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.

Thank you