Neurological examination in psychiatry

Abid rizvi

Junior resident 3

Department of psychiatry

Major section of neurological examination

• Mental status

• Cranial nerves

• Motor

• Sensory

• Reflexes

• Cerebellar functions and co-ordination

• Gait and station

• Abnormal movements

Mental Status Exam1. level of consciousness

2. attention and concentration.

3. Orientation

4. Speech and language

5. Memory

6. Calculation skills

7. Logic and abstractions

8. test for agnosia and apraxia

9. judgement and insight

Level of consciousness

• “ability to relate to both self and surrounding”

• Quantitative lowering of consciousness

fully alertness to coma

Clouding of consciousness to drowsiness to coma

• Clouding of consciousness- deterioration in thinking, attention, perception and memory.

• Drowsiness- patient is awake but drift into sleep if not stimulated.

• Coma-unconscious (no verbal, motor or response to painful stimuli.

• Glassgow coma scale

Eye opening Verbal response Motor response

Spomntaneous (4) Oriented (5) Obeys (6)

To speech (3) Confused (4) Localizes (5)

To pain (2) Inappropriate words (3) Withdraws (4)

Nil (1) incomprehensible (2) A flexiuon (decorticate) (3 )

Nil (1) A.Extension decerebrate(2)

Nil (1)

• Quanlitative change in consciousness

Delirium

Fluctuation of consciousness

confusion

• Twilight state

Abrupt onset and end

Variable duration, few hrs to weeks.

Voilent emotional outburst and acts.

Disturbance in the continuity of consciouness

Epilepsy, brain tumor, alcohol intox, neurosyphillis

• Dream like state (oneiroid state). –delirium

• Stupor

Doesn't fall on continuum from alertness to coma

Mutism + akinesia

Patient may appear awake and alert.

Attention and concentration.

• Attention:” ability to attend to a specific stimuli without being distracted by external or internal stimuli”.

• Sustained attention is concentration.

Tests for attention

• Digit repetition tests

Digit span forward- 7 +_2

Digit span backwards 5 +_1

Difference between the two should not be more than 2

Tests of concentration;

“A” random letter tests.

• 7 serial subtraction tests

• Counting WORLD BACKWARDS

ORIENTATION

• Orientation to time, place, person and their situation

Speech and language

1. Patient is conscious but making no attempt to speak – MUTISM

2. Patient is trying to speak but whispers –APHONIA.

3. Volume of sound and the content of speech is normal ,but the articulation and enunciation of individual words distorted –DYSARTHRIA.

4. Disorder of language - APHASIA

Examination of speech

1. Listen

2. British constitution, royal Devonshire

constabulary, triruvanathpuarm, Muzzafarpur,

chakravarthy rajgopalchary..(my baby ate a

cupcake on the train)

3. Read a paragraph

4. Count till 30.

Listen to the words for

• Slurring

• Rhythm (jerky, explosive, or monotonous)

• Loud or too soft.

• Particular letters presenting with difficulty.

• Nasal tone

• Disturbance constant or intermittent, increasing or

decreasing

• Correct co ordination of lips, tongue, palate,

larynx, and muscle of respiration.

• Upper motor neuron, lower motor neuron,

actual muscle, the coordinating system,

cerebellum and EPS.

Speech abnormal

language fn abn- aphasia

language function n

voice,volume,pitch,timbre

normal abnormal

dysphonia

hoarse,whispery,mute high pitched

adductor spasm

cough abnormal cough normal

voice,volume,pitch,timbre normal

Speech rhythm prosody abnormal speech rhythm prosody normal

hypernasal (Palatal

Weakness)

Speech slurred drunken speech flat monotonous ab labial (papa ma

Scanning no emotional tone facial weakness)

Cerebellar EP ,RIGHT FL

abn lingual(daddy

Abn velar (coke kuh ) palatal post tongue weak anterior tongue weak

Cerebellar dysarthria

• Speaks slowly, deliberately syllable by syllable

as if scanning.

• Flow of words is lost and each word is given

equal emphasis.

Pseudobulbar dysarthria

• Individual syllables are slurred and presision

of consonant production is lost.

• Brizh conshishushon

APHASIA

• DEF “defect in the power of expression or

comprehension by speech, writing, reading, or

gesture”.

• ? Any localizing value.

• Dr BROCA “ the diagram maker”

• Rt or left dominance natural; or enforced.

• Spontaneous speech

• Comprehension

• Naming object

• Repeatition

• Reading

• Writing

• Calculation

•Spontaneous speech: Note the patient's fluency, including phrase length, rate, and abundance of spontaneous speech. Also note tonal modulation and whether paraphasic errors (inappropriately substituted words or syllables), neologisms (nonexistent words), or errors in grammar are present.

•Comprehension: Can the patient understand simple questions and commands? Comprehension of grammatical structure should be tested as well

•Naming: Ask the patient to name some easy (pen, watch, tie, etc.) and some more difficult (fingernail, belt buckle, stethoscope, etc.) objects

•Repetition: Can the patient repeat single words and sentences (a standard is "no ifs ands or buts")?

•Reading: Ask the patient to read single words, a brief passage, and the front page of the newspaper aloud and test for comprehension.

•Writing: Ask the patient to write their name and write a sentence.

BROCA’S APHASIA

• FLUENCY- impaired

• COMPREHENISON - normal

• REPEATITION - impaired

• NAMING - impaired

• WRITING - impaired (only small sentences)

• READING - impaired (only simple sentences).

Wernicke’s aphasia

• FLUENCY – normal (jagron or neologism)

• COMPREHENISON -impaired

• REPEATITION - impaired

• NAMING - impaired

• WRITING - impaired)

• READING - impaired

• Conduction aphasia – repetition impaired.

• Transcortical aphasia – repetition normal

• Anomic aphasia - naming impaired.

MEMORY

• Immediate recall (short term memory)

digit recall test.

• Recent memory.

orientation and ability to learn new material.

• Remote memory.- tests patients fund of knowledge

APRAXIA

“failure to carry out well organised voluntary movement correctly despite intact motor, sensory and co=ordinatory function.”

Method of testing

• Simple movements- put out your tongue,closeyour eyes,(if impaired look for automatic mov)

• More complex- how to use comb,pen,scissors.

• 3 steps task – lightening a cigarette, hammering a nail. (both with and without object.)

Types

• Ideomotor apraxia

• Ideational apraxia

• Constructional apraxia

• Dressing apraxia

IDEOMOTOR APRAXIA

• Patient can perform automatic movements (blowing nose, runing back hand in hair)

• Can describe and plan the action.

• Cannot carry out the motor movement.

• Most comman.

Ideational apraxia

• Part of the whole movement can be carried out but the whole act not,

• Can carry out each step correctly but not the whole movement.

Constructional apraxia

• Drawing geometrical figures and clock face and marking time on it.

• Dressing apraxia.

• Lesion in the parietal lobe.

AGNOSIA

• “failure to recognise familiar object by one or more senses.”

• Agnosia for smell and taste unknown.

Calculation skills

Logic and abstractions

Cranial nerve examination

I – olfactory VII - facial

II – optic VIII - vestibulocochlear

III –occulomotor IX - glossopharyngeal

IV – trochlear X - vagus

V – trigeminal XI – spinal

accessory

VI – abducens XII – hypoglossal

CN I - Olfactory• Ask for any changes in sense of smell

• bottles of smells

• Test each nostril separately

• Avoid noxious stimuli

CN II - optic• Visual acuity

• Visual fields

• Fundoscopy

• Color vision

CN III, IV, & VI• CN III (oculomotor)

– Most extraocular movements

– Pupillary reflex

– Eyelid opening

• CN IV (trochlear)– Supplies superior oblique

– (SO4)

– Downward and inward eye movement

• CN VI (abducens)– Supplies lateral rectus

– (LR6)

– Lateral eye movement

Test full range of

movement of extraocular

muscles

Check for double vision

(by asking patient)

CN V - trigeminal• Three divisions

– CN V1 – ophthalmic (sensory)

– CN V2 – maxillary (sensory)

– CN V3 – mandibular (sensory and motor)• Motor to muscles of mastication

• Sensation

– Fine touch (cotton wool tip)

– Pain (neurotip)

• Motor

– Clench teeth to assess mastication muscles

• Corneal and jaw jerk reflexes

– not done routinely

CN VII - facial

• Motor – muscles of face, scalp

and ears

• Sensory– Taste to anterior 2/3

tongue

– Ear canal/postauricular

• (Autonomic)

Assessment:• Look at face

• Elevate eyebrows

• Scrunch up eyes (try to open)

• Show teeth/smile

• (sensation not routinely assessed)

CN VIII - vetibulocochlear

• Hearing and balance

To test:

• Crude hearing test (whisper double digit number in one ear)

• Rinne

• Weber (lateralisation)

• (Rombergs)

CN IX - glossopharyngeal

• Motor

– Pharyngeal muscles

• Sensory

– Taste to posterior 1/3 tongues

– Pharynx, tonsils, fauces, TM, posterior ear canal

• (Autonomic)

To assess:

• Open mouth, look at palate (lesion deviates soft palate to opposite side)

• Assess swallow

• (gag reflex, mucosal anaesthesia)

CN X - vagus• Motor, autonomic and sensory to:

– Palate, pharynx, larynx, neck, thorax, abdomen

• To assess:

– Listen to voice

– (gag reflex)

CN XI – spinal accessory• Motor to

– Sternocleidomastoid

– Upper trapezius

• To assess:

– Shrug against resistance

– Head rotation and movement

against resistance

CN XII - hypoglossal• Motor to tongue

• To assess:

– Look for muscle wasting,

fasciculations, deviation

– Assess strength

– (Lesion deviates tongue

towards affected side)

Motor system

• Bulk

• Tone

• Power

Sensory system

• Pain, touch and temperature

• Propioceptive sensation

• Graphaesthesia and two point discrimination.

REFLEXES

• Present or absent

• If present, is it normal or abnormal.

• If absent, defect at the sensory or motor level.

• Abnormality are unilateral or bilateral. Can any level can be appreciated.

Prerequesites

1. Comforetable relaxed patient

2. A good hammer

3. Flexible wrist

4. Knowledge of the reflex arch

Classification of reflex

• Deep tendon reflex

• Superficial reflex

• Pathological reflexes

Deep tendon reflexes.

Bicep jerk:

• Midway between flexion and extension, slightly pronated and arm resting on lap of the patient.

• C5-C6

Tricep jerk:

midway between flexion and extension and resting in the patients lap.

• C6-C7

Supinator jerk:

• forearm in semiflexion and semipronation

• Stike at the base of the styloid process

• Flexion of the forearm

• Muscle tested is brachioradialis.

• C5-C6

The patellar reflex:

Various ways to elicit the jerk.

L2-L4

THE ANKLE JERK :

• DIFFERENT POSITIONS

• SI – S2

SUPERFICIAL REFLEXES

• PALMAR REFLEXES

• SCAPULAR OR INTERSCAPULAR REFLEXES

• SUPERFICIAL ABDOMINAL REFLEXES

• THE CREMASTERIC REPLEX.

• ANAL REFLEX

THE PLANTAR REFLEX

• POSITION

supine – hips and knee in full extension and heel resting on the bed.

sitting – knee extended and foot held either in examiners hand or on knee.

• OBJECT

“blunt point”, applicator stick, handle of reflex hammer, a broken tongue blade, thumbnail, key

HENRY MILLER – “bentley key”.

babisnski- “goose quill”.

• Technique

- a delibirate firm stimulus which is not too painful nor too light.

- Lateral side of sole starting from heel towards the little toe (as described by Babinski).

- Medial movement across the metatarsal pad (not described by Babinski). All such movement should stop short of great toe.

• Normal response- plantarflexion of great toe.

• Abnormal response- dorsiflexion of great toe.

• Warm foot more response

• Triple response

• See first movement at metatarsophalangealjoint

• Absent in anxious individual.

• Babinski negative – no such term

Babinski sign

Chaddock sign

Oppenheim sign

Gordon sign

Schaefer sign

Some of the other methods to test extensor-planter response :

Disorder Of Gait

Normal physiology of gait

• Brainstem and spinal cord- Central pattern generator.

• Subthalamus and midbrain (pedunculopontinenucleus).

• Gait cycle – heel strike heel stike

• Stance phase

To bear weight

• Swing phase

To advance the limb

• One limb support double limb support

• Stance phase (60%).-initial ct, loading, mid stance and terminal stance.

• Swing phase(40%)-pre swing, initial contact,mid swing,and terminal stance.

• Double limb support-10%

• 80m p/m,113 steps /m ,stride length of 1.41m• Base of feet-2 inches(1st compensatory effort)

• C.G- ANTERIOR TO S 2

• “ An efficient gait minimizes the displacement of the central of mass by roatating and tilting the pelvis and felxing and extending the various joint involved”

• Abnormal gait-Increased energy expenditure ,and falling.

Abnormal gait

Parkinsonism• Stooped posture-(head and neck forward).

• Knee flexed

• Flexion - elbow shoulder & wrist but fingers extented.

• “freezing”- as start hesitation, or threshold akinesia (even during talking or eating)

• Small ,slow, flat footed shuffles.

• “festination” {latin-festinaire- to hurry}

• Difficulty in stopping and turning ‘en block’

• Impaired postural reflexes and tendency to fall forward (propulsion) –countered by festination.

• Souques’ leg sign

• PSP (progressive supranuclear palsy)

• CBD (corticobasal degeneration)

• PPD (primary pallidial degeneration)

• Wilson’s disease

• Multisystem atophy

Frontal gait disorder

• Gait apraxia- “lack of ability to use the legs without deficit in sensory, motor or cordination”.

• Marche a petis pas(walk of little steps).

slow, short,shuffling gait.

• Magnetic gait and Lower body parkinsonism

• Greatest difficulty in initiation- gait ignition failure and start hesitation.

• Small feeble stepping movement with minimal forward progress.

• Unable to lift the feet(as if glued)

• After few shuffles- stride length increase-slipping clutch gait.

• Turn hesitation

• Diffuse frontal lobe envolvement

• Normal pressure and other hydrocephalous.

• Vascular disease in frontal lobe ,(subcorticalsmall vessel disease)

Cerebellar ataxic gait

• Wide based, clumsy, unsteady, lurching & irregular.

• Staggering and drunken gait.

• Tendency to sway, eratic and unpredictiblestride length.

• Romberg sign +/_

• Difficulty in walking tandem.

• Hemispheric lesion- deviates towards the side.

• Vermis-grossly unstable, reels ion both direction, need 2 people support.

• Stroke, trauma, tumor, neurodegenerative changes and cerebellar degeneration.

Gait of sensory ataxia

• Normal balance –

vestibular system

proprioception

vision

• looses the awareness of lower extremity or whole body in space.

• Depend upon visual input.( incred on eye clos)

• Walks with eyes down.

• “steppage” or double tap gait.(heel first)

“to increase the proprioceptivefeedback”.

Foot drop gait.

• lift leg ,to clear the toe.

• unable to stand on heel

• Toe first touch

• Toe end of the shoe is worn out..

+

Gait of spastic hemiperesis.

• loss of normal arm swing and circumductionof leg.

Scissoring gait.

• Tightness of hip adductors so that knees cross one in front of other with each step.

• Seen in cronic myelopathies as in MS. And cervical spondilosis,

Herperkinetic gait.

• synderham chorea,huntington’s disease,andother athetosis, dystonia and other abnormal movement – accentuate during.

• Walking accentuate not only movement but also postural instability

Abnormal movements

Answer these :

• Part of body affected,

• Constant or episodic,

• At rest or on movement or both,

• Voluntary movement suppress or increases it,

• Positional alteration,

• Altered by emotion,enviroment or temperature,

• Effect of eye closure

• Is the patient aware of it

• Effect of attention

Abnormal involuntary movement as a spectrum

Regular /predictible Intermediate Fleeting /unpredictible

Tremor Dystonias Fasciculation

Hemibalism Athetosis Myoclonus

Partial myoclonus Tic Chorea

Myokymia Dyskinesia

Steriotypy

TREMOR:

• involuntary, relatively, rhythmic, purposeless, oscillatory

movement.

• Define its:

location, rate amplitude, rhythmicity, relationship to rest

and activity,

• Underlying pathology and etiology.

• Tremor-

slow- 3 to 5 hz

medium- 5 to 10 hz

fast – 10 to 20 hz

• Fine, coarse, and medium

tremor

action

postural kinetic

rest

• Rest tremor- decreases on use of part.(P.syn)

• Action tremor

Postural tremor – limbs maintained in an antigravity position.(ET & enhanced physiological tremor)

Kinetic tremor – intentional tremor.

Rest tremor

• Disappear or atleast decreases on activity.

• Most commanly- distal extremity but can also affect leg arm, tongue jaw head , eyelids or rarely entire body.

Parkinsonian tremor-• resting, nonintentional, slow and coarse.• 4 to 5 hz (slow).• Repititive contraction of agonist and antagonists.• Initially unilateral in one digit, eventually becoming

bilateral.• Disappears on sleeping and exercebated by anxierty

and fatigue.• Classically pill rolling.

action tremors

Postural tremors

Physiological tremors-

• 8 to 12 hz.(slower in children and young adult)

• hand in postural tension

• Anxiety,fright,fatigue,

• hyperthyroidism- enhanced physiological tremor(fine,rapid at outstreached fingers)

Essential tremors,.

• Commanest of all

• Familial, appear in second decade t0 sixth decade and worsons.

• Senile tremor is a form of ET.

• ETOLOGY OBSCURE.

• MADE WORSE BY ANXIETY

ESSENTIAL TREMOR PARKINSON’S TREMORS

MOST PROMINENT AT SUSTAINED PSTUREHENCE PATIENT MAY SPILL WATER WHILE DRINKING

AT RESTNO SPILLAGE

HEAD AND VOICE INVOLVED RARELY INVOLVED,(ONLY IN LATE STAGE

ALCHOHAL AND BETA BLOCKER IMPROVES NO EFFECT

INTENTIONAL TREMOR.

• Cerebellar disease.

• Appear when precision is required to touch a object.

• Finger shaking perpendicular to the line of travel.

• Amplitude of oscillation increases towards the end of the motion.

• Finger nose test.

“wing beating tremor” of:

wilson’s disease

chorea

• Involuntary, irregular, random nonrhythmic, hyperkinetic movement which are abrupt, brief, jerky and ill sustained.

• Individual movement discrete,but variable in type and location.

• Chaotic, multiform constantly changing movement

• seems to flow from one part of the body to another.

• Movement seems voluntary but are involuntary.

• Persists at rest ,are increased by activity and tension and disappears in sleep.

• One extremity,trunk, face, tongue, lips.

• Piano playing movement and milkmaid grip.

• Parakinesia

• Snake darting and fly catching

• Huntingtons chorea and synderham’s chorea.

• Huntington’s- facial grimacing more marked, chorea more slow and less jerky and more bizzare

• Bizzare prancing gait due to chorea.

Athetosis(a –thetosis without fixed position.)

• Slow, somewhat sustained, involuntary, irregular, coarse writhing movement.

• Face, neck, trunk, fingers, hand and toes.

• Any combination of flexion, extention, abduction and adduction.

• Flow from one part of the body to another their direction changes.

• Usually congenital- perinatal injury to basal ganglia.

• Pseudoathetosis( sensory athetosis).

asterixis

A- not ; sterixis – fixed

• An irregular sharp brief loss of posture especially evident in the outstreched hand.

• Occurs in decompensated hepatic failure and uremia, poisoning with hypnotic drugs and respiratory failure.

hemibalism

Hemibalismus

• Wild flinging continuous movement that occur on one side of the body.

• Infarction or hemorrhage in contra lateral subthalamic nucleus,

• Continuous throughout waking disappear only in deep sleep

•

dyskinesia

• All hyperkinetic movement- technically dyskinesia.

• Term reserved for dyskinesia duie to drug.

• Comman problem in patients of PD treated with lecvodopa.

Orofacial dyskinesia.

• Involuntary movement of the mouth, face, jaw or tongue consist of incessant chewing , pursing of the lips, tongue thrusting, licking and incessant chewing movement

• Tardive dyskinesia – dopamine antagonists

• More common in old females

• Difficult to treat.

• Other tardive phenomenon can also occur-tardive tremor, tardive dystonia, tardive tics, tardive chorea./

`

dystonia

“spontaneuos, involuntary, sustained muscle contraction forcing affected part of the body in abnormal posture”

• Any part can be affected.

• Can be generalized, focal, intermittent, segmented and hemidistribution.

• Writer’s cramp, blepharospasm, spasmodic totticolis, belly dancer dystonia.

myoclonus

• “repetitive, abrupt, brief, rapid, lightening like jerky movement of one muscle or a group of muscle.”

• Usually occurs in paroxysms at irregular intervals, during rest or active movement .often precipritated by emotional, mental state, tactile,visual or auditory stimuli.

• Can be physiological- hiccups, hypic jerks.

• Often the myoclonic jerks are quite voilent.

• Seen with epilepsy (JME, WEST SYNDROME)

• Myoclonus without prominent seizure seen in-CZ disease, Hallervorden Spatz syndrome,WD, SSPE, AD.

Tics

• Some degree of awareness of movement, but make movement in response to some urge or compelling inner force.

• Tension and restlessness

• Unvoluntary.

• Co-ordinated repititive seemingly purposeful act involving a group of muscle in their normal synergistic relationship.

• Tics are exagerated during emotional tension and disappear during sleep.

• When under scrutiny patient may supresstheir tics, but they reaapear when their attention get divided.

• Giiles de la tourrete- multiple tics type, motor as well as vocal.( including obscenities).

akathesia.

• Inner restlessness and urge to move.

• Type of seizure ?

• Region of the brain involved ?

thank you

• Questions ??????????????