Download - Neurological examination
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Neurological Examination
Adam Zeman
Professor of Cognitive and Behavioural Neurology
University of Exeter Medical School
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Neurological examination
• History rules!
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Neurological examination
• History rules!
– and you are very good at it
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Neurological examination
• History rules!
– and you are very good at it
• History yields hypotheses
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Neurological examination
• History rules!
– and you are very good at it
• History yields hypotheses
– Where?
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Neurological examination
• History rules!
– and you are very good at it
• History yields hypotheses
– Where?
– What?
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Neurological history taking
• Diagnostic hypothesis – where, then what?
– Where?
• Muscle
• NMJ
• Peripheral nerve
• Spinal cord
• Brain
– Brain stem
– Cerebellum
– Thalamus
– basal ganglia
– Lobe or network
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Neurological history taking
Some common symptom patterns:
• NMJ – Fatiguable weakness
• LMN – Distal weakness and numbness
– Dysarthria, dysphagia
• UMN – Dexterity, dragging foot, exertional worsening, clonus, spasms and
sphincter disturbance
• Extrapyramidal – Aching, slowing up, shuffling, dexterity, handwriting
• Cerebellar – Slurring of speech, clumsiness, unsteadiness
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Neurological history taking
• Diagnostic hypothesis – where, then what?
– What?
eg spinal cord syndrome:
• Compression
– Disc
– tumour
• Demyelination
• Stroke…
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Neurological history taking
• ‘Whats’ – Inherited vs acquired
– Vascular
– Inflammatory
– Neoplastic
– Traumatic
– Allergic
– Metabolic
– Endocrine
– Drugs
– Iatrogenic
– Psychiatric
– Mechanical/Structural
– Degenerative
– Deficiency
– Sleep-related
– Physiological
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Neurological examination
• Examination tests the hypotheses framed
from the history
• It rarely surprises
• So why do it?
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Neurological examination
• It’s expected
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Neurological examination
• It’s expected
• Helps to build a relationship
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Neurological examination
• It’s expected
• Helps to build a relationship
• Allows some more history taking
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Neurological examination
• It’s expected
• Helps to build a relationship
• Allows some more history taking
• Buys time for thought
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Neurological examination
• It’s expected
• Helps to build a relationship
• Allows some more history taking
• Buys time for thought
• Allows you to recognise ‘normal’
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Neurological examination
• It’s expected
• Helps to build a relationship
• Allows some more history taking
• Buys time for thought
• Allows you to recognise ‘normal’
• May provide confirmatory signs
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Neurological examination
• It’s expected
• Helps to build a relationship
• Allows some more history taking
• Buys time for thought
• Allows you to recognise ‘normal’
• May provide confirmatory signs
• Occasionally springs a surprise
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Neurological examination
• It’s expected
• Helps to build a relationship
• Allows some more history taking
• Buys time for thought
• Allows you to recognise ‘normal’
• May provide confirmatory signs
• Occasionally springs a surprise
• Therapeutic ritual
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Neurological examination
• Neurologists have two advantages –
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Neurological examination
• Neurologists have two advantages –
– Calibration by many normal examinations
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Neurological examination
• Neurologists have two advantages –
– Calibration by many normal examinations
– Knowledge of neurological disorders:
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Neurological examination
• Neurologists have two advantages –
– Calibration by many normal examinations
– Knowledge of neurological disorders:
‘the eye will not see what the mind does not
know’
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Neurological examination
• Focus on aspects that are
– Most robust
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Neurological examination
• Focus on aspects that are
– Most robust
– Most revealing – especially in neuropsychiatry
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Useful patterns of signs
• Neuromuscular junction
– fatiguable weakness (eg ptosis)
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Useful patterns of signs
• Neuromuscular junction
– fatiguable weakness (eg ptosis)
• Lower motor neuron
– Wasting, fasciculation
– Decreased tone
– Weakness
– Reduced or absent reflexes
– +/- accompanying sensory loss, often distal
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Useful patterns of signs
• Upper motor neuron
– Spastic posture
– Clasp-knife increase in tone
– ‘Pyramidal pattern’of weakness
– Excessively brisk reflexes
– Extensor plantars
– +/- accompanying sensory loss
• sensory level
• hemisensory loss
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Useful patterns of signs
• Extrapyramidal (pathology in basal ganglia)
– Reduced spontaneous movement if akinetic
rigid syndrome (eg Parkinson’s)
– chorea if hyperkinetic (eg Huntington’s)
– Rigid increase in tone if akinetic
– Power near normal once mobilised
– Reflexes normal
– Decrementing bradykinesia in Parkinson’s
disease
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Cortico-striatal loops
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Useful patterns of signs
• Cerebellar
– DANISH
• Dysdiadochokinesia
• Ataxic gait
• Nystagmus
• Intention tremor
• Slurred speech
• Hypotonia
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Useful patterns of signs
• Functional weakness (‘hysterical’)
– Hoover’s sign (voluntary hip extension weak,
automatic hip extension on flexion of opposite
leg normal)
• - Fluctuating or ‘collapsing’ weakness
• ‘acrobatic’ gait
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Neurological examination
• Informal observation
– Muscle bulk
– Posture
• Spastic
• Dystonic
– Involuntary movements
• Tics, choreoathetosis, tremor, myoclonus
– Paucity of movement
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Neurological examination
• Informal observation
– Gait
• Stiff
• Ataxic
• Bradykinetic
• Lurching
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Neurological examination
• Gait
– Ordinary
– Heel-toe
– Romberg’s
– Heel, toe walking
– Rise from squat
– Hopping on one leg at a time
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Neurological examination
• I eg head injury
• II
– Acuity eg optic neuropathy
– Fields eg tumour
– Fundi…postpone
• III, IV, VI eg PSP, MS
– Pursuit
– Saccadic
– Convergence
…Fundi eg papilloedema, atrophy
…pupillary responses eg Syphilis
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Neurological examination
• V eg Sjogren’s syndrome
– Motor
– Sensory
• VII eg Lyme disease
• VIII eg mitochondrial cytopathy
• IX/X eg MND
• XI
• XII eg cerebellar, spastic, extrapyramidal
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Neurological examination
• Limbs
– Observation
– Tone
– Power
– Reflexes
– Sensation • Temperature or pin-prick
• Vibration or joint position
– Coordination
…hunting for the patterns….
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Neurological examination
• History rules
• Yields hypotheses –
– Where?
– What?
• Examination tests these
• Much of this is informal
• LMN, UMN, cerebellar, extrapyramidal patterns
are (relatively) robust
• Some signs are especially revealing
• Calibration and knowledge are keys
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Neurological examination
• ps
– Ask your neurologist to perform a mental state
examination
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Neurological examination
• An example
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