4/3/2020 1 Neurological Exam Disclosures Goals

4/3/2020

Neurological Exam WAPA-2020 Madison, Wisconsin

Christopher Luzzio, MD Associate Professor of Neurology UW, SMPH

Disclosures • None applicable.

The painting "A Clinical Lesson at the Salpêtrière" by Pierre Aristide André Brouillet. This painting shows Charcot demonstrating hypnosis on a "hysterical" Salpêtrière patient, "Blanche" (Marie "Blanche" Wittmann), who is supported by Dr. Joseph Babiński (rear).

Goals • SOME Neurological Exam highlights. – Basic principles – Tools – Special tests – Some anatomy • This could be a 6-hour talk / 300-page textbook (in 45 minutes.) • Sorry, videos and audio bits not allowed.

1 4/3/2020

Determine Purpose of the Exam- Establish a Clear Goal • Alert Patient – General full exam • New Patient • Vague complaints • Disability/Reference – Focused differential driven • Less time/urgent care/follow-up/primary care – Cognitive detailed-when indicated • Confused/delirious/impaired alertness – Tailor/Customize • Coma – Glasgow Coma Scale (eye-opening, verbal, motor) – Prognostication—”brain death” • Stroke-TPA evaluation (NIH Stroke Scale) • Clinical Trials (EDSS in MS)

Points • Take a complete history (90% diagnosis). – Onset, frequency, duration, severity, character, precipitating factors, associated features, relieving factors, timing, for example. • Do a good general exam. • Know the anatomy, physiology, pathology. • Time: sufficient for history and exam. • Have all the tools (Hammer, Tuning Fork, etc.) • Tempo: get the exam done. • Space: room for walking, etc. • Consideration: Is the patient comfortable?

Basic Tools for Neurological Exam

• Light / Ophthalmoscope (fundus, pupils) • 2-3 mm Red pin, or object • Otoscope (ears) • Tuning Fork 128Hz (auditory and sensory exams) • Reflex Hammer (long stem Queens Square best) • Clean Safety-Pin, or microfilament (sensation) • Visual Acuity/Contrast Chart (Snellen) • Striped Ribbon – https://www.youtube.com/watch?v=CG5n516PCXM • Vials of Salt, Sugar, Coffee (smell, taste) • Syringe (caloric test) • Stethoscope (heart, carotid bruits) • Most Importantly ……your hands

2 4/3/2020

Closed-Loop Analysis • Additional history after exam. • Note patterns (stroke syndromes). • Final exam-focused (Tinel's Sign for CTS, or tests to determine non-organic etiology). • Return later date (allow time for disease to manifest itself as in Parkinson’s). • History/exam guides the diagnostic tests. – Tests are an Extension of your physical exam ! • EMG, for example. • Goal is diagnosis.

Localization • Where is the lesion? • Understanding the circuits of the nervous system.

Case: Localization Young adult:

ED visit Complete right facial weakness (upper and lower face). Mild blurred vision especially when looking right. Mild headache.

? Bell’s Palsy ? Stroke ? Other

3 4/3/2020

General Neurological Exam---alert person

• Observe the patient while taking history. – Exam begins with the history. – Normal morphology? – What do you observe during history? – Behavior and body language. – Gown accordingly for exam. – Explain purpose for exam.

4 4/3/2020

Cognition

• Is cognition the complaint? – Very helpful to query family or friend. – Doing well at work? • General observations – Consider age, education, experience, previous illness – Work history (a math professor should know PI) • Specific tests (triage/monitor) – MMS (copyright issues) – SLUMS – Cognitive skill, memory, reasoning and problem solving, judgement, abstract thought, emotional state • Detailed tests (neuropsychological assessment) – Disability – Work or Driving at Risk

• Neglect (alert, focused) vs. Delirium (not alert, unfocused)

Dementia (look for)

• Focal signs • Involuntary movement • Pseudobulbar signs 1. Slow and indistinct speech 2. Dysphagia (difficulty in swallowing) 3. Small, stiff and spastic tongue 4. Brisk jaw jerk 5. Dysarthria 6. Labile affect 7. Gag reflex may be normal, exaggerated or absent

• Primitive reflexes – Seen in infants, aged, dementia

Language • Test if necessary, note during history – Name objects – Repeat Phrases – Write complete sentence – Describe scene – Simple math – Follow commands

– Dysarthria (disarticulation), content of speech unaffected – Dysphasia (loss of production or comprehension of language) • Broca’s (motor or expressive, frontal lobe) – Non-fluent, hesitant, telegraphic (words omitted), good comprehension – Handwriting poor • Wernicke’s (sensory or receptive, parietal/temporal) – Comprehension impaired, speech non-sensical but fluent, patients unaware – Neologisms-nonexistent words – Paraphrasia-half-right words – Handwriting poor. • Conduction (speech nonsensical, fluent, comprehension intact, repetition poor) arcuate fasciculus • Global Dysphasia, large area of dominant hemisphere

5 4/3/2020

Cranial Nerves Highlights

• Consider examining by nerve (1-12) or by function/associations. • Smell / Taste (1, 7, 9)----if history requires (otherwise skip) – Refined taste relies on smell (hold your nose and eat) – Q-tip (salt, sugar); apply to sides, back of tongue – Coffee; one nostril closed

• Loss of taste in Bell’s Palsy • Loss of smell in trauma or frontal lobe tumor

Cranial Nerves Highlights • Vision / Gaze (huge topic and too much to cover) – Nerves 2, 3, 4, 6 – Visual fields (check for loss, or neglect (cerebral lesion)) • Confrontation with RED PIN – Test: Goldman Perimeter, Humphrey Field Analyzer • Hemi-field, Quarter-field, Central, Temporal

– Visual acuity: Best vision with glasses, Snellen Chart, Contrast Chart • Pinhole test: refractive error vs. nerve dysfunction. • Pupil reaction, size, shape, equality – Relative Afferent Pupillary Defect » Swinging-Light Test – Accommodation, convergence, contralateral response – Lid: sympathetic (Horner’s) or 3rd • Fundus: papilledema is most important not to miss! • Other – Sclera: Is it green? – Iris: copper ring? (Wilson’s Disease)

Total Solar Eclipse: Casper, Wyoming 2017 18

6 4/3/2020

Anatomy of Vision

Retina-papilledema, optic neuritis

Eye to eye Small beam Follow vessels Each wearing glasses may help. Dilate if Necessary

• Papilledema • Headache, nausea, no visual loss • Disk swelling, hemorrhages, cotton wool spots • Optic Neuritis • Retrobulbar pain, decreased acuity Vision loss: don’t miss • Loss red vision, APD, disk swelling TIA, Giant Cell Arteritis • AION (Anterior ischemic optic neuropathy ) Increased ICP, Tumor • Acute painless vision loss Consult Ophthalmologist • hemi-altitudinal defect

Complements of Dr. Yanjun (Judy) Chen, UW Ophthalmology

7 4/3/2020

Complements of Dr. Yanjun (Judy) Chen, UW Ophthalmology

8 4/3/2020

Gaze

– Gaze: check slowly • Conjugate ? Normal magnitude • Nystagmus (direction, sustained, evoked) • Paralysis one or both? • Note eyes in Neutral position. • Gaze preference or palsy (cortical verses brainstem lesion) • Note head position (tilted?) • Note which direction causes worst double vision – Double vision due to paralysis is not present when one eye is closed. – Up-gaze decreases with age.

Double Vision

Note: Direction of maximal displacement of image.

Determine pair of muscles involved.

Consider: Identify source of outer image with colored lens. (or close one eye then the other)

9 4/3/2020

Nystagmus (brainstem/cerebellum/vestibular)

• Examine with otoscope or magnifier. • Can occur in “normal” person with > 30 degree deviation. • Slow drift with fast corrective movement. • Nystagmus is in the “fast direction” phase. • Maximal when eyes turned to direction of fast phase. • Horizontal? (brainstem/vestibular) • Vertical? Always indicates pathology, cerebellum, brainstem. • See-saw • Convergence • Downbeat • Opsoclonus • Congenital

Cranial Nerves Highlights

• Speech/Swallow (5, 7, 9, 10, 12) – Lips, face, jaw. • Open close mouth, blow, smile, close eyes, look up – Note symmetry, upper/lower facial weakness – Jaw-Jerk – Oral structures • Tongue (deviates to side of lesion)(12) – Look for atrophy, fasciculations • Palate (gag) (uvula swings to normal side)(9,10) • P, T, K – Larynx (recurrent nerve 10th) – Diaphragm/chest • Hoarseness/hypophonia

Cranial Nerves Highlights

• Other Motor – Lids (3rd verses sympathetic) – Face (upper and lower), tone, activation, magnitude • Stroke verse Bell’s Palsy – Shoulder Shrug (#11, trapezius) – Head Rotation (#11, sternomastoid)

10 4/3/2020

Cranial Nerves Highlights

• Sensation – Cervical trigeminal – 5 (3 divisions), 9, upper cervical (back of head) – Corneal reflex • Hearing – Crude testing for acuity (speech, 512) – Weber, Rinne (128, 256 Hz) – Refer to audiology • Sweat – Horner’s / dryness

Rinne’s and Weber’s Test

Check cochlear Component (whisper/mask) Examine canal and tympanic membrane. Differentiate: conductive deafness (middle ear pathology) nerve deafness

Hold: vertex.

Hold at Mastoid Bone until no sound CD heard. Then hold near ear. Louder affected ear. Normal: hear vibration. ND Louder normal ear.

CD Bone conduction better than air conduction. ND Both bone and air conduction impaired.

Transit of Venus Across Sun 2012 from Madison, Wisconsin

11 4/3/2020

Motor System Levels of Dysfunction

Brain Brainstem Spinal Cord (upper vs. lower) Upper motor neuron

Lower Motor neuron (Nerve root)

Plexus Peripheral Nerve Neuromuscular junction Muscle

• Mass – Appearance of muscles – Wasting, hypertrophy, fasciculations • Tone (resistance to passive movement) – Clasp-knife, Lead-pipe, Cog-wheel – Pronation/Supination, Lift Knee • Power (scaled 0-5) (with increments 4-5) CNS-circuits • Speed (MS) • Endurance Circa 1940’s – (often reported / tested in Myasthenia) – Pronator Drift—stroke testing

Serratus Anterior Brachioradialis C5,6,7 C5,6 Long Thoracic Radial

Deltoid Triceps C5,6 C6,7,8 Axillary Radial

Biceps Pronation C5,6 Median Musculocutaneous Supination Radial

Extensor Pollicis (L,B) Opponens Pollicis Extensor Digitorum C7,8 C8,T1 C7,8 Posterior Interosseous Median Posterior Interosseus

FDI Flexor Dig. FDI, Abductor Dig. Min. C8,T1 Median C7,8 C8,T1 Ulnar Ulnar C7,8 Ulnar 36

12 4/3/2020

Hip Extension Adductors Gluteus Max. Knee Extension Obturator N. L2,3,4 Inferior Gluteal N. L5,S1,S2 Quadriceps Femoral N. L2,3,4

Adduction Hip Flexion Knee Flexion Gluteus Med, Min, TFL Iliopsoas Hamstrings Superior Gluteal N. L4,5 Femoral N. L1,2,3 Sciatic N. L5, S1, 2 37

Eversion Inversion Toe Extension Peroneus L, B Tibialis Posterior Extensor Hallucis Longus Superficial Peroneal N. L5, S1 Tibial N. L4,5 Deep Peroneal N. L5

Dorsiflexion Plantarflexion Tibialis A. Deep Peroneal N. L4,5 Gastrocnemius, Soleus Tibial N. S1,2 38

Brachial Plexus and Lumbar Plexus

Exiting nerve roots combine and split to form peripheral nerves.

Lesions here may cause loss of power, reflexes, and sensation. Complicated anatomy.

Please review at your leisure.

13 4/3/2020

Reflexes (arc)

Upper Motor Myelopathy Radiculopathy Neuropathy

Rated 0, 1, 2, 3, 4 (clonus) Triceps C6, C7 Biceps C5, C6 Brachioradialis / Supinator C6, C7 Fingers C8, T1

Patella L4 By Marta Aguayo Achilles S1

Note: foot inversion good for L5 Babinski Sign Present in adult when #1 toes extends Hoffman Reflex Flick terminal phalanx: flexed thumb=hyper-reflexia 40

Upper Limb Reflexes

Triceps Jerk Supinator Jerk

Hoffman

Biceps Jerk Finger Jerk 41

Lower Limb Reflexes

Ankle Jerk

Knee Jerk

Babinski: big toe extends. Upper motor neuron lesion.

14 4/3/2020

Coordination

• Cerebellum-fine motor control – Proprioceptive system – Ipsilateral signs (motor cortex: contralateral)

• Finger -Nose • Heel-Shin

• Involuntary Movements – Tremor (rest, action, magnitude, frequency, distribution) – Dystonia, Chorea • Speed

Gait

• Stance • 25 foot walk – Ataxia, spasticity, hemi-weakness, foot-drop, festinating, stooped posture, steppage, myopathic-waddling, frontal lobe-wide apart, hysterical-bizarre, spastic-robotic • Heel to Toe (tandem walking) – Coordination, done when gait is normal-exacerbates abnormality • On Heel, On Toe – Test L4-S1 • Squat – Proximal muscles • Hop – Power, coordination, some scoring and clinical trials

• Romberg Sign verses Retropulsion (as see in Parkinson’s Disease) – Stand straight, hands to side, 4-6 inches apart, close eyes – Tests proprioception / Dorsal Columns – Now Test Retropulsion: Pull shoulders back and observe ability to maintain balance.

Sensation

• Levels and Modalities of Dysfunction • Brain to Periphery • Somatic Loss vs. Neglect • With or Without Motor Loss, Pain, CNs • Time (fast loss = serious/intervention required) • Geography: Dermatomes • Slower Fibers – Pain, Temp • Spinothalamic • Faster Fibers – Two Point Discrimination, Proprioception, Vibration, Fine-Touch • Dorsal column-Medial Lemniscus System

Sensory Inattention (competing sensations) Stereognosis (recognize objects in hand) Graphaesthesia (recognize numbers, letters drawn on hand) Paresthesia (tingling, numbness) Dysasthesia (painful abnormal sense of touch, burning)

15 4/3/2020

By Polarlys and Mikael Häggström -

Sensory Exam Upper Limb (not complete)

16 4/3/2020

Sensory Exam Lower Limb (not complete)

Perineum

• Sacral Lesions – Sphincter tone – Sacral dermatomes – Anal reflex – Extended bladder

Frontal Release Signs

• Pout Reflex • Glabellar Reflex • Grasp Reflex • Palmomental Reflex

17 4/3/2020

Special • Meningitis – Kernig’s Sign • Extend knee and flex hip – Brudzinski's sign • Flex neck • Obtunded patient/coma/ICU – Painful stimuli – Cold Caloric Test (eyes turn to cold) – Doll’s Eye – Blink – Tone – Posturing

Inconsistencies

• Non-organic exam – Functional exam – Malingering – Conversion Disorder – Pseudo-Seizures – Repeat portions of exam for consistency • Give-way weakness • Astasia-abasia (hysteric gait, bizarre) • Sensory midline • Optokinetic nystagmus

General Exam

• Skin-signs • Heart-stroke • Vessels-bruits • Breathing: coma • Behavior (psychological)