Neurologic Exam for the Practitioner Reason for a Neurological Exam ´ Physiology of the Nervous System ´ Disruption in physiology – localizes issue ´ Correlation with history ´ Correlation with imaging Components of the Exam ´ Mental Status ´ Orientation to person, place, time, situation ´ Speech and Language ´ Verbal and written output ´ Ability to follow verbal and written commands ´ Memory 3 objects after 5 minutes Components of the Exam ´ Mental Status – expanded ´ Concentration: spell WORLD backwards ´ Attention: mental arithmetic ´ Executive skills: Clock drawing ´ Mental status batteries MMSE, MoCA Components of the Exam ´ Cranial Nerves ´ 1 – test of smell head injuries ´ 2 – test of vision visual acuity best ´ 3,4,6 – tested as a group ´ Pupillary reflex ´ Eye movements Components of the exam Components of the exam Components of the exam Components of the Exam ´ Cranial nerves ´ 5 – test of facial sensation: pin prick, light touch, corneal reflex ´ 7 – test of facial motor function, (taste)(hearing) ´ 8 – test of auditory acuity and vestibular function ´ 9,10 – gag and soft palate movement, (taste) ´ 11 – sternomastoid muscle bulk ´ 12 – tongue function Components of the exam Components of the exam Components of the Exam ´ Motor examination ´ Strength testing in upper and lower limb ´ Posture holding in arms ´ Power testing in muscle groups ´ Evaluation of muscle tone and bulk ´ Size and feel of muscle ´ Resistance to movement – spasticity, rigidity Components of the Exam Components of the Exam Components of the Exam ´ Motor Examination ´ Coordination testing ´ Finger to nose, heel to shin ´ Rapid alternating movements, eg patting ´ Observation for involuntary movements ´ Tics, tremors, myoclonus, choreoathetoid Components of the Exam Components of the Exam Components of the Exam Components of the Exam ´ Sensation ´ Pin prick, vibratory sense ´ Temperature, position sense ´ Light touch, two point discrimination ´ Tactile localization ´ Graphesthesia Components of the Exam Components of the Exam Components of the Exam Components of the Exam ´ Walking and Balance ´ Walking ´ Arm swing, leg posture, foot posture ´ Truncal posture, head turn ´ Balance ´ Balance when starting; when turning ´ Tandem walk forward and backward ´ Romberg examination- eyes open/closed stationary eyes open/closed marching Components of the Exam Components of the Exam Components of the Exam ´ Reflexes ´ Deep tendon ´ Upper: Brachioradialis, biceps, triceps ´ Lower: Knee, ankle ´ Superficial ´ “Babinski” aka superficial plantar reflex ´ Grasp reflex, glabellar tap reflex ´ Abdominal reflex Components of the Exam Components of the Exam Vertigo ´ Physiology of the vestibular system ´ Semicircular canals – angular acceleration ´ Utricle – movements with/against gravity ´ Saccule – linear acceleration ´ 8th cranial nerve – auditory and vestibular ´ Vestibular nuclei – central projections: eyes, cerebellum ´ Vertigo: presenting manifestation ´ An illusion of movement Vestibular system Vertigo ´ History of vestibular disorders ´ “Dizziness” – what does this mean ´ Vertigo – what circumstances? rest, movement with standing, laying, rolling over ´ Nausea and vomiting ´ Hearing loss, tinnitus ´ Vision? diplopia, oscillopsia ´ Dysequilibrium ´ What drugs have you been taking? Vertigo ´ Examination in vertigo ´ Hearing ´ Eye movements – looking for nystagmus ´ At rest –spontaneous nystagmus ´ With eye movement ´ With head movement – Dix Hallpike test - head shaking test Vertigo ´ Examination in vertigo ´ Coordination ´ Limb ataxia, past pointing ´ Gait and balance testing ´ Standard gait ´ Observe with turning – catch on rapid turn ´ Romberg examination; sharpened Romberg ´ Fukuda stepping test Vertigo Vertigo Vertigo Acknowledgements Neurological Exam Website: http:// library.med.utah.edu/neurologicexam Movies drawn from the Neurologic Exam website are used by permission of Paul D. Larsen, MD, University of Nebraska Medical Center and Suzanne S. Stensaas, PhD, University of Utah School of Medicine. Additional materials for Neurologic Exam are drawn from resources provided by Alejandro Stern, Stern Foundation, Buenos Aires, Argentina; Kathleen Digre, MD, University of Utah; and Daniel Jacobson, MD, Marshfield Clinic, Wisconsin. Subsequent re-use of any materials outside of this program, presentation, or website requires permission from the original producers. .