The University of Newcastle
Faculty of Medicine and Health Sciences
Bachelor of Medicine
Year 2
Professional Skills
Neurology
YEAR TWO
Prepared by:
Dr I Kerridge
Dr M Parsons
Dr D Williams
THE NEUROLOGICAL EXAMINATION
CONTENTS
Page
NEUROLOGY: PROFESSIONAL SKILLS ............................................................................. 3
MENTAL STATUS EXAMINATION ...................................................................................... 4
HIGHER CENTRES .................................................................................................................. 5
SPEECH..................................................................................................................................... 6
GAIT .......................................................................................................................................... 8
CRANIAL NERVES ................................................................................................................. 9
UPPER LIMBS ........................................................................................................................ 14
LOWER LIMBS ...................................................................................................................... 17
CEREBELLAR ........................................................................................................................ 20
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NEUROLOGY: PROFESSIONAL SKILLS
The neurological examination may be divided into a number of parts. These are:
1.
MMSE
]
2.
Higher Centres
]
3.
Speech
]
4.
Cranial Nerves
5.
Gait
6.
Cerebellar
7.
Upper limb
8.
Lower limb
Crossover
There is a huge amount of information that can be elicited in a neurological
examination, but a fairly complete examination can be done in 10-15 minutes if the examiner
is well-practised.
The general approach to neurological short case examinations is for the candidate to:
1.
Listen to the examiner.
2.
Be sensitive to the patient. This includes talk to the patients and making any
commands clearly. In many cases the exact wording of commands needs a lot
of practise.
3.
Inspect :
skin, scars
posture
drips/catheters
face
involuntary movements
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voice.
4.
Palpation
5.
Tone
6.
Power
7.
Reflexes
8.
Co-ordination
9.
Sensation
The aim of the neurological examination is to recognize various patterns of signs that allow
you to decide:
1.
What are the findings on examination? e.g.
-
Hemiparesis
2.
Where is the lesion(s)? e.g.
-
Cortex
3.
What is the underlying cause? e.g.
-
CVA
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MENTAL STATUS EXAMINATION
Folsteins’ Mini-Mental State Examination (MMSE)
The mini-mental state examination is a test of cognitive dysfunction. It is important
that a low score on a mini-mental state exam should not automatically lead the examiner to
state that the patient has dementia because there are a number of reasons why a person might
have cognitive dysfunction, including delirium and dementia and depression.
The major dificulty with using the MMSE is that the normal range of scores varies
with age and educational level. For example, the median score for a 50 year old with some
higher education is 30 (and the 25th percentile is 28), whereas the median score for n 85 year
old with less than 4 years education is 20 ( and the 25th percentile is 15).
Tables of normal values for the MMSE are available (see for example Crum RM,
Anthony JC, Bassett SS et al. “Population-based norms for the Mini-mental State
examination by age and educational level.” JAMA 269: 2386-91, 1993., however most
clinicians appear to simply remember a cut off score of about 23 in which those above are
thought of as normal and those below are thought of as impaired. If this approach is used, it
must be supplemented by the examiner -carefully looking at the responses to each question
and asking if the response is consistent with the age and educational level of the patient. For
example, a professor of English literature who cannot spell the word “world” backwards, has
clearly got a degree of cognitive decline, whereas an illiterate labourer wit the same answer
may be perfectly normal.
There are a number of other problems with the MMSE that the user should be aware
of. Some questions are known to be a little unclear, (for example the marking of question 4 is
unclear), and no time limit. Furthermore, other ethnic groups are known to score badly on
some items compared to English speakers (including season, county, spelling, serial
subtraction, and “no ifs ands or buts”) Some of the questions need to be modified slightly for
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other countries (ie “county” has no meaning in Australia.)
With these limitations in mind, the MMSE is a useful screening test for cognitive
dysfunction.
Specific Test
Function and Area Tested
Points
1. What is the year/season/day/date/month?
Orientation (frontal)
5
2. What is the state/county/town/
Orientation (frontal)
5
3. Repeat three items
Registration (frontal)
3
4. Serial subtraction of sevens or spell
Concentration (frontal)
5
Naming (dominant
2
Score
hospital/floor?
“World” backwards
5. Name wristwatch and pen
Temporoparietal)
6. Say “no ifs, ands, or buts”
Expressive speech (dominant
1
frontal)
7. Take this paper in your right hand, fold it
in half and put it on the table.
Three-stage command
3
(frontal)
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8. Read “close your eyes” and do it
Reading (dominant
1
temporoparietal)
9. Remember the three items from
Part 3 above
10. Write a sentence
Short-term memory
3
(dominant hippocampal)
Writing (dominant
1
temporoparietal)
11. Copy intersecting pentagons
“Construction” (non-
1
dominant parietal)
TOTAL
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There are a number of alternative tests to the Folstein’s MMSE including the “Blessed Six
Item Orientation-Memory-Concentration Test”.
Total score:
< 8 - normal or minimal impairment;
9 to 19 - moderate impairment;
> 20 - indicates severe impairment.
Reference: Katzman et al American Journal of Psychiatry 140 (1983) 6.
Item
Number of
Score given
errors
for each error
Score
possible
1. What YEAR is it now?
1
x4
2. What MONTH is it now?
1
x3
MEMORY PHRASE: Repeat this phrase after me:
“John Brown, 42 Market St, BRISBANE.”
3. About what TIME is it? (Within 1 hour)
1
x3
4. Count backwards 20 to 1
2
x2
5. Say the months in reverse order
2
x3
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6. Repeat the memory phrase
5
x2
TOTAL
/30
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HIGHER CENTRES EXAMINATION
1.
ASK PATIENT IF LEFT OR RIGHT-HANDED:
The text books have very conflicting data about handedness and dominance. One
often quoted figure is :
94% Right-handed persons
-
Dominant Left hemisphere
60% Left-handed persons
-
Left dominant
30% Left-handed persons
-
Mixed dominant
10% Left-handed persons
-
Right dominant
however there are many other figures suggested. In general, the important fact is that almost
all right handed people have left hemisphere dominance, but that some left-handed people
have right or mixed dominance.
2.
ORIENTATION (MMSE)
3.
SPEECH
4.
PARIETAL LOBE FUNCTION
DOMINANT
: "Gerstmann’s" ‘
Acalculia/Agraphia/Left-Right
disorientation/Finger Agnosia
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NON-DOMINANT
: Spatial neglect (clockface)/Apraxia (PJ's, house)
NON-LOCALIZING
: Inattention (sensual and visual)/Homonomous
hemionopia.
Cortical sensory loss i.e. Proprioception, 2-point
discrimination, Inattention (visual and sensory),
Touch-localisation, Graphaesthesia (numbers),
Astereognosis (objects).
5.
OCCIPITAL
- Homonomous Hemianopia
- "Cortical" blindness (bilateral)
- Topographical amnesia
- Unable to
: recognize faces (prosopagnosia)
: read (alexia)
: recognize objects (visual agnosia)
6.
TEMPORAL
- STM loss (4 words: honesty, brown, tulip, eyedropper)
- LTM loss (AWhen did WWII start? ... finish?)
- Confabulation (Have we met before?)
- Dysphasia (receptive) and Nominal dysphasia (angular gyms of
temporal lobe)
- Upper Quadrant Hemianopia
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7.
FRONTAL
- Anosmia
- Proverb interpretation
- Gait ataxia (wide-based, shuffling)
- Primitive reflexes: grasp, pout, snout, suck, palmar-mental
- Incontinence
- Expressive dysphasia (Dominant: Broca's area)
- Personality change
: abulic (decreased initiation and spontaneity)
: impaired concentration/attention
: cannot pursue goals
: personality change
: disinhibition
SPEECH
Dysphasia
:
Disturbance in understanding or production of language.
:
Dominant hemisphere lesion.
:
Speech disorder is either fluent or non-fluent:
Fluent -
Sentences are of normal length and words flow
easily but words are used incorrectly and
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speech is difficult to understand. Patient
uses paraphrasias,
e g : literal paraphrasia, verbal
paraphrasia and/or neologisms.
Non-fluent -
Speech slurred and lacks “fillers” (and,
the, so, to) therefore sounds like a
telegram.
:
Most common dysphasias: expressive, receptive, conductive and
nominal.
Dysarthria
:
Difficulty with articulation.
:
Cerebellar disease, bulbar palsy, pseudobulbar palsy, extrapyramidal
disease. (Differentiation is difficult in terms of the quality of speech
alone. Diagnosis can usually be made by the associated neurological
abnormalities!).
Dysphonia
:
Altered quality of voice.
:
Laryngeal disease, recurrent laryngeal nerve palsy, hysteria,
myopathy.
To Test:
1.
Introduce yourself and shake hands.
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2.
3.
Free speech
Comprehension
:
How long have you been in hospital?
:
What sort of work do you do?
:
Do you understand what I am saying?
:
Close your eyes (1-step command).
:
With your right finger touch your nose and then
your ear (2-step command).
:
I would like you to pick up this piece of paper,
fold it in half and then place it back on the
bed/table (3-step command).
4.
Repetition/Dysarthria
assessment :
Please repeat after me......”No ifs, ands or buts.”
...”West Register Street.”
...”British Constitution.”
:
Repeat PUH (lip weakness), TUH (tongue) KUH
(palate).
5.
Naming objects
:
Shirt, sleeve, cuff, button.
Watch, band, face, hand, tell time.
6.
Reading
:
“Read what it says on this card and do what it
says”.
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7.
Writing
:
“Please write a sentence”.
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TYPES OF DYSPHASIA
NON-FLUENT
FLUENT
EXPRESSIVE
RECEPTIVE
CONDUCTIVE
NOMINAL
Understands but cannot
Speech fluent but
Repeats statements and
Cannot name objects
answer.
disorganized. Unable to
names objects poorly but
but all other aspects of
understand written or
can follow commands.
speech normal.
spoken words/commands.
BROCA’S AREA
WERNICKE’S AREA
TEMPORAL LOBE
Dominant Posterior
Dominant Third Frontal
Dominant Temporal First
Arcuate Fasciculus
Temporoparietal area:
Gyrus
Gyrus
Linking W and B area.
Angular gyrus
NAMING
Poor
Poor
Poor
Poor
REPETITION
May be possible with effort.
Poor
Poor
Normal
COMPREHENSION
Normal
Poor
Normal
Normal
READING
May have dyslexia
Neologisms paraphrasias
Poor
Normal
Abnormal content
Impaired
Normal
Gerstmann’s Hemianopia
Paraphrasia
Use long sentences to
SITE
WRITING
OTHER
Hemiparesis
overcome
word-finding
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difficulty
(circumlocution)
GAIT
Complex.
For locomotion need
:Basal ganglia
:Locomotor Region (mesencephalon)
:Cerebellum
:Spinal cord
:Sensory input from joints/muscular afferents
1.
Ask ... "May I walk Mr/Mrs ....."
2.
Ask someone else to assist. YOU WATCH
3.
Observe:
posture
arm swing
stride
base
involuntary movements
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4.
Tandem Gait (walk heel-to-toe)
5.
Rhombergs (Need 2 of 3: eyes, vestib, JPS)
6.
Screening:
Arms held in front with eyes closed + touch nose + lift arms up
straight and then down to the horizontal.
7.
Stand on toes
(weak gastrocnemius)
8.
Stand on heels
(foot-drop)
9.
Squat
(proximal myopathy)
+/10.
If suspect cerebellar:
1. Walk around chair (fall to side of lesion)
2. March on spot (unterbergers: turn to side of lesion)
COMMON GAIT DISORDERS
1.
High stepping
:
Unilateral foot drop
2.
High and slapping
:
1. Bilateral foot drop (Peripheral neuropathy, HMSN)
2. Sensory ataxia (MS, Tabes dorsalis, Spinocerebellar
Degeneration, sensory neuropathy)
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3.
Waddling (shoulders swap/tilt trunk/flex knee + hip) ‘ Weak hip abductors (proximal
myopathy, OA)
4.
Hemiparetic: Arm flexed, foot extended, circumduction.
5.
"Scissor" (Spastic Paraparetic): both legs circumduct. (Cerebral Palsy, M.S.)
6.
Parkinsonian: (freeze, no arm swing, festination, propulsion, retropropulsion)
7.
Broad-based shuffle and small steps: (marche à petit pas) [Normal Pressure
Hydrocephalus (Dementia, incontinence), Multi-infarct Dementia (Hyper-reflexic,
brisk jaw jerk).]
8.
Ataxic/ wide-based.
‘
1.
Unilateral cerebellar (falls to side of lesion)
2.
Midline (staggers in all directions)
CRANIAL NERVES
CN 1: OLFACTORY
sensory
usually not tested
may wish to test in the presence of personality disturbance, hemiparesis or visual loss
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Test each nostril separately (use easily recognized substance e.g. peppermint oil, oil of
cloves).
CN 2: OPTIC
1.
Observe
:
:
2.
Acuity :
Level of eyelid
Position of eye
-
Ptosis (CN 3 lesion, myasthenia,Horner’s)
-
Lid retraction
-
Exopthalmos (Graves, tumour)
-
Enopthalmos (Horner’s)
(Using two acuity cards - patient may use glasses)
-
"What is the smallest line you can read?" (Snellen card)
-
If less than 6/60: Counting fingers
:Hand waving
:Perception of light and dark
3.
Gross visual fields/visual inattention: Finger confrontation.
4.
Visual fields (red pin)
Test with red pin:
White objects more easily seen than red.
Central vision ‘ Colour : cones
Peripheral vision ‘ B+W : rods
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Therefore earlier peripheral loss with red pin.
Fig.1.
The visual pathways as seen from above the brain. Letters A-F refer to visual field defects following
lesions in the corresponding brain areas. Circles indicate
what the left and right eyes see (the left and right visual
fields). Black areas represent visual field defects.
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A.
Constricted field left eye (e.g. end-stage glaucoma). When constricted fields are bilateral, it
sometimes signifies hysteria.
B.
Central scotoma (e.g. optic neuritis in multiple sclerosis).
C.
Total blindness of the left eye.
D.
Bitemporal hemianopia (e.g. pituitary gland tumor).
E.
Right homonymous hemianopia (e.g. stroke).
F.
Right superior quadrantopia.
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5.
Blind spot (red pin)
6.
Pupils
Afferent
-
optic nerve
Efferent
-
PNS component of CN 3
20% difference in size -
Normal (Anisocoria)
Small pupil
-
SNS lesion
Large pupil
-
PNS lesion
: Light Reflex -
direct
-
consensual
: Accommodation
: Swinging light test:
Normal
:
Pupil always constricts
Abnormal
:
Pupil dilates to light
‘
Afferent pupillary defect
‘
Marcus Gunn pupil
‘
Anterior to chiasm (optic neuritic or
compression of the optic nerve)
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Fig. 2. The pathways for the pupillary light reflex and accommodation. LGB, lateral geniculate body. The
depicted lesions presumably also interrupt light reflex fibers crossing from the opposite side of the brian stem.
The pathway shown innervating the eye is highly schematic; the light reflex pathway involves only pupillary
constriction, whereas the accommodation pathway affects both pupillary constriction and ciliary body
accommodation.
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7.
Fundoscopy using Opthalmoscope
: Red reflex
: Retina: Locate vessel: follow to disc then periphery
: Venous pulse : (at cup)
: Retinal background
: Dilate pupil with tropic amide (DO NOT USE IN GLAUCOMA)
CN 3: OCULOMOTOR
CN 4: TROCHLEAR
CN 6: ABDUCENS
Motor to eye
Autonomic
Eye movements have complex control including:
1. Saccadic/command (frontal)
2. Pursuit (occipital/parietal)
3. Vestibular/positional
(cerebellar/vestibular nuclei)
Test
1.
2.
Observe: position of head (head tilted away from the side of a CN 4 lesion).
:
eyelid (ptosis suggest CN 3 lesion or a Horners)
:
eye position (one eye looking up or down suggests skew deviation).
Screen:
Instruct patient to “look up, look down, look to the left, look to the
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right.”
3.
Pursuit movements
: following a pin
4.
Saccadic movements
: finger to fist
5.
Accommodation/convergence
: "Look in to the distance ... now at my finger"
6.
Consider Cover Test
Note: *
Diplopia (double vision) is usually maximal in the direction of gaze of the
affected muscle. This indicates the abnormal cranial nerve.
*
In diplopia the false image is usually the outer image. This indicates the
abnormal eye,
e.g.
CN 6
:
Diplopia on lateral gaze.
CN4
:
Diplopia maximal looking down and in.
Images at an angle. Unable to look down and
out.
*
Comment on Nystagmus
- Nystagmus defined in direction of fast movement.
- When testing take inward looking eye to edge of caruncle - any further
will cause physiological nystagmoid jerks.
- Peripheral (vestibular) disease causes symmetrical nystagmus with the
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fast phase away from the side of the lesion. The fast phase remains in
the same direction despite the direction of gaze. The amplitude of
nystagmus is sometimes increased by looking in the direction of the fast
phase.
- Central (brainstem) disease cause asymmetrical nystagmus. It is
rotatory or vertical (always implies brainstem dysfunction in the
absence of drugs) and may demonstrate fast phase changes with change
in gaze direction.
- Cerebellar disease classically cause nystagmus with the fast phase
towards the side of the lesion, however, there is often distortion of the
brainstem and nystagmus may be much more complex. Vermis lesions
can cause up-beating nystagmus.
*
Internuclear opthalmoplegia: eye movements frequently normal when each eye
tested individually but abnormal when pursuit movements are tested together.
e.g.
Left INO :
Left eye fails to adduct
Right eye develops nystagmus
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Fig.3. The pathway for lateral conjugate gaze.
PPRF - pontine paramedian reticular formation.
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CN 5: TRIGEMINAL
Sensorimotor
Motor to temporalis and masseter sensory to face.
Large sensory nucleus extending from Pons to upper cervical cord: light touch in
Pons, pain/temparature in Medulla/cervical. (Therefore pontine lesions may
demonstrate loss of light touch with preservation of pain and temperature.
Test: 1.
2.
Corneal reflex (CN5 to feel CN7 to blink)
Sensation: (Test pin-prick/soft-touch in each of the three anatomical
divisions - opthalmic, maxillary and mandibular).
3.
Motor: i “Clench your jaw.” Palpate temporalis/masseter bulk.
ii
Strength of jaw opening. “Hold your jaw open.” (Look
for deviation to the side of weakness.)
iii Jaw-jerk.
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Fig.4. Trigeminal nerve sensory dermatomes.
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CN 7 :
FACIAL
Sensory, motor, autonomic
Motor :
Facial musculature
Ear
Tensor tympani and stapedius
:
Taste :
( via chordae tympani) to the anterior 2/3 of the tongue.
Test: 1.
"Smile"
CN 8 :
2.
"Show me your teeth"
3.
"Screw up your eyes"
4.
"Look up to the ceiling"
5.
"Whistle"
6.
"Blow out your cheeks"
AUDITORY
Auditory/vestibular function.
Test: 1.
Hearing
: Whispering numbers (at arms length whilst
occluding the opposite ear).
2.
Webers
: 512 Hz tuning fork held on the centre of the head.
"Where is it louder?"
3.
Rinne's
: 512 Hz tuning fork held on the mastoid then in front
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of the ear to test bone and air conduction. Normally
air conduction better than bone conduction.
4.
Vestibular
: Gait
Nystagmus
not usually part of CN exam
Caloric testing
WEBERS
RINNE’S IN DEAF EAR
Conductive Deafness
Heard in deaf ear
BC>AC
Sensorineural Deafness
Heard in normal ear
AC>BC
CN 9 :
GLOSSOPHARYNGEAL
Sensory
:
Posterior 1/3 of tongue, soft palate, pharynx.
Motor
:
Stylopharyngeus
Test
:
Gag reflex (bilaterally)
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CN 10 :
VAGUS
Sensory
:
External ear
Motor
:
Palate, pharynx, larynx (via recurrent laryngeal)
Test
:
1.
Cough, voice quality
2.
"Say Ahh"
-
Observe soft-palate movement. If normal
uvula stays in midline
-
If weak uvula deviates (pulled over) to the
normal side.
3.
CN 11:
SPINAL ACCESSORY
Motor :
Test
Gag (Sensory - CN 9, Motor - CN 10)
:
Supplies
-
ipsilateral trapezium
-
ipsilateral sternomastoid
1.
Shoulder elevation (trapezius)
2.
Lateral head rotation (opposite sternomastoid)
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3.
Pushing forehead forward against resistance (bilateral
sternomastoid, weakness, myopathy).
CN 12 :
HYPOGLOSSAL
Motor to tongue
Test
:
1.
Observe in mouth for wasting, fasiculations.
2.
Stick out the tongue: Tongue points toward (pushed) to the weak side.
3.
Test tongue strength.
UPPER LIMBS
1)
OBSERVE THE ENTIRE PATIENT
2)
SHAKE HANDS (Grip strength, co-ordination, myotonia)
3)
ASK PATIENT TO SIT ON THE EDGE OF THE BED
4)
INSPECT:
wasting (distal/proximal)
deformity
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fasciculation
tremor
5)
HOLD OUT ARMS/EYES CLOSED
Drift -
UMN weakness
(down)
-
cerebellar
(up: hypotonia)
-
post column loss
(impaired JPS)
6)
PIANO PLAYING (SCREENING)
7)
PALPATE
:
muscle bulk
tenderness
thickened nerves
8)
TONE :
-
median
:
wrist
ulnar
:
elbow
Clonus (> 3 beats)
Rigidity
Spasticity
Cog-wheeling
9)
POWER (GRADE 0 - 5)
SHOULDER:
Elevation
-
C3,4 + CN11
Abduction
-
C5 Deltoid (Axillary n.) + Supraspinatus
Adduction
-
C7 Pectoralis Major (Pectoral nerves)
Latissimus Dorsi
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ELBOW:
WRIST:
Flexion
-
C6 Biceps (Musculocutaneous n.)
Extension
-
C7 Triceps (Radial n)
Thumb up
-
C6 Brachioradialis (Radial n.)
Flexion
-
C7 Flexor carpi ulnaris (Median)
Extension
-
C7 Extensor carpi radialis (Radial)
wrist drop.
FINGERS:
Extension
-
C8 Extensor digitorum (Radial - post
interosseous n.)
Flexion
-
C8 Flexor digitorum superficialis and
profundus
Abduction
-
T1 1st Dorsal interossei, Abductor digiti
minimi (Ulnar)
Thumb
10)
11)
REFLEXES :
-
T2 Abductor pollicus brevis (Median)
Biceps
C5
Triceps
C7
Brachioradialis
C6
Finger
C8
CO-ORDINATION :Finger-nose
:Dysdiadokokinesis
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12)
SENSORY
With sensory examination consider cortical, intracapsular, cord, dermatomal,
peripheral nerve distribution.
there is significant overlap between dermatomes and between peripheral nerves
therefore the area of sensory loss in dermatome or nerve lesions may be less
than illustrated/expected.
1. Pain/temperature (enters cord and crosses 1-2 segments above):
Pin
Chest wall first
Dermatomal.
Dull or sharp
Start proximally (unless cord compression or
peripheral neuropathy suspected)
Move from abnormal to normal
2. Vibration (128 Hz) (Dorsal column)
3. Proprioception (Spinocerebellar tract: Ipsilateral)
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4. Light touch (Posterior column and Anterior spinothalamic tract)
C4 chest to shoulders
T2
Axilla
C5 arm to below elbow
C6 thumb/wrist
T1
elbow
C8
little finger
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Median nerve]
NOTE: Small muscles of hand supplied by:
+ T1 nerve root.
Ulnar nerve ]
Therefore look at Abductor digiti minimi, First dorsal interossei, Abductor pollicus
brevis.
1.
APB weak
:
Median nerve
2.
ADM and 1st DI weak
:
Ulnar
3.
All three weak
:
Many causes; cord, root, plexus
lesion. Peripheral neuropathy.
Motor neuron disease etc.
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LOWER LIMBS
1)
GAIT : Can I walk Mr/Mrs ...? If yes ... see Gait exam:
Rhombergs
Normal
Heel-toe
Stand on toes
Stand on heels
Squat
2)
LIE DOWN
3)
OBSERVE -
Expose legs (use towel)
-
?IDUC
-
Wasting: esp -
1.
Generalized
-
2.
Tibialus Anterior/EDB/Quadriceps
-
3.
Pes cavus (High arch, clawed toes,
thick foot) HMSN, Friedreichs, Spina
bifida.
4)
-
Fasciculations
-
Tremor
-
Deformities
PALPATE -
Tenderness
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5)
TONE
-
Bulk
-
Tap/flick for fasiculations
-
Thickened nerves
-
Leg roll
-
Knee (lift up with hand in popliteal fossa)
-
Clonus : ankle (sustained rhythmical contractions ‘ UMN)
+/- patella clomnus.
6)
POWER
[1. LMN: Weak, wasted, flaccid, hyporeflexic, fasciculation.
[2. UMN: Spastic, clonus, hyper-reflexic, Babinski,
UMN pattern weakness -
Arm: Abd + Ext]
Leg:
HIP:
Add+Flex]
Flexion
-
L2
Ilipsoas (Femoral n)
Extension
-
L5 S1-2
Gluteus Maximus (Inf glueal n)
Abduction
-
L4-5 S1
Gluteus medium/minimus + Tensor
fascia lata (Sup gluteal n)
Adduction
-
L2-3
(Obturator n)
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KNEE:
ANKLE:
Flexion
-
L5 S1
Hamstrings (Sciatic n)
Extension
-
L3
Quadriceps (Femoral n)
Plantarflex
-
S1
Soleus/Gastrocnemius (tibial n)
Dorsiflex
-
L4-5
Tibialus Anterior (Common peroneal n)
Eversion
-
L5 S1
Peroneus Longus (Common peroneal n)
UMN
Inversion
-
L4
Tibialus Posterior (Tibial n) Root/Plexus
L5 S1
Ext digitarum longus (Deep peroneal n)
-
L4
Quadriceps
Ankle
-
S1
Gastrocnemius
Plantar -
S1 Plantar or babinski
Anal
-
S3-4-5
Ant Abdo
-
Upper
-
T6-8
Lower
-
T10-12
Dorsiflex toe -
7)
8)
REFLEXES: Knee
CO-ORDINATION:
Heel-shin
Finger-toe
Foot-tap
9)
SENSORY:
Pin prick
]
Vibration sense
] If a sensory level is present: Go to the abdomen
Proprioception
]
Check saddle sensation
Soft touch
]
Check anal reflex
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10)
BACK:
Deformity
Scars
Neurofibroma
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L3
knee
L4
to heel (medial)
L5
lateral leg and large toe
S1
sole + small toe
S2
up middle of leg at posteriorly
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CEREBELLAR
FUNCTION: Basically a servocontrol mechanism
1.
Maintain posture/balance
2.
Fine voluntary movements
3.
Co-ordinate smooth tracking movements of eyes
4.
Control trajectory, velocity and acceleration of movements.
STRUCTURE: Complex
Inputs: Ascending
1. spinocerebellar
2. vestib apparatus
Descending
1. pyramidal
2. extrapyramidal
Outputs:
1. Motor cortex
2. Basal ganglia
3. Red nucleus
4. Reticular formation
5. Vestib appartus
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EXAMINATION TECHNIQUE
1.
LISTEN:
"This patient has a problem with co-ordination." (DDx : Cerebellar,
posterior column, extrapyramidal lesions)
2.
EYES :
Nystagmus (when look to side of lesion Central
Labyrinthe
3.
:Rapid to side of lesion.)
:Rapid away from lesion.)
SPEECH: Impaired rate, rhythm and amplitude i.e.Jerky, explosive and loud with
irregular separation of syllables:
West Register Street
Irish Constabulatory
British Constitution
4.
UPPER LIMBS
: Drift
: Rebound
: Tremor (agonist hypotonia)
: Hypotonia (loss facilitatory influence on spinal motor neurons)
5.
FINGER NOSE
: Intention tremor
: Past-pointing
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6.
RAPID MOVEMENTS
7.
DYSDIADOKOKINESIS
8.
LEGS
: tone
: heel-shin
: foot-tap
9.
SIT ON BED
: truncal ataxia
: reflexes (pendular)
10.
GAIT
PATTERNS
Midline:
Dysarthria gait and truncal ataxia
Hemispheric:
Limb ataxia, tremor, nystagmus, hypotonia
I.
UNILATERAL
-
Ischaemia (Lateral Medullary Sydnrome), MS,
Tumour, abscess, trauma, PNS
II.
BILATERAL
-
Drugs (ETOH, Phenytoin), MS, SOL, PNS,
Friedreichs Ataxia, Hypothyroid, Arnold Chiar
malformation.
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III.
MIDLINE
IV.
ROSTRAL/VERMIS
(Spares arms)
-
PNS, Midline tumours
-
Alcohol
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