIII - XII
• Vestibulocochlear (VIII) hearing/balance
• Glossopharyngeal (IX) taste on posterior 1/3
of tongue, and swallowing. Open mouth and
say “ah”, see if uvula moves to one side
instead of straight backwards.
• Vagus (X) larynx moves with speech
• Accessory (XI) shrug shoulders, w/resistance
• Hypoglossal (XII) stick out tongue (does it
deviate to one side?)
Cranial Nerves
• Olfactory (I) smell
• Optic (II) Visual Acuity
• Extraocular Movement (III)
– Pupil Reactions to light
– Nystagmus
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Superior oblique (Trochlear IV)
Lateral Rectus (Abducens VI)
Trigeminal (V) sensory of face
Facial Motor (VII) blink and smile
Vestibulocochlear (VIII) hearing/balance
Glossopharyngeal (IX) swallowing, say “ah”, and taste anterior tongue
Vagus (X) larynx moves with speech
Accessory (XI) shrug shoulders
Hypoglossus (XII) stick out tongue, and taste posterior tongue
Sensation
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Hot, Cold
Pain (pointy wheel)
Light Touch (cotton swab)
Vibration (tuning fork)
Proprioception (thumb up or down)
Two-point discrimination (pointy caliper)
Perform each of these tests
throughout the dermatome map.
Map of Dermatomes
Test from the sides of the neck , to the
shoulder
For pain, use the pointy wheel and
circumscribe the upper and lower arms
Test down the front of the chest or back
Test the lateral sides of the thigh
Circumscribe the leg
Sensation
• Temperature sensation can be tested with a
cool piece of metal such as a tuning fork or
stethoscope diaphragm. Warms can be tested
with warm hands or warmed cloth.
• Light touch is best tested with a cotton-tipped
swab
• Pain is tested by poking gently with a sharp
object, such as a broken wooden stick from a
Q-Tip
Sensation
• Vibration
– Have patient close their eyes. Place the stem of a
vibrating tuning fork on the fleshy portion of the
patient's toe or finger and ask him to report when
you stop the vibration by grasping the top of the
fork with your hand.
– Take care not to place the tuning fork on a bone,
since bones conduct the vibration to much more
proximal sites, where they can be detected by
nerves far from the location being tested.
Sensation
• Proprioception (joint position)
– Patient closes eyes. Move the patient's thumb up
and down and then stop, asking the patient to
report if it is up or down right now.
– Hold the digit lightly by the sides while doing this
so that tactile inputs don't provide significant
clues to the direction of movement.
Sensation
• Two-point discrimination
– Use a caliper or bent paper
clip, touch the patient with
one or both points,
alternating randomly.
– Ask them each time: can
you feel one prong or two?
If you use two and they say
“one”, spread the clip points
wider and try again.
– The minimal separation (in
millimeters) at which the
patient can distinguish
these stimuli should be
recorded in each extremity.
Eye Exam
Visual Acuity
• Stand 20 feet from eye chart, read line 8. If no
errors, you have 20/20 vision.
Colorblind test
• Read the numbers from the color patterns in
the book in the front of the room.
Retinal Exam
• Have the patient stare at a the corner of the
room where the ceiling meets the wall.
• Approach the right eye from the right side of the
patient. Place one hand on their forehead so you
have depth perception and don’t run into their
face. Put the knuckle of your third digit on their
cheek.
• Direct the light onto their pupil, then look into
the pupil. Examine the fundus (interior of the
eye) for abnormalities.
Normal Fundus
Diabetic Retinopathy
Diabetic Retinopathy
Middle Ear Exam
• Make sure the light is OFF, then switch to the
ear piece.
• Make sure a disposable specula is on the
otoscope!
• Approach the patient from the side.
• Grasp the pinna (external ear) and gently pull it superiorly
and posteriorly to straighten out the ear canal.
• Place the specula of the otoscope into the ear first, before
looking into the otoscope. Otherwise, you might drive the
specula in too deep and hurt the patient.
• Then look into the otoscope. Examine the canal for redness,
look for perforation or scars on the tympanum (ear drum).
Normal Ear
Inflamed Ear
Hearing Loss
• Conductive hearing loss happens when there
is a problem conducting sound waves through
the outer ear, tympanic membrane (eardrum)
or middle ear (ossicles).
• Sensorineural hearing loss is a problem in the
vestibulocochlear nerve (Cranial nerve VIII),
the inner ear, or central processing centers of
the brain.
Weber Test
• Weber Test: only tests unilateral problems. A
tuning fork is touched to the middle of the
forehead:
– Sensorineural hearing loss: sound is heard louder
in the normal ear because the damage is to the
nerve, so bone conduction of the sound is
ineffective.
– Conductive hearing loss: sound is heard louder in
the problem ear (earwax, etc) because reflected
soundwaves cannot escape the ear canal, so they
penetrate deeper into the inner ear.
Rinne Test
• Performed by placing a vibrating tuning fork
on the mastoid process (from the ear lobe, go
2” down and 2” back) until sound is no longer
heard, the fork is then immediately placed just
outside the ear. Normally, the sound is audible
at the ear, indicating a positive Rinne test.
• If they cannot hear the sound at the ear, it is a
negative Rinne test, and indicates
Sensorineural hearing loss