Neurological Examination(Physical Diagnosis)
Dr. Saleem Khoury
Department of NeurologyHadassah Ein-Kerem
"From the brain and the brain only arise our pleasures, joys, laughter and jests, as well as our sorrows, pains, grieves, and tears.... These things we suffer all come from the brain, when it is not healthy, but becomes abnormally hot, cold, moist or dry.“
Hippocrates (460-370 BC)
Questions of Neurological Diagnosis
1. Is there a lesion? (neurological abnormality)
2. Where is the lesion? (localization)
3. What is the lesion? (differential diagnosis)
Why perform the neurological examination?
1. Detect the presence of neurological abnormality.
2. Localize the abnormality within the nervous system (may later be confirmed by investigations).
Basic Plan
• General examination (vital signs etc.)• Conscious state• Cognition• Meningeal signs• Cranial nerves• Motor• Sensory• Cerebellum• Extrapyramidal
DON’T DO EVERYTHING!
• Screening tests vs. detailed testing.
• Problem-orientated approach Screen all systems. Concentrate on systems relevant to the complaint. Formal cognitive testing may be skipped if patient is cognitively
intact during history and problem seems unrelated.• e.g. foot-drop
Neurological History
• Age, sex, occupation, ethnicity, handedness
• History of present complaint• Neurological screening questions• Past medical history• Drug history• Family history• Social history
Systematic ApproachInterpretation of patient’ssymptoms
Time course of symptoms
Generate hypothesis andDifferential diagnosis
Neurological screening history
Impact of neurological problem on life, home, work and family
Conventional background historyPast medical history; drug history; social history; family history
Synthesize differential diagnosis and hypotheses to test duringexamination
Test hypothesis
Ask about associated features
Ask about risk factors
The Holistic Approach
“A physician is obligated to consider more than a diseased organ, more even than the whole man - he must view the man in his world.”
Harvey Cushing (1869-1939)
Conscious state
• Normal: patient awake and alert, attentive to surrounding and the examiner.
• Depressed: - Drowsiness - Confusion/Lethargy - Stuporous - Comatose
Conscious stateGlasgow Coma Scale (GCS)(Teasdale & Jennet, 1974)
• Created to reflect measure of global brain function.
Mainly useful for trauma patients.
• Limited value in neurological patients. Many processes selectively affect
components, e.g.: - Bilateral ptosis - Aphasia - Quadriplegia
Therefore best to record functions individually.
Score
Eyes open
Spontaneously 4
To verbal stimuli 3
To pain 2
Never 1
Best verbal response
Orientated and converses 5
Disorientated and converses 4
Inappropriate words 3
Incomprehensible sounds 2
No response 1
Best motor response
Obeys commands 6
Localizes pain 5
Flexion- withdrawal to pain 4
Abnormal flexion (Decorticate) 3
Abnormal extension (Decerebrate) 2
No response 1
Total 15
Cognition
• MMSE (Folstein et al., 1975)
- Broad screening test of cognitive function,
including attention, memory and language.
- Good for diagnosing / monitoring certain
types of dementia, especially AD.
- Other types of dementia / cognitive
problems require different tests.
Maximal score: 30 28-30: does not support the diagnosis of
dementia. 25-27: borderline. <25: suggests dementia (acute confusional
state, depression).
Cognition 2
• “Frontal functions”
- Attention & Concentration (serial seven, digit span)
- Abstraction (explain proverb)
- Judgment child lost in street…what would you do?
- Planning How to plan a holiday
Draw a clock
Cognition 3
• Frontal release signs
- Glabellar tap- Snout- Rooting- Sucking- Palmomental- Grasp
Usually appear in chronic diseases with bilateral frontal involvement (dementia).
Other Cognitive Functions
• Neglect- Failure to pay attention to area of space- Usually due to right parietal lesions where neglect
left-sided space
(asomatognosia, anosognosia)
• Praxis- Ability to perform learned action- e.g. dressing, brushing teeth, combing hair
Meningeal Signs
• Neck stiffness• Brudzinski• Kernig
- Most frequently found in patients with meningitis or SAH.
- Meningismus: Cervical lymphadenopathy, pharyngitis, apical pneumonia, cervical spondylosis.
- Generalized stiffness: parkinsonism.
Cranial NervesOlfactory (I)
- Ask the patient to identify common scents (coffee, vanilla, orange etc.) with eyes closed.
- Test each nostril separately.
- Use not irritants.
It is less important to determine whether the patient can correctly identify a particular odor than whether the presence or absence of the stimulus is perceived.
Cranial NervesOptic (II)
• Visual Acuity (Snellen chart)• Fundi (ophthalmoscopic
examination)• Visual Fields (confrontation)
- Patient and examiner stand at eye level at about arm’s length.
- Test each eye separately (the patient covers his own eye).
- Threat testing is applied when the patient is less than fully alert or is uncooperative.
• Pupils: resting state and reaction to light.
- Direct- Consensual- Swinging flashlight test
• Pupils reaction to Accommodation
Pupillary reflex to light: afferent II efferent III
Cranial NervesOcculomotor (III), Trochlear (IV), Abducens (VI)
• Ptosis?• Pupils (already examined)• Extraocular movements (H and X).• Saccades and smooth pursuit.• Diplopia?• Nystagmus?
EOM: L6SO4
Cranial NervesTrigeminal (V)
• Sensory: facial sensation• Motor: muscles of
mastication- Observe symmetry of
mouth opening and closing.
- Look for atrophy and fasciculations.
• Jaw jerk• Corneal reflex
- Afferent: V
- Efferent: VII
Cranial NervesFacial (VII)
• Motor: muscles of facial expression• Autonomic: taste (ant. 2/3 tongue) + salivary
glands.• Sensory: auditory meatus + part of the auricle.
• Corneal reflex
Mild facial asymmetry without weakness: normal.
Ptosis is not due to weakness of muscles supplied by VII.
Cranial NervesVestibulocochlear (VIII)
• Auditory acuity- Thumb rubbing
• Weber’s test• Rinne’s test
- 516 Hz tuning fork- Air vs. bone conduction- Sensorineural loss- Conductive loss
• Vestibular function- Dix-Hallpike maneuver
Cranial NervesGlossopharyngeal (IX) & Vagus (X)
• Palatal elevation- Say ‘ah’
• Gag reflex- Afferent: IX- Efferent: X- Post. Pharyng. wall- Test both sides
• Sensory function- Side of soft palate- Test both sides
• Taste- Post. 1/3 tongue
• Voice quality- Hoarseness- Val-Salva maneuver
Cranial NervesAccessory (XI)
• Sternocleidomastoid- Turn head
• Trapezius- Shrug shoulders
Cranial NervesHypoglossal (XII)
• Observation- Atrophy- Fasciculations
• Midline protrusion- Deviation?
• Power
• Dexterity- Fast movement side to
side
Motor System
Upper Motor Neuron (UMN)
• Cell body within motor cortex- Precentral gyrus
• Axon terminates:- Cranial nerve motor nucleus
“Corticobulbar”
- Anterior horn of spinal cord “Corticospinal”
Motor System
Lower Motor Neuron (LMN)
• Cell body of:- Motor cranial nerve nucleus- Anterior horn cell
• Axon terminates- Motor end plate (skeletal muscle)A.K.A Neuromuscular junction (NMJ)
Motor System
Systematic approach to weakness
– Muscle– NMJ– Nerve– Nerve roots– Spinal cord– Brainstem– Cerebrum
» Cerebellum
Motor SystemDiagram of Motor Pathways
Motor SystemFive patterns of muscular weakness
UMN LMN Muscle disease
NMJ Functional weakness
Inspection of muscles
Normal
(disuse atrophy)
Atrophy
Fasciculations
Atrophy Normal Normal
Tone Increased
(unless acute)
Decreased
(or normal)
Decreased Decreased
(or normal)
Normal
Power (MRC scale) 0-5/5
Decreased Decreased Decreased Fatiguable weakness
Normal
Tendon reflexes
Increased
(unless acute)
Decreased
Absent
(or normal)
Decreased
(or absent)
Normal
(Decreased with Facilitation)
Normal
Pathological reflexes
Present Absent Absent Absent Absent
Motor System• Muscle Bulk
- Atrrophy (with fasciculation?)- Hypertrophy
• Muscle Tone- Decreased (floppy, flaccid,
hypotonic)- Normal- Increased (spastic vs. rigid)
• Reflexes
• Muscle Strength (Medical Research Council scale=MRC)
5 = normal power 4+ = submaximal movement against resistance 4 = moderate movement against
resistance 4- = slight movement against
resistance 3 = moves against gravity but not resistance 2 = moves with gravity eliminated 1 = flicker 0 = no movement
Motor SystemMuscles of Arm
Movement Muscle Nerve Root
Shoulder abduction Deltoid Axillary C5
Elbow flexion Biceps Musculocutaneous C5,C6
Elbow extension Triceps Radial (C6),C7,(C8)
Finger extension Extensor digitorium Posterior interosseus C7,(C8)
Finger flexion Flexor digitorium Median & Ulnar C8
Finger abduction 1st dorsal interosseus Ulnar T1
Finger adduction 2nd palmar interosseus Ulnar T1
Thumb abduction Abductor pollicis brevis
Median T1
Motor SystemMuscles of Leg
Movement Muscle Nerve Root
Hip flexion Iliopsoas Lumbar sacral plexus L1,L2
Hip extension Gluteus maximus Inferior gluteal nerve L5,S1
Knee extension Quadriceps Femoral L3,L4
Knee flexion Hamstrings Sciatic L5,S1
Foot dorsiflexion Tibialis anterior Deep peroneal nerve L4,L5
Plantarflexion Gastrocnemius Posterior tibial nerve S1
Big toe extension Extensor hallucis longus Deep peroneal nerve L5
Toes extension Extensor digitorium brevis Deep peroneal nerve L5,S1
Motor SystemDeep Tendon Reflexes
0 = absent
± = present only with
reinforcement
1+ = present but
depressed
2+ = normal
3+ = increased
4+ = clonus
Muscle Nerve Root
Biceps Musculocutaneous C5, (C6)
Supinator Radial C6, (C5)
Triceps Radial C7
Patellar Femoral L3-L4
Achilles Tibial S1-S2
Motor SystemBabinski Reflex
Motor SystemPyramydal Tract Signs
(extensor plantar response)
Motor System
• Brisk tendon reflexes signify upper motor lesions, absence reflexes occur in peripheral nerve or nerve root lesions.
• An extensor plantar or Babinski response is a definite immediate sign of an upper motor neuron lesion, presents well before clonus or hyperreflexia.
• Ankle clonus, when sustained or unsustained but of more than six beats duration, provides definite evidence for an upper motor neuron lesion.
Motor System Abdominal reflexes
• Lightly scratch the abdominal wall: this should contract on the same side.
• Afferents: segmental sensory nerves.
• Efferents: segmental motor nerves.
• Roots:– Above umbilicus (T8,T9).– Below umbilicus (T10,T11).
Absent:
• Pyramidal tract involvement• Peripheral nerve abnormality• Obesity• Previous operations• Pregnancies• Age
LocalizationTetraparesis
• With increased reflexes & extensor plantar responses
– Cervical spinal cord
– Lower Brainstem
– Bilateral pyramidal lesions
• With absent reflexes
– Polyradiculopathy
– Peripheral neuropathy
– Myopathy
• Mixed UMN (in legs) & LMN in arms
– Motor neuron disease
– Mixed cervical myopathy & radiculopathy
• Normal reflexes– NMJ: MG, LEMS.
– Non-organic
LocalizationParaparesis
• UMN-type– Spinal cord
• Cervical• Thoracic
– Frontal midsagittal
• LMN-type– Polyradiculopathy– Cauda equina– Peripheral neuropathy
LocalizationHemiparesis
• Cervical cord (Brown-Sequard)• Contralateral sensory findings (pain & temp. loss)
• Brainstem• Contralateral cranial nerve lesions
• Hemispheric (cortical/subcortical)• Ipsilateral facial or tongue weakness
LocalizationMonoparesis
• UMN
– Spinal cord– Brainstem– Cerebral hemisphere
• LMN
– Radiculopathy– Mononeuropathy
Sensory System
• Modalities
– Pain– Temperature
– Vibration– Proprioception
Spinothalamic(Small fibre)
Post. Columns(Large fibre)
Sensory System
• Problem orientated approach
• Right vs. Left (online/offline?)
• Spinal sensory level
• Radicular/Dermatomal/Nerve distribution
• Distal vs. Proximal
LocalizationPatterns of sensory loss
• Single nerve• Multiple nerves (mononeuritis multiplex)• Root or roots• Spinal cord• Brainstem (nuclei/fibers)• Thalamic• Internal capsule• Cortical (parietal)• Functional
Sensory SystemSensory Syndromes
Symptoms & Signs of Cerebellar Disease (VANISH’D)
• Vertigo• Ataxia (usually falls towards lesion)
• Nystagmus (increased with gaze towards lesion)
• Intention Tremor
• Scanning speech
• Hypotonia
• Dysdiadochokinesia + Dysmetria
Cerebellar Tests
• Finger-nose test
• Heel-shin test
• Repeated movements
Romberg sign is not a cerebellar one!
Localization
• Unilateral incoordination• Ipsilatral cerebellar syndrome
• Bilateral incoordination– Bilateral cerebellar syndrome
• Truncal ataxia, gait ataxia, without limb incoordination– Midline cerebellar syndrome
Stability and Gait
• Check ability to stand straight with eyes open.
• Check ability to stand straight with eyes closed.– If significantly worse than with eyes open= positive Romberg
sign.
– Usually signifies defect in pathways involved in proprioception.
– May signify vestibular disease.
• Check gait.
Extrapyramidal Signs(TRAP)
• Tremor ( rest, pill-rolling)
• Rigidity ( lead-pipe, cog-wheel)
• Akinesia / bradykinesia
• Postural instability
Check ONLY if pathology suspected (e.g., Parkinson’s disease)
Normal Examination Report (1)
• Patient fully conscious, orientated in time, place and person.
• Speech and language intact.• No meningeal signs.• Pupils PERLA, fundi intact, acuity and visual fields intact.• EOM full, no nystagmus.• Facial sensation preserved.• Face symmetrical.• (Hearing normal).• Palate/uvula rises symmetrically.• Gag preserved bilaterally.• Tongue central.
Normal Examination Report (2)
• No muscular atrophy/fasciculations.
• Muscle tone preserved.
• Power 5/5 in 4 limbs.
• Reflexes symmetrical.
• No pyramidal signs.
Normal Examination Report (3)
• Sensation preserved.
• No cerebellar signs.
• Romberg negative.
• Gait normal/stable.
How to present
• Keep to order.
• Mention all abnormalities.
• Include “core” points.
• Mention all “important negative points”– Leg weakness…”no sensory level”.– History of MS with optic neuritis…”no RAPD”– Complains of difficulty chewing…mention power of
masticatory muscles.