The Neuro Exam
for Non-Neurologists
A handy guide
Date: 20 September 2013
Author: Dr Paul Masiowski
The Neuro Exam for Non-Neurologists
A handy guide
Objectives
The neurological examination
This handy guide will help you review and develop your neuro exam skills!
We will:
•Review the full neuro exam in overview
•Study the “Saskatoon Screening Exam”
(a 5 minute neuro exam sufficient to make most diagnoses)
•Study a faster screening exam
(a 2 minute neuro exam sensitive enough to rule out serious pathology in most
patients)
•Discuss tips and tricks for improving the sensitivity and reliability of the exam
•Consider how and when to expand the screening exam screening for:
•dementia, headache, parkinsonism, tremor, myasthenia, myelopathy, neuropathy, etc.
All that in 40 minutes (give or take)!
The Neuro Exam for Non-Neurologists
A handy guide
Biography and disclosures
•Queen’s Medicine, 2005
•USask Neurology residency, 2005-10
•FRCPC (Neurology) 2010
•Community practice at Lakeview Neurology
Associates
•Clinical Assistant Professor at USask
•SMA Section Rep
•Received honoraria from Allergan
•Interests: Migraine, Neuropsychiatry, Movement
Disorders
The Neuro Exam for Non-Neurologists
A handy guide
The neurological examination is a diagnostic
test
One that tells you where the problem is
Like all tests, you need it to be reliable.
• Find important abnormalities
• Recognize when something unusual is actually
normal
You need to know what the implications are of normal or abnormal
results
The Neuro Exam for Non-Neurologists
A handy guide
Outline of the neurological examination
The overview
1.Mental Status
2.Cranial nerves
3.Motor
4.Reflexes
5.Sensory
6.Coordination & Gait
The Neuro Exam for Non-Neurologists
A handy guide
The Saskatoon Screening Exam
Reviewed with JURSIs weekly at RUH since 1994
A 5 minute examination of the following:
1.Mental Status
2.Cranial nerves
3.Motor
4.Reflexes
5.Sensory
6.Coordination & Gait
This is as much of the neuro exam as you need to know, most of the
time
The Neuro Exam for Non-Neurologists
A handy guide
Mental status exam
The Saskatoon Screening Exam
Assessed during history taking (overall
impression)
If the patient can give a good history...
(well organized and detailed
demonstrating normal attention and memory
with good language function)
...there’s little to be gained from any further
testing
The Neuro Exam for Non-Neurologists
A handy guide
Cranial nerve exam
The Saskatoon Screening Exam
•Visual fields by confrontation (II)
•Pupils (II & III)Eye movements (III, IV & VI)
•Facial strength (VII)Speech clarity (IX, X, XII)
The Neuro Exam for Non-Neurologists
A handy guide
Motor exam
The Saskatoon Screening Exam
•Pronator driftStrength in arms and legs
(proximal & distal):
•Deltoids
•Finger extensors
•Hip flexors
•Tibialis anterior
The Neuro Exam for Non-Neurologists
A handy guide
Reflexes exam
The Saskatoon Screening Exam
•Brachioradialis, biceps,
tricepsKnee jerk, ankle
jerkBabinski
The Neuro Exam for Non-Neurologists
A handy guide
Sensory exam
The Saskatoon Screening Exam
• Lateralizing sensory loss:
•pin on both sides, face/arm/leg
•vibration on both sides, in toes
... or ...
•Distal sensory loss:
•pin ascending from toes
vibration ascending from toes
The Neuro Exam for Non-Neurologists
A handy guide
Coordination exam
The Saskatoon Screening Exam
•Finger to nose task
•Heel to shin task
•Rapid alternating
movements
•finger tapping
•open/close hands
•foot tapping
The Neuro Exam for Non-Neurologists
A handy guide
Gait exam
The Saskatoon Screening Exam
•Normal gait
•Tandem gait (not in elderly)
•Romberg? (not in elderly)
The Neuro Exam for Non-Neurologists
A handy guide
The 2 minute screening exam
So easy, you can do it with any patient
1.Mental status: conversation / history (note speech)
2.Cranial nerves: visual fields, eye movements (look at pupils too),
grimace
2a. Fundi (if headache is a concern)
1.Strength: pronator drift, strength in 2 muscles in each limb
2.Reflexes: 2 per limb, Babinski
3.Sensation: skip it (!)
4.Coordination and gait: finger-nose, gait, tandem
The Neuro Exam for Non-Neurologists
A handy guide
Tips and Tricks to improve your exam skills
All opinions here are my own
Pitfalls to the neuro exam:
•Subtle findings
•Unexpected findings
•Chronic findings
•Normally abnormal findings
•Findings not due to neurological
disease
•Patient cooperation (sometimes)
Need to have reliable techniques, so
you can be confident in the results
The Neuro Exam for Non-Neurologists
A handy guide
Mental status exam
•Most
historians have normal mental status.
Tips good
and Tricks
•Attention tests should be simple
(weekdays or months, backwards) -- avoid math (serial
7s)
•Patients who can’t recall 3 words will think for a
moment or confabulate or distract; those who say
immediately
“I can’t remember” have a good prognosis
• A quick clock drawing can tell you whether or not to
worry
The Neuro Exam for Non-Neurologists
A handy guide
Cranial nerves testing
Tips and Tricks
Not frequently tested by neurologists:
•Smell
•Visual acuity
•Hearing
•Corneal reflex (except in coma)
•Gag reflex
•Strength in the neck
...unless the situation calls for it
The Neuro Exam for Non-Neurologists
A handy guide
Visual fields testing
Tips and Tricks
I use “static fingers”, testing by quadrant:
•Hold up 1 or 2 fingers in one quadrant
•Then on the opposite side
•Then test both sides at once (for visual extinction)
One eye or two?
•Both eyes at once is OK, except in headache patients
•Advantage of one-eye-at-a-time is catching pre-chiasmatic lesions (pituitary etc)
•Disadvantage is time
Wiggling fingers in from periphery is unreliable, test macular (central vision)
instead
I show fingers for only a second or two, which is all it takes.
The Neuro Exam for Non-Neurologists
A handy guide
Pupils testing
Tips and Tricks
Observe for symmetry in room light
If pupils equal, they’re normal
No need for flashlight!
Normal variants:
•Physiologic anisocoria: pupil asymmetry preserved across spectrum of light/dim
•Asymmetric pupil from trauma, surgery, etc
Subtle finding:
•Horner’s syndrome: miosis usually mild, goes with mild ptosis of upper and lower
lids.
Pupil asymmetry increases in the dark, so check in the dark
The Neuro Exam for Non-Neurologists
A handy guide
Eye movements testing
Tips and Tricks
“Follow my finger”...
...all the way to one side, then the other
...then up, down and right at them (convergence)
•No need for “H” or other shapes
•Observe alignment, don’t ask about diplopia during test
Normal variants:
•Strabismus, usually congenital (ask).
Test each eye separately, movements should be ~normal
•Gaze evoked nystagmus: few beats, symmetric at extremes of
horizontal gaze. Very common with age, fatigue, mediations (sedatives)
The Neuro Exam for Non-Neurologists
A handy guide
Facial strength testing
Tips and Tricks
Look for symmetry at rest and spontaneously
Grimace: show don’t tell what you want them to do
No need to test facial movements one by one
Normal variant:
•Some asymmetry of the face is normal (except in Hollywood)
Ask family if face is different than usual
Subtle finding:
•Symmetric facial weakness will be missed if you only check for
symmetry
Look for strength of eye closure (“squeeze them shut”) or lip closure
The Neuro Exam for Non-Neurologists
A handy guide
Speech testing
Tips and Tricks
Is speech clear?
Can almost always decide during conversation
If not, test:
•Palate elevation (midline?)
•Tongue protrusion (midline?)
The Neuro Exam for Non-Neurologists
A handy guide
Pronator drift testing
Tips and Tricks
Very sensitive test for mild weakness
Patient holds hands outstretched forward, palms up and fingers straight
Eyes closed, wait 10+ seconds to rule out drift
Subtle findings:
•Abnormal drift is sometimes down, sometimes turning over (pronating)
and sometimes up (“sensory” drift)
Normal variant:
•Some patients will wave their hands up and down repeatedly and may
sway back and forth, even when encouraged to hold still. (I scan them
anyway)
The Neuro Exam for Non-Neurologists
A handy guide
Strength testing
Tips and Tricks
Test muscles likely to be weak with mild deficits (screening test)
•Deltoids
•Finger extensors
•Hip flexors
•Ankle dorsiflexors
... are all weaker than their antagonists with an UMN lesion (“corticospinal tract”
distribution)
Normal variant:
•To detect variable effort (“giveway” weakness), make the patient move first, to a
target, then against resistance.
The Neuro Exam for Non-Neurologists
A handy guide
Sensory testing
Tips and Tricks
Test pin and vibration, not light touch, temperature or proprioception
•Pin: broken tongue depressor
•Vibration: 128 Hz tuning fork (not audible)
Ask:
•Does this feel sharp?
•Do you feel the buzz?
•Is it the same on the other side?
Slight variations from side to side are OK.
•Move from left to right (screening for central problems)
•From distal to proximal (screening for neuropathy)
•From numb areas to normal areas (ask patient to show you where the transition is)
The Neuro Exam for Non-Neurologists
A handy guide
Coordination testing
Tips and Tricks
Finger/nose task
•Hold target still, no need to move it around
•Look for smooth, accurate movements
Heel/shin task
•Difficult to teach / learn
•Limited ROM (arthritis, pain) limits the value of the test
Rapid alternating movements:
•Finger tapping, open/close fist better than “clap-flip-clap-flip” task, which is difficult
Subtle finding:
•Mild dysmetria suggests mild weakness
Normal variant:
•“accurate” missing
The Neuro Exam for Non-Neurologists
A handy guide
Gait testing
Tips and Tricks
Walk across the room (down the hall) and back. OK to repeat if needed
•Width of feet (should nearly touch)
•Leg swing
•Foot drop
•Arm swing
Walk on toes / heels (sensitive test of distal strength)
Tandem gait: not if elderly
Romberg: best done with distraction
•I tell them we’re doing a “concentration test”
The Neuro Exam for Non-Neurologists
A handy guide
Additional testing for specific situations
Expanding your basic exam to answer harder questions
1.Cerebrum: Does this patient have dementia? Aphasia?
2.Basal ganglia: Is this a Parkinsonian tremor?
3.Brainstem and cranial nerves: Does this patient have a central cause of
dizziness?
4.Cerebellum: Does this patient have a central cause of imbalance?
5.Spinal cord: Does this patient have a spinal cord lesion?
6.Motor neuron: Does this patient have ALS?
7.Peripheral nerve: Is this numbness due to neuropathy?
8.Neuromuscular junction: Is this patient fatigued because of myasthenia?
9.Muscle: Is this weakness due to myopathy?
The Neuro Exam for Non-Neurologists
A handy guide
Cerebrum: dementia, aphasia
Expanding your basic exam to answer harder questions
Mental status quick screen (prefer this to MMSE or MoCA):
•orientation
•memory -- delayed recall of 3 word list
•attention -- months of the year backwards
•clock drawing
Language testing (simple --> complex):
•naming
•repetition
•comprehension (commands)
•fluency (in conversation)
The Neuro Exam for Non-Neurologists
A handy guide
Basal ganglia: tremor, parkinsonism
Expanding your basic exam to answer harder questions
Tremor:
•at rest? (usually in hands) -- worse with distraction
•with posture (hands, head)
•with activity (finger-nose)
Rigidity
•at wrist, elbow, knee -- worse with distraction
Bradykinesia
•finger tapping, open-close fists, foot tapping
•masked face, decreased blinking, hypophonic voice
Gait
•shuffling, decreased arm swing, flexed posture, en bloc turns
The Neuro Exam for Non-Neurologists
A handy guide
Brainstem and cranial nerves: vertigo
Expanding your basic exam to answer harder questions
Cranial nerves:
•Horner’s syndrome
•eye movements, nystagmus
•dysarthria
•facial sensation, symmetry
Sensory and Motor:
•crossed findings (face on one side, arm/leg on the other)
Special test: Head Impulse test
Patient focuses eyes on tip of your nose. Gently but suddenly twist head 10-15 degrees to one side,
then the other.
If eyes remain fixed, normal. If corrective saccade brings them back to midline, vestibular dysfunction.
A normal head impulse test in the setting of acute vertigo suggests stroke or other central cause.
The Neuro Exam for Non-Neurologists
A handy guide
Cerebellum: imbalance, clumsiness
Expanding your basic exam to answer harder questions
Ataxia:
•ataxia / dysmetria on finger-nose and/or heel-shin tasks
•clumsiness with rapid movements (finger tapping etc)
•slurred speech
•difficulty walking in tandem
Tremor: intention tremor with finger-nose
Eye movements: nystagmus (especially up or downbeating)
Gait: wide based, unable to walk in tandem
NB: Romberg is not a “cerebellar” test, it’s a test of proprioception
The Neuro Exam for Non-Neurologists
A handy guide
Spinal cord: myelopathy
Expanding your basic exam to answer harder questions
xxx:
•ataxia / dysmetria on finger-nose and/or heel-shin tasks
•clumsiness with rapid movements (finger tapping etc)
•slurred speech
•difficulty walking in tandem
Tremor: intention tremor with finger-nose
Eye movements: nystagmus (especially up or downbeating)
Gait: wide based, unable to walk in tandem
NB: Romberg is not a reliable “cerebellar” test
The Neuro Exam for Non-Neurologists
A handy guide
Motor neurons: ALS
Expanding your basic exam to answer harder questions
Strength testing:
•expect “corticospinal” pattern of weakness
•may be only in 1-2 limbs early in disease
Muscle atrophy
Fasciculations
•Look in larger muscles (calves, quads, triceps, deltoids, pecs)
•Patient may be able to direct you
Reflexes: expect an “upper motor neuron” sign (hyperreflexic,
Babinski)
No sensory symptoms or signs
The Neuro Exam for Non-Neurologists
A handy guide
Peripheral nerve: Neuropathy
Expanding your basic exam to answer harder questions
Sensory loss / painful dysesthesiae
•in distribution of a single nerve (branch)
•in distribution of a single root
•distal symmetric (stocking-glove)
Weakness / atrophy
•in distribution of a single nerve (branch)
•in distribution of a single root
•distal symmetric (stocking-glove)
Requires enough neuroanatomy to be satisfied that other nerves/roots
are OK
...complex pictures can be hard to sort out (even for
specialists)cover_image.asp
The Neuro Exam for Non-Neurologists
A handy guide
Neuromuscular junction: myasthenia
Expanding your basic exam to answer harder questions
“PD 3”:
•ptosis (usually asymmetric, variable)
•diplopia / eye movement abnormalities (esp upgaze)
•dysarthria (nasal speech)
•dysphagia (to liquids, on history)
May also have:
•facial weakness (symmetric)
•neck weakness (check flexors)
•limb weakness (proximal > distal, usually symmetric)
Test fatigability:
•prolonged upgaze (ptosis, upgaze)
•dysphagia (to liquids, on history)
The Neuro Exam for Non-Neurologists
A handy guide
Muscle: myopathy
Expanding your basic exam to answer harder questions
Weakness:
•proximal > distal limbs
•usually symmetric
May have bulbar weakness:
•facial weakness (usually symmetric)
•dysarthria
•neck weakness (check flexors)
Ocular muscle weakness / ptosis not usually from myopathy
No fascics, usually not much atrophy
Reflexes and sensation normal
Gait can be myopathic (“waddling”, Trendelenburg)
Thanks!
Any questions?
Feel free to email me with questions:
pmasiowski@gmail.com