Neurological Neurological ExaminationExamination

Physical Diagnosis IIIPhysical Diagnosis IIISteve Sager, MPAS, PA-CSteve Sager, MPAS, PA-C

Learning ObjectivesLearning Objectives Upon satisfactory completion of this lecture, and in Upon satisfactory completion of this lecture, and in

conjunction with textbooks, lecture handouts, WebCT, conjunction with textbooks, lecture handouts, WebCT, and recommended internet web sites, the student will be and recommended internet web sites, the student will be able to: able to: Select appropriate questions to elicit from the patient with a Select appropriate questions to elicit from the patient with a

neurological complaint during a patient interviewneurological complaint during a patient interview Differentiate “normal” from “abnormal” findings on neurological Differentiate “normal” from “abnormal” findings on neurological

examinationexamination Identify common causes of various cranial nerve palsiesIdentify common causes of various cranial nerve palsies Differentiate conductive hearing loss from sensorineural hearing Differentiate conductive hearing loss from sensorineural hearing

lossloss Determine location of neurological lesionDetermine location of neurological lesion Differentiate amongst the various movement disordersDifferentiate amongst the various movement disorders

Learning ObjectivesLearning Objectives Differentiate between the following:Differentiate between the following:

atrophyatrophy hypertrophyhypertrophy pseudohypertrophypseudohypertrophy

Differentiate between the following:Differentiate between the following: spasticityspasticity rigidityrigidity flaccidityflaccidity

Differentiate CNS disorders from PNS disorders, and Differentiate CNS disorders from PNS disorders, and identify location of the lesion & common causesidentify location of the lesion & common causes

Compare and contrast the five clinical levels of Compare and contrast the five clinical levels of consciousnessconsciousness

Given a case study perform the appropriate focused Given a case study perform the appropriate focused history and physical examination and formulate a history and physical examination and formulate a differential diagnosisdifferential diagnosis

Purpose of the Neurological ExamPurpose of the Neurological Exam

Determine if there is a neurological deficitDetermine if there is a neurological deficitsensorysensorymotormotorbehavioralbehavioralcoordinativecoordinative

Localize the site of the problemLocalize the site of the problemDetermine the etiology of the problemDetermine the etiology of the problem

FocusesFocuses

Mental statusMental statusCranial nervesCranial nervesMotor functionMotor functionReflexesReflexesSensory statusSensory statusCoordination and balanceCoordination and balance

Sensory PathwaysSensory Pathways Ascending tractsAscending tracts Register sensationRegister sensation Posterior root to spinal cordPosterior root to spinal cord Synapses:Synapses:

secondary neuronssecondary neurons to motor neurons = DTRsto motor neurons = DTRs brainstem or spinal cordbrainstem or spinal cord

Impulses reach brain via:Impulses reach brain via: spinothalamic tractspinothalamic tract posterior columnsposterior columns

Motor PathwaysMotor Pathways Originating in the cerebral cortex:Originating in the cerebral cortex:

Corticospinal tractsCorticospinal tracts originate in the cerebral cortexoriginate in the cerebral cortex laterallateral

synapse with alpha motor neurons & interneuronssynapse with alpha motor neurons & interneurons anterioranterior

Cross at the cervical levelCross at the cervical level primarily modulates motor neurons that innervate neck and arm primarily modulates motor neurons that innervate neck and arm

musclesmuscles anterolateralanterolateral

Originating in the brain stemOriginating in the brain stem Tectospinal tractTectospinal tract

mediate reflex postural movements in response to visual (+/- mediate reflex postural movements in response to visual (+/- auditory) stimuli auditory) stimuli

Rubrospinal tractRubrospinal tract control muscle tone of flexor muscle groupscontrol muscle tone of flexor muscle groups

Vestibulospinal tractsVestibulospinal tracts facilitate spinal cord reflexes and muscle tone facilitate spinal cord reflexes and muscle tone

Spinothalamic TractSpinothalamic Tract Fibers cross in the spinal cord & Fibers cross in the spinal cord &

pass up to thalamuspass up to thalamus Neurons are located primarily in Neurons are located primarily in

the dorsal hornthe dorsal horn Lateral:Lateral:

pain, temperature, & crude touchpain, temperature, & crude touch

AnteriorAnterior light touchlight touch

also transmitted by the posterior also transmitted by the posterior columncolumn

when lesioned, little or no disturbance when lesioned, little or no disturbance in function is produced in function is produced

Posterior ColumnsPosterior Columns convey 3 different types of convey 3 different types of

sensation:sensation: ProprioceptionProprioception

sensory receptors are the sensory receptors are the muscle spindles and Golgi muscle spindles and Golgi tendon organstendon organs

vibratory sensevibratory sense sensory receptor is the sensory receptor is the

Pacinian corpusclePacinian corpuscle discriminative touchdiscriminative touch

sensory receptor is the sensory receptor is the Meissner corpuscleMeissner corpuscle

Synapse in medulla, cross Synapse in medulla, cross & continue to thalamus& continue to thalamus

Sensory PathwaysSensory Pathways

Thalamic level Thalamic level general sensation - No fine distinctions general sensation - No fine distinctions

Neurons from thalamus to Neurons from thalamus to sensory cortexsensory cortex here stimuli localized & discrimination here stimuli localized & discrimination

? Causative lesion? Causative lesionpatterns of sensory loss + motor findingspatterns of sensory loss + motor findings

TerminologyTerminology

ParesisParesis slight or incomplete paralysisslight or incomplete paralysis

Paralysis (plegia)Paralysis (plegia) loss or impairment of motor functionloss or impairment of motor function

HemiparesisHemiparesis

HemiplegiaHemiplegia

ParaplegiaParaplegia

QuadriplegiaQuadriplegia

TerminologyTerminology AtrophyAtrophy

HypertrophyHypertrophy enlargement of an organ or part due to an increase in size of its enlargement of an organ or part due to an increase in size of its

constituent cellsconstituent cells

PseudohypertrophyPseudohypertrophy increase in size without true hypertrophyincrease in size without true hypertrophy

SpasticitySpasticity hypertonicity with increased DTRshypertonicity with increased DTRs

RigidityRigidity stiffness or inflexibilitystiffness or inflexibility

FlaccidityFlaccidity loss of tone with diminished DTRsloss of tone with diminished DTRs

Abnormal MovementsAbnormal Movements

Abnormal MovementsAbnormal Movements

Abnormal MovementsAbnormal Movements

Abnormal MovementsAbnormal Movements

HistoryHistory

Chief complaintChief complaintPQRSTPQRSTHeadache?Headache?Vertigo?Vertigo?Visual disturbance?Visual disturbance?Tremors or dyskinesias?Tremors or dyskinesias?Weakness?Weakness?Dysesthesias/Paresthesias?Dysesthesias/Paresthesias?Loss of consciousness?Loss of consciousness?

Key components of H&PKey components of H&P

ComplaintComplaint HxHx P.E.P.E.

Altered mental Altered mental statusstatus

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

VertigoVertigo Differentiate between true vertigo and lightheadedness! Present at rest; affected by positional changes

CN VIII function; Dix-Hallpike maneuver; nystagmus

HeadacheHeadache Thorough hx; “worst headache ever?”; associated sx’s; neck pain/stiffness

CN function; pupillary reaction; fundoscopic exam; palpate temporal artery; Marcus-Gunn

SeizuresSeizures Previous hx; frequency; motor activity; aura; LOC; post-ictal confusion; external etiology

Search for focal deficits; signs of trauma; hyperreflexia

WeaknessWeakness Generalized or focal; loss of strength; pain; progressive or recurrent fatigue

Asymmetry7; atrophy; sensory deficits; fasciculations; DTRs

Mental StatusMental Status AlertnessAlertness OrientationOrientation

Person, Place, Time, & SituationPerson, Place, Time, & Situation Appearance & behaviorAppearance & behavior Cognitive functionCognitive function

AttentionAttention PerceptionPerception

Illusions = Illusions = misinterpretations of real external stimulimisinterpretations of real external stimuli Hallucinations = Hallucinations = subjective sensory perceptions in the absence of stimulisubjective sensory perceptions in the absence of stimuli

JudgmentJudgment MemoryMemory

Short-term & long-termShort-term & long-term SpeechSpeech

Rate & rhythmRate & rhythm SpontaneitySpontaneity FluencyFluency Simple vs. complexSimple vs. complex

Mini Mental Status Exam (MMSE)Mini Mental Status Exam (MMSE)

Screening test for cognitive dysfunctionScreening test for cognitive dysfunctionAssesses:Assesses:

orientationorientationattentionattention immediate and short-term memoryimmediate and short-term memory language/speechlanguage/speechability to follow simple verbal and written ability to follow simple verbal and written

commands commands

AttentionAttention

Depends on the integrity of the dominant Depends on the integrity of the dominant hemisphere as well as patient’s intelligencehemisphere as well as patient’s intelligence

Spell W-O-R-L-D backwardsSpell W-O-R-L-D backwards Recite the months forwards and backwardsRecite the months forwards and backwards Digit spanDigit span

recite a series of digits of increasing lengthrecite a series of digits of increasing length Serial 7s (or 5s):Serial 7s (or 5s):

ask patient to start with 100ask patient to start with 100 subtract 7 (or5)subtract 7 (or5) then subtract 7 (or 5) from the result and continue then subtract 7 (or 5) from the result and continue

doing sodoing so

MemoryMemory

Immediate recall, recent & remote memoryImmediate recall, recent & remote memory Immediate memory:Immediate memory:

name 3 objects - have pt immediately repeat name 3 objects - have pt immediately repeat

Recent memory:Recent memory: ask patient to recall previous 3 objects after 5 ask patient to recall previous 3 objects after 5

minutesminutes

Remote memory:Remote memory: ask patient regarding well-known events in past ask patient regarding well-known events in past be sure information asked is verifiablebe sure information asked is verifiable

Thought content and perceptionsThought content and perceptions Generally assessed throughout the interviewGenerally assessed throughout the interview Thought processThought process

logic, relevance, organization and coherencelogic, relevance, organization and coherence Thought contentThought content

delusions, obsessions, compulsions, phobiasdelusions, obsessions, compulsions, phobias PerceptionsPerceptions

hallucinations hallucinations InsightInsight Ask questions such as:Ask questions such as:

"Do you ever hear things that other people don't "Do you ever hear things that other people don't hear or see things that other people don't see?“hear or see things that other people don't see?“

"Do you feel that someone is watching you or "Do you feel that someone is watching you or trying to hurt you?“trying to hurt you?“

"Do you have any special abilities or powers?" "Do you have any special abilities or powers?"

JudgmentJudgmentRequires higher cerebral functionRequires higher cerebral functionAsk the patient to interpret a simple Ask the patient to interpret a simple

problem:problem:What would you do if you noticed an What would you do if you noticed an

addressed envelope with an un-cancelled addressed envelope with an un-cancelled stamp on it on the street near a mailbox?stamp on it on the street near a mailbox?

What would you do if you suddenly lost What would you do if you suddenly lost your job?your job?

What would you do if you were in a What would you do if you were in a crowded movie theater and a fire started?crowded movie theater and a fire started?

AbstractionAbstractionHigher cerebral function that requires Higher cerebral function that requires

comprehension and judgmentcomprehension and judgment

Proverbs are commonly usedProverbs are commonly used

Ask patient to interpret following Ask patient to interpret following sayings:sayings: ““People who live in glass houses should People who live in glass houses should

not throw stones”not throw stones” ““A rolling stone gathers no moss”A rolling stone gathers no moss”

SpeechSpeechQuantityQuantity

spontaneityspontaneity

RateRate fastfastslowslow

RhythmRhythmhesitanthesitant

VolumeVolume

LanguageLanguage

Can the patient understand simple questions and Can the patient understand simple questions and commands?commands?

Ask the patient to read single words or a brief Ask the patient to read single words or a brief passage.passage.

Ask the patient to write their name and write a Ask the patient to write their name and write a sentence. sentence.

Ask the patient to name some easy (pen, watch, Ask the patient to name some easy (pen, watch, tie, etc.) and some more difficult (fingernail, belt tie, etc.) and some more difficult (fingernail, belt buckle, stethoscope, etc.) objects.buckle, stethoscope, etc.) objects. naming parts of objects is often more difficultnaming parts of objects is often more difficult

Comprehension of grammatical structure should Comprehension of grammatical structure should be tested as wellbe tested as well "Mike was shot by John. Is John dead?" "Mike was shot by John. Is John dead?"

SpeechSpeech

Assess articulation and fluency:Assess articulation and fluency:Ask patient to recite “no ifs, ands, or buts”Ask patient to recite “no ifs, ands, or buts”

Aphasia = difficulty producing or understanding Aphasia = difficulty producing or understanding languagelanguage

lesion in dominant cerebral hemispherelesion in dominant cerebral hemisphere Broca’s or Wernicke’sBroca’s or Wernicke’s

Dysarthria = difficulty in articulationDysarthria = difficulty in articulation lesions of tongue & palatelesions of tongue & palate

Dysphonia = difficulty in phonationDysphonia = difficulty in phonation lesions of palate & vocal cordslesions of palate & vocal cords

Dysphasia = difficulty comprehending or speakingDysphasia = difficulty comprehending or speaking cerebral dysfunction cerebral dysfunction

Neurological changes with agingNeurological changes with aging

Altered mental statusAltered mental status forgetfulnessforgetfulness dementiadementia

Ocular changes:Ocular changes: presbyopiapresbyopia alterations in EOMs, pupil size/shape/reactivityalterations in EOMs, pupil size/shape/reactivity

PresbycusisPresbycusis VertigoVertigo Motor dysfunction/weaknessMotor dysfunction/weakness TremorsTremors Diminished reflexesDiminished reflexes

Levels of ConsciousnessLevels of Consciousness Alert and OrientedAlert and Oriented DisorientedDisoriented LethargicLethargic ObtundedObtunded

Drowsy/somnolentDrowsy/somnolent Clouded consciousnessClouded consciousness Slow thought, movement, and speechSlow thought, movement, and speech

StuporousStuporous Marked reduction in mental and physical activityMarked reduction in mental and physical activity Vigorous stimuli needed to provoke a responseVigorous stimuli needed to provoke a response

ComatoseComatose Completely unconsciousCompletely unconscious Cannot be aroused by painful stimuliCannot be aroused by painful stimuli Absence of voluntary movementAbsence of voluntary movement +/- reflexes+/- reflexes

The Mini-Mental State ExamPatient____________________________ Examiner ___________________ Date____________

Maximum Score Orientation5 ( ) What is the (year) (season) (date) (day) (month)?5 ( ) Where are we (state) (country) (town) (hospital) (floor)?

Registration3 ( ) Name 3 objects:

1 second to say each. Then ask the patient all 3 after you have said them.Give 1 point for each correct answer. Then repeat them until he/she learns all 3.Count trials and record. ___________

Attention and Calculation5 ( ) Serial 7’s. 1 point for each correct answer.

Stop after 5 answers.Alternatively spell “W-O-R-L-D” backward.

Recall3 ( ) Ask for the 3 objects repeated above. Give 1 point for each correct answer.

Language2 ( ) Name a pencil and watch1 ( ) Repeat the following “No ifs, ands, or buts”3 ( ) Follow a 3-stage command: “Take a paper in your hand, fold it in half, and put it on the table.”1 ( ) Read and obey the following: CLOSE YOUR EYES1 ( ) Write a sentence.1 ( ) Copy the design shown.

____ Total Score (30 points possible)

ASSESS level of consciousness along a continuum ____________ (Alert, Drowsy, obtundedStupor, Coma)

Glasgow Glasgow Coma Coma ScaleScale

The Neurological Exam on aThe Neurological Exam on aStuporous or Comatose PatientStuporous or Comatose Patient

VSVS respirationsrespirations

PupilsPupilsOcular movementOcular movement

observe position of eyesobserve position of eyesOculocephalic Reflex (“Doll’s eyes”)Oculocephalic Reflex (“Doll’s eyes”)

assesses brainstem functionassesses brainstem functionhold open upper eyelids, turn head quickly, first to hold open upper eyelids, turn head quickly, first to

one side & then to other one side & then to other

The Neurological Exam on aThe Neurological Exam on aStuporous or Comatose PatientStuporous or Comatose Patient

Oculovestibular reflex (calorics):Oculovestibular reflex (calorics): if oculocephalic reflex is absentif oculocephalic reflex is absent

provides further assessment of brainstem provides further assessment of brainstem

rarely performed in a conscious patientrarely performed in a conscious patient insure intact eardrums and clear canalsinsure intact eardrums and clear canals elevate patient’s head to 30elevate patient’s head to 30°° place kidney basin under ear & inject ice water place kidney basin under ear & inject ice water

through small catheter into ear canalthrough small catheter into ear canal watch for deviation of eyes in horizontal planewatch for deviation of eyes in horizontal plane

The Neurological Exam on aThe Neurological Exam on aStuporous or Comatose PatientStuporous or Comatose Patient

Posture & Muscle Tone:Posture & Muscle Tone:observe patient’s postureobserve patient’s posture

if no spontaneous movement, apply a painful if no spontaneous movement, apply a painful stimulus and classify the resulting movement:stimulus and classify the resulting movement:normal = avoidant normal = avoidant stereotypic (decorticate or decerebrate)stereotypic (decorticate or decerebrate)flaccid paralysis or no responseflaccid paralysis or no response

test muscle tone test muscle tone

PosturingPosturing

DECORTICATE RIGIDITYDECORTICATE RIGIDITY Abnormal flexor responseAbnormal flexor response Characterized by rigidity, flexion of the arms, Characterized by rigidity, flexion of the arms,

clenched fists, and extended legsclenched fists, and extended legs the arms are bent inward toward the body with the wrists the arms are bent inward toward the body with the wrists

and fingers bent and held on the chestand fingers bent and held on the chest Destructive lesion of Corticospinal tractsDestructive lesion of Corticospinal tracts

PosturingPosturing

DECEREBRATE RIGIDITYDECEREBRATE RIGIDITY Abnormal Extensor ResponseAbnormal Extensor Response Characterized by rigid extension of the arms and legs, Characterized by rigid extension of the arms and legs,

downward pointing of the toes, and backward arching of the downward pointing of the toes, and backward arching of the headhead

Typicall caused by deterioration of the structures of the Typicall caused by deterioration of the structures of the nervous system, particularly the upper brain stemnervous system, particularly the upper brain stem lesion in diencephalon, midbrain, ponslesion in diencephalon, midbrain, pons metabolic disordersmetabolic disorders

The Neurological Exam on aThe Neurological Exam on aStuporous or Comatose PatientStuporous or Comatose Patient

General physical examination:General physical examination: ? unusual odors? unusual odors ? skin abnormalities ? skin abnormalities ? trauma scalp & skull ? trauma scalp & skull inspection for facial asymmetryinspection for facial asymmetry corneal reflexes & fundicorneal reflexes & fundi ears, nose, mouth & throatears, nose, mouth & throat heart, lungs, & abdomenheart, lungs, & abdomen motor, sensory, & reflex functionmotor, sensory, & reflex function meningeal signs meningeal signs

Malingering (Nonorganic)Malingering (Nonorganic)

““Willful faking of symptoms”Willful faking of symptoms” Commonly present in a glove-and-stocking Commonly present in a glove-and-stocking

distributiondistribution Examples:Examples:

hand drophand drop blindnessblindness

EOM/IEOM/I unilateral diplopiaunilateral diplopia ammonia reactionammonia reaction

Test for:Test for: absence of pain or weakness in different positionsabsence of pain or weakness in different positions Hoover testHoover test

Organic DiseaseOrganic Disease

Suggested by signs that cannot be faked:Suggested by signs that cannot be faked:asymmetric pupillary responseasymmetric pupillary responseabnormal fundoscopic examabnormal fundoscopic examocular divergenceocular divergencemarked nystagmusmarked nystagmusmuscle atrophymuscle atrophy fasciculationfasciculationmultiple complex signs and symptomsmultiple complex signs and symptoms

The “Difficult” PatientThe “Difficult” Patient

Observation is key!Observation is key! Use ingenuity!Use ingenuity! Be patient! Be patient! AgitatedAgitated

may be threatening or violentmay be threatening or violent UnresponsiveUnresponsive

fail to participatefail to participate UnreliableUnreliable

inattentive, preoccupied, inconsistent informationinattentive, preoccupied, inconsistent information HystericalHysterical

uncooperativeuncooperative

Testing Cognitive FunctionTesting Cognitive Function

Information & vocabularyInformation & vocabulary commoncommon

CalculatingCalculating simple mathsimple math word problemsword problems

Abstract thinkingAbstract thinking proverbsproverbs similarities/differencessimilarities/differences

ConstructionConstruction copy figures of increasing difficulty (i.e. circle, clock)copy figures of increasing difficulty (i.e. circle, clock)

Abnormalities of Thought ProcessesAbnormalities 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 ContentAbnormalities 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. DementiaDelirium vs. Dementia Although confusion and/or disorientation are signs of both Delirium and Although confusion and/or disorientation are signs of both Delirium and

Dementia, they are differentDementia, they are different Delirium is an Delirium is an acuteacute confusional state confusional state

potentially reversiblepotentially reversible usually occurs over a period of days to monthsusually occurs over a period of days to months

Dementia is slow and insidiousDementia is slow and insidious progresses slowly over months to yearsprogresses slowly over months to years not reversible not reversible

Condition Onset Pattern Orientation Attention Memory Duration

Delirium 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

Mnemonics: DELIRIUMMnemonics: DELIRIUM

D = drugs, ethanolD = drugs, ethanolE = electrolyte imbalanceE = electrolyte imbalanceL = low PO2 (hypoxia)L = low PO2 (hypoxia) I = injury to brainI = injury to brainR = relapsing fever (malaria)R = relapsing fever (malaria) I = infectionI = infectionU = uremiaU = uremiaM = metabolic (liver damage)M = metabolic (liver damage)

Mnemonics: DEMENTIAMnemonics: DEMENTIA

D = drugs & toxins D = drugs & toxins E = endocrineE = endocrineM = metabolic & mechanicalM = metabolic & mechanicalE = epilepsyE = epilepsyN = nutritional & nervous systemN = nutritional & nervous systemT = tumor & traumaT = tumor & trauma I = infectionI = infectionA = arterial compromiseA = arterial compromise

Visual disturbanceVisual disturbance

Onset?Onset?acute ~ vascularacute ~ vascular

Monocular vs. binocular?Monocular vs. binocular?Constant vs. intermittent?Constant vs. intermittent? Improved with glasses = refractive errorImproved with glasses = refractive errorProgression?Progression?

retinal detachments = minutes to hoursretinal detachments = minutes to hours tumors = monthstumors = months retinal degeneration = yearsretinal degeneration = years

Visual disturbanceVisual disturbance

TIA = brief, intermittent visual lossTIA = brief, intermittent visual loss

Migraine = “wavy”Migraine = “wavy”

Retinal detachment = “drawn curtain”Retinal detachment = “drawn curtain”

Acute glaucoma = “rainbows” or “halos”Acute glaucoma = “rainbows” or “halos”

Digitalis toxicity = yellow hueDigitalis toxicity = yellow hue

VertigoVertigo A sense of spinningA sense of spinning

personperson environmentenvironment

Suggests dysfunction of:Suggests dysfunction of: vestibular apparatusvestibular apparatus vestibular nervevestibular nerve

Differentiate from “lightheadedness” and Differentiate from “lightheadedness” and “faintness”“faintness” results from impairment of brain oxygenationresults from impairment of brain oxygenation

cardiac arrhythmiacardiac arrhythmia hypotensionhypotension psychological factorspsychological factors

Dix-Hallpike maneuverDix-Hallpike maneuver

NystagmusNystagmus

Involuntary eye movements usually triggered by Involuntary eye movements usually triggered by inner ear stimulationinner ear stimulation

It usually begins as a slow pursuit movement It usually begins as a slow pursuit movement followed by a fast, rapid resetting phase.followed by a fast, rapid resetting phase.

Named by the direction of the fast phaseNamed by the direction of the fast phase right or left beatingright or left beating up- or down-beatingup- or down-beating direction changingdirection changing rotationalrotational

movements are not purely horizontal or verticalmovements are not purely horizontal or vertical

Nystagmus associated with BPPV is usually Nystagmus associated with BPPV is usually provoked with the head turned to one sideprovoked with the head turned to one side

NystagmusNystagmus

Etiologies:Etiologies:congenitalcongenitalEOM spasmsEOM spasmsMSMScerebellarcerebellarvestibular diseasevestibular diseasedrug toxicitydrug toxicity

Testing for AphasiaTesting for AphasiaWord 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.

LocalizationLocalization

CNS vs. PNSCNS vs. PNSbrain/brain stembrain/brain stemspinal cordspinal cordperipheral nervesperipheral nerves

Difficult when evaluating:Difficult when evaluating: radicular painradicular paindysesthesia/paresthesiadysesthesia/paresthesia tremorstremors incoordinationincoordination

LocalizationLocalization CerebrumCerebrum

impaired intellect, memory, higher brain functionimpaired intellect, memory, higher brain function Brain stemBrain stem

unconsciousnessunconsciousness LMNLMN

paralysis with loss of DTRsparalysis with loss of DTRs muscle atrophy with fasciculationmuscle atrophy with fasciculation

LMN + anesthesiaLMN + anesthesia peripheral nerve or spinal rootperipheral nerve or spinal root

UMNUMN involves whole muscle groupsinvolves whole muscle groups increased or spastic muscle toneincreased or spastic muscle tone +/- paralysis with DTR accentuation+/- paralysis with DTR accentuation positive Babinskipositive Babinski

Organic DiseaseOrganic Disease

Asymmetric pupillary light reflexAsymmetric pupillary light reflexAbnormal fundusAbnormal fundusOcular divergenceOcular divergenceNystagmusNystagmusMuscular atrophyMuscular atrophyFasciculationsFasciculationsMultiple complex signs/symptoms Multiple complex signs/symptoms

explained by a single lesionexplained by a single lesion

HeadacheHeadache

55thth most common reason for OP visit most common reason for OP visit International Classification of Headache International Classification of Headache

Disorders, 2Disorders, 2ndnd edition editionpublished by IHSpublished by IHS

Symptom! (not a disease)Symptom! (not a disease)Most important diagnostic clueMost important diagnostic clue is a is a

steady, bilateral, nonthrobbing pain that issteady, bilateral, nonthrobbing pain that isworse in the a.m.worse in the a.m.may awaken patientmay awaken patientworse with VALSALVAworse with VALSALVA

Headache HistoryHeadache History LocationLocation

Unilateral ~ migraineUnilateral ~ migraine Periorbital (+/- visual disturbance) ~ glaucoma/uveitisPeriorbital (+/- visual disturbance) ~ glaucoma/uveitis Parietal/Occipital ~ tensionParietal/Occipital ~ tension Neck ~ meningitis or Subarachnoid hemorrhageNeck ~ meningitis or Subarachnoid hemorrhage

QualityQuality ““Throbbing” ~ vascularThrobbing” ~ vascular ““Intermittent jabbing” ~ Trigeminal neuralgiaIntermittent jabbing” ~ Trigeminal neuralgia ““Pressure” ~ sinusPressure” ~ sinus

Radiation?Radiation? SeveritySeverity TimingTiming

Constant vs. intermittentConstant vs. intermittent Worse in a.m. or p.m.Worse in a.m. or p.m.

Worst headache ever?????Worst headache ever?????

Headache HistoryHeadache History Palliative or provocative measures?Palliative or provocative measures?

PressurePressure ETOHETOH

Associated Sx’sAssociated Sx’s Visual disturbanceVisual disturbance VertigoVertigo N/VN/V DysesthesiasDysesthesias AuraAura

Past medical historyPast medical history Family historyFamily history Current medication/drug useCurrent medication/drug use Suspect an extracranial etiology if pain is the only Suspect an extracranial etiology if pain is the only

symptomsymptom

Physical ExaminationPhysical Examination

AppearanceAppearanceBehavior/MannerismsBehavior/Mannerisms

Gait and PostureGait and PostureMotor behaviorMotor behaviorFacial expressionsFacial expressions

Mood vs. AffectMood vs. AffectMMSEMMSE

““FOGS”FOGS”

Physical ExaminationPhysical Examination

Test Cranial Nerves II through XIITest Cranial Nerves II through XII Test motor nerve functionTest motor nerve function

Station and gait – Station and gait – ambulate, turn, toes, heels, heel-to-toe, ambulate, turn, toes, heels, heel-to-toe, knee bendknee bend

Grip/SARGrip/SAR RombergRomberg

Test sensory nerve functionTest sensory nerve function Pain +/- Light touchPain +/- Light touch Two point discriminationTwo point discrimination Proprioception/Stereognosis/VibrationProprioception/Stereognosis/Vibration

Test deep tendon reflexesTest deep tendon reflexes

Physical ExaminationPhysical Examination

Fundoscopic examination Fundoscopic examination Test for meningeal irritationTest for meningeal irritationStraight leg raiseStraight leg raiseTest CoordinationTest Coordination

Finger-to-noseFinger-to-noseRapid alternating movements of hands & feetRapid alternating movements of hands & feet

Physical Examination – Neck/SpinePhysical Examination – Neck/Spine

Look for pertinent positives and negatives:Look for pertinent positives and negatives: edema, ecchymosis, erythema edema, ecchymosis, erythema deformitydeformity spinal step off (spondylolisthesis, spina bifida) spinal step off (spondylolisthesis, spina bifida) lordosis/scoliosis lordosis/scoliosis tenderness (where?) tenderness (where?) positive SLR/ crossover SLR positive SLR/ crossover SLR diminished range of motion (ROM)diminished range of motion (ROM) diminished muscle strengthdiminished muscle strength spasms (where) spasms (where)

VALSALVA (intrathecal pressure) VALSALVA (intrathecal pressure) Rectal Exam Rectal Exam

Physical ExaminationPhysical Examination

Patrick’s testPatrick’s testHoover testHoover testBrudzinski’s test Brudzinski’s test Kernigs test Kernigs test Gaenslen's sign (Sacroiliac)Gaenslen's sign (Sacroiliac)Trendelenburg test (hip) Trendelenburg test (hip) Babinski Babinski

Neuro Exam - ShoulderNeuro Exam - ShoulderNerve Motor Sensory Reflex

C5 abduct arm,abduct arm,flex bicepsflex biceps

lateral armlateral arm(axillary n.)(axillary n.)

bicepsbiceps

C6 extend wrist, extend wrist, flex bicepsflex biceps

lateral forearm,lateral forearm,

11stst & 2 & 2ndnd digits digits (musculocutaneous n.)(musculocutaneous n.)

brachioradialisbrachioradialis

C7 flex wrist, flex wrist, extend fingers, extend fingers, extend forearmextend forearm

middle fingermiddle finger tricepstriceps

C8 hand instrinsics, hand instrinsics, finger flexorsfinger flexors

Medial forearm/ 4Medial forearm/ 4thth & 5& 5thth digits digits (medial (medial antebrachial cutaneous antebrachial cutaneous n.)n.)

Neuro Exam - SpineNeuro Exam - SpineNerve Motor Sensory Reflex

T1 hand intrinsics, hand intrinsics, finger abductionfinger abduction

finger adductionfinger adduction

medial Armmedial Arm(medial antebrachial (medial antebrachial cutaneous n.)cutaneous n.)

L1 inversion of footinversion of foot medial aspect of medial aspect of foot/calffoot/calf

PatellarPatellar

L5 dorsiflexion of big dorsiflexion of big toetoe

dorsum of foot dorsum of foot and lateral calfand lateral calf

S1 eversion of footeversion of foot lateral aspect foot lateral aspect foot and soleand sole

AchillesAchilles

S5 anal sphincter toneanal sphincter tone

ReflexesReflexes

CornealCornealPharyngealPharyngealBicepsBicepsTricepsTricepsBrachioradialisBrachioradialisAbdominalAbdominalPatellar (knee jerk)Patellar (knee jerk)Achilles (ankle jerk)Achilles (ankle jerk)BabinskiBabinski

Test Cranial Nerve functionTest Cranial Nerve function

II - Olfactory- Olfactory IIII - Optic- Optic IIIIII - Oculomotor- Oculomotor IVIV - Trochlear- Trochlear VV - Trigeminal- Trigeminal VIVI - Abducens- Abducens VIIVII - Facial- Facial VIIIVIII - Vestibulocochlear (Acoustic)- Vestibulocochlear (Acoustic) IXIX - Glossopharyngeal- Glossopharyngeal XX - Vagus- Vagus XIXI - Accessory- Accessory XIIXII - Hypoglossal- Hypoglossal

Cranial NervesCranial Nerves

Olfactory Nerve (CN I) - many causes for Olfactory Nerve (CN I) - many causes for loss of smell:loss of smell:Nasal diseaseNasal diseaseHead traumaHead traumaSmokingSmokingUse of cocaineUse of cocaineCongenital causesCongenital causes

Avoid noxious odors when testingAvoid noxious odors when testing

Cranial NervesCranial NervesOptic Nerve (CN II) Optic Nerve (CN II)

disorders of optic disc:disorders of optic disc:optic atrophyoptic atrophy

Cranial NervesCranial Nerves

PapilledemaPapilledema

Disorders of visual Disorders of visual fields by confrontation:fields by confrontation: Visual extinction = lesion Visual extinction = lesion

in parietal cortexin parietal cortex

CN II Injury: Clinical correlationCN II Injury: Clinical correlation

Damage to the optic nerve will also result in a Damage to the optic nerve will also result in a monocular visual defect due to loss of input from the monocular visual defect due to loss of input from the ipsilateral eye. The patient will complain of blindness ipsilateral eye. The patient will complain of blindness in that eye.in that eye.

CN II Injury: Clinical correlationCN II Injury: Clinical correlation Damage to the medial aspect of the optic chiasm, as is Damage to the medial aspect of the optic chiasm, as is

often seen with a pituitary gland tumor, may compromise often seen with a pituitary gland tumor, may compromise the decussating fibers from both nasal hemiretinas. The the decussating fibers from both nasal hemiretinas. The loss of peripheral vision in both eyes is called bitemporal loss of peripheral vision in both eyes is called bitemporal hemianopia.hemianopia.

Damage to the lateral aspect of the optic chiasm, as may Damage to the lateral aspect of the optic chiasm, as may occur in the case of an aneurysm of the internal carotid occur in the case of an aneurysm of the internal carotid artery, will affect the fibers of the ipsilateral temporal artery, will affect the fibers of the ipsilateral temporal hemiretina (nasal visual field).hemiretina (nasal visual field).

Pupil AbnormalitiesPupil Abnormalities

Motor or sensory injury results in a Motor or sensory injury results in a contralateral defectcontralateral defect

Pupillary reflex is consensualPupillary reflex is consensualbrain-stem mediated reflexbrain-stem mediated reflex

Asymmetry of pupil size of >1mm suggests Asymmetry of pupil size of >1mm suggests CN III compressionCN III compression

Pupil AbnormalitiesPupil AbnormalitiesBilateral dilation

anoxiaanoxiadrug affectdrug affect

Unilateral constriction sympathetic dysfunction (Horner syndrome)sympathetic dysfunction (Horner syndrome)carotid artery dissectioncarotid artery dissection

Bilateral constrictionpontine hemorrhagepontine hemorrhagedrugs (opiates, Clonidine)drugs (opiates, Clonidine) toxins (organophosphates)toxins (organophosphates)

Pupil AbnormalitiesPupil AbnormalitiesAnisocoriaAnisocoria

>2mm difference in size>2mm difference in size

Adie’s (Tonic) pupilAdie’s (Tonic) pupilsluggish responsesluggish response

Argyll Robertson pupilArgyll Robertson pupil irregular/unequal pupilsirregular/unequal pupilsweak/absent reaction to light (poor dilation)weak/absent reaction to light (poor dilation)exaggerated contraction to accommodationexaggerated contraction to accommodation? neurosyphilis? neurosyphilis

Pupil AbnormalitiesPupil Abnormalities

Horner’s syndromeHorner’s syndromecentral, preganglionic, or postganglioniccentral, preganglionic, or postganglioniccharacterized by:characterized by:

ptosisptosis due to oculosympathetic palsydue to oculosympathetic palsy

miosismiosisfacial anhydrosisfacial anhydrosis

Pupil AbnormalitiesPupil AbnormalitiesMarcus-Gunn pupilMarcus-Gunn pupil

results from reduced afferent input in the results from reduced afferent input in the affected eye**affected eye**

pupil fails to constrict fullypupil fails to constrict fully rapidly stimulate each eye in succession and rapidly stimulate each eye in succession and

observe the direct and consensual light observe the direct and consensual light response in eachresponse in eachstimulation of the normal eye produces full stimulation of the normal eye produces full

constriction in both pupils.constriction in both pupils.immediate subsequent stimulus of the affected eye immediate subsequent stimulus of the affected eye

produces an apparent dilation in both pupils since produces an apparent dilation in both pupils since the stimulus carried through that optic nerve is the stimulus carried through that optic nerve is weakerweaker

EOM InnervationsEOM Innervations

MuscleMuscle InnervationInnervation Primary Primary actionaction

Secondary Secondary actionaction

Tertiary Tertiary actionaction

Medial rectusMedial rectus CN IIICN III AdductionAdduction

Superior rectusSuperior rectus CN IIICN III ElevationElevation IntortionIntortion AdductionAdduction

Inferior rectusInferior rectus CN IIICN III DepressionDepression ExtortionExtortion AdductionAdduction

Inferior obliqueInferior oblique CN IIICN III ExtorsionExtorsion ElevationElevation AbductionAbduction

Superior Superior obliqueoblique

CN IVCN IV IntorsionIntorsion DepressionDepression AbductionAbduction

Lateral rectusLateral rectus CN VICN VI AbductionAbduction

CN III: Clinical correlationCN III: Clinical correlation

CN III: Clinical correlationCN III: Clinical correlation

Marcus-Gunn pupilMarcus-Gunn pupil Adie’s tonic pupilAdie’s tonic pupil Argyll-Robertson pupilArgyll-Robertson pupil

caused by damage to cells in the pretectal region of caused by damage to cells in the pretectal region of the midbrainthe midbrain

signals carried by CN II from the retina are not signals carried by CN II from the retina are not relayed via the pretectal nucleus on the affected side relayed via the pretectal nucleus on the affected side

results in a loss of both the direct and consensual results in a loss of both the direct and consensual pupillary light reflex when light is shined in the eye on pupillary light reflex when light is shined in the eye on the affected sidethe affected side

because the accommodation reflex pathway is distinct because the accommodation reflex pathway is distinct from the light reflex pathway the from the light reflex pathway the accommodation reflex is unaffected

Left Trochlear (CN IV) palsyLeft Trochlear (CN IV) palsy

CN VI: Clinical correlationCN VI: Clinical correlation

Inability to abduct the affected eye beyond the Inability to abduct the affected eye beyond the midline of gazemidline of gaze

StrabismusStrabismus inability to direct both eyes to the same objectinability to direct both eyes to the same object

when asked to look at an object located laterally to the side when asked to look at an object located laterally to the side of the lesion, the patient's affected eye will be unable to be of the lesion, the patient's affected eye will be unable to be abducted beyond the midline of gaze. The opposite normal abducted beyond the midline of gaze. The opposite normal eye will be adducted to effectively fixate on the object.eye will be adducted to effectively fixate on the object.

causes horizontal diplopia (double vision)causes horizontal diplopia (double vision) patients may compensate by turning their head so that the patients may compensate by turning their head so that the

affected eye is focused on an object and then moving the affected eye is focused on an object and then moving the normal eye so as to fixate on the object.normal eye so as to fixate on the object.

Abducens Nerve (CN VI) PalsyAbducens Nerve (CN VI) Palsy

Trigeminal nerve (CN V) palsyTrigeminal nerve (CN V) palsyWeak or absent contraction of temporal & Weak or absent contraction of temporal &

masseter muscles masseter muscles Difficult to interpret without teethDifficult to interpret without teethDecrease or loss of facial sensationDecrease or loss of facial sensation

if loss of sharp/dull - confirm w/ tempif loss of sharp/dull - confirm w/ temp

Corneal reflexCorneal reflex contacts may abolish reflexcontacts may abolish reflexsensory = CN Vsensory = CN Vmotor = CN VII motor = CN VII

Facial nerve (CN VII) palsyFacial nerve (CN VII) palsy

Differentiate UMN vs. LMNDifferentiate UMN vs. LMNCerebral lesions cause contralateral Cerebral lesions cause contralateral

paralysis to lower half of faceparalysis to lower half of facePalsies can occur secondary to:Palsies can occur secondary to:

Bell’s palsyBell’s palsyLyme diseaseLyme diseaseGuillain-Barré SyndromeGuillain-Barré SyndromeMSMSALSALSTumors, syphilis, PolioTumors, syphilis, Polio

UMN vs. LMNUMN vs. LMN Characteristic indications of an Characteristic indications of an

UMN lesion of CN VII include the UMN lesion of CN VII include the following: following:

Facial asymmetryFacial asymmetry

Weakness of muscles ofWeakness of muscles of lower lower portion of the face on affected side*portion of the face on affected side*

No eyebrow droopNo eyebrow droop**

Intact folds on forehead*Intact folds on forehead*

Smoothing of nasolabial folds on Smoothing of nasolabial folds on affected sideaffected side

Intact conjunctival reflex (orbicularis Intact conjunctival reflex (orbicularis oculi innervation is intact)oculi innervation is intact)

Lips cannot be held tightly together Lips cannot be held tightly together or pursedor pursed

Difficulty keeping food in mouth Difficulty keeping food in mouth while chewing on affected sidewhile chewing on affected side

Characteristic indications of a LMN Characteristic indications of a LMN lesion of CN VII include the lesion of CN VII include the following:following:

Marked facial asymmetryMarked facial asymmetry

Weakness of all facial muscles on Weakness of all facial muscles on the ipsilateral sidethe ipsilateral side

Eyebrow droopEyebrow droop

Smoothing out of forehead and Smoothing out of forehead and nasolabial foldsnasolabial folds

Drooping of the corners of the Drooping of the corners of the mouthmouth

Loss of efferent limb of conjunctival Loss of efferent limb of conjunctival reflex (cannot close eye)reflex (cannot close eye)

Lips cannot be held tightly together Lips cannot be held tightly together or pursedor pursed

Diificulty keeping food in mouth Diificulty keeping food in mouth while chewing on the affected sidewhile chewing on the affected side

Uncontrolled tearingUncontrolled tearing

Vestibulocochlear (CN VIII) nerveVestibulocochlear (CN VIII) nerve

Responsible for sense of hearing and balanceResponsible for sense of hearing and balance Composed of the cochlear and vestibular nervesComposed of the cochlear and vestibular nerves SensorySensory Test hearingTest 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

Vagus nerve (CN X) palsyVagus nerve (CN X) palsy

Results in diminished motor, autonomic, and sensory functionsResults in diminished motor, autonomic, and sensory functions

Branches to: Branches to: http://www.med.yale.edu/caim/cnerves/cn10/cn10_13.html pharynxpharynx larynxlarynx esophagusesophagus heartheart bronchiolesbronchioles stomachstomach liverliver celiacceliac

Perform indirect examination of the vocal cordsPerform indirect examination of the vocal cords lesions of CN X may cause:lesions of CN X may cause:

hoarsenesshoarseness aphoniaaphonia dyspnea (stridor)dyspnea (stridor)

Disorders of SpeechDisorders of Speech

3 groups:3 groups:voice problemsvoice problemsarticulation problemsarticulation problemsproduction of languageproduction of languagecomprehension of languagecomprehension of language

AphoniaAphonia

AphasiaAphasia

AphasiaAphasia

Disorder of comprehension or use of words or Disorder of comprehension or use of words or symbolic languagesymbolic language lesion in dominant hemisphere lesion in dominant hemisphere

Test:Test: word comprehensionword comprehension word repetitionword repetition object namingobject naming reading comprehensionreading comprehension writingwriting

Wernicke’s AphasiaWernicke’s Aphasia

Spontaneous speech Spontaneous speech fluent, often rapid, voluble & effortlessfluent, often rapid, voluble & effortless good inflection & articulationgood inflection & articulation sentences lack meaningsentences lack meaning

++ incomprehensible incomprehensible paraphasia & neologismsparaphasia & neologisms

Impaired word comprehensionImpaired word comprehension Impaired naming & repetitionImpaired naming & repetition Impaired reading comprehension & writingImpaired reading comprehension & writing Lesion = posterior superior temporal lobeLesion = posterior superior temporal lobe

Broca’s AphasiaBroca’s Aphasia

Spontaneous speechSpontaneous speech Non-fluent, slow, few words & laborious effortNon-fluent, slow, few words & laborious effort Impaired inflection & articulationImpaired inflection & articulation Words are meaningfulWords are meaningful

Fair to good word comprehensionFair to good word comprehension Impaired naming but pt recognizes objectsImpaired naming but pt recognizes objects Impaired repetitionImpaired repetition Fair to good reading comprehension Fair to good reading comprehension Impaired writingImpaired writing Lesion = posterior inferior frontal lobeLesion = posterior inferior frontal lobe

AphasiaAphasia

Broca’sBroca’s Wernicke’sWernicke’s

Word comprehensionWord comprehension FairFair ImpairedImpaired

RepetitionRepetition ImpairedImpaired ImpairedImpaired

NamingNaming ImpairedImpaired ImpairedImpaired

Reading comprehensionReading comprehension FairFair ImpairedImpaired

WritingWriting ImpairedImpaired ImpairedImpaired

Spinal Accessory nerve (CN XI)Spinal Accessory nerve (CN XI)

Bilateral weakness of sternocleidomastoidBilateral weakness of sternocleidomastoiddifficulty raising head off pillowdifficulty raising head off pillow

Paralysis of trapeziusParalysis of trapeziusdrooping shoulderdrooping shoulderdisplaced scapula (down & lateral)displaced scapula (down & lateral)

Hypoglossal Nerve (CN XII)Hypoglossal Nerve (CN XII)Check for dysarthria Check for dysarthria

Atrophy + fasciculationsAtrophy + fasciculationsALSALSPolioPolio

Unilateral cortical lesions Unilateral cortical lesions causes the protruded causes the protruded tongue to deviate toward tongue to deviate toward the the affectedaffected side side

Integration of Motor ActivityIntegration of Motor Activity

Praxis = ability to perform a motor activityPraxis = ability to perform a motor activityApraxia = inability to perform voluntary Apraxia = inability to perform voluntary

movement in the absence of deficits movement in the absence of deficits Dyspraxia = difficulty performing an Dyspraxia = difficulty performing an

activityactivityTest by:Test by:

ask the patient to pour water from a pitcher into a ask the patient to pour water from a pitcher into a glass and drink the waterglass and drink the water

patients with dyspraxia will either drink water from patients with dyspraxia will either drink water from pitcher or try to drink from the empty glasspitcher or try to drink from the empty glass

Motor FunctionMotor Function InspectionInspection

symmetrysymmetry muscle bulkmuscle bulk size and contourssize and contours

flat or concave; unilateral or bilateral; proximal or distalflat or concave; unilateral or bilateral; proximal or distal

atrophyatrophy

PalpationPalpation muscle tonemuscle tone

PercussionPercussion ? fasciculations? fasciculations

Motor FunctionMotor Function Check motor strengthCheck motor strength Body positionBody position

during movement and at restduring movement and at rest

Involuntary movementsInvoluntary movements location, quality, rate, rhythm, amplitudelocation, quality, rate, rhythm, amplitude relation to posture, activity, fatigue, or emotionsrelation to posture, activity, fatigue, or emotions

If an abnormality exists: If an abnormality exists: identify muscle(s) involvedidentify muscle(s) involved determine central vs. peripheraldetermine central vs. peripheral learn muscle innervationslearn muscle innervations

Motor FunctionMotor Function Muscle toneMuscle tone

slight residual tension in normal relaxed muscleslight residual tension in normal relaxed muscle feel muscle’s resistance to passive stretchfeel muscle’s resistance to passive stretch cogwheel rigidity = jerky, released in degreescogwheel rigidity = jerky, released in degrees UMN paralysis = spasticity (increased tone)UMN paralysis = spasticity (increased tone) LMN paralysis = hypotoniaLMN paralysis = hypotonia

Muscle strengthMuscle strength wide variance - stronger dominant sidewide variance - stronger dominant side test by asking patient to actively resist movementtest by asking patient to actively resist movement if muscles too weak - test against gravity only or eliminate if muscles too weak - test against gravity only or eliminate

gravitygravity if patient fails to move, watch or feel for weak contractionif patient fails to move, watch or feel for weak contraction

Suspect decreased resistance?Suspect decreased resistance? hold forearm and shake hand loosely hold forearm and shake hand loosely

Resistance increased?Resistance increased? varies or persists throughout movement varies or persists throughout movement

The Motor SystemThe Motor System

Causes of atrophyCauses of atrophymotor neuron diseasesmotor neuron diseasesdisuse of musclesdisuse of muscles rheumatoid arthritisrheumatoid arthritisprotein-calorie malnutritionprotein-calorie malnutrition

Causes of decreased muscle toneCauses of decreased muscle tonedisease of PNSdisease of PNScerebellum dysfunctioncerebellum dysfunctionacute spinal cord injuryacute spinal cord injury

CoordinationCoordination

Cerebellar diseaseCerebellar disease incoordination is worse with eyes closedincoordination is worse with eyes closed

dysmetriadysmetriapoint-to-point movements are clumsy, unsteady, point-to-point movements are clumsy, unsteady,

inappropriately varying in speed, force, & directioninappropriately varying in speed, force, & directionmay initially overshoot mark but finally reaches it may initially overshoot mark but finally reaches it

The Motor SystemThe Motor System GaitGait

tandem walking - uncover unobvious ataxic gait tandem walking - uncover unobvious ataxic gait inability to heel walk inability to heel walk

corticospinal weaknesscorticospinal weakness

difficulty hopping difficulty hopping weakness, lack of position sense, or cerebellar dysfunctionweakness, lack of position sense, or cerebellar dysfunction

difficulty with shallow knee bend difficulty with shallow knee bend proximal weakness. weak quads, or bothproximal weakness. weak quads, or both

difficulty rising from sitting position or stepping up on difficulty rising from sitting position or stepping up on sturdy stool sturdy stool

proximal weakness involving pelvic girdle & legsproximal weakness involving pelvic girdle & legs

Common Gait AbnormalitiesCommon Gait Abnormalities

Function and InnervationsFunction and Innervations

Muscle(s)Muscle(s) FunctionFunction Primary NervePrimary Nerve OriginOriginDELTOIDDELTOID Shoulder abductionShoulder abduction AxillaryAxillary C5-C6C5-C6

BICEPSBICEPS Elbow flexionElbow flexion MusculocutaneousMusculocutaneous C5, C6C5, C6

TRICEPSTRICEPS Elbow extensionElbow extension RadialRadial C6, C7, C8C6, C7, C8

WRIST EXTENSORSWRIST EXTENSORS RadialRadial C6, C7, C8C6, C7, C8

WRIST FLEXIONWRIST FLEXION MedianMedian C6, C7C6, C7

HAND GRIPHAND GRIP Grasp FingersGrasp Fingers MedianMedian C7, C8, T1C7, C8, T1

FINGER ADDUCTIONFINGER ADDUCTION MedianMedian C7-T1C7-T1

FINGER ABDUCTIONFINGER ABDUCTION UlnarUlnar C8, T1C8, T1

THUMB OPPOSITIONTHUMB OPPOSITION MedianMedian C8, T1C8, T1

HIP FLEXIONHIP FLEXION IliopsoasIliopsoas L2, L3, L4L2, L3, L4

HIP EXTENSIONHIP EXTENSION Gluteus maximusGluteus maximus S1S1

Function and InnervationsFunction and Innervations

Motor FunctionMotor Function MusclesMuscles Primary NervePrimary Nerve OriginOriginKNEE EXTENSIONKNEE EXTENSION QuadricepsQuadriceps L2, L3, L4L2, L3, L4

KNEE FLEXIONKNEE FLEXION HamstringsHamstrings L4, L5, S1, S2L4, L5, S1, S2

FOOT DORSIFLEXIONFOOT DORSIFLEXION Tibialis AnteriorTibialis Anterior Deep peroneal Deep peroneal L4, L5L4, L5

ANKLE PLANTAR ANKLE PLANTAR FLEXIONFLEXION

GastrocnemiusGastrocnemius mainly S1mainly S1

EXTENSION OF GREAT EXTENSION OF GREAT TOETOE

Extensor Extensor hallicus longushallicus longus

L5L5

Grading Muscular ResponseGrading Muscular Response

GradeGrade Muscular ResponseMuscular 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”

Causes of Generalized WeaknessCauses of Generalized Weakness AlcoholismAlcoholism AnemiaAnemia Brain mass/tumorBrain mass/tumor BotulismBotulism CachexiaCachexia CancerCancer Cervical myelopathiesCervical myelopathies Chronic fatigue syndromeChronic fatigue syndrome Collagen vascular diseaseCollagen vascular disease Congenital disordersCongenital disorders DiabetesDiabetes DiphtheriaDiphtheria Drug overdosesDrug overdoses Drug reactionDrug reaction EndocrinopathiesEndocrinopathies Guillain-Barré syndromeGuillain-Barré syndrome HIVHIV HysteriaHysteria InfectionsInfections Lyme diseaseLyme disease Lumbar stenosisLumbar stenosis

Metabolic myopathiesMetabolic myopathies Muscular dystrophiesMuscular dystrophies Myasthenia gravisMyasthenia gravis Myotonic dystrophyMyotonic dystrophy NeurastheniaNeurasthenia NeuritisNeuritis NeurosyphilisNeurosyphilis Parkinson diseaseParkinson disease Periodic paralysesPeriodic paralyses Peroneal muscular atrophyPeroneal muscular atrophy PolymyositisPolymyositis PorphyriasPorphyrias Postictal statesPostictal states Radiation myelopathiesRadiation myelopathies Spinal cord compressionSpinal cord compression Spinal cord injuriesSpinal cord injuries Tick paralysisTick paralysis Toxic myopathiesToxic myopathies Transverse myelitisTransverse myelitis Tropical myeloneuropathiesTropical myeloneuropathies Vertebral collapseVertebral collapse

Causes ofCauses of Focal or Asymmetrical weakness Focal or Asymmetrical weakness

ArthritisArthritis Brachial neuritisBrachial neuritis Cerebral palsiesCerebral palsies Cerebrovascular diseaseCerebrovascular disease

ischemicischemic hemorrhagichemorrhagic

Cervical radiculopathiesCervical radiculopathies Cervical ribsCervical ribs Entrapment neuropathiesEntrapment neuropathies Intervertebral disc disordersIntervertebral disc disorders MononeuropathiesMononeuropathies

DiabetesDiabetes PolyarteritisPolyarteritis

Motor neuron diseaseMotor neuron disease

Multiple myelomaMultiple myeloma Multiple sclerosisMultiple sclerosis PoliomyelitisPoliomyelitis SciaticaSciatica ScoliosisScoliosis Space-occupying massSpace-occupying mass

IntracranialIntracranial IntraspinalIntraspinal

Spinal vascular diseaseSpinal vascular disease IschemicIschemic HemorrhagicHemorrhagic

SyringomyeliaSyringomyelia Systemic diseaseSystemic disease TraumaTrauma

Peripheral Nerve InjuriesPeripheral Nerve Injuries

NerveNerve Motor function impairedMotor function impaired

Radial (C5-C8)Radial (C5-C8) Elbow & wrist extension (wrist drop); extension of the Elbow & wrist extension (wrist drop); extension of the fingers at the MCP joints; triceps reflexfingers at the MCP joints; triceps reflex

Median (C6-T1)Median (C6-T1) Wrist flexion and radial deviation; flexion of thumb and Wrist flexion and radial deviation; flexion of thumb and index/middle fingers; thumb opposition; forearm pronationindex/middle fingers; thumb opposition; forearm pronation

Ulnar (C8-T1)Ulnar (C8-T1) Wrist flexion and ulnar deviation; flexion of the ring & little Wrist flexion and ulnar deviation; flexion of the ring & little fingers; abduction/adduction of the fingersfingers; abduction/adduction of the fingers

Musculocutaneous (C5-6)Musculocutaneous (C5-6) Elbow flexion; forearm supination; biceps reflexElbow flexion; forearm supination; biceps reflex

Axillary (C5-6)Axillary (C5-6) Abduction, flexion and extension of the shoulderAbduction, flexion and extension of the shoulder

Femoral (L2-L4)Femoral (L2-L4) Hip flexion; knee extension; patellar reflexHip flexion; knee extension; patellar reflex

Obturator (L2-L4)Obturator (L2-L4) Hip adductionHip adduction

Sciatic (L4-S3)Sciatic (L4-S3) Knee flexionKnee flexion

Tibial (L4-S3)Tibial (L4-S3) Foot inversion; ankle plantarflexion; Achilles reflexFoot inversion; ankle plantarflexion; Achilles reflex

Common peroneal (L4-S2)Common peroneal (L4-S2) Foot eversion; ankle & toe dorsiflexion (foot drop)Foot eversion; ankle & toe dorsiflexion (foot drop)

Sensory FunctionSensory Function

Fatigues quicklyFatigues quickly Efficiency Efficiency Special attention to areas of:Special attention to areas of:

symptomologysymptomologymotor or reflex abnormalitiesmotor or reflex abnormalities trophic changes trophic changes

Confirm with repeat testing!!Confirm with repeat testing!! Patterns of testing:Patterns of testing:

SymmetricalSymmetrical Distal vs. proximal: scattered stimuliDistal vs. proximal: scattered stimuli Vary the pace Vary the pace

The Sensory SystemThe Sensory System

Meticulous mapping importantMeticulous mapping importantCompare distal & proximalCompare distal & proximalStocking & glove sensory loss Stocking & glove sensory loss

polyneurpathyVibration sense Vibration sense

peripheral neuropathy posterior column disease posterior column disease

The Sensory SystemThe Sensory System

Lesions of sensory cortexLesions of sensory cortexastereognosisastereognosis inability to recognize numbersinability to recognize numbersdecreased two-point discriminationdecreased two-point discriminationdecreased point localizationdecreased point localizationextinctionextinction

Deep Tendon ReflexesDeep Tendon Reflexes

Hyperactive reflexesHyperactive reflexessuggest CNS diseasesuggest CNS diseasesustained clonus (confirms)sustained clonus (confirms)

Diminished or absent reflexesDiminished or absent reflexes loss of sensationloss of sensationdamage to spinal segmentsdamage to spinal segmentsdamage to peripheral nervesdamage to peripheral nervesdiseases of musclesdiseases of musclesdiseases of the neuromuscular junctionsdiseases of the neuromuscular junctions

Testing Testing the nerves the nerves

of the of the upper upper

extremityextremity

Sensory distribution of the handSensory distribution of the hand

Testing Testing the nerves the nerves

of the of the upper upper

extremityextremity

Sensory Function TestingSensory Function Testing

Look for abnormalitiesLook for abnormalitiesMap out boundaries in detailMap out boundaries in detailDistribution of sensory abnormalities Distribution of sensory abnormalities

and kinds of sensations affectedand kinds of sensations affected+/- motor/reflex abnormality +/- motor/reflex abnormality Demonstrate to patient before testingDemonstrate to patient before testing

Sensory specific testingSensory specific testing

TemperatureTemperatureVibrationVibrationProprioceptionProprioceptionTactile localizationTactile localizationDiscriminative sensationsDiscriminative sensations

ProprioceptionProprioception

Conscious:Conscious:connects with the thalamus and cerebral connects with the thalamus and cerebral

cortexcortexlesions produce contralateral defectslesions produce contralateral defects

able to “describe” the position of a limbable to “describe” the position of a limbUnconscious:Unconscious:

connects with the cerebellum via the connects with the cerebellum via the spinocerebellar tractspinocerebellar tractlesions produce ipsilateral malfunctionlesions produce ipsilateral malfunction

perform complex acts without “thinking” about perform complex acts without “thinking” about themthem

Discriminative SensationsDiscriminative Sensations

StereognosisStereognosisGraphesthesiaGraphesthesiaTwo-point discriminationTwo-point discriminationTest ability of sensory cortex to correlate, Test ability of sensory cortex to correlate,

analyze, & interpret sensationsanalyze, & interpret sensationsDependent on touch & position senseDependent on touch & position senseScreen first with stereognosis - proceed to Screen first with stereognosis - proceed to

other methods if indicatedother methods if indicated

Spinal Reflexes: DTRsSpinal Reflexes: DTRs

Segmental levels of DTRs:Segmental levels of DTRs:Biceps reflexBiceps reflex C5, 6C5, 6Brachioradialis reflexBrachioradialis reflex C5, 6C5, 6Triceps reflexTriceps reflex C6, 7C6, 7Abdominal reflexes - upper Abdominal reflexes - upper T8, 9, 10T8, 9, 10 - lower- lower T 10, 11, 12T 10, 11, 12Knee (Patellar)Knee (Patellar) L2, 3, 4L2, 3, 4Achilles reflexAchilles reflex S1 primarilyS1 primarilyPlantar responsesPlantar responses L5, S1L5, S1

Deep Tendon Reflexes: GradingDeep Tendon Reflexes: Grading

GradeGrade DTR ResponseDTR Response4+4+ Very brisk, hyperactive, with Very brisk, hyperactive, with

clonusclonus

33 Brisker than average, Brisker than average, slightly slightly hyperreflexichyperreflexic

2 2 Average, expected response;Average, expected response;

normalnormal

1 1 Somewhat diminished, lowSomewhat diminished, low

normalnormal

0 0 No response, absentNo response, absent

Jendrassik’s ManeuverJendrassik’s Maneuver Reinforcement Reinforcement

techniquetechnique Upper extremitiesUpper extremities

clench teethclench teeth squeeze thighsqueeze thigh

Lower extremitiesLower extremities lock fingers and lock fingers and

pull one against the pull one against the otherother

Anal ReflexAnal Reflex

Superficial reflexSuperficial reflexLoss of anal reflex suggests Loss of anal reflex suggests

lesion of S2 - S4 reflex arclesion of S2 - S4 reflex arcPossible lesion of cauda equinaPossible lesion of cauda equina

ClonusClonus

Rhythmic Oscillation

Flexion/ExtensionFlexion/Extension

UMN LesionUMN Lesion

Cerebellar FunctionCerebellar Function

Requires integration of:Requires integration of:Motor systemMotor systemCerebellar system Cerebellar system Vestibular systemVestibular systemSensory systemSensory system

Cerebellar FunctionCerebellar Function

Assessed by:Assessed by:Rapid alternating movementsRapid alternating movementsFinger-to-NoseFinger-to-NoseHeel-to-Knee TestHeel-to-Knee TestRomberg’s TestRomberg’s TestGaitGait

Cerebellar vs. Basal Ganglia Cerebellar vs. Basal Ganglia lesionslesions

CerebellarCerebellarawkwardness of intended movementsawkwardness of intended movements

intention tremorintention tremorataxiaataxia

Basal GangliaBasal Ganglia involuntary movementsinvoluntary movements

resting tremorresting tremorchoreachoreaathetosisathetosishemiballismushemiballismus

Meningeal IrritationMeningeal Irritation

Occur with meningitis & subarachnoid Occur with meningitis & subarachnoid hemorrhagehemorrhage

Two of the physically demonstrable Two of the physically demonstrable symptoms of meningitis are Kernig's sign symptoms of meningitis are Kernig's sign and Brudzinski’s sign.and Brudzinski’s sign.

Lab/X-rayLab/X-ray CBC, CMP, U/ACBC, CMP, U/A Specific drug levelsSpecific drug levels Plain films of the spinePlain films of the spine CT of the brain & headCT of the brain & head MRI of the brain & spineMRI of the brain & spine

greater resolution then CT for soft tissue/plaquesgreater resolution then CT for soft tissue/plaques AngiographyAngiography CSF examCSF exam EEGEEG EMG & NCSEMG & NCS PET/SPECTPET/SPECT

CSFCSF

Obtained through lumbar punctureObtained through lumbar puncture Indications:Indications:

suspected CNS infection (i.e. syphilis)suspected CNS infection (i.e. syphilis)suspected subarachnoid hemorrhagesuspected subarachnoid hemorrhage

Contraindicated if cerebral mass/lesion is Contraindicated if cerebral mass/lesion is suspectedsuspected

Measure opening pressureMeasure opening pressureObtain samples for cell counts, glucose, Obtain samples for cell counts, glucose,

protein level, and culturesprotein level, and cultures

Computed Tomography (CT)Computed Tomography (CT) Gives adequate information about brain anatomyGives adequate information about brain anatomy Used primarily to detect hemorrhage & tumorsUsed primarily to detect hemorrhage & tumors Can be performed with/without contrastCan be performed with/without contrast Indications:Indications:

focal neurologic deficitsfocal neurologic deficits altered mental statusaltered mental status head traumahead trauma new-onset seizurenew-onset seizure increased ICPincreased ICP suspected mass lesionsuspected mass lesion suspected subarachnoid hemorrhagesuspected subarachnoid hemorrhage (with contrast) abscess, intracranial tumor(with contrast) abscess, intracranial tumor (with contrast) chronic subdural hematoma, infarct, vascular (with contrast) chronic subdural hematoma, infarct, vascular

malformationmalformation

Review of Neurological ExamReview of Neurological Exam

Six categoriesSix categories: : Mental status & speechMental status & speechCranial nervesCranial nervesMotor functionMotor functionSensory functionSensory functionReflexesReflexesCerebellar functionCerebellar function

Carefully evaluate the hx of the CCCarefully evaluate the hx of the CCCN assessment is essential!CN assessment is essential!

SummarySummary

Select appropriate questions to elicit from the Select appropriate questions to elicit from the patient with a neurological complaint during a patient with a neurological complaint during a patient interviewpatient interview

Compare and contrast the five clinical levels of Compare and contrast the five clinical levels of consciousness.consciousness.

Determine location of neurological lesionDetermine location of neurological lesion Differentiate upper motor neuron lesions from lower Differentiate upper motor neuron lesions from lower

motor neuron lesionsmotor neuron lesions Differentiate CNS disorders from PNS disorders, Differentiate CNS disorders from PNS disorders,

and identify location of the lesion & common and identify location of the lesion & common causes.causes.

SummarySummary

Differentiate “normal” from “abnormal” findings Differentiate “normal” from “abnormal” findings on neurological examinationon neurological examination Identify common causes of various cranial nerve Identify common causes of various cranial nerve

palsiespalsies Differentiate conductive hearing loss from Differentiate conductive hearing loss from

sensorineural hearing losssensorineural hearing loss Differentiate amongst the various movement Differentiate amongst the various movement

disordersdisorders Differentiate atrophy, hypertrophy, and Differentiate atrophy, hypertrophy, and

pseudohypertrophypseudohypertrophy Differentiate between spasticity, rigidity, and Differentiate between spasticity, rigidity, and

flaccidity, and identify common causes of eachflaccidity, and identify common causes of each

ReferencesReferences

Bickley, L.S., Bickley, L.S., Bates’ Guide to Physical Bates’ Guide to Physical Examination and History Taking, 8Examination and History Taking, 8thth Ed. Ed., , Lippencott, Williams & Wilkins, 2003.Lippencott, Williams & Wilkins, 2003.

Goldberg, S., Goldberg, S., The Four-minute Neurologic The Four-minute Neurologic ExamExam. Merck, MedMaster, 1999.. Merck, MedMaster, 1999.

DeGowin, R.L., DeGowin, R.L., Diagnostic Examination, Diagnostic Examination, 66thth Ed Ed., McGraw-Hill: New York, 1994.., McGraw-Hill: New York, 1994.