1_12 Neurological Exam

NEUROLOGICALNEUROLOGICALEXAMEXAM

Clinical Reasoning II: 2010Clinical Reasoning II: 2010

John G. Quinlan, M.D.John G. Quinlan, M.D.

NEUROLOGICAL EXAMNEUROLOGICAL EXAM

MENTAL STATUSMENTAL STATUS II-XIIII-XII MOTORMOTOR SENSORYSENSORY GAITGAIT

Mental Status ExamMental Status Exam

Level of consciousnessLevel of consciousness OrientationOrientation Specific evaluation of languageSpecific evaluation of language Memory and AttentionMemory and Attention

Cranial Nerves II-XIICranial Nerves II-XII(General Comments)(General Comments)

We skip CN-IWe skip CN-I Certain nerves are “bundled” (e.g. eye Certain nerves are “bundled” (e.g. eye

movements and speech production).movements and speech production). Reflexes allow us to evaluate brain stem Reflexes allow us to evaluate brain stem

function, even in comatose patients.function, even in comatose patients.

Cranial Nerve IICranial Nerve II

Cranial Nerve IICranial Nerve II

Pupils and MorePupils and More

Cranial Nerves III, IV and VICranial Nerves III, IV and VI

Diplopia worsens in Diplopia worsens in gaze direction of the gaze direction of the action of the paretic action of the paretic muscle.muscle.

The “outer image” is The “outer image” is always the pathological always the pathological image.image.

Oculocephalic ReflexOculocephalic Reflex

Eye Control CircuitsEye Control Circuits

Cranial Nerves V and VIICranial Nerves V and VII

Check V with light Check V with light touch and by palpating touch and by palpating the masseter.the masseter.

Check VII by testing Check VII by testing frontalis, oculi and oris frontalis, oculi and oris muscles.muscles.

Corneal reflex is tested Corneal reflex is tested in comatose patient.in comatose patient.

Cranial Nerve VIIICranial Nerve VIII

Eyes must be closed.Eyes must be closed. Rubbing fingers creates mid to high Rubbing fingers creates mid to high

frequencies.frequencies. Be random in delivering the stimuli.Be random in delivering the stimuli.

Cranial Nerves VII, IX, X, XIICranial Nerves VII, IX, X, XII(Tested by analyzing speech)(Tested by analyzing speech)

Phonation Phonation ““Pa”, “Ta” and “Ka”Pa”, “Ta” and “Ka” Spastic dysarthria (strangled phonation and Spastic dysarthria (strangled phonation and

slowed rates)slowed rates) Flaccid dysarthria (“breathy” phonation and Flaccid dysarthria (“breathy” phonation and

fairly normal rates)fairly normal rates)

Motor Examination: Muscle Motor Examination: Muscle Strength TestingStrength Testing

Use mechanical Use mechanical advantage.advantage.

Use your own weight.Use your own weight. Watch out for “muscle Watch out for “muscle

substitutions” (what substitutions” (what muscle(s) is this muscle(s) is this examiner testing?).examiner testing?).

We’ll cover specifics in We’ll cover specifics in the small groups.the small groups.

Motor Examination: Muscle Stretch Motor Examination: Muscle Stretch Reflex TestingReflex Testing

Patient must be relaxed Patient must be relaxed and well positioned.and well positioned.

You must know “roots You must know “roots and nerves” for reflexes and nerves” for reflexes (and muscles).(and muscles).

Motor Examination: “RAMs” and Motor Examination: “RAMs” and the Babinski responsethe Babinski response

Upper motor neuron Upper motor neuron pathology slows pathology slows rrapid apid aalternating lternating mmovement ovement (RAM) rates.(RAM) rates.

Watch the great toe Watch the great toe carefully (Babinski and carefully (Babinski and “triple-flexion”. “triple-flexion”.

Motor Examination: Cerebellar Motor Examination: Cerebellar FunctionFunction

I like finger-nose-finger and toe-finger testing.I like finger-nose-finger and toe-finger testing. Heel-shin maneuver.Heel-shin maneuver. Limb dysmetria is seen with IPSILATERAL Limb dysmetria is seen with IPSILATERAL

cerebellar hemishere disease.cerebellar hemishere disease.

Sensory ExaminationSensory Examination

Pin and vibratory sense Pin and vibratory sense are nice tools for are nice tools for evaluating the nerves, evaluating the nerves, cord and brainstem.cord and brainstem.

Know your “cortical Know your “cortical sensations” (e.g. sensations” (e.g. stereognosis and stereognosis and graphesthesia)graphesthesia)

Gait and StationGait and Station

Rhomberg testRhomberg test Regular walking (a fine Regular walking (a fine

way to test for early way to test for early parkinsonism).parkinsonism).

Tandem walking Tandem walking (rigorous testing for (rigorous testing for ataxia).ataxia).

Neurological ExamNeurological ExamPRS CasesPRS Cases

Young Man with WeaknessYoung Man with Weakness

A 28 year old man noted that he was stumbling A 28 year old man noted that he was stumbling as he walked home from work yesterday evening. as he walked home from work yesterday evening. This morning, his legs were so weak that he fell on This morning, his legs were so weak that he fell on the way to the bathroom. He has not been able to void the way to the bathroom. He has not been able to void for more than 12 hours. He felt his arms were strong. for more than 12 hours. He felt his arms were strong. He complained of moderately-severe mid back pain.He complained of moderately-severe mid back pain.

He has no significant medical problems.He has no significant medical problems.

Young Man with WeaknessYoung Man with WeaknessExam 1Exam 1

He has tenderness to percussion in his mid back. He has tenderness to percussion in his mid back. There is less than antigravity strength (2/5) in both There is less than antigravity strength (2/5) in both legs. He has normal reflexes. Rapid alternating legs. He has normal reflexes. Rapid alternating movements (RAMS) are very slow and the patient movements (RAMS) are very slow and the patient has bilateral Babinski responses. Joint position sense has bilateral Babinski responses. Joint position sense and vibration sense are absent in toes bilaterally. He and vibration sense are absent in toes bilaterally. He can only feel sharpness at the level of his umbilicus.can only feel sharpness at the level of his umbilicus.

The remainder of neurological exam is normal.The remainder of neurological exam is normal.

Where do you localize the lesion?Where do you localize the lesion?

1 2 3 4 5

0% 0%

100%

0%0%

1.1. Right frontal lobeRight frontal lobe

2.2. Right ponsRight pons

3.3. Left frontal lobeLeft frontal lobe

4.4. Left ponsLeft pons

5.5. None of the above are None of the above are correct.correct.

4141 4242 4343 4444 4545 4646 4747 4848 4949 5050 5151 5252 5353 5454 5555 5656 5757 5858 5959 6060

6161 6262 6363 6464 6565 6666 6767 6868 6969 7070 7171 7272 7373 7474 7575 7676 7777 7878 7979 8080

Where do you localize the lesion?Where do you localize the lesion?

1 2 3 4 5

4%

81%

0%8%8%

1.1. Bilateral parasagital Bilateral parasagital cortexcortex

2.2. Thoracic cordThoracic cord

3.3. Peripheral nervesPeripheral nerves

4.4. Medial ponsMedial pons

5.5. Non-neurologicalNon-neurological

4141 4242 4343 4444 4545 4646 4747 4848 4949 5050 5151 5252 5353 5454 5555 5656 5757 5858 5959 6060

6161 6262 6363 6464 6565 6666 6767 6868 6969 7070 7171 7272 7373 7474 7575 7676 7777 7878 7979 8080

Where do you localize the lesion?Where do you localize the lesion?

1 2 3 4 5

0% 0% 0%

98%

2%

1.1. Bilateral parasagital Bilateral parasagital cortexcortex

2.2. C5 cord levelC5 cord level

3.3. T5 cord levelT5 cord level

4.4. T10 cord levelT10 cord level

5.5. Non-neurologicalNon-neurological

121121 122122 123123 124124 125125 126126 127127 128128 129129 130130 131131 132132 133133 134134 135135 136136 137137 138138 139139 140140

141141 142142 143143 144144 145145 146146 147147 148148 149149 150150 151151 152152 153153 154154 155155 156156 157157 158158 159159 160160

What is the most likely cause of What is the most likely cause of the patient’s symptoms?the patient’s symptoms?

1 2 3 4 5

30%

4%6%

45%

15%

1.1. Ischemia Ischemia

2.2. Hemorrhage Hemorrhage

3.3. TumorTumor

4.4. InflammationInflammation

5.5. None of the aboveNone of the above

4141 4242 4343 4444 4545 4646 4747 4848 4949 5050 5151 5252 5353 5454 5555 5656 5757 5858 5959 6060

6161 6262 6363 6464 6565 6666 6767 6868 6969 7070 7171 7272 7373 7474 7575 7676 7777 7878 7979 8080

Which test would you order? Which test would you order?

1 2 3 4 5

77%

0% 2%0%

21%

1.1. MRI scan of the spine.MRI scan of the spine.2.2. EEG (Electroencephalogram) EEG (Electroencephalogram) 3.3. Nerve conduction studies.Nerve conduction studies.4.4. Cerebral angiogram.Cerebral angiogram.5.5. None of the above.None of the above.

8181 8282 8383 8484 8585 8686 8787 8888 8989 9090 9191 9292 9393 9494 9595 9696 9797 9898 9999 100100

101101 102102 103103 104104 105105 106106 107107 108108 109109 110110 111111 112112 113113 114114 115115 116116 117117 118118 119119 120120

Young Man with WeaknessYoung Man with Weakness

A 28 year-old man noted that he was stumbling A 28 year-old man noted that he was stumbling as he walked home from work yesterday evening. as he walked home from work yesterday evening. This morning, his legs were so weak that he fell on This morning, his legs were so weak that he fell on the way to the bathroom. He denied loss of bladder the way to the bathroom. He denied loss of bladder control. He felt his arms were strong. He complained control. He felt his arms were strong. He complained of moderately-severe mid back pain.of moderately-severe mid back pain.

He has no significant medical problems.He has no significant medical problems.

Young Man with Weakness:Young Man with Weakness:Exam 2Exam 2

There is less than antigravity strength There is less than antigravity strength (2/5) in both legs. Reflexes are absent in legs (2/5) in both legs. Reflexes are absent in legs and arms. Foot speed (RAMS) is normal. Both and arms. Foot speed (RAMS) is normal. Both great toes are flexor to plantar stimulation. great toes are flexor to plantar stimulation. Absent JPS and vibration sense in toes and Absent JPS and vibration sense in toes and fingers.fingers.

Remainder of the neurological exam is Remainder of the neurological exam is normal.normal.

Where do you localize the lesion?Where do you localize the lesion?

1 2 3 4 5

11%

2% 0%

18%

68%1.1. Bilateral parasagital Bilateral parasagital

cortexcortex

2.2. Thoracic cordThoracic cord

3.3. Peripheral nervesPeripheral nerves

4.4. Medial ponsMedial pons

5.5. Non-neurologicalNon-neurological

8181 8282 8383 8484 8585 8686 8787 8888 8989 9090 9191 9292 9393 9494 9595 9696 9797 9898 9999 100100

101101 102102 103103 104104 105105 106106 107107 108108 109109 110110 111111 112112 113113 114114 115115 116116 117117 118118 119119 120120

What is the most likely cause of What is the most likely cause of the patient’s symptoms?the patient’s symptoms?

1 2 3 4 5

0% 0%

13%

88%

0%

1.1. Ischemia Ischemia

2.2. Hemorrhage Hemorrhage

3.3. TumorTumor

4.4. InflammationInflammation

5.5. None of the aboveNone of the above

4141 4242 4343 4444 4545 4646 4747 4848 4949 5050 5151 5252 5353 5454 5555 5656 5757 5858 5959 6060

6161 6262 6363 6464 6565 6666 6767 6868 6969 7070 7171 7272 7373 7474 7575 7676 7777 7878 7979 8080

Which test would you order? Which test would you order?

1 2 3 4 5

5%0% 4%0%

91%1.1. MRI scan of the spine.MRI scan of the spine.2.2. EEG (Electroencephalogram) EEG (Electroencephalogram) 3.3. Nerve conduction studies.Nerve conduction studies.4.4. Cerebral angiogram.Cerebral angiogram.5.5. None of the above.None of the above.

4141 4242 4343 4444 4545 4646 4747 4848 4949 5050 5151 5252 5353 5454 5555 5656 5757 5858 5959 6060

6161 6262 6363 6464 6565 6666 6767 6868 6969 7070 7171 7272 7373 7474 7575 7676 7777 7878 7979 8080

A Woman in PainA Woman in Pain

A 41 year-old woman had the fairly sudden A 41 year-old woman had the fairly sudden onset of moderate neck pain about two weeks ago. onset of moderate neck pain about two weeks ago. Yesterday, she sneezed several times and afterward Yesterday, she sneezed several times and afterward noted: 1) the pain has worsened and radiated to her noted: 1) the pain has worsened and radiated to her left shoulder, 2) she has left hand numbness, and 3) left shoulder, 2) she has left hand numbness, and 3) left arm weakness.left arm weakness.

She has no significant medical problems and She has no significant medical problems and takes no medications. She works as a waitress.takes no medications. She works as a waitress.

A Woman in Pain: ExamA Woman in Pain: Exam

She has restricted range of motion of her She has restricted range of motion of her neck and shoulder. Otherwise, her general neck and shoulder. Otherwise, her general exam was normal. She has weakness in the exam was normal. She has weakness in the left deltoid and biceps muscles and an absent left deltoid and biceps muscles and an absent left biceps reflex. Her sharp sensation is left biceps reflex. Her sharp sensation is reduced over her left thumb. Otherwise, her reduced over her left thumb. Otherwise, her neurological exam was normal. neurological exam was normal.

Where would you localize the Where would you localize the lesion? lesion?

1 2 3 4 5

4%0% 0%

13%

83%1.1. Left median nerve.Left median nerve.2.2. Right frontal lobe Right frontal lobe 3.3. Left C5 rootLeft C5 root4.4. Left C7 rootLeft C7 root5.5. None of the above.None of the above.

161161 162162 163163 164164 165165 166166 167167 168168 169169 170170 171171 172172 173173 174174 175175 176176 177177 178178 179179 180180

181181 182182 183183 184184 185185 186186 187187 188188 189189 190190 191191 192192 193193 194194 195195 196196 197197 198198 199199 200200

What is the most likely cause of What is the most likely cause of the patient’s symptoms?the patient’s symptoms?

1 2 3 4 5

9% 9%

58%

11%14%

1.1. Ischemia Ischemia

2.2. Hemorrhage Hemorrhage

3.3. TumorTumor

4.4. InflammationInflammation

5.5. TraumaTrauma

8181 8282 8383 8484 8585 8686 8787 8888 8989 9090 9191 9292 9393 9494 9595 9696 9797 9898 9999 100100

101101 102102 103103 104104 105105 106106 107107 108108 109109 110110 111111 112112 113113 114114 115115 116116 117117 118118 119119 120120

Which test would you order? Which test would you order?

1 2 3 4 5

82%

0%5%

0%

14%

1.1. MRI scan of the cervical spine.MRI scan of the cervical spine.2.2. EEG (Electroencephalogram) EEG (Electroencephalogram) 3.3. Nerve conduction studies.Nerve conduction studies.4.4. Cerebral angiogram.Cerebral angiogram.5.5. None of the above.None of the above.

8181 8282 8383 8484 8585 8686 8787 8888 8989 9090 9191 9292 9393 9494 9595 9696 9797 9898 9999 100100

101101 102102 103103 104104 105105 106106 107107 108108 109109 110110 111111 112112 113113 114114 115115 116116 117117 118118 119119 120120

QuestionsQuestions