Transcript The Neurological Examination

Neurological Assessment in
the GP setting
Dr Godwin Mamutse
Department Neurology
NNUH
The Neurological assessment
• Format
 Neurological history taking
 Neurological examination with main focus
on examination relevant for cerebral
localisation
The neurological assessment
• Questions to be answered:
 Is there a neurological lesion?
 Where is the lesion? (localisation)
 Is the lesion(s) focal, multifocal or
diffuse?
 What is the likely underlying cause of
the lesion?
Task
Chief complaint
Goal
Possible anatomical localisation
Possible aetiologies
History
Possible anatomical localisation
Possible aetiologies
Neurological examination
Confirmation of anatomical localisation
List of possible diseases
Review of patient specific features
Rank order of likelihood of
possible diseases
Differential diagnosis
Bradley et al, 2004
Clinical assessment
• Clinical history
 Nature of symptoms
 Time course of symptoms
• Neurological examination
 Confirm presence/absence of signs
 Refine neuroanatomical localisation
• Investigation
 Confirm/ exclude diagnosis
Neurological history
• Name- age- Lt /Rt handed- occupation
• Presenting complaint- date or days/ weeks/ months or
years ago
• History of presenting complaint
• Neurological and systems screening questions
• History of previous illnesses
• Drug and allergy history
• Social history
• Family history
Neurological history
• Chief compliant- “What is your main
problem?”
 Duration- date or days/ weeks/ months/
years
• List of other complaints- duration
Neurological history
• History of present illness
 Mode of onset
-Sudden onset suggests vascular aetiology, e.g.,
infarction or haemorrhage
 Course
-Exacerbations and remissions suggest inflammation
-Slowly progressive course suggests neoplasm
-Paroxysmal episodes suggest seizures, migraines,
e.t.c
Bradley et al, 2004
Neurological history
• History of present illness
 Temporal relationship of one symptom to
another
 Progression of each symptom
 Are symptoms getting better, staying the same
or getting worse
 What relieves symptoms and what makes them
worse
Bradley et al, 2004
Neurological history
• Neurological screening questions- ask about disturbances
in (from ‘top down’):
 Cognition, personality, mood change
 Hallucinations, seizures and other impairments of
consciousness
 Headaches; special senses; speech; language function;
swallowing
 Limb coordination; slowness of movement; involuntary
movement
 Strength and sensation; gait and balance; pain; bladder/
bowel/ sexual function
• Review of other organ systems
Bradley et al, 2004
Where could the lesion be?
• Possible locations of neurological lesions:
 Central nervous system
 Peripheral nervous system
Where could the lesion be?
• Possible locations of
neurological motor lesions:
 Central nervous system (UMN)
-Cerebral cortex
-Internal capsule
-Brainstem (cerebral peduncles, pons,
medulla)
-Spinal cord
 Peripheral nervous system
-Anterior horn cells or brainstem
-Root, plexus, peripheral nerve
-Neuromuscular junction
-Muscle
LMN
Neurological history
• Diagnostic hypothesis- what?
 e.g., brain syndrome
-Stroke (sudden onset)
-Demyelinating (relapsing- remitting)
-Tumour (progressive worsening)
-Degenerative
-Epilepsy/ migraine (paroxysmal)
Neurological Examination
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Conscious state
Cognitive function
Cranial nerve examination
Peripheral examination
Cognition
• Subjective memory loss alone –
unlikely to have neurological disorder
• Concerning symptoms
 Abnormal behaviour,
 inability to give a history
 concern from relatives or employers.
Cognition
• Assess attention
• If impaired this precludes all other cognitive
tests
• Acute attention deficit suggests confusional
state
 infection
 metabolic disturbance
 drug toxicity
Dysphasia
• Show your watch, what is this?
• What are the things that move round and
point at the numbers?
• What is this knob on the side?
• What is this that holds it on my wrist?
• What is this that holds the strap together?
• Simple one step commands to assess
comprehension
Formal Tests of Cognition
• MMSE
• ACE-R
Cranial Nerves
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I
II
III
IV
V
VI
olfactory
optic
oculomotor
trochlear
trigeminal
abducens
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VII
VIII
IX
X
XI
XII
facial
vestibulocochlear
glossopharyngeal
vagus
accessory
hypoglossal
Olfactory nerve I
• Not tested if patient reports
to be normal
• Sense of smell
• Synapses with olfactory
bulbs and projects via
olfactory tract to olfactory
cortex (rhinencephalon)
• Test using familiar odours
held under each nostril
Optic nerve II
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Visual acuity
Pupillary response to light
Colour perception
Visual fields by confrontation, including
double simultaneous stimulation
• Pupillary responses
• Fundoscopy
Visual acuity
• Stand 6 m from chart
• Test each eye separately
• Acuity =
6
Line correctly read
Colour perception
• Ishihara chart
Visual Fields
• Test each eye
separately
• Remember fields cross
i.e. left visual field
projects to right visual
cortex and conversely
• Lesions affecting optic
nerve cause monocular
defects
• Lesions affecting optic
chiasm may cause
bitemporal field defects
Pupillary
light response
• Afferent limb optic nerve II
• Efferent limb oculomotor
nerve III (via Edinger
Westphal nucleus)
• Direct reflex
• Consensual (indirect) reflex
Fundoscopy
• Examination of optic nerve
and retina with
ophthalmoscope
Ocular movements- nerves III, IV, VI
• Horizontal and vertical
eye movements
• Presence of nystagmus
Trigerminal nerve, V
• Jaw clenching
• Pin prick and touch sensation on
face
• Corneal reflex
Trigeminal nerve V
• Motor (mandibular division)
– Muscles of mastication
(masseter, pterygoids,
temporalis)
• Sensory to face
– 3 divisions
• Ophthalmic V1
• Maxillary V2
• Mandibular V3
– Patient shuts eyes
• Light touch
• temperature
• Corneal reflex
Facial Nerve VII
• Close eyes
• Show teeth
Facial weakness UMN vs LMN
• Upper face receives bilateral
innervation
• UMN lesion
– Spares upper face
– Contralateral lower facial
weakness
• LMN lesion
– Ipsilateral face is weak (both
upper and lower parts)
Facial Nerve VII
• Muscles of facial
expression, stapedius,
stylohyoid and posterior
belly of digastric
• Parasympathetic
– Lacrimal gland
– Submandibular and
sublingual glands
– Mucous membranes of
pharynx and soft palate
• Taste
– Anterior 2/3 tongue
• Sensation
– Small area behind ear
– Concha of auricle
Vestibulocochlear nerve VIII
• Perception of rubbing of
fingers
• If impaired look in
external auditory canals
and perform Rinne and
Weber’s tests
Vestibulocochlear nerve VIII
• 2 components
– Vestibular (balance)
– Cochlear (hearing)
• Auditory acuity
• Weber test
• Rinne test
Glossopharyngeal and
vagus, IX &X
• Palate lifts in the midline
• Gag reflex present
Glossopharyngeal nerve IX
• Motor
– stylopharyngeus
• Autonomic
– Parotid gland
• Sensation
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Pharynx
Posterior tongue
External ear
Gag reflex (afferent limb)
• Taste
– Posterior 1/3 tongue
Vagus nerve X
• Widespread projections
• Motor
– Pharynx
– Larynx
– Gag reflex (efferent limb)
• Sensation
– Somatic
– Visceral
• Autonomic
– Parasympathetic
innervation smooth muscle
and glands of pharynx,
viscera of thorax and
abdomen
Accessory nerve XI
• Shrug shoulders
Accessory nerve XI
• Cranial root (medulla)
• Spinal root (lateral portion of
upper cervical cord)
• Innervates
– Trapezius
– Sternocleidomastoid
Hypoglossal nerve XII
• Inspect tongue for wasting,
fasciculations
• Protrude tongue, looking for
deviation
Peripheral neurological examination
• Inspect for involuntary movements, wasting
fasciculations
• Muscle tone in response to passive flexion
and extension
• Power of main muscle groups
 Hold arms extended in supination (eyes open and
closed)
 Rise from floor without using hands
 Walk on toes and heels
Power
• Examine upper and lower limbs
 Know segmental innervation of specific
muscles
 Know peripheral nerve innervation of specific
muscles
 Patterns of weakness
-proximal vs distal
-‘pyramidal’
-fatiguable
Peripheral neurological examination
1a afferent
• Reflexes
 Monosynaptic reflex arc
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Biceps C5/6
Brachioradialis C5/6
Triceps C7
Finger C8
Knee L3/4
Ankle S1
 Increased in spasticity/UMN
lesions
 Reduced/absent in
radiculopathies and
neuropathies
• Plantar response
quadriceps
Alpha
motor neuron
Muscle spindle
Tendon of
quadriceps
Peripheral neurological examination
• Coordination
 Finger to nose and heel to shin testing,
performance of rapid alternating movements
 Tandem walking
Peripheral neurological examination
• Sensation
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Pin prick and light touch on hands and feet
Double simultaneous stimuli on hands and feet
Joint position sense on hallux and index finger
Vibration at ankle and index finger
• Gait
• Romberg test
The neurological assessment
• Questions to be answered:
 Is there a neurological lesion?- when
the answer is NO
Features suggestive of functional
disorder
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Inconsistent variable history
Pain “all over”
Midline splitting of sensation
Inconsistencies between function and
bedside exam
• Patient can’t lift leg by themselves but when
passively flexed, can maintain
• Give-way and stop start weakness
• Hoover’s sign
Quick Neuro Exam
• Gait: normal or abnormal? Walking aids
• Romberg’s test: feet together, eyes closed
(be ready to catch if the patient falls).
• Hold hands outstretched with palms up and
look for drift.
• Eyes still closed; touch right middle finger and
ask ‘touch your nose with this finger’; repeat
with left index finger.
• Eyes open: play the piano; tap your
hand…faster.
• Walk on heels, on toes, then tandem walk.
Quick Neuro Exam
• Look at my face…point at the finger that
moves (right lower…left lower… both
together, upper – possible inattention)
• Follow my finger (eye movements).
• Screw up your eyes (look also for pupillary
response on eye opening) then look at
forehead for elevated eyebrow – possible
Horner’s syndrome. Grin – show me your
teeth.
• Lie on the couch…fundoscopy, tendon
reflexes, plantars
• Pulse and blood pressure
Reduced:
•pain
•temperature
•touch
•vibration
•proprioception
(e.g. MCA stroke)
Analgesia - reduced pain
Also reduced
temperature sensation
C6
T7
L2
S2
Reduced touch and
proprioception
Major white matter tracts of the spinal cord
Sensory pathways in spinal cord – dorsal columns
Vibration
Joint position
The sensory system
C6
L2
Reduced:
•pain
•temperature
T7
S2
Sensory pathways in spinal cord – spinothalamic modalities
Lateral spinothalamic tract
Pain
Temperature
C6
L5
Reduced:
•pain
•temperature
•vibration
•touch
•proprioception
T7
S2
Cross sectional anatomy of the spinal cord