NEUROLOGICAL EXAMINATION:

 ASSESSMENT of PERIPHERAL FUNCTION  ASSESSMENT of MOTOR FUNCTION: Sometimes pluses and minuses can be used for even finer grading. This is important in stroke and peripheral nerve or root lesions.  o 0: No contraction; paralysis o 1: Trace of contraction. o 2: Moves if gravity is eliminated. o 3: Moves against gravity. o 4: Moves against gravity and against some resistance. o 5: Normal strength.  Motor Abnormalities:  o Hysteria: To test whether weakness in the leg is from hysteria or is organic, put a hand on both limbs and have the patient lift one limb against the hand's resistance. o . If the cause of motor weakness is organic, then examiner should feel the other leg move the opposite direction in compensation. . If it is hysteria, then the other leg remains still. o Fasciculations: Twitchings in resting muscles. May be normal if they are occasional or precipitated by cold. They may be a sign of Amyotrophic Lateral Sclerosis (ALS) if they are accompanied by weakness. o Tics: Normal movements of muscle groups (such as winking or grinning) occurring involuntarily, as in Tourette's Syndrome. o Tetany: Involuntary muscle spasms. o . Causes: Tetanus, hypocalcaemia, hypomagnesaemia, hyperventilation syndrome. . Chvostek's Sign: Tap over facial nerve anterior to ear, and look for contraction of the facial muscles, especially shutting of eyes. . Trousseau's Phenomenon: Inflate a blood-pressure cuff to systolic pressure and maintain for 1-2 minutes. Induction of carpal-pedal spasm indicates latent tetany. o Tremors: Oscillating movements caused by involuntary contractions of muscle groups.  SENSORY EVALUATION  o Peripheral Neuropathies tend to occur in hand-and-glove distribution -- at the distal ends of the extremities. o PAIN: Upon pinprick, patient may experience hypalgesia (reduced pain), hyperalgesia, or analgesia (no pain). o LIGHT TOUCH: o . Hypaesthesia = Impaired light touch sensation. Also related to light-touch are hyperaesthesia, paraesthesia, and anaesthesia (no light touch). o Sensory Extinction or Sensory Inattention: In parietal lobe lesions, if you put a pinprick on both sides of the body of a patient simultaneously, the patient will not perceive the prick on the affected side of the lesion. If the pins are placed sequentially, then the patient still retains normal sensation on both sides.  STEREOGNOSIS: Being able to identify objects with your eyes closed.  CEREBELLAR FUNCTION:  o Dysergia: Improper co-ordinated function of a muscle group. o Dysmetria: Inability to properly gauge the distance between two points. Tested with finger-to-nose movements. o Dysdiadochokinesia: Inability to do rapid alternating movements. o Scanning Speech: Prolonged separation of syllables, often seen with cerebellar dysfunction. o GAIT Disturbances: o . Cerebellar Lesions: Central cerebellar lesion shows unsteady gait, but conventional cerebellar signs may be normal. . Posterior Columns Lesions: Loss of proprioception results in unsteady gait when eyes are closed, but relatively normal gait when eyes are open. . Festinating Gait: Parkinsonian gait, shuffling walk. o Romberg's Test: Patient can't maintain balance with legs tight together, with eyes closed. o Titubation: Body tremor when standing or walking, sign of cerebellar disease.  REFLEXES:  Deep Tendon Reflexes:  o Upper Extremity: o . Biceps Reflex: Elbow flexion. . Triceps Reflex: Forearm extension. . Brachioradialis Reflex: Tap distal radius ------> flexion and partial supination of the forearm. o Lower Extremity: o . Patellar Reflex: Contraction of Quadriceps (strongest muscles in body) and extension of leg. . Suprapatellar Reflex: Above the knee; same response. . Achilles Reflex: Causes plantar-flexion of foot.  Reflex grading:  o 0: Complete absence o 1: Diminished o 2: Normal Reflex o 3: Hyperactive reflex o 4: Clonus present (remember to test for this).  Superficial Reflexes:  o Upper Abdominal: Ipsilateral contraction of abdominal muscles on the stroked side. o Lower Abdominal: Ipsilateral contraction of abdominal muscles on the stroked side. o Cremasteric: Stroke inner thigh ------> elevation of testes.  Brainstem Reflexes:  o Corneal Reflex o Pupillary Light Reflex o Gag Reflex  Abnormal Reflexes:  o Babinski Sign: Stroke bottom of the foot ------> fanning (eversion) of big toe. o Chaddock's Reflex: When the external malleolar skin area is irritated, extension of the great toe occurs in cases of organic disease of the corticospinal reflex paths. o Oppenheim's Sign: Scratch inner side of leg ------> extension of toes. Sign of cerebral irritation. o Gordon's Sign: Squeeze the calf muscles and note the response of the great toe. Fanning or extension is considered abnormal. o Hoffman's Sign: Flexion of the terminal phalanx of the thumb and of the second and third phalanges of one or more of the fingers when the volar surface of the terminal phalanx of the fingers is flicked. o . It is significant for pyramidal tract disease when it is unilateral. If it is bilateral than the meaning is uncertain.  Absence of Superficial Reflexes: Unilateral suppression of superficial reflexes often results from upper motor lesions subsequent to a CVA.  Primitive Reflexes: Presence of primitive reflexes is often a sign of frontal lobe lesions.  o Suck Reflex: Gently tap or rub the upper lift ------> elicit a reflexive sucking or puckering response. o Grasp Reflex: Stroke the patient's palm, causing him to grasp your fingers. A positive test occurs when the patient does not let go of your fingers. o Palmomental Sign: Rub the thenar eminence ------> elicit reflexive contraction of the muscles of the chin.  CRANIAL NERVE EVALUATION:  CN I: OLFACTORY  o TEST: Have patient identify objects by smell. o ABNORMAL: o . Head trauma with fracture of cribriform plate . Neoplasm in anterior fossa: meningioma  CN II: OPTIC  o TEST: Visual acuity, fundoscopic exam o ABNORMAL: Lots of causes of blindness  CN III: OCULOMOTOR  o TEST: o . Have patient move eyes through all fields of vision. Intact 3rd nerve means that eyes can move medially, superiorly, and inferiorly. . Pupillary Reflex: Check for pupillary response to light in same eye and contralateral eye. . Ptosis: Ptosis may occur due to 3rd nerve palsy. o ABNORMAL: o . Unilateral CN-III Palsy: Subarachnoid haemorrhage resulting from aneurysm, diabetes, atherosclerosis. . Horner's Syndrome: Usually occurs from bronchogenic carcinoma (Pancoast Tumour) impinging on the Superior Cervical Ganglion.  CN IV: TROCHLEAR  o TEST: o ABNORMAL:  CN V: TRIGEMINAL  o TEST: o . Sensory: Check corneal reflex. Test facial sensation with eyes closed. . Motor: Have patient clench teeth and palpate masseter muscle. o ABNORMAL: o . Lost Corneal Reflex: Tumour of the cerebellopontine angle. . Tic Douloureux: Irritative lesions of the CN V sensory roots. . Spasm of muscles of mastication: tetanus, adverse reaction to Phenothiazines.  CN VI: ABDUCENS  o TEST: Look laterally. o ABNORMAL: o . Diabetes, atherosclerosis, increased ICP, neoplasm.  CN VII: FACIAL  o TEST: Have patient smile, blink, frown, wrinkle forehead. o ABNORMAL: Bell's Palsy o . Central Lesion of VII: The supratrochlear muscles are spared, as they receive bilateral innervation from both facial nerves. Below the eyes, the contralateral side will be paralysed. . Peripheral Lesion of VII: There is an entire facial hemiplegia, with the paralysis occurring on the contralateral side.  CN VIII: VESTIBULOCOCHLEAR  o TEST: Standard hearing and vestibular tests. o ABNORMAL: A variety of disorders  CN IX: GLOSSOPHARYNGEAL  o TEST: Have patient open mouth and say "Aaahhh." o ABNORMAL: See Vagus N. below.  CN X: VAGUS  o TEST: Have patient open mouth and say "Aaahhh." o ABNORMAL: o . Aortic Aneurysm, Bronchogenic Carcinoma may damage the recurrent laryngeal nerve. . Uvula will deviate toward the damaged side.  CN XI: SPINAL ACCESSORY  o TEST: Have patient shrug shoulders. o ABNORMAL: Polymyositis  CN XII: HYPOGLOSSAL  o TEST: Have patient stick out tongue. o ABNORMAL:  MENTAL STATUS EXAM:  STATE of CONSCIOUSNESS: The Glasgow Coma Scale  ORIENTATION  ABILITY to COOPERATE  MOOD  THOUGHT PROCESS  MEMORY for RECENT and REMOTE EVENTS  ABILITY to HANDLE CONCEPTS and PROVERBS  PRACTICAL SKILLS  SPEECH PROBLEMS and RECOGNITION of APHASIA  Abbreviated Mental Test Score and MSQ - tests for memory  PATIENTS with ABNORMAL NEUROLOGICAL STATUS:  APPROACH to the STROKE PATIENT:  APPROACH to the COMATOSE PATIENT:  APPROACH to the DELIRIOUS PATIENT:  APPROACH to the PATIENT with PERIPHERAL NEUROPATHY:  APPROACH to the PATIENT with SIGNS of MENINGEAL IRRITATION:

Glasgow Coma Scale

 Overview:  The Glasgow coma scale is used to assess patients in coma. The initial score correlates with the severity of brain injury and prognosis.  Glasgow coma scale =  = (score for eye opening) + (score for best verbal response) + (score for best motor response) 

Eye Opening Score spontaneously 4 to verbal stimuli 3 to pain 2 never 1

 

Best Verbal Response Score oriented and converses 5 disoriented and converses 4 inappropriate words 3 incomprehensible sounds 2 no response 1

 

Best Motor Response Score obeys commands 6 localises pain 5 flexion withdrawal 4 abnormal flexion (decorticate rigidity) 3 extension (decerebrate rigidity) 2 no response 1  Interpretation:  • maximum score is 15 which has the best prognosis  • minimum score is 3 which has the worst prognosis  • scores of 8 or above have a good chance for recovery  o • scores of 3-5 are potentially fatal, especially if accompanied by fixed pupils or absent oculovestibular responses

  • young children may be nonverbal, requiring a modification of the coma scale for evaluation. Abbreviated Mental Test

Overview:

The Abbreviated Mental Test can be used to quickly test the cognitive function in elderly patients. This is also referred to as the Hodkinson's Mental Test Score.

Item Score age 1 time to the nearest hour 1 year 1 name of place 1 recognition of 2 persons 1 birthday (date and month) 1 date of World War I 1 name of your country's Ruler, President or 1 Prime Minister able to count from 20 to 1 backwards 1 address - 42 West Street 1

Interpretation

• minimum score: 0

• maximum score: 10 • a higher score indicates greater cognitive function

• a score of 6 is used as the cut-off to separate normal elderly persons from those who are confused or demented with a correct assignment of 81.5%

References:

  Jitapunkul S, Pillay I, Ebrahim S. The Abbreviated Mental Test: Its use and validity. Age Aging. 1991; 20: 332-336.

Kalra L, Crome P. The role of prognostic scores in targeting stroke rehabilitation in elderly patients. J Am Geriatr Soc. 1993; 41: 396-400.

Qureshi KN, Hodkinson HM. Evaluation of a ten-question mental test in the institutionalised elderly. Age Ageing. 1974; 3: 152-157.

Vardon VM, Blessed G. Confusion ratings and abbreviated mental test performance: A comparison. Age Ageing. 1986; 15: 139-144.

Mental Status Questionnaire

Overview:

The Mental Status Questionnaire can also be used to quickly test the cognitive function in elderly patients. This has similar roots to the Abbreviated Mental Test Score, but was developed in Scotland.

Item Score Today's DATE 1 Today's MONTH 1 Today's YEAR 1 This TOWN 1 Present SITUATION 1 AGE 1 MONTH of BIRTH 1 YEAR of BIRTH 1 PRIME MINISTER 1 PREVIOUS PRIME MINISTER 1

Interpretation

• minimum score: 0 • maximum score: 10

• a higher score indicates greater cognitive function

• a score of 7 is used as the cut-off to separate normal elderly persons from those who are confused or

Nervous: Examination

1. Consciousness 2. Environment, general appearance 3. Handedness, speech 4. Head, neck, neck stiffness 5. Cranial nerves 6. Upper limbs: inspect, tone, power, reflexes, coord, sensory 7. Lower limbs: inspect, tone, power, reflexes, coord, gait, sensory 8. Systems: spine, carotid bruit, aspiration

Consciousness

 If unconscious, See Unconscious Examination.

Environment

 Bed: one siderail raised (hemiplegia).  Bed: pt.'s bad eye side placed against wall so they can't be surprised (stroke).  Bed: soft mattress to avoid pressure sores (mobility difficulty).  Bed: V-shaped posture pillows since pt. unable to support self.  Tables: all meds, etc. within reach of non-siderailed arm (hemiplegia).  Room: hoist, wheelchair, walker (paralysis).  Room: NG tube (palsy of throat CN's).  Room: ventilator, life support machines.

General appearance

 Age of pt. (Parkinson's usu. 45+, etc).  Chorea (Huntington's, rheumatic fever, drugs, etc).  Ethnicity (scandinavian: multiple sclerosis).  Ballisma, dystonia (usu. drugs), noticeable tremor.  Posture: leaning to one side (hemiplegia).  Posture: stooped forward (Parkinson's).  Only using one hand on tray (hemiplegia).

Handedness, speech  Ask to shake hand, ask if R or L-handed.  Ask name, present location, how long in hospital. See Mental Status Reference.  If detect abnormality while pt. talks, See Speech Disorders Reference.

Head

 Asymmetry, unilateral facial drooping (stroke).  Ptosis.  Serpentine stare (Parkinson's).  Licking of lips.  Scars of previous operations.  Trauma, injury, abnormalities.  Mental retardation syndrome facies: Down's, FAS, etc.  Eyes: exophthalamos (thyroxicosis), Kayser-Fleisher rings (Wilson's).

Neck, neck stiffness

 Neck: thymectomy scar (MG).  Neck: thyroidectomy scar (thyrotoxicosis).  Beware of performing manipulation on a cervical spine injury pt.  Hand under occiput, flex neck to chin and see if resistance. • Resistance causes: raised ICP, cervical fusion or spondylosis, Parkinson's meningitis.  If suspect meningitis (fever, photophobia) do Kernig's sign.

Cranial nerves

 See Cranial Nerves Examination.

Upper limbs

The upper/lower limb exams checklist is a SCRIPT:

 Sensation  Coordination  Inspection  Power  Tone

But just reassemble them back into a logical order: inspection always goes first; sensation goes last since takes so long.

Upper limbs: inspect

 Pt sits over side of bed facing Dr.  For rest of examination, comparing L side to R side.  Asymmetry.  Deformities: wrist drop, waiter's tip, claw hand.  Muscle wasting, fasciculations. Include shoulder girdle.  Tremor: • Intention (cerebellar). • Resting with pill-rolling (Parkinson's). • Action tremor (BAT: Benign essential tremor syndrome, Anxiety, Thyrotoxicosis).  Feel hand for heat (thryrotoxicosis), grip.  Pronator drift: pt's eyes closed, arms extended, with palms up. Tap pt's arms briskly downward (arm drifting into pronation: UMNL, cerebellar, post. column loss).  Pseudoathetosis from proprioceptive loss.  Muscle bulk, tenderness.

Upper limbs: tone

 Ask pt. if any tenderness in any joints, so won't hurt them when manipulating them for tone.  Grasp under elbow and wrist, and rotate the 2 joints to assess resistance. • If Parkinson's, cogwheel rigidity in wrist [combination of tremor and increased tone]. • If Parkinson's, lead pipe resistance when flexing forearm.  If ulnar nerve indicated, Froment's sign [who is this Paper From?]: • Give pt a piece of paper for each hand. • Ask pt to grasp papers by moving straightened thumb to radial side of index finger. • Affected thumb is forced to flex at interphalangeal joint to grip paper.  If median nerve indicated, pen touching test: • Pt's hand supine. • Dr. hold's pen above thumb • Ask pt. to lift thumb to touch it. • Affected thumb can't touch pen.

Upper limbs: power

 Assess shoulder, elbow, wrist, fingers. • Assess by ability to push against Dr's hand. • Assess across a single joint at a time [eg: Dr's hand on bicep, not forearm, to assess shoulder power].  If MG suspected: • Pt. holds arms above head. • MG pt. will lose power after contractions.  See Power Scale Reference.

Upper limbs: reflexes

 Supinator/Brachioradialis (C5-6).  Biceps (C5-6).  Triceps (C7-8).  Fingers (C7-T1).  See Deep Tendon Reflexes Reference.

Upper limbs: coordination

 Pt. finger touches Dr's fingers, then to pt's nose testing for dysdiadochokinesia, rebound.  Dysdiadochokinesia: • Pt's palm on dorsum of their opposite hand. • Pt flips their hand quickly so the two hand dorsums touch. • Repeat quickly.

Upper limbs: sensory

 Dorsal columns (vibration): • Place on sternum [the last area lost] so pt. knows how the buzzing feels. • Pt's eyes shut and 128 Hz fork on distal interphalangeal joint: ask if felt. • If can feel, ask pt. to say when it stops, then later stop it. • If deficient: assess dermatomes at wrist, elbow, shoulder, both anterior and posterior. • See Dermatomes Reference.  Dorsal columns (proprioception): o Grasp pt's distal phalynx, move up and down to show what to do. o Tell pt to close eyes. o Repeat the moving up or down, then leave it either up or down. o Ask pt is whether it's up or down.  Spinothalamic (pain, forget temperature): • Sterile toolpick or broken wood tongue depressor on forehead or anterior chest. • Pt. closes eyes, tells if sharp or dull. • Stick each dermatome looking for cord, dermatome, peripheral nerve, stocking glove.  Light touch: cotton wool. Dab skin lightly, don't stroke.  If lesion, feel for thickened nerves: • Ulnar at elbow • Median at wrist • Radial at wrist • Axilla.

Lower limbs: inspect

 Asymmetry.  Muscle wasting, fasciculations, tremor.  Muscle bulk: quads, anterior tibials.  Foot bruising, infections from peripheral neuropathy.

Lower limbs: tone

 Orthopods may roll legs for a quick preliminary inspection of tone.  Tone of knees, ankles.  Test knee clonus by pushing lower end of quads sharply down towards knee (sustained contractions: UMNL).

Lower limbs: power

 Power: hips, knees, ankles. "Lift leg, don't let me push it down". "Push leg down, don't let me push it up".  See Power Scale Reference.

Lower limbs: reflexes

 Knee (L3-4).  Ankles (S1-2).  Plantar (L5, S1-2).  Ankle clonus test: • Place pt's knee bent, thigh externally rotated. • Dr lifts pt's heel in Dr's cupped hand. • Dr quickly dorsiflexes pt's ankle and holds it flexed for 3 seconds. • Clonus if sustained movement afterwards.  See Deep Tendon Reflexes Reference.

Lower limbs: coordination

 Heel-shin test: • Pt kicks a heel out, then touches that heel to other shin. • Repeat in a smooth motion loop. • Alternatively: heel sliding up and down on opposite shin.  Toe-touching test.  Tapping of feet.

Lower limbs: gait

 Walk few feet then walk back.  Notice signature gaits: • Trendelenberg gait (proximal myopathy). • Shuffling gait (Parkinson's). • High-stepping gait (foot drop). • Hemiplegic gait [swinging one leg in lateral arc] (usu. stroke).  Walk heel to toe (hard: midline cerebellar).  Walk on heels (hard: L4-5 footdrop).  Squat or sit then stand up (proximal myotrophy).  Romberg sign positive if unsteadiness is worse when eyes closed.

Lower limbs: sensory

 Sensory pin prick, vibration, proprioception, light touch. Same as was for Upper Limbs.  If peripheral sensory loss, try to establish sensory level. See Dermatomes Reference.  Examine sensation in saddle region.  Test anal reflex (S2-4).

Spine

 Back: deformity, scars, neurofibromas.  Palpate for tenderness over vertebral bodies.  Straight leg raising test: • Pt tries to lift straight leg. • Full lifting will be prevented if slipped disc.  For more, See Rheumatoid Examination.

Carotid bruit

 Auscultate for bruits (atherosclerotic dz).  See Carotid Examination for details.

Aspiration

 Paralyzed pt may have aspirated fluid. See Pulmonary Examination.  Feeding assistance devices, such as PEG (dysphagia, usu. 2º to neurological damage, like stroke).