Phase 3A - Exam Technique

8/2/2019 Phase 3A - Exam Technique

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Approach to examination of the

neurological system

Dr Nortina Shahrizaila

Consultant NeurologistUniversity of Malaya Medical Centre



5 Possible Scenarios

• “Please examine this patient’s..”

1. Eyes

2. Cranial nerves excluding the eyes

3. Speech

4. Upper or Lower Limb

5. Cerebellar system



Motor Nervous System

CEREBRAL HEMISPHERES

BRAINSTEM/CEREBELLUM

SPINAL

CORD SPINAL NERVES

CRANIAL NERVES

UMN LMN

N M J

HEAD + NECKMUSCLES

N M J

LIMBMUSCLES



Cranial Nerves and Speech





SCENARIO 1

• “Please examine this patient’s eyes”

• Examiners want to see if you can do a

thorough eye examination.



System

• Inspection

• Optic nerve (II)

• Eye movements (III, IV, VI)



Inspection

• Clues by bed

– Eyepatch: diplopia

– Magnifying glass: poor acuities

• Face

– Ptosis

– Pupil size / symmetry



• TIP 1 – Whenever you see asymmetrical pupils, look

for ptosis

• TIP 2

– Whenever you see ptosis, look at pupil sizes



–

small pupil and ptosis• Horner’s (sympathetic lesion)

– large pupil and ptosis• 3rd nerve palsy (eye usually ‘down&out’ aswell)

Pupil size and Ptosis : 4 Patterns



- ptosis BUT equal pupils

Think Myasthenia Gravis

(levator palpebrae)

- unequal pupilsBUT no ptosis

Usuallly Holmes Adie pupil(parasympathetic lesion) –

large at onset–

shrinkswith age



II

• Acuity

• Fields

• Fundoscopy

• Pupillary reflexes



“I’

d like toformally

examine vision

with a Snellenchart”

60

36

24

18

12

9

6

5



Optic Nerve

Chiasm

Optic Tract

3 3

L R

ANTERIOR

POSTERIOR Occipital Cortex

Visual

Fields

2. Bitemporal hemianopia

3. C/l Homonymous hemianopia



Visual Fields



“I’d like to assess the

fundi”



Normal



Optic Atrophy

Causes

1. MS

2. Chronic

raised ICP



Papilloedema

Causes1. Raised ICP

2. Hypertension





Pupil reflexes

• Light (direct + consensual) – Normal pupil

• constricts to light, dilates to dark

– Failure to constrict or dilate•

Implies severe optic nerve lesion – Relative failure to constrict in light (RAPD)

• Implies moderate optic nerve lesion

– Shine light on each eye in turn

– Consensual dilation to dark in an affected pupil overrides impaired

direct constriction to light => affected pupil dilates despite light

• Accommodation

– Failure suggests Holmes Adie or 3rd N palsy



III, IV, VI

• Eye movements

– Range

– Diplopia

– Nystagmus



6 3

4

33

3

ABduction ADduction

Eye Movements: Patient’s right eye



Partial right-sidedptosis

R pupil >> left

R eye lookingdown +/- out

So this is a (partial)right-sided 3rd(oculomotor) nerve palsy



Summary

• II Horner’s (CxR); RAPD (MRI)

•

III,VI Recognise; DM (BM, BP, MRI)

• Ptosis U/l: Horner’s (CXR)

B/l: Myasthenia (Ach R ab, EMG),

Myotonic dystrophy (gene test)



Scenario 2

• “Please examine the cranial nerves

excluding the eyes”



System

• Inspection

• I

• V

• VII

• VIII

•IX-X

• XI

• XII



I

“Have you noticed any change in your sense

of smell?”

• If yes, may be due to frontal lesions (eg tumour), or

neurodegenerative conditions (Alzheimer’s, Parkinson’s)



V

• Sensory

• Motor

• Reflex



NB. V1 supplies tip

of nose

NB. V3 does not

supply angle of jaw

C2

Sensory supply of face



• Test sensation in each division

–

Ideally with a pin

• Clench teeth

– Feel masseter & temporalis

• Ask to open mouth

– Watch for deviation (to weak side)

– Resist closure

• “I would like to examine the corneal reflexes”



VII

• Motor

• Distinguish between UMN & LMN



Inspection



VIII

• Test with whispered numbers or finger rub

• Cover c/l ear

• If u/l hearing loss, say “I would like to

perform Rinne’s and Weber’s tests to

distinguish between sensorineural and

conductive deafness”



Interpreting Rinne’s

• Normal

– AC > BC

• Sensorineural

– AC > BC

•Conductive – BC > AC

NB. Weber’s test just confirms conductive deafness



IX - X

• IX

– Sensory (gag)

• X

– Motor (uvula)



• “I would like to test the gag reflex”

• Ask patient to say ‘Aaah’

– Uvula pulled away from weak side

– Complete failure to elevate suggests b/l palatal

weakness



XI

• Trapezius

– Shoulder shrug

• Sternocleidomastoid

– “Turn your head against my hand”

– Remember you are testing muscle on oppositeside



XII

• Inspection (in mouth)

• Deviation

• Strength

• Speed



Tongue deviates to left

Strong (R) side pushesweaker (L) side past themidline

So this is a left-sided

12th (hypoglossal) palsy



Summary

• I, IX,X,XI very rare

• V stroke; MS

• VII UMN: stroke

LMN: Bell’s

•VIII sensorineural: age, neuroma

conductive: wax, otitis media

• XII stroke; MND



Scenario 3

• “Please examine this patient’s speech”



System

• Easy question (eg name, address)

• Free speech: listen carefully!

• Comprehension (increasing sophistication)• Naming (increasing sophistication)

• Consonants (p, t, k)

•Phrases (british constitution, baby

hippopotamus, west register st)



• Fluent

– Comprehension intact• Normal

– Comprehension affected

• Receptive dysphasia

• Non-fluent

– Naming problems

•Expressive dysphasia

– Articulation problems

• Dysarthria



Types of Dysarthria

• Cerebellar

– Explosive (poor control of volume)

– Staccatoed

• Bulbar/Pseudobulbar

– Nasal

– Strangled

• Parkinsonian

– Quiet

– Mumbled



Summary

• Dysphasia Stroke (CT)

•Dysarthria – Consonant VII, IX-X, XII (MRI)

– Cerebellar MS (MRI), tumour

(CT), genetic (gene test)

– Bulbar/Pseudobulbar MND (EMG), Strokes (MRI)

Myasthenia (Ach R ab, EMG)

– Parkinsonian Parkinson’s! (clinical)



Limbs & Cerebellum



Scenario 4

“Please examine this patient’s

upper / lower limbs”



Upper or Lower Limb

Aims

a) localise the lesion

– R or L

– Motor or sensory (or both)

– If motor, UMN or LMN (or both)

b) give a reasonable differential based onthat lesion site (s)



• So you need an anatomical / structuraloverview of the nervous system

• And a list of 3-4 differentials for each site



Structure of (motor) nervous system

• Brain

• Spinal cord

• Anterior horn cell

• Nerve root / plexus

• Peripheral nerve

• Neuromuscular junction

• Muscle

Structure



Main differentials per part

• Brain and cord MRI – Vascular (stroke)

– Tumour

– Central demyelination (multiple sclerosis)

– Infection (herpes encephalitis, zoster myelitis) – Degenerative disease (Parkinson’s, Alzheimer’s)

• Anterior horn cell NCS/EMG

– MND

– Infection (polio)

(NCS / EMG = Nerve conduction studies / Electromyography)

Structure



• Nerve root / plexus NCS/EMG

– Intervertebral disc

– Tumour

– Demyelination (Guillain-Barre)

– Infection (Lyme)

• Peripheral nerve NCS/EMG

– Diabetes

– Alcohol/drugs

– Genetic (Charcot-Marie-Tooth)

– Peripheral demyelination (Guillain-Barre)

– Infection (syphilis)



• Neuromuscular junction (NMJ)

– Antibody (myasthenia, LEMS) AChR Ab

– Infection (botulism, diphtheria) Culture

• Muscle

– Genetic

• Muscular dystrophy Gene test

• Myotonic dystrophy Gene test

•Mitochondrial myopathy Muscle biopsy

– Myositis CK, ENA



Conventional system of Examination

• Inspection

• Tone

• Power

• Reflexes

• Coordination

• Sensation



Inspection



• Bedside

– Walking aids

• Patient

– Wasting & Fasciculations (LMN)

– Spotters

• Parkinson’s

• Myasthenia gravis

• Myotonic dystrophy



LMN

• Wasting

• Fasciculations



Parkinson’s

• Reduced facial expression

• Rest tremor

• Bradykinesia ( if undertreated)

• Dyskinesia ( from treatment)



Myasthenia gravis

• Ptosis (u/l or b/l)

• Difficulty rising fromchair with arms folded

Myotonic dystrophy

•Bilateral ptosis

• Grip myotonia

• Tent-shaped mouth



Tips 1 and 2

Best ways to start a limb examination

• For UL exam

– First test arms outstretched

• For LL exam

– First test gait

UL exam



Outstretched arms - 4 signs:

• Hemiparesis

•Pronator drift – Palms up

• Rebound

• Pseudoathetosis

• Gross weakness

•Subtle UMNweakness

• Cerebellar sign

• Proprioceptive loss

Funny walksLL exam



Funny walks

• Broad base

• Shuffling

• Waddling

• Stamping

• High stepping

• Circumduction

• Antalgic

• Ataxic

• Parkinsonian

• Myopathic

• Neuropathic

• Foot drop

• UMN

• Non-neurological / functional



Tone

• Upper Limbs

– Elbow: flexion / extension, feel

– Wrist: flexion / extension & rotation, feel

• Lower Limbs

– Knee: flex hip quickly, observe for heel lift from bed

– Knee: flexion / extension, feel

– Ankle: roll thigh, observe movement

– Ankle: rapidly flex knee and ankle, observe for clonus

Tone



Abnormal tone

• Reduced (Flaccid)

– Difficult unless clear asymmetry

• Increased

– Clasp knife (Spastic)

– Lead Pipe / Cogwheel (Rigid)

Tone



Clasp Knife vs Lead Pipe

Pyramidal Extrapyramidal

Sudden give/catch Even resistance



Power

• Start proximally, work distally

• Compare R with L

• Isolate the joint when testing

• UL LL

SAB HF/HE

EF/EE KF/KE

WE DF/PF

FAB

Thumb abduction

Power



MRC Grading

• 0 no muscle or joint movement

• 1 muscle contraction only

• 2 joint movement (gravity removed/aided)

• 3 joint movement (despite gravity)

• 4 joint movement (despite resistance)

• 5 full power

Power



Tip 3

Interpreting power findings

•Look for patterns of weakness



Patterns of Weakness

Focal v Diffuse

Nerve or nerve root Proximal v Distal?

Muscle Neuropathy Neither

Pyramidal (UMN) Non-specific




Focal weakness

• Wrist drop

– Radial nerve palsy

– C7 radiculopathy

• Foot drop

– Common peroneal nerve palsy

– L5 radiculopathy




Proximal v Distal

• Proximal

– Muscle / Neuromuscular junction

– EXCEPTION : Myotonic dystrophy

• Distal

– Peripheral Neuropathy – AND Myotonic dystrophy

UMNPatterns of Weakness



UMN

• PostureFlexed,

Pronated arm

Extended,

Adducted

leg

Anti-Gravity

Muscles>

Antagonistic

muscles



Reflexes

• Hold Tendon hammer loosely

• Compare sides

• Practice reinforcement

• Babinski – Scratch outside of foot and round below toes

– Observe the first movement of the big toe only

Reflexes



Root levels

(1 2 3 4 5 6 7 )

• Ankle S1

•Knee L2,3,4

• Biceps C5,6

• Supinator C5,6

• Triceps C7

Reflexes



Interpretation

• Absent (after reinforcement)

– LMN lesion

– Very helpful sign

– But remember acute UMN areflexia

• Brisk

– Normal: Young, anxious

– Abnormal: UMN

• Especially if asymmetrical



Coordination (see later)

• Upper Limb

– Finger-nose

– Dysdiadochokinesia (DDCK)

• Lower Limbs:

– Heel-shin – Tandem gait

S i



Sensation

• Difficult! This will be taken into account.

• Learn the dermatomes & practice them

• Ensure you test

– Pin Prick

– Proprioception (including Romberg’s test)

• “I’d like to test vibration sense using a tuning fork ”

• “I’d like to test temperature sense using hot and cold water insuitable containers”

Sensation



Tip 4

Once again, look for patterns!

Sensation



1. Glove and stocking

– peripheral neuropathy

2. Dermatomal

– root lesion

– cord lesion (sensory

‘level

’)

• T4 (nipples)

• T10 (umbilicus)

3. Romberg – Implies proprioceptive or vestibular failure, NOT

cerebellar disease



Scenario 5

“Please examine this patient’s

cerebellar system”

Cerebellum



System

• Speech

• Eyes

• Arms

• Legs

• Gait

Cerebellum



Speech

• “How did you get here today”

• Repetition

– British Constitution

– West Register Street

– Baby hippopotamus

• Usually a mix of non-fluent, staccato,variable volume, monotone pitch

Cerebellum



Eyes

• Nystagmus

– Increases towards side of cerebellar lesion

• Eye movements – Pursuit (slow ‘tracking’ movements)

– “Follow my finger”

• Broken, jerky

– Saccades (rapid ‘finding’ movements)

– Look “left”, “right”, “up”, “down”

• Overshoots

A

Cerebellum



Arms

•Finger

– nose

– Tip of nose to tip of finger

– “as quickly and accurately as possible”

Observe past-pointing, intention tremor(NB,. If tremor seen, check rest & postural components)

• DDCK

– “Tap your hand like so” (demonstrate)

– “as fast as possible”

Observe errors



Legs

• Heel-shin

– “Place your heel onto your knee

– “Then run it down your shin”

– “As quickly and accurately as possible”

Observe: overshooting

Cerebellum



Gait

• First test truncal ataxia on bed

– Ability to sit upright unsupported

• Then stand them, observe base

• Then ask to walk normally, observe base

• Assess balance, especially on turns

• Ask to walk heel to toe (tandem), unless too

unsteady

Observe: broad base, unsteady turns & tandem

Cerebellum



Causes?

Same as for rest of brain:

• Stroke

• MS

• Tumour

• Infection

• Degenerative (genetic)



SUMMARY



•Limited number of clinical scenarios – Eyes

– Cranial nerves except the eyes

– Speech

– Limbs

– Cerebellum

– Spotters (ptosis, mask-like face & gait)

Summary



Tip 5

Don’t be too specific with the diagnosis

Identify the site of the lesion from the findings

Then reel off your pre-prepared differential

Motor summary



Motor summary

UMN

(Cortico-

spinal)

Basal ganglia Cerebellar Anterior

horn, root,

nerve

Neuro-

muscular

junction

Muscle

Inspection UL flexed

LL extended

Rest tremor

Mask-like

face

Titubation Wasting

Fascics

Ptosis Ptosis

Wasting

Tone Spasticity Lead pipe/

cogwheeling

Reduced

Power Pyramidal

weakness

Distal

weakness

Proximal

weakness

Proximal

weakness

Reflexes Brisk

Babinksi+

Absent Absent

Co-

ordination

Ataxic

Gait Circumducts Festinant

Reduced

armswing

Broad based Waddling

Additional

Features

Pronator

Drift

Bradykinesia

Soft voice

Dysarthria

Nystagmus

Fatigueable



• Be polite (with patient)

• Be confident (with examiner)

• Be complete (with examination)

• Be accurate (with findings)

• Be sensible (with diagnosis & DD)

•Be succint (with investigations)

Documents

Phase 3A - Exam Technique