The Basic Neurological Exam Part I Physical Exam

The Basic Neurological Exam (Part I) Physical Exam Curriculum

Outline Lecture ➢ Review a brief version of the complete neurological exam ➢ Highlight the highest yield components of the neurological exam – Focus on primary care ➢ Discuss how to focus a neurological exam based upon symptoms Practice! ➢ Ophthalmoscopic exam ➢ Any component of the neuro exam

The Well-Visit Neurology Exam Cognition Motor ∙ ∙ ∙ Wakefulness and alertness Orientation Basic language and speech function o Repeating phrases o Naming objects o Following commands (ascertained through rest of exam) Pronator drift Finger tapping Coordination ∙ ∙ Finger to nose Heel to shin Sensory Cranial nerves ∙ ∙ ∙ ∙ Gait Pupillary exam Eye movements Facial strength Palatal elevation Shoulder shrug Tongue movements ∙ ∙ ∙ Romberg testing Normal walk and turn Stand on heels, Stand on toes Tandem gait

The Well-Visit Neurology Exam Cognition ∙ ∙ ∙ Motor Wakefulness and alertness ∙ Pronator drift Orientation ∙ Finger tapping Basic language and speech function Coordination • This is not a “rule out neurology” exam o Repeating phrases Finger with to nose o Naming • objects Please never just do this exam for ∙anyone ∙ Heel to shin o Following commands (ascertained through neurologic complaints rest of exam) Sensory DISCLAIMER • Please never just do this exam while rotating on Cranial nerves neurology ∙ Romberg testing • You still have to use your brain to figure out the ∙ Pupillary exam Gait ∙ Eye movementsnecessary parts of the exam ∙ Normal walk and turn ∙ Facial strength • When in doubt, test more and/or refer to neuro ∙ Stand on heels, Stand on toes ∙ ∙ ∙ Palatal elevation Shoulder shrug Tongue movements ∙ Tandem gait

The Complete Neurological Exam ❑ Cognition ❑ Cranial Nerves ❑ Motor Function ❑ Deep Tendon Reflexes ❑ Sensation ❑ Coordination (cerebellar) ❑ Gait

Mental Status and Cognition ➢ ➢ Complete exam includes discussion of: – Level of consciousness – memory – Alertness – visuospatial processing – Language – executive functioning – Speech – perceptual disturbances – Attention – thought form/content MMSE: orientation, attention, concentration, memory, language, construction abilities – Sn 71 -92%, Sp 56 -96% – not as good in MCI ➢ MOCA: useful for detecting mild cognitive impairment (MCI) – Sn 90%, Sp 87% Simmons, et al. Evaluation of Suspected Dementia Am Fam Physician. 2011 Oct 15; 84(8): 895 -902.

Mental Status and Cognition Screening tests for Dementia ➢ Clock Draw (organization/planning) Sn 76%, Sp 81% ➢ Verbal Fluency (animal naming) (<15), Sn 88%, Sp 96% ➢ Mini-Cognitive Assessment Instrument (Mini-Cog), Sn 76%, Sp 89% – Three item recall plus clock draw – 0 -2: high likelihood of dementia, 3 -5: low likelihood of dementia Simmons, et al. Evaluation of Suspected Dementia Am Fam Physician. 2011 Oct 15; 84(8): 895 -902.

The Complete Neurological Exam ❑ Cognition ❑ Cranial Nerves ❑ Motor Function ❑ Deep Tendon Reflexes ❑ Sensation ❑ Coordination (cerebellar) ❑ Gait

Cranial Nerves

Cranial Nerves: How do I test? ➢ Olfactory: smelling salts ➢ Optic: fundoscopic exam, visual fields, visual acuity, pupillary light reflex ➢ Oculomotor/Trochlear/Abducens: extraocular movements ➢ Trigeminal: sensation across three planes of face (V 1, V 2, V 3), forced bite ➢ Facial: close eyes tightly, smile, grimace, puff out cheeks ➢ Vestibulocochlear: finger rub, tuning fork tests (Rinne, Weber) ➢ Glossopharyngeal/Vagus: gag reflex, “ahhh” ➢ Spinal Accessory: shrug shoulders, turn head ➢ Hypoglossal: tongue movement from side to side

More Details on Extraocular Movement Testing ▶ Strength of eye movements – testing patients for fullness of eye movements to assess for gaze paresis e. g. abducens nerve palsy, internuclear ophthalmoplegia ▶ Examining quality of eye movements – Fast saccades – Smooth pursuits ▶ Examining for nystagmus – First test at primary gaze i. e. have the patient stare straight at your finger and observe eye movements. The eyes should not move. – Look for nystagmus during and at the end of eye movements – Physiologic nystagmus – 3 -4 beats of lateral beating nystagmus at end gaze (e. g. look all the way to the right) that extinguishes – Any other nystagmus is potentially abnormal! – Vertical nystagmus is very, very bad and can indicate posterior fossa disease

The Complete Neurological Exam ❑ Cognition ❑ Cranial Nerves ❑ Motor Function ❑ Deep Tendon Reflexes ❑ Sensation ❑ Coordination (cerebellar) ❑ Gait

Motor Exam ➢ Muscle Bulk: inspection – LMN: muscle wasting or atrophy ➢ Muscle Tone: resistance to passive movement – Increased tone: “rachety” (cogwheel-->Parkinson’s), “clasp knife” (spasticity->UMN), “lead pipe” (basal ganglia) – Decreased tone: indicative of lower motor neuron disease ➢ Muscle Strength: graded on scale – 0=no movement, 1= flicker, 2=horizontal plane, 3= against gravity, 4= against some resistance, 5=normal – Pronator Drift: helps elucidate subtle arm weakness (weaker arm “drifts”) ➢ Dexterity: finger taps, open/close hand, toe taps – slowed movement suggests pyramidal/extrapyramidal issues ➢ Note any abnormal movements – chorea, tremor

The Complete Neurological Exam ❑ Cognition ❑ Cranial Nerves ❑ Motor Function ❑ Deep Tendon Reflexes ❑ Sensation ❑ Coordination (cerebellar) ❑ Gait

Deep Tendon Reflexes ➢ Reflexes: – Achilles: S 1, S 2 – Patellar: (L 2), L 3, L 4 – Biceps: C 5, C 6 – Triceps: (C 6), C 7, C 8 ➢ Grading: – Absent (0), Reduced (1+), Normal (2+), Brisk (3+), Clonus (4+) – Hyperactive reflexes: UMN – Brisk reflexes can be normal in young healthy people – Reduced reflexes: LMN • ➢ May be present in radiculopathies and mononeuropathies Babinski/Plantar Response: – Normal: flexion of great toe with curling of toes – Present: great toe extends and toes fan out <--UMN lesion

The Complete Neurological Exam ❑ Cognition ❑ Cranial Nerves ❑ Motor Function ❑ Deep Tendon Reflexes ❑ Sensation ❑ Coordination (cerebellar) ❑ Gait

Sensation ➢ Dermatomes: ➢ Neuropathies: – small-fiber = pain/temp • DM – large-fiber = vibration/proprioception • ➢ B 12 Modalities: – light touch – pain and temperature – vibratory – Proprioception (includes Romberg Test)

Sensation ➢ Romberg Testing: • Patient stands with eyes closed • ➢ Positive test: imbalance Where to test • If unclear localization, test hands and feet • If spinal cord localization is suspected, test for sensory level • If spinal cord or nerve root is suspected, test for specific dermatomes

The Complete Neurological Exam ❑ Cognition ❑ Cranial Nerves ❑ Motor Function ❑ Deep Tendon Reflexes ❑ Sensation ❑ Coordination (cerebellar) ❑ Gait

Coordination ➢ Involve multiple integrated systems: sensory, vestibular, pyramidal, extrapyramidal, basal ganglia, cerebellum ➢ Cerebellum combines proprioception with information from muscles to allow smooth limb/trunk movements – ➢ ➢ Abnormalities results in ataxia (midline lesions cause truncal ataxia) Testing for appendicular ataxia: – finger to nose – heel to shin – rapid alternating movements (rhythmic) Testing for truncal ataxia: – stance – gait

Gait ➢ Assessment: – Speed – Stride Length – Turning – Associated Movements ➢ Assess for symmetry ➢ Testing: walk and turn, stand on heels/toes, tandem ➢ Types of abnormal gaits: – Ataxic (cerebellar): wide-based, “drunk” – Gait spasticity (UMN): stiffness – Hemiparetic gait: favoring one side – Parkinsonian: decreased arm swing, shuffling

The Complete Neurological Exam ❑ Cognition ❑ Cranial Nerves ❑ Motor Function ❑ Deep Tendon Reflexes ❑ Sensation ❑ Coordination (cerebellar) ❑ Gait

The Well-Visit Neurology Exam Cognition Motor ∙ ∙ ∙ Wakefulness and alertness Orientation Basic language and speech function o Repeating phrases o Naming objects o Following commands (ascertained through rest of exam) Pronator drift Finger tapping Coordination ∙ ∙ Finger to nose Heel to shin Sensory Cranial nerves ∙ ∙ ∙ ∙ Gait Pupillary exam Eye movements Facial strength Palatal elevation Shoulder shrug Tongue movements ∙ ∙ ∙ Romberg testing Normal walk and turn Stand on heels, Stand on toes Tandem gait