Neurological examination for psychiatrists Dr T M Jenkins MBChB MRCP PhD Clinical Lecturer in Neurology June 2014 Neurophobia (n) fear of neurology amongst medical students ( and professionals) What are the reasons for neurophobia? High interest Difficult Basic science Neuroanatomy Multiplicity of diagnoses …and… Causes of neurophobia Poor or inadequate teaching Why is it necessary (objectives)? Syllabus Relevant in real life differentials Relevant to part 1 exams- 10 neurology MCQs/EMIs Syllabus Be aware of the equipment required in the full neurological examination Overview of examination of the nervous system Understand how to examine each pair of cranial nerves with reference to common abnormalities and how to elicit them Understand how to examine the CNS and PNS with reference to common abnormalities and how to elicit them Equipment used “The neurologist” Jose Perez Oil on canvas Neurologists love to observe and measure. Historically, their tools have been the percussion hammer for knee jerks, the vibrating fork for bone conduction, and the pins for determining whether the patient is numb or faking it. Today, neurologists use electroencephalograms to tell when we're brain dead. Medical students can spot a neurology professor a ward away. They're almost invariably serious-minded, academically oriented males with a penchant for raising the possibility of an extremely rare and always incurable malady named after some seventeenth-century Frenchman. Polyneuropathy, neuropraxia, amyotrophy, and encephalopathy are just some of the hard-to-pronounce words neurologists typically love to let casually roll from their tongues. No doubt the doctor peering into the centaur's skull is about to pronounce the poor fool as suffering from anencephaly. Neurological examinationan approach Make an anatomical diagnosis (where is the lesion?) Make a pathological diagnosis (what is the lesion?)- go back to history Question An 86yo man is referred to the psychiatry clinic with progressive confusion, visual and auditory hallucinations over 6 months and is struggling to cope at home. Neurological examination Cranial nerves are normal. There is bilateral limb rigidity and resting tremor, but normal power, reflexes, coordination and sensation. Movements are slow and show a decrement on repetitive testing. He is confused and scores 59/100 on Addenbrooke’s cognitive examination. What is the likely pathophysiology? A: Neurofibrillary tangles B: Tauopathy C: Lewy bodies D: Prion protein E: Dopamine excess Technique • What does the neurological examination tell us? COGNITIVE IMPAIRMENT, PARKINSONISM • What does the history tell us? DEMENTIA • Which type of dementia is associated with hallucinations and Parkinsonism? (AD/ FTD/ LBD/ prion/ vascular) LEWY BODY DISEASE What is the likely pathophysiology A: Neurofibrillary tangles B: Tauopathy C: Lewy bodies D: Prion protein E: Dopamine excess Overview of examination of the CNS Cranial nerves Arms Legs T/P/R/C/S Cognitive, lobar Anatomical localisation: common patterns Cortical- brain UMN- brain (consider cranial nerves) UMN- cord Cauda equina LMN- anterior horn cell to muscle, often neuropathy NMJ- MG Myopathy Localisation: cranial nerves- rule of four 1,2,3,4 above pons 5,6,7,8 pons 9,10,11,12 medulla Factors of 12: 3,4,6,12 in midline Rule of four M- midline Motor pathway Motor nerves/nuclei (3,4,6,12) MLF Medial lemniscus S- side Spinothalamic tract Spinocerebellar Sympathetic Sensory nucleus of V The cranial nerves 12 pairs Origin Sensation Motor Autonomic III, VII, IX, X Remembering names On Old Olympus' Towering Top A Fine Vested German Viewed A Hop Question A 50yo man presents with behavioural change over the previous year. Previously he was very neat and tidy, but now his wife says “he has become a slob”. He appears apathetic. On examination, he has lost his sense of smell and has a pout reflex. What is the likeliest diagnosis? A: Depression B: Parkinson’s disease C: Olfactory groove meningioma D: Glioblastome multiforme E: Fronto-temporal dementia Which of these tests is most likely to provide the diagnosis? A: HADS assessment B: Clinical examination of limbs C: CT brain D: SPECT scan E: Addenbrooke’s cognitive assessment 1. Olfactory Sense of smell Olfactory nerve meningioma History and examination Frontal Olfactory nerve Slow growing What is the likely diagnosis? A: Depression B: Parkinson’s disease C: Olfactory groove meningioma D: Glioblastome multiforme E: Fronto-temporal dementia Which of these tests is most likely to provide the diagnosis? A: HADS assessment B: Clinical examination of limbs C: CT brain D: SPECT scan E: Addenbrooke’s cognitive assessment II. Optic nerve Vision Eyes: 5 things (minimum) Acuity Fields Pupils Fundi Eye movements (colour vision) (near vision) (accommodation and convergence) (etc) II: optic nerve Visual fields Pupil reactions to light and near (accommodation) Visual acuity Fundoscopy Visual fields 3, 4 and 6: the nerves controlling eye movements Left eye 6. Abducens The rest: 3. Oculomotor 4. Trochlear Convergence 3, 4 and 6 3. Oculomotor palsy 4. Trochlear palsy E.g. Trauma E.g. Coning 6. Abducens palsy E.g. Multiple sclerosis Question: Which of the following eye signs is thought to be pathognomic of multiple sclerosis? A: Argyll-Robertson pupil B: Bilateral internuclear ophthalmoplegia C: Holmes-Adie pupil D: Horner’s syndrome E: Kayser-Fleischer ring Argyll-Robertson pupils Bilateral, light-near dissociation, normal acuity Internuclear ophthalmoplegia Nystagmus Look to right Look straight ahead Pons level Convergence usually normal Look to left MLF Modified from Notz et al, Consultant, 2009 and Gray’s anatomy Holmes-Adie pupil Left pupil relatively dilated, poor reaction to light Tonic reaction to accommodation Usually unilateral, can be bilateral, test AJs Modified from neurology.org Horner’s syndrome Anisocoria more noticeable in dark, reacts normally Modified from mrcpopth.com Kayser-Fleischer ring KF ring Modified from Hepatitis Monthly, 2009 Question: Which of the following eye signs is thought to be pathognomic of multiple sclerosis? A: Argyll-Robertson pupil B: Bilateral internuclear ophthalmoplegia C: Holmes-Adie pupil D: Horner’s syndrome E: Kayser-Fleischer ring Question: Which of the following lesions is most likely to cause bitemporal hemianopia? A: Parietal lobe tumour B: Occipital lobe tumour C: Pituitary tumour D: Cerebrovascular disease E: Frontal lobe tumour Visual fields Question: Which of the following lesions is most likely to cause bitemporal hemianopia? A: Parietal lobe tumour B: Occipital lobe tumour C: Pituitary tumour D: Cerebrovascular disease E: Frontal lobe tumour Question: Which of the following is associated with ptosis and depression? A: Third nerve palsy B: Myasthenia gravis C: Horner’s syndrome D: Levator dehiscence E: Sixth nerve palsy Question: Which of the following is associated with ptosis and depression? A: Third nerve palsy B: Myasthenia gravis C: Horner’s syndrome D: Levator dehiscence E: Sixth nerve palsy 5. Trigeminal Sensation to face Muscles of jaw Reflexes corneal “Open your mouth” “Clench your teeth” jaw jerk 5. Trigeminal Trigeminal neuralgia Question: what neurological condition did George Clooney suffer from? 7. Facial nerve Upper motor neurone e.g. stroke Lower motor neurone e.g Bell’s “Raise your eyebrows” “Close your eyes” “Blow out your cheeks” “Show me your teeth” Question You notice a tonic spasm on a woman who cannot resist closing her right eye while talking to you. She is able to carry out most of her daily activities including watching TV normally. This is best described as: Question A: Blepharospasm B: Tonic seizures C: Multiple sclerosis D: Normal phenomenon E: Catatonic posturing What it is not: Catatonia Tonic seizures Multiple sclerosis Possibilities Blepharospasm Motor tics ??Bell’s with aberrant reinnervation Usually bilateral Common in children Involuntary Can be suppressed May be triggered by flickering lights Can be situationspecific Question A: Blepharospasm B: Tonic seizures C: Multiple sclerosis D: Normal phenomenon E: Catatonic posturing 8. Vestibulo-cochlear Hearing Balance Testing hearing Rinne’s test Normal air > bone Weber’s test Quieter in affected ear: sensorineural Louder in affected ear: conductive Modified from: drdavidson.ucsd.edu Same: no help Question: A nurse noticed that she has to raise her voice considerably when talking to an elderly patient whose threshold to voices has increased. This is: A: Hyperaesthesia B: Paraesthesia C: Hypoesthesia D: Hypoalgesia E: Hyperalgesia Question: A nurse noticed that she has to raise her voice considerably when talking to an elderly patient whose threshold to voices has increased. This is: A: Hyperaesthesia B: Paraesthesia C: Hypoesthesia D: Hypoalgesia E: Hyperalgesia aisthesis “sensation” algos “pain” 9. Glossopharyngeal and 10. Vagus Palate movement Gag Cough NB Speech “puh” “kah” “tah” Say “aaah” Question: link the speech defect to the anatomical cause 1: Hypophonia 2: Expressive dysphasia 3: Pseudobulbar dysarthria 4: Phonation on inhalation 5: Scanning dysarthria 6: Nasal dysarthria 7: Receptive dysphasia 8: High pitched and variable A: Cerebellum B: Wernicke’s area C: Extrapyramidal lesion D: Hysterical E: Broca’s area F: Myasthenia gravis G: Upper motor neurone lesion H: Vocal cord paralysis Question: link the speech defect to the anatomical cause 1: Hypophonia 2: Expressive dysphasia 3: Pseudobulbar dysarthria 4: Phonation on inhalation 5: Scanning dysarthria 6: Nasal dysarthria 7: Receptive dysphasia 8: High pitched and variable A: Cerebellum B: Wernicke’s area C: Extrapyramidal lesion D: Hysterical E: Broca’s area F: Myasthenia gravis G: Upper motor neurone lesion H: Vocal cord paralysis XI. Accessory “Turn your head against my hand” “Shrug your shoulders” 12. Hypoglossal “Stick your tongue out” “Waggle it side to side” Question An 80 year old man presents with a 6 month history of progressive weakness, swallowing problems, slurred speech and weight loss. On examination of his tongue, there is bilateral wasting and fasciculations. The jaw jerk is normal. Question: what is the likeliest abnormality of his speech? A: Hypophonia B: Flaccid dysarthria C: Scanning dysarthria D: Expressive dysphasia E: Spastic dysarthria Question: what is the likeliest abnormality of his speech? A: Hypophonia B: Flaccid dysarthria C: Scanning dysarthria D: Expressive dysphasia E: Spastic dysarthria Summary: cranial nerves POTTER On On On They Travelled And Found Voldermort Guarding Very Ancient Horcruxes CRANIALS Olfactory Optic Oculomotor Trochlear Trigeminal Abducens Facial Vestibulocochlear Glossopharyngeal Vagus Accessory Hypoglossal Questions? Arms and legs Tone Power Reflexes Coordination Sensation Gait GCS Cognitive exam Lobar signs Tone Normal Reduced Rigid/cogwheel Clasp-knife Power Normal Proximal Distal Pyramidal Hemiparesis/Paraparesis Fatiguable NB Bradykinesia Reflexes Normal Absent Brisk Plantars Coordination Cerebellar ataxia Sensory ataxia Sensation Glove and stocking Sensory level Dissociated sensory loss (eg syrinx, anterior cord infarct, subacute combined degeneration) Which gaits are associated with which disorders? A: High-stepping B: Festinant C: Waddling D: Circumducting E: Broad-based F: Trendelenburg G: Pigeon H: Marche a petit pas I: Stamping J: Magnetic K: Scissoring 1: Spastic paraparesis 2: Diffuse cerebrovascular disease 3: Stroke 4: Myopathy 5: Normal pressure hydrocephalus 6: Bilateral foot drop 7: Sup. gluteal nerve lesion 8: Musculoskeletal disorders of childhood 9: Sensory ataxia 10: Parkinson’s disease 11. Cerebellar ataxia Which gaits are associated with which disorders? A: High-stepping B: Festinant C: Waddling D: Circumducting E: Broad-based F: Trendelenburg G: Pigeon H: Marche a petit pas I: Stamping J: Magnetic K: Scissoring 1: Spastic paraparesis 2: Diffuse cerebrovascular disease 3: Stroke 4: Myopathy 5: Normal pressure hydrocephalus 6: Bilateral foot drop 7: Sup. gluteal nerve lesion 8: Musculoskeletal disorders of childhood 9: Sensory ataxia 10: Parkinson’s disease 11. Cerebellar ataxia A Glasgow coma score between 9 and 12 indicates: A: Severe head injury B: Mild head injury C: Moderate head injury D: No head injury involved E: Alert and orientated A Glasgow coma score between 9 and 12 indicates: A: Severe head injury B: Mild head injury C: Moderate head injury D: No head injury involved E: Alert and orientated Glasgow coma scale Best eye response (E) 1. No eye opening 2. Eye opening in response to pain 3. Eye opening to speech 4. Eyes opening spontaneously Best verbal response (V) 1. No verbal response 2. Incomprehensible sounds 3. Inappropriate words 4. Confused 5. Orientated Best motor response (M) 1. No motor response 2. Extension to pain (abduction of arm, external rotation of shoulder, supination of forearm, extension of wrist, decerebrate response) 3. Abnormal flexion to pain (adduction of arm, internal rotation of shoulder, pronation of forearm, flexion of wrist, decorticate response) 4. Flexion/Withdrawal to pain (flexion of elbow, supination of forearm, flexion of wrist when supra-orbital pressure applied ; pulls part of body away when nailbed pinched) 5. Localizes to pain (Purposeful movements towards painful stimuli; e.g., hand crosses mid-line and gets above clavicle when supra-orbital pressure applied.) 6. Obeys commands Grading severity of head injury GCS Mild 13-15 Moderate 9-12 Severe 8 or less Addenbrooke’s cognitive examination Attention and orientation Memory Fluency Language Visuospatial Cutoff <88/100 18 26 14 26 16 Cognitive examinationprofile? Attention and orientation Memory Fluency Language Visuospatial Total 54/100 12/18 2/26 11/14 24/26 6/16 Alzheimer’s disease Classic presentation is amnestic for dayto-day events Visuospatial deficits Adapted from Pick’s disease support group Cognitive examination Attention and orientation Memory Fluency Language Visuospatial Total 54/100 12/18 22/26 2/14 4/26 14/16 Front-temporal dementia Behavioural and language variants Adapted from Pick’s disease support group Question: The part of the brain involved in working memory is: A: Thalamus B: Hypothalamus C: Prefrontal cortex D: Hippocampus E: Basal ganglia Question: The part of the brain involved in working memory is: A: Thalamus B: Hypothalamus C: Prefrontal cortex D: Hippocampus E: Basal ganglia Memory memory Working memory prefrontal cortex Long term memory Explicit memory (declarative) episodic semantic Implicit memory Skills/ habits cerebellum, basal ganglia Conditioned reflexes cerebellum, others Emotional amygdala Cortical lobar examination Frontal Parietal Temporal Occipital NB Seizures Dysphasia Neglect Hemianopia The most common type of seizure with an aura is: A: Grand mal B: Petit mal C: Complex partial seizure D: Absence seizure E: Pseudoseizure The most common type of seizure with an aura is: A: Grand mal B: Petit mal C: Complex partial seizure D: Absence seizure E: Pseudoseizure Miscellaneous questions Which EEG waveform typically has a frequency of 4-7.5 Hz? A: Theta B: Gamma C: Alpha D: Delta E: Beta Miscellaneous questions Which EEG waveform typically has a frequency of 4-7.5 Hz? A: Theta B: Gamma C: Alpha D: Delta E: Beta Which of the following is not dyskinesia? A: Chorea B: Athetosis C: Hemiballism D: Oculogyric crisis E: Akathisia Which of the following is not a dyskinesia? A: Chorea B: Athetosis C: Hemiballism D: Oculogyric crisis E: Akathisia “Abnormal involuntary movements” Question A 23yo woman presents with hallucinations and delusions. She has become paranoid that people were trying to kill her, afraid of going out. She had heard voices telling her she was going to die and seen people coming to get her in her house. Her mother said that in the previous week, sometimes she did not seem to be listening to her, was “tuned out”, fiddling with things and not appearing to listen. Her concentration was poor. Examination On examination, she appeared confused and agitated and pyrexial with writhing movements evident in her face and limbs. Question: what is the likeliest diagnosis? A: Schizophrenia B: Drug-induced psychosis C: Anti-NMDA receptor encephalitis D: Viral encephalitis E: Bacterial meningitis Question: what is the likeliest diagnosis? A: Schizophrenia B: Drug-induced psychosis C: Anti-NMDA receptor encephalitis D: Viral encephalitis E: Bacterial meningitis Question: A 40 year old man presents with a 4 week history of confusion. His MRI scan is shown below What is the likely cause of his confusion? A: Viral encephalopathy B: Delirium C: Prion dementia D: Bacterial sepsis E: Huntington’s disease What is the likely cause of his confusion? A: Viral encephalopathy B: Delirium C: Prion dementia D: Bacterial sepsis E: Huntington’s disease Huntington’s A 28 year old man with a history of alcohol excess is admitted in a confused, hallucinating and combative state. On examination, his gaze is directed to the right. What is the likeliest diagnosis? • • • • • A: Left-sided subdural haematoma B: Bacterial meningitis C: Hyponatraemia D: Hepatic encephalopathy E: Wernicke’s encephalopathy A 28 year old man with a history of alcohol excess is admitted in a confused, hallucinating and combative state. On examination, he is unable to look to the left. What is the likeliest diagnosis? • • • • • A: Left-sided subdural haematoma B: Bacterial meningitis C: Hyponatraemia D: Hepatic encephalopathy E: Wernicke’s encephalopathy Question A 28yo lady with a history of personality disorder collapses during an argument with her boyfriend, who witnesses her shaking violently for 20 minutes before recovering. Immediately afterwards, she told the paramedics she had no memory of the event. She tells you she felt dizzy beforehand. What is the likeliest diagnosis? A: Episode of grand mal status epilepticus B: Absence seizure C: Non-epileptic attack D: Vaso-vagal syncope E: Complex partial seizure What is the likeliest diagnosis? A: Episode of grand mal status epilepticus B: Absence seizure C: Non-epileptic attack D: Vaso-vagal syncope E: Complex partial seizure Where neurology and psychiatry collide Seizures and NEAD Encephalitis and psychosis Depression and long-term neurological illness Confusional states Summary Be aware of the equipment required in the full neurological examination Overview of examination of the nervous system Understand how to examine each pair of cranial nerves with reference to common abnormalities and how to elicit them Understand how to examine the CNS and PNS with reference to common abnormalities and how to elicit them Neurophilia effect Cognitive neuroscience students were shown complex data and received 2 explanations with and without neurological terminology Grey graphs shows satisfaction to a meaningless explanation without and with neurological terminology Good luck!