Learning Objectives • Differentiate atrophy, hypertrophy, and pseudohypertrophy. • Differentiate

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  • NEUROLOGICAL EXAMINATION

    Physical Diagnosis

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  • Learning Objectives • Select appropriate questions to elicit from the

    patient with a neurological complaint during a patient interview

    • Differentiate “normal” from “abnormal” findings on neurological examination

    • Identify common causes of various cranial nerve palsies

    • Differentiate conductive hearing loss from sensorineural hearing loss

    • Determine location of neurological lesion • Differentiate amongst the various movement

    disorders

  • Learning Objectives • Differentiate atrophy, hypertrophy, and

    pseudohypertrophy. • Differentiate between spasticity, rigidity, and flaccidity,

    and identify common causes of each. • Differentiate upper motor neuron lesions from lower

    motor neuron lesions. • Differentiate CNS disorders from PNS disorders, and

    identify location of the lesion & common causes. • Compare and contrast the five clinical levels of

    consciousness. • Given a case study perform the appropriate focused

    history and physical examination and formulate a differential diagnosis

  • Purpose

    • Determine if there is a neurological deficit – Sensory – Motor – Behavioral – Coordinative

    • Localize the site of the problem • Determine the etiology of the problem

  • Terminology

    • Paresis – slight or incomplete paralysis

    • Paralysis (plegia) – loss or impairment of motor function

    • Hemiparesis

    • Hemiplegia

    • Paraplegia

    • Quadriplegia

  • Terminology

    • Atrophy – a decrease in size

    • Hypertrophy – enlargement of an organ or part due to an increase in size

    of its constituent cells

    • Pseudohypertrophy – increase in size without true hypertrophy

    • Spasticity – hypertonicity with increased DTRs

    • Rigidity – stiffness or inflexibility

    • Flaccidity – loss of tone with diminished DTRs

  • Focuses

    • Mental status • Cranial nerves • Motor function • Reflexes • Sensory status • Coordination and balance

  • History

    • Chief complaint • PQRST • Headache? • Vertigo? • Visual disturbance? • Tremors or dyskinesias? • Weakness? • Dysesthesias/Paresthesias? • Loss of consciousness?

  • Key components of H&P

    Complaint Hx P.E.

    Altered mental status

    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

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

    CN VIII function; Dix-Hallpike maneuver; nystagmus

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

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

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

    Search for focal deficits; signs of trauma; hyperreflexia

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

    Asymmetry7; atrophy; sensory deficits; fasciculations; DTRs

  • Mental Status • Alertness • Attention • Orientation

    – Person, Place, Time, & Situation • Cognitive function • Perception

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

    • Judgment • Memory

    – Short-term & long-term • Speech

    – Rate & rhythm – Spontaneity – Fluency – Simple vs. complex

  • Levels of Consciousness • Alert and Oriented • Disoriented • Obtunded

    – Drowsy/somnolent – Clouded consciousness – Slow thought, movement, and speech

    • Stuporous – Marked reduction in mental and physical activity – Vigorous stimuli needed to provoke a response

    • Comatose – Completely unconscious – Cannot be aroused by painful stimuli – Absence of voluntary movement – +/- reflexes

  • Glasgow Coma Scale

  • Malingering (Nonorganic)

    • Hand drop • Blindness

    – EOM/I • Unilateral diplopia • Ammonia reaction (CN V vs. CN I) • Absence of pain or weakness in different

    positions

  • The “Difficult” Patient • Observation is key! • Use ingenuity! • Be patient! • Agitated

    – May be threatening or violent • Unresponsive

    – Fail to participate • Unreliable

    – Inattentive, preoccupied, inconsistent information • Hysterical

    – Uncooperative

  • Testing Cognitive Function • Information & vocabulary

    – Common • Calculating

    – Simple math – Word problems

    • Abstract thinking – Proverbs – Similarities/differences

    • Construction – Copy figures of increasing difficulty (i.e. circle, clock)

  • Abnormalities 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 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. Dementia • Although confusion and/or disorientation are signs of both Delirium and

    Dementia, they are different • Delirium is an acute confusional state

    – It is potentially reversible – Delirium usually occurs over a period of days to months

    • Dementia is slow and insidious – It progresses slowly over months to years – Dementia is 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

  • Visual disturbance

    • Onset? • Progression? • TIA = brief, intermittent visual loss • Migraine = “wavy” • Retinal detachment = “drawn curtain” • Acute glaucoma = “rainbows” or “halos” • Digitalis toxicity = yellow hue

  • Vertigo

    • A sense of spinning – Person – Environment

    • Suggests dysfunction of – Vestibular apparatus – Vestibular nerve

    • Differentiate from “lightheadedness” and “faintness” – Results from impairment of brain oxygenation

  • Dix-Hallpike maneuver

  • Testing for Aphasia Word 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.

  • Localization

    • CNS vs. PNS – Brain/Brain stem – Spinal cord – Peripheral nerves

    • Difficult when evaluating: – Radicular pain – Dysesthesia/paresthesia – Tremors – Incoordination

  • Localization • Cerebrum

    – Impaired intellect, memory, higher brain function • Brain stem

    – unconsciousness • LMN

    – paralysis with loss of DTRs – muscle atrophy with fasciculation

    • LMN + anesthesia – peripheral nerve or spinal root

    • UMN – involves whole muscle groups – increased or spastic mus