Exam Documentation
Neurological Exam
• Neuro: WNL
– We Never Looked
• Neuro: Non Focal
– The patient spoke in sentences, walked to the
exam table without limping and was able to lift
his shirt with both hands so that the heart could
be auscultated.
Tim Powell, M.D.
Providence Epilepsy Center
Spokane, WA
Neurologic Exam
•
•
•
•
•
•
•
Mental Status
Cranial Nerves
Motor
Sensory
Cerebellar
Gait
Deep Tendon Reflexes
• Neuro: Grossly Normal
– No neuro exam took place. The patient looked
O.K. to all superficial appearances and had no
specific neurologic complaints.
Folstein’s
Mini Mental
Status Exam
http://www4.parinc.com/
50 Test forms: $66
Mental Status Screen
•
•
•
•
Orientation to person, place, time/date.
Recall of Three Words (test of memory)
Spell WORLD backwards (test of attention)
Word Fluency: (Sensitive for Dementia)
– “A” Test: Ask the patient to give as many words as possible
b i i with
beginning
ith the
th letter
l tt "A" without
ith t using
i proper
names.Well educated >8/min, poorly educated at least 6/min
– “Animal” Test: Name as many animals as possible in 1
minute.
Cranial Nerves I & II
• I: Olfactory
– Rarely tested. Always test in trauma
– Test unilaterally with one nostril occluded
• cinnamon, soap, vanilla (avoid noxious odors: stims V)
• II: Optic
– Pupillary Response:
• M
Monitor
i size
i andd symmetry
• Direct vs. Consensual Response
• Afferent pupillary defect
– Visual Field testing
• Confrontational testing
If the patient has difficulty with any of the above, a full
mental status examination is indicated.
– Most sensitive to movement
– Red object for testing color vision
– Acuity: Eye Chart
– Fundoscopic Exam
1
Pupillary Neuroanatomy
Optic Tracts
http://en.wikipedia.org/wiki/Retina
http://www.aan.com/go/education/curricula/family/chapter2/section1
http://www.edoctoronline.com/medical-atlas.asp?c=4&id=21964
Grade I Papilledema Grade II Papilledema Grade IV Papilledema
Cranial Nerves III, IV & VI
• III: Oculomotor
– Pupillary Response
– Extraocular Movements (All directions except IV & VI)
• Eye Alignment: Cover/Uncover test
– Ptosis- Levator Palpebrae Muscle: principle eyelid opener
• IV: Trochlear
– Extraocular movements (Down and In)
– Intorts the eye
Normal
– Pearls: The only cranial nerve contralateral to the end organ.
– Most common CN affected by trauma
• VI: Abducens
– Extraocular movements (Lateral / Abduction)
Optic Neuritis
Ant. Ischemic Optic Neuropathy
Emboli/Stroke
Eye Muscles / Movements
Superior Rectus
Lateral Rectus
Inferior Oblique
3
3
Cranial Nerves V & VII
• V: Trigeminal
– Motor: Muscles of mastication, Jaw jerk V3
– Sensory: Test PP, T, LT in all areas: V1, V2, V3
• Pearl: Innervation overlaps at midline
• Corneal Response (afferent)
3
6
Clinical Neuroanatomy made Riduculously Simple, 1990
Medial Rectus
• VII: Facial
– Muscles of facial expression
Inferior Rectus
4
3
Right Eye
Bate’s Guides to Physical Examination, 2002, Lippincott Williams & Wilkins
• Raise forehead, close eyes, show teeth, puff cheeks
Superior Oblique
– SYMMETRY!
• Corneal Response (efferent)
• Taste: Ant 2/3 of tongue.
Clinical Neuroanatomy made Ridiculously Simple, 1990
http://www.fpnotebook.com/Neuro/Anatomy/CrnlNrv7.htm
2
Central VII Nerve Palsy
Peripheral VII Nerve Palsy
Bate’s Guides to Physical Examination, 2002, Lippincott Williams & Wilkins
Bate’s Guides to Physical Examination, 2002, Lippincott Williams & Wilkins
Cranial Nerves VIII, IX, X
Cranial Nerves XI & XII
• VIII: Vestibulocochlear
– Nystagmus
– Test high pitched sounds
• XI: Spinal Accessory
– Motor to Sternocleidomastoid: turns head to
opposite side. Neck flexion when both sides
contract.
– Motor to Trapezius: Shoulder shrug.
shrug Scapular
winging if weak.
• Finger Rub, Whisper
• 512 hz tuning fork
– Conductive hearing loss vs Nerve Deafness
• IX: Glossopharyngeal
– Gag
– Palatal Elevation
– Taste on posterior 1/3 of tongue
• XII: Hypoglossal
512hz
• X: Vagus
– Tongue protruding. Deviates to the weak side
– Palatal Elevation
– Articulation- Palatal: “Ka” Guttural: “Ga”
?hoarse speech
• Lateral push against tongue blade
– Monitor tongue at rest inside mouth for
fasciculation's (overcalled)
Motor
• Bulk: Atrophy/Hypertrophy
• Abnormal Movements
MRC Scale
0
No muscle movement.
1
Visible muscle movement, but no movement at the
joint.
2
Movement at the joint, but not against gravity.
– Spasticity: velocity dependent
– Rigidity: velocity independent
3
Movement against gravity, but not against added
resistance.
• Continuous vs. Cogwheeling
4*
Movement against resistance, but does not attain
normal strength.
5
Normal strength.
– Tremor / Fasciculation's
– Seizure activity
• Tone
• Power: MRC Scale
– Breakaway vs True weakness
– Myotomes
• Pronator Drift
* Grades 4 - , 4 and 4+ maybe used to indicate movement
against slight, moderate and strong resistance respectively
3
Myotomes
Sensory
• General Sensation (Examine distally to proximally)
– Light Touch
– Pin Prick
– Vibration
– Temperature
– Position Sense
• Cortical Sensation
– Stereognosis
128hz
– Graphesthesia
– Two point Discrimination (nl 2-4 mm)
– Double Simultaneous Stimulation (Extinction)
• Romberg
Aids to the Examination of the Peripheral Nervous System, 5e [Paperback]
Michael O'Brien MD FRCP (Author)
Patterns of Sensory Loss
Sensory
Dermatomes
Peripheral Nerve: Loss of all sensation in the nerve distribution
Sensory Root: Loss of all sensation in spinal segments involved
Central Cord: Loss of pain and temperature in involved dermatomes
Posterior Columns: Loss of position/vibration below the lesion
Transection: Loss of position/vibration below the lesion on the
involved side, loss of pain/temp below lesion on opposite side
Thalamus: Decrease of all sensation on entire opposite body
Sensory Cortex: Loss of discriminative sensation on opposite side
Bate’s Guides to Physical Examination, 2002, Lippincott Williams & Wilkins
Cerebellar
• Rapid Alternating Movements
– Finger tap, toe tap or hand flip (Don’t overcall the
non-dominant hand)
– Looking for Dysdiadochokinesia (inability to follow
one movement with its opposite)
• Point to Point testingg
– Finger to Nose or Heel-Knee-Shin
– Looking for Dysmetria (clumsy, unsteady, varying
rate, movements that undershoot/overshoot target)
Gait
• Routine walking: check stride, stance, arm
swing, symmetry, turning
• Toe and Heel walking: Tests for plantar flexion
and dorsiflexion strength and balance
balance.
• Tandem Walking: Sensitive for detecting ataxia.
Age may begin to affect this ability >60
• Pearls:
– Cerebellar deficits are ipsilateral to the lesion.
– Motor weakness can mimic cerebellar dysfunction
4
Abnormalities of Gait
Deep Tendon Reflexes
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•
•
•
•
•
•
Ataxic / Cerebellar
Hemiparetic / Stroke
Shuffling / Parkinsonian
Slap / Sensory ataxia
Spastic / Scissoring
Steppage / Foot drop
Myopathic / Hip or Pelvic Girdle
instability
• Astasia-Abasia / Hysterical
Bate’s Guides to Physical Examination, 2002, Lippincott Williams & Wilkins
Deep Tendon Reflexes
Common DTR’s
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•
•
•
•
Biceps: C5, C6
Brachioradialis: C5, C6
Triceps: C6, C7
Patellar: L3, L4
Achilles / Ankle:
L5, S1, S2
•
•
•
•
•
Babinski Testing
Grading of DTR’s
0 : Absent
1+ : Diminished
2+ : Normal/Average
3+ : Brisk,, Increased
4+ : Markedly increased,
Often associated w/
clonus
Pearl: In general, reflexes are not pathologic if they are
symmetric, unless they are 4+ or truly absent
Pearl: Babinski’s are either Present or Absent.
There is no such thing as a positive or negative Babinski.
http://zionmedicalstudent.blogspot.com/2010/07/how-to-check-babinski-sign-related-word.html
Neuro Exam References
Nerve Whiz App
• http://icarus.med.utoronto.ca/NeuroExam/main.htm
– Thorough, well done, video demonstration of the entire
neuro exam
5
Case #1 History
Neurological Exam
• 45 y.o. male, drug rep, involved in a MVA
and sustained cervical and rib fractures. He
was noted to be unable to move his R UE.
Case Studies
Case #1: Exam
Case #1 Potential Localization
• Right Upper Extremity Weakness
– L Motor Cortex
– L Internal Capsule
– Brainstem
– Spinal Cord
– R Brachial plexus / Peripheral Nerves
– Mental Status: Oriented, in pain
– Cranial Nerves: Pupils reactive, EOM intact,
Face symmetric.
– Motor: Complete inability to move the R UE,
retained ability to move R LE and L side
Sensory: Intact to touch and pinprick in all 4
extremeties
– Cerebellar: FNF intact on the L
– Gait: Normal toe, heel, tandem walking
– DTR’s: 2+ & symmetric, except the R UE
which is 3+. Babinski on R.
Homunculus
Case #1 Potential Localization
• Right Lower Extremity Weakness
– L Motor Cortex
– L Internal Capsule
– Brainstem-Very
Brainstem Very hard to just affect entire arm
and nothing else
– Spinal Cord – Same thing
– R Brachial plexus / Peripheral Nerves-Reflexes
are present, and toe is upgoing
Motor
Sensory
http://tmww.blogspot.com/2011/05/homunculus-of-touch.html
6
Case #2 History
Case #1
Cortical
Contusion
Axial T2
FLAIR
• 36 yo female, newscaster, noted by coworker
to have mildly slurred speech and left facial
weakness. Pt c/o left facial numbness, but
had not noticed weakness.
Coronal T1
Case #2 Exam
Case #2 Potential Localization
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•
•
•
R Cortical
Posterior limb R Internal Capsule
Brainstem: L Pons
L CN VII
Case #2 Potential Localization
•
•
•
•
– Mental Status: Oriented, Memory intact, naming and
repetition normal,
– Speech: Mild dysarthria
– Cranial Nerves: EOMI, pupils equal, widened L
palpebral
l b l fissure,
fi
L facial
f i l droop-upper
d
andd lower,
l
sensation intact, tongue midline, neck/shoulder 5/5.
– Motor: 5/5 throughout, tone normal, PND absent
– Sensory: Intact
– Cerebellar: Intact
DTR’s: 2+, toes downgoing
– Gait: Normal
Case #2 (Bells Palsy)
R Cortical Forehead is not spared
Posterior limb R Internal Capsule-Same
Brainstem: L Pons-Maybe…
L CN VII
http://www.sciencephoto.com/media/251817/enlarge
http://www.facebook.com/pages/Bells-Palsy-Support-Group/351858436387
http://meded.ucsd.edu/clinicalimg/neuro_central_cn7_palsy2.htm
7
Case #3 History
• 28 yo male, works in landscaping, complains
of chronic ‘numbness’ in his right hand. He
is dropping tools now, and presented to his
PCP The numbness sometimes wakes him
PCP.
up at night, but it does not bother him in the
morning hours.
Case #3 Exam
Case #3 Potential Localization
•
•
•
•
•
L Cerebral cortex
L posterior limb Internal Capsule
Thalamus (Sensory component only)
C8 root, T1 root, Brachial Plexus
Peripheral Nerve-Ulnar vs Median vs Both
Case #3 Exam
– Mental Status: Normal
– Cranial Nerves: Normal
– Motor: Weak thumb opposition and abduction.
Atrophy of the R thenar eminence. Hand
g and wrist extension 5/5
intrinsics,, finger
– Sensory: decreased pinprick in lateral/palmar
aspect of R hand, Sensation above the wrist is
normal.
– Cerebellar: No dysmetria, RAM normal
– Gait: Normal
– DTR’s: +Tinels, otherwise 2+
http://cmapspublic.ihmc.us
/
http://drwolgin.com/carpaltunnel.aspx
Case #3 Potential Localization
•
•
•
•
L Cerebral cortex: Only 2 muscles involved
L posterior limb Internal Capsule: Same
Thalamus: Only explains sensory
C8 root, T1 root, Brachial Plexus: Clinical
Exam is too focal
• Peripheral Nerve-Ulnar vs Median vs Both:
Not Ulnar distribution
Case #4 History
• 48 yo female, homemaker, woke up with
numbness “from the waist down,” and
weakness of the L leg.
Diagnosis
Median Nerve compression at the wrist:
Carpal Tunnel Syndrome
8
Case #4 Potential Localization
• Right midline cortical lesion
• Spinal Cord
• Lumbar Polyradiculopathy
Case #4 Potential Localization
Case #4 Exam
– Mental Status: Normal
– Cranial Nerves: II-XII Intact
– Motor: Diffuse L LE paresis
– Sensory: Decreased Pinprick below the
umbilicus on the R, decreased vibration
below the umbilicus on the L
– Cerebellar: Intact
– Gait: Cannot stand without assistance
– DTR’s: 3+ of the L LE, with a L Babinski,
o/w 2+ throughout.
Case #4
(T 10 lesion-myelopathy)
• Right midline cortical lesion Sensory Level
• Spinal Cord• Lumbar Polyradiculopathy- DTR’s are 3+
with
i a Babinski
i
i
Case #5 History
• 63 yo accountant noticed sudden
incoordination using his R hand on his
calculator, followed within 30 seconds by
intense vertigo, nausea and vomiting. He
stood to run to the bathroom, but fell down
and could not stand back up.
Case #5 Potential Localization
• Brainstem-Pons/Medulla
• Cerebellum
• Herniation syndrome
9
Case #5 Exam
– Mental Status: Alert, too nauseated and
vertiginous to cooperate with detailed testing
– Cranial Nerves: Subtle nystagmus when
looking to the right, face symmetric
– Motor: Dyscoordination of the R UE
– Sensory: Intact to pinprick and vibration,
Romberg positive
– Cerebellar: Dysmetria of the R UE, and R LE
– Gait: Ataxic
– DTR’s: Trace throughout. Toes downgoing
Case #5 (Cerebellar Infarct)
Case #5 Potential Localization
• Brainstem-Pons/Medulla Dysmetria
• Cerebellum
• Herniation syndrome
Case #6 History
• 57 yo female, restaurant owner, slipped on
the ice, falling on her back and hitting her
head. She had sudden radiating pain down
both legs,
legs and inability to stand due to B leg
weakness. She complains of a headache.
Denies having loss of consciousness.
Case #6 Exam
Case #6 Potential Localization
• Lower spine
• Lumbar plexus
• Midline hemispheric hemorrhage
– Mental Status: A little slow in responses, but A&O
x4, memory intact
– Cranial Nerves: II-XII intact
– Motor: L: 4+ Quads, 3+ Ant Tib. R: 3+ Gastroc.
– Sensory: Decreased Pinprick in L lateral thigh &
shin. Decreased Pinprick over the length of the
posterior
t i R leg
l
– Cerebellar: RAM/FNF intact
– Gait: L Foot drop (can’t heel walk). Unable to
Plantar flex the R foot (can’t toe walk).
– Unsteady, radiating pain
– DTR’s: Absent L patellar, Absent R Ankle, o/w 2+
throughout. Toes are downgoing
10
Case #6 Potential Localization
Case #6 (Cauda Equina Syndrome)
• Lower spine Asymmetric nerve distributions
• Lumbar plexus- L4 (L) and S1 (R) nerves
• Midline Hemispheric lesion Obviously Not
• L4-L5 Disc
Herniation
http://www.netterimages.com/image/4808.htm
Case #7 History
• 75 yo male, retired Vet, with sudden onset of
painless visual loss on the right side.
Case #7 Potential Localization
•
•
•
•
Case #7 Exam
– Mental Status: A&O x 4, All Normal
– Cranial Nerves: EOMI, Pupil is 4 mm on R and 3
mm on L. The direct pupillary response is absent on
the R & intact on the L. The consensual pupillary
response with the light shining in the R eye is absent,
and with the light shining in the L eye is present.
present
Visual fields show monocular visual loss of the right
eye. Vision field is intact on the left. Fundoscopic
exam-no hemorrhage, mild papilledema on the right.
Face is symmetric. All other cranial nerves are
intact.
– Motor, Sensory, Cerebellar, Gait, DTR’s: All intact
and symmetric. Toes downgoing.
L Occipital lobe
L Optic radiations
R Optic nerve
R Retina/Eye
Case #7 Potential Localization
•
•
•
•
L Occipital lobe-Monocular Visual Loss
L Optic radiations- Same
R Optic nerveR Retina/Eye- Fundoscopic exam
unremarkable except for papilledema
11
Case #7 Ischemic Optic Neuropathy
Case #8 History
• 67 yo female, retired truck driver, who had
sudden onset of weakness of the entire Left
side of the body, (face, arm and leg), causing
h to
her
t fall.
f ll
Case #8 Potential Localization
•
•
•
•
Right Cortex
Right Internal Capsule
Brainstem
Cervical Cord
Case #8 Potential Localization
Case #8 Exam
– Mental Status: Normal
– Cranial Nerves: Left lower facial weakness,
forehead spared, dysarthric, tongue midline, Facial
sensation is intact and symmetric, EOMI, Pupils
equal
– Motor: Severe weakness of all muscle groups on the
Left side.
– Sensory: Intact pp/vib/temp throughout, symmetric
– Cerebellar: Intact on the R, unable to test on L
– Gait: L hemiparetic
– DTR’s: 3+ on the L, 2+ on the R, Toe upgoing on L
Case #8 Pure Motor Hemiparesis
Lacunar Syndrome
• Right Cortex: R MCA Stroke is usually
Face &Arm > Leg. It would have to be a
huge cortical infarct, or massive
subarachnoid to affect the entire left body.
body
• Right Internal Capsule
• Brainstem-R Ventral Pons/Basis Pontis
• Cervical Cord?
– (Arm and Leg, Yes…Face? No)
12
Case #9 History
• 23 yo male with HIV presents one week after
developing complaints of blurred vision,
sometime seeing double.
Case #9 Exam
– Mental Status: Mild decrease in mentation
according to S.O.
– Cranial Nerves: Right eye will not abduct. Left
eye will not deviate down and in. Left pupil is
unreactive. There is nystagmus when looking to
the right.
right He is mildly dysarthric and has a mild
L facial droop.
– Motor: 5/5 throughout, Normal tone
– Sensory: Intact pin prick/temperature/vibration
Cerebellar: No dysmetria
– Gait: Mildly ataxic
– DTR’s: 2+, Babinski’s absent
Case #9 Basilar Meningitis-Tb
Case #9 Potential Localization
•
•
•
•
Occipital cortex
Brainstem
CN III
Globe
Case #9 Potential Localization
• Occipital cortex Visual Fields Intact
• Brainstem
– Cranial Nerves (R IV, R VI, R VIII, L III,
L VII, IX )
• CN III Does not explain all findings
• Globe No
Case #10 History
• 63 yo female, retired math professor, with
sudden onset of inability to talk or move her
right side
Osborn, Diagnostic Imaging Brain 2004
13
Case #10 Potential Localization
Case #10 Exam
– Mental Status: Profound expressive aphasia, unable to
follow commands
– Cranial Nerves: Eyes deviated to the L, unable to cross
the midline to the R with oculocephalic maneuvers,
pupils reactive, R facial droop, absent gag.
– Motor: No voluntary mvt of RUE, and no withdrawal to
pinch. R lower extremity is externally rotated, and
withdraws to pinch.
– Sensory: As above. Withdraws briskly on the L
– Cerebellar: L-reached for object w/o difficulty
– Gait: Unable to test
– DTR’s: 3+ on the right, R Babinski
• Brain
Case #10 Potential Localization
Case #10
L MCA w/ hemorrhagic transformation
• Brain-L Hemisphere
Case #11 History
• 46 y.o. male with onset of numbness and
paresthesias in his distal lower extremities 2
weeks prior to admission. He also complained
of his muscles feelingg “tired” in his legs
g only.
y
• His symptoms have progressed to where he is
now having trouble climbing stairs and
complaints of paresthesias in his hands.
Case #11 Potential Localization
• Paresthesias
– Peripheral nerves
• Lower extremity weakness
– Intrahemispheric mass lesion
– Lumbar spinal cord
– Conus Medularis (symmetric motor weakness)
– Bilateral Lumbar Plexus / Peripheral nerves
14
Case #11 Exam
– Mental Status: A & O x4
– Cranial Nerves: EOMI, face symmetric, speech
normal, All intact
– Motor: 4+/5 bilateral distal LE symmetric
weakness
– Sensory: Prominent stocking-glove gradient
sensory loss to all modalities on all 4 extremities
– Cerebellar: Intact
– DTR’s: Absent throughout. Babinski’s absent
– Gait: No ataxia or asymmetries, but appears
labored
Case #11 Guillain-Barre Syndrome
Case #11 Potential Localization
• Paresthesias
– Peripheral nerves
• Lower extremity weakness
– Intrahemispheric
I
h i h i mass lesion
l i Absent
Ab
DTR’
DTR’s
– Lumbar spinal cord, Conus Medularis (symmetric
motor weakness) Absent DTR’s
– Bilateral Lumbar Plexus / Peripheral nerves
Case #12 History
Acute inflammatory demyelinating polyneuropathy (AIDP)
• Exam and History are Classic
• CSF revealed elevated protein of 53
without increased WBC’s
(“albuminocytologic dissociation”)
• Rx with IVIG
• 21 yo Burmese refugee who immigrated to
the US. By report, he has had seizures since
the age of 16. Through an interpreter, the
seizures start with tingling in his L hand.
hand
The symptoms can spread from there and
result in a convulsion.
http://www.childrenshospital.org/az/Site974/mainpageS974P0.html
Case #12 Potential Localization
• R Cortical Sensory Strip
Case #12 Exam
– Mental Status: Alert, follows commands.
Memory 3/3 recall. Naming was unable to be
tested.
– Cranial Nerves: II- XII Intact
– Motor: Strength is 5/5 throughout. Tone normal.
– Sensory: Appears symmetric to touch. Difficult
to test in detail due to language barrier.
– Cerebellar: No dysmetria.
– Gait: Nl toe, heel, tandem walking.
– DTR’s: 2+ and symmetric with downgoing toes.
15
Case #12 Potential Localization
Case #12 Neurocysticercosis
• R Cortical Sensory Strip
– Based on history only
Case #13 History
• 62 yo female, nurses aide, with a history of
Epilepsy, who has noticed progressive
difficultyy with balance and
tingling/numbness in her hands and feet.
Case #13 Exam
– Mental Status: Alert and oriented. Memory Intact.
Follows commands.
– Cranial Nerves: Gaze evoked nystagmus, Saccadic
dysmetria, Scanning Speech and mild dysarthria
– Motor: Strength is 5/5 throughout. Tone is normal. Mild
rubral tremor when testingg Pronator Drift.
– Sensory: : Decreased vibration and PP in a
stocking/glove fashion on all 4 extremities, LE>UE
– Cerebellar: Dysmetria with Finger-to-nose and Heelknee-shin maneuvers
– Gait: Ataxic
– DTR’s: Absent throughout with downgoing toes
Case #13 Potential Localization
• Brain/cerebellum
• Spinal cord (posterior columns)
• Peripheral nerves
Case #13 Potential Localization
• Brain/cerebellum Distal/Proximal Gradient
Sensory Loss
• Spinal cord (posterior columns) Eye findings,
speech tremor
speech,
tremor, Absent DTR’s
DTR s & Absent
Babinski’s
• Peripheral nerve Eye findings, speech,
tremor
Findings cannot be explained with 1 focus/lesion
16
Case #13 Chronic Dilantin Therapy
Cerebellar Atrophy and Peripheral Neuropathy
17