Neurological exam

NEUROLOGICAL EXAM

Dept of Neurology

St Vincent’s University Hospital
Wash your hands

Introduce yourself to the patient and ask what they would like to be called

Ask consent, any pain?
Examine in order:

Gait, Speech, Intellect

Cranial nerves, Motor, Sensory, Cerebellar, Extra-pyramidal, Other
Gait

• 
  Walk away & back
  
  • 
    Look at posture, arm swing, stride length, feet width, height of step, stability of pelvis
    
• 
  If stable, walk heel-toe (walk beside pt)
  
• 
  Stand on heels, toes (hold pt’s hands): slide your toes under theirs
  
• 
  Romberg’s test (stand beside pt): feet together, eyes closed + if pt sways w/ eyes closed
  
• 
  Pull test/Right reflex for retropulsion (stand in front of pt, then behind pt)
  

Speech: Articulation (BBB, TTT, CCC, ‘Buttercup’); Follow instructions; Naming

Intellect: Orientation in time, place and person.

MMSE or MOCA (Montreal cognitive assessment)

Draw a clockface with time at ten past eleven
CRANIAL NERVE EXAM

CN I olfactory

• 
  Any change in sense of smell?
  
• 
  If yes, make sure nostrils are clear and have pt smell peppermint or coffee
  
• 
  Nasal causes: physical obstruction by smoking, rhinitis, sinusitis
  
• 
  Anosmia causes: destr of receptors/axon filaments by flu, herpes, peg-IFN for hep C
  
• 
  Central pathology: Kallmann’s syn (congenital, anosmia + hypogonadism), albinism, head injury (car accident, deceleration), SAH, cranial surgery, meningioma, aneurysm, PD
  

CN II optic

• 
  Any problems with your visions? Near or far sighted?
  
• 
  (glasses on and off i.e. corrected and uncorrected visual acuity; one eye covered at a time)
  
• 
  Visual acuity— best corrected vision using Snellen chart (3 or 6m) and Jaeger plates
  
• 
  Colour vision (Isihara plates)
  
• 
  Visual fields— test each quadrant with fingers
  
• 
  Central scotoma- red topped hat pin
  
• 
  Light and Accommodation (including Swinging light tests for RAPD)
  
• 
  Fundoscopy— need ophthalmoscope + darkened room
  
  • 
    Look cup/disc ratio? Retinopathy (DM)? If suspect IE, Roth spots?
    
  • 
    Assess red reflex for presence of media opacities
    

CN III, IV, VI

• 
  Inspect for ptosis, strasbismus (squint), proptosis, square wave jerks
  
• 
  Test ocular muscles:
  
• 
  Pursuit movements: horizontal then vertical then ‘corners’ (say muscles as testing them)
  
• 
  Ask if see one or two, look for nystagmus
  
• 
  Saccadic eye mvmts: hold finger + pen apart and tell pt when to look at them (pen, finger, pen…) ?INO
  

CN V trigeminal

• 
  Any numbness or altered sensation in face?
  
• 
  Sensory: light touch V1-V3, corneal reflex (afferent V1; cotton wool)
  
• 
  Motor: clench teeth, open & close mouth against resistance (masseter, temporalis, pterygoids)
  
• 
  Reflex: jaw jerk (pt’s mouth slightly open, index finger across chin, strike finger, jaw should close slightly)
  

C
Visceral sensory: taste ant 2/3 tongue

Reflex: afferent branch of corneal
N VII facial

• 
  Look for facial asymmetry, ask about taste, loud noises
  
• 
  Check ears and hard palate for vesicles Ramsey Hunt syn
  
• 
  Raise eyebrows—temporalis
  
• 
  Close eyes tightly (eyelashes buried)—orbicularis oculi
  
• 
  Show teeth—orbicularis oris
  
• 
  B
  Vestibular: nystagmus, stance & gait, Unterberger’s, Romberg’s, Dix-Hallpike; caloric reflexes (COWS)
  Cochlear: Rinne, Weber
  
  low out cheeks
  

CN VIII vestibulocochlear

• 
  Any problem with hearing or balance? Examine EAM + tymp membr
  
• 
  Whisper in 1 ear while rubbing fingers at other ear
  
• 
  Rinne (512 Hz tuning fork)
  
  • 
    Strike, mastoid process, in front of ext aud meatus: which is louder?
    
  • 
    N = air conduction is better than bone conduction
    
  • 
    Conductive hearing loss = louder at mastoid process (bone conduction better)
    
  • 
    SNHL = ?no difference
    
• 
  Weber (512 Hz tuning fork)
  
  • 
    Strike, place on pt’s forehead: louder on one side or equal?
    
  • 
    N = equal
    
  • 
    Conductive hearing loss= lateralizes to affected ear (b/c better adapted to bone conduction)
    
    • 
      Louder in affected ear
      
  • 
    SNHL = lateralizes to un-/less affected ear
    
    • 
      Louder in unaffected ear
      

CN IX glossopharyngeal

CN X vagus

• 
  Any difficulty swallowing?
  
• 
  Palatal elevation: say ahhhh
  
• 
  Ask pt to cough
  
• 
  Vocal cord function: test articulation (BBB, TTT, CCC)
  
• 
  Gag reflex: touch post pharyngeal wall
  

C

CN III palsy causes:

Space-occupying lesion (benign/malig)

Aneurysm compression (PComm)

Microvascular (DM)

• 
  Pupil-sparing= microvasc (DM)
  
• 
  Pupil involving = compressive
  

N XI spinal accessory

• 
  Trapezius: shoulder shrug + resist
  
• 
  SCM: turn head + resist
  

CN XII hypoglossal

• 
  Open mouth: look for fasiculations & wasting at rest
  
• 
  Stick tongue out: note any deviation (towards lesion)
  
• 
  Side to side: look for slowness, seen in UMN lesion
  

Nerve palsies

CN III—eye down and out

CN IV—can’t look down & diagonal (stairs, newspaper)

CN VI—cross-eyed (longest intracranial course ↑ICP)

CN VII—UMN lesion on R: L forehead spared but L

lower face droops;

LMN lesion on R: entire L face droops = Bell’s palsy

Lesion in cavernous sinus may affect CN III, IV, V1, V2, VI

Motor Exam

Inspection

• 
  Expose appropriately
  
• 
  Any obvious abnormalities (Ex tremor)
  
• 
  Scars, swelling, skin changes (hair loss, ulcers)
  
• 
  Deformity
  
• 
  Muscle bulk, fasciculations (LMN)
  

Tone

UPPER

• 
  Elbow flex-ext: leadpipe rigidity in PD, clasp-knife in spasticity
  
• 
  Forearm pronation-supination: pronator catch in spasticity
  
• 
  Wrist flex-ext: cogwheel rigidity in PD
  

LOWER

• 
  Roll leg back & forth: ↑ tone in spasticity
  
• 
  Quickly flex knee: quads catch in spasticity
  
• 
  Ankle clonus
  

Power

UPPER

• 
  Shoulders
  
• 
  Elbow flex/ext
  
• 
  Wrist flex/ext
  
• 
  Fingers abd/add (piece of paper)
  
• 
  Hand grip, pincer grip
  
• 
  Thumb add, abd, ext
  

LOWER

• 
  Hip flex/ext (like ballerina)
  
• 
  Knee flex/ext (heel to bum & away)
  
• 
  Ankle dorsi/plantar flex, invert/evert
  
• 
  Hallux flex/ext
  

Rate power

0. 
   No contraction
   
1. 
   Muscle flicker
   
2. 
   w/out gravity (on bed)
   
3. 
   w/gravity
   
4. 
   Submaximal pwr against resistance
   
5. 
   Full power
   

Coordination

UPPER

• 
  Finger to nose to target (forward & backward)
  
  • 
    Intention tremor increases as approaches target
    
  • 
    If eyes closed, tests proprioception
    
• 
  Rapid alternating mvmt: pronate/supinate one hand over other as fast as possible
  
  • 
    Tests for disdiadochokinesis = cerebellar dysfunction
    
• 
  Bradykinesia: ‘duck hands’ as fast as possible, or thumb-index
  
  • 
    Slower in PD
    

LOWER

• 
  Heel to knee, down shin, lift & back up to knee X3
  

Reflexes

• 
  Joints at 90’
  

• 
  Can do reinforcement to bring out reflexes = Jendrassik’s manoeuvre
  

UPPER

• 
  Biceps: C5-6
  
• 
  Brachioradialis:
  
• 
  Triceps: C7-8
  

LOWER

• 
  Ankle: S1-2 (have pt flex knee and let leg drop out to side)
  
• 
  Patellar: L3-4 (support pt’s leg w/knee in flexion)
  
• 
  Plantar (Babinski): firmly press sharp object along outer edge of foot (heel-toe) & across towards hallux
  
  • 
    Stop as soon as see mvmt in hallux (upgoing or downgoing)
    

Sensation

• 
  Light touch: use finger or cotton wool over dermatomes
  
• 
  Discriminatory touch (pinprick): sharp vs dull
  
  • 
    First test on pt’s sternum to fell sharp vs dull
    
• 
  Vibration: 128 Hz tuning fork on bony prominences w/ eyes closed; first test on pt’s sternum
  
  • 
    Let me know when you feel the vibration
    
  • 
    Let me know when it stops
    
  • 
    Start distally and move proximally
    
  • 
    UPPER: thumb IP joint, MCP, radial head, etc
    
  • 
    LOWER: hallux IP joint, MTP, malleolus, etc
    
• 
  Proprioception: pt has eyes closed; hold sides of joint & ask pt to tell you if the body part is up or down
  
  • 
    Start distally and move proximally
    
  • 
    UPPER: thumb IP joint, MCP, radial head, etc
    
  • 
    LOWER: hallux IP joint, MTP, malleolus, etc
    
• 
  Temperature: only tested in special circumstances
  
  • 
    Cold and hot water in test tubes
    

SPECIFIC EXAMS
Parkinson’s Disease

Gait

• 
  Walk away & back: see
  
  • 
    Bradykinesia: difficulty initiating movement
    
  • 
    Stooped/flexed posture, postural instability (late)
    
  • 
    Shuffling steps: marche a petit pas
    
  • 
    Decreased/absent arm swing
    
  • 
    Clockface turning
    
• 
  Romberg’s sign (stand beside pt): feet together, eyes closed: + if pt sways
  
• 
  Pull test for retropulsion (stand in front of pt, then behind pt)
  

Inspection

• 
  Resting tremor: asymmetric pill-rolling, esp hands, 4-6Hz
  
  • 
    Ask pt to draw a spiral
    
• 
  Decreased facial expression, hypophonia & aprosody (monotonous)
  

Tone

• 
  Elbow: leadpipe rigidity
  
• 
  Wrist: cogwheel rigidity
  
  • 
    Both: can bring out by tapping other leg = ?Kinnear Wilson sign/Froment’s
    

Other

• 
  Glabellar tap: tap b/w eyes & pt blinks every time (normally should stop blinking after few taps)
  
• 
  Bradykinesia: ‘duck hands’ quickly-- will be slow
  
• 
  Micrographia: ask pt to write out address
  
• 
  Ask about: anosmia, depression, sleep disturbance, anxiety, constipation (late)
  

Parkinson’s Plus

• 
  PSP: vertical gaze palsy
  
• 
  MSA: autonomic dysfunction (incontinence, postural hypotension)
  
• 
  CBD: alien limb
  
• 
  LBD: visual hallucinations
  
• 
  Vascular: lower body parkinsonism from multiple infarcts
  

Myasthenia Gravis

Inspection

• 
  Bilateral ptosis, ophthalmoplegia
  

Fatiguability

• 
  Skeletal muscles:
  
  • 
    Close eyes tightly (can’t bury eyelashes)
    
  • 
    Test shoulder power; ask pt to lift arms 10X then reassess power (decreased)
    
• 
  Ocular: diplopia (hold gaze to one side?), ptosis
  
• 
  Bulbar: dysarthria (articulating words), dysphagia (swallowing)
  
• 
  Speech: sounds more nasal as progresses
  

Diagnosis

• 
  Tensilon test (edrophonium): short acting AChE –tor
  
  • 
    See transient improvement in S/S (2 minutes)
    
  • 
    Do this with patient lying or sitting b/c of bradycardia
    
• 
  EMG: on repetitive stimulation see decremental response and jitter
  
• 
  Abs: anti-AchR, MUSK Ab
  
• 
  CT/MRI for thymoma or thymic hyperplasia
  

Treatment

• 
  Thymectomy, IVIg, steroids +/- azathioprine, pyridostigmine (long acting AChE –tor)
  

Multiple Sclerosis

General inspection

• 
  E.g.Female ? pt in wheelchair, uses rollator to walk, unassisted
  

Gait

• 
  Spastic paraparesis often seen
  
• 
  Normal stride length w/ scissoring of legs or toe walking = spastic gait
  
  • 
    Bilateral circumduction due to spastic paraparesis from MS (also CP or cord compression)
    

Inspection

• 
  ?Decreased muscle bulk, ulcers
  

Tone

• 
  Elbow: clasp-knife spasticity
  
• 
  Forearm: pronator catch
  
• 
  Roll legs: ↑ tone
  
• 
  Quickly lift knee: quads catch/stiffness
  
• 
  Ankle clonus
  

Power

Coordination

Reflexes

• 
  ++brisk (patellar, Achilles, plantars extensor?)
  

Sensation – spinothalamic and posterior column assessment

Other

• 
  Ask about numbness & tingling when get out of hot bath = Uhtoff’s phenom
  
• 
  Bend neck forward & feels tingling in body = Lhermitte’s phenom
  

Dx

• 
  LP for unmatched oligoclonal bands (IgG in CSF and not blood)
  
• 
  MRI: see areas of high signal on T2 scan (periventricular, pericallosal Dawson’s fingers)
  
• 
  Visual evoked response (VER): delay of approx 110ms compared to other eye
  

Treatment

• 
  IFN-B—reduce # relapses, injection
  
• 
  Glatiramer acetate—reduce # relapses, injection
  
• 
  Fumarate
  

• 
  Natalizumab—for aggressive MS, monthly infusion—risk of PML (1/500)
  
• 
  Fingolomid
  

• 
  Alemtuzumab
  

• 
  Acute presentation: high dose methylpred (usually 1g/day IV for 3 days))
  
• 
  Symptomatic therapy- spasticity, bladder, bowel, swallow etc issues
  

RG