Neurological Examination Sherif Elwatidy MSc, FRCS(SN), MD Professor of Neurosurgery, College of Medicine - KSU

Neurologic History Like history in Medicine & Surgery Personal history History of the present complaints Social History Past medical History

From the history we should be able to answer 2 important questions: Where is the problem ? (brain, spine –Cx., Thoracic, lumbar) What is the nature of the problem ? (Congenital, inflammatory, neoplastic, degenerative, ….)

The objective of a neurological exam is threefold. 1. To identify an abnormality in the nervous system. 2. To differentiated peripheral from central nervous system lesions.

Neurologic examination includes: I- General Appearance, including posture, motor activity, vital signs and perhaps meningeal signs if indicated. II- Mini Mental Status Exam, including speech observation. III- Cranial Nerves, I through XII. IV - Motor System, including muscle atrophy, tone and power. V- Sensory System, including vibration, position, pin prick, temperature, light touch and higher sensory functions. VI- Reflexes, including deep tendon reflexes, clonus, Hoffman's response and plantar reflex. VII- Coordination, gait and Rhomberg's Test Examining the comatose patient

General appearance Level of consciousness Personal hygiene and dress Posture and motor activity Height build and weight Vital signs

POSTURE Chorea refers to sudden, ballistic movements, Athetosis refers to writhing, repetitive movements. Fasciculations are fine twitching of individual muscle bundles, most easily noted on the tongue. Dystonia refers to sudden tonic contractions of the muscles of the tongue, neck (torticollis), back (opisthotonos), mouth, or eyes (oculogyric crisis). Early signs of tardive dyskinesia are lip smacking, chewing, or teeth grinding. Damage to the substantia nigra may produce a resting tremor. This tremor is prominent at rest and characteristically abates during volitional movement and sleep. Damage to the cerebellum may produce a volitional or action tremor that usually worsens with movement of the affected limb. Spinal cord damage may also produce a tremor, but these tremors do not follow a typical pattern and are not useful in localizing lesions to the spinal cord.

Higher mental functions Consciousness (GCS) Intelligence Nominate week days forward & backward Nominate months Forward & backward Digit span (6 forward & 4 backward) Spelling short word forward & backward e.g W-O-R-L-D and D-L-R-O-W - Memory Short term Long term Language Spoken written

Language

Cranial nerve examination I: Olfactory II: Optic III-IV-VI: extraoculars V: Trigeminal VII: Facial VIII: Vestibulocochlear IX-X: Glossopharyngeal, Vagus XI: Accessory XII: Hypoglossal

CN I: Olfactory Usually not tested. Observe for rash, deformity of nose or discharge (CSF). Test each nostril with essence bottles of coffee, vanilla, peppermint.

CN II: Optic With patient wearing glasses. Test each eye separately on eye chart/ card using an eye cover. Examine visual fields by confrontation , keep examiner's head level with patient's head. If poor visual acuity, map fields using fingers and a quadrant-covering card. Look into fundi.

papilloedema Normal papilloedema Optic atrophy

Light Reflex

Fudoscopy Papilledema Optic atrophy

CN III, IV, VI: Oculomotor, Trochlear, Abducens Look at pupils: shape, relative size, ptosis. Shine light in from the side to gauge pupil's light reaction. • Assess both direct and consensual responses. • Assess afferent pupillary defect by moving light in arc from pupil to pupil. unne). Optionally: as do arc test, have pt place a flat hand extending vertically from his face, between his eyes, to act as a blinder so light can only go into one eye at a time. "Follow finger with eyes without moving head": test the 6 cardinal points in an H pattern. Look for failure of movement, nystagmus [pause to check it during upward/ lateral gaze]. Convergence by moving finger towards bridge of pt's nose. Test accommodation by pt looking into distance, then a hat pin 30cm from nose. If MG suspected: pt. gazes upward at Dr's finger to show worsening ptosis.

CN V: Trigeminal Corneal reflex: patient looks up and away. • Touch cotton wool to other side. • Look for blink in both eyes, ask if can sense it. • Repeat other side [tests V sensory, VII motor]. Facial sensation: sterile sharp item on forehead, cheek, jaw. • Repeat with dull object. Ask to report sharp or dull. • If abnormal, then temperature (heated/ water-cooled tuning fork), light touch (cotton). Motor: pt opens mouth, clenches teeth (pterygoids). • Palpate temporal, masseter muscles as they clench. Test jaw jerk (pseudobulbar palsy).

CN VII: Facial Inspect facial droop or asymmetry. Facial expression muscles: pt looks up and wrinkles forehead. • Examine wrinkling loss. • Feel muscle strength by pushing down on each side [UMNL preserved because of bilateral innervation]. Pt shuts eyes tightly: compare each side. Pt grins: compare nasolabial grooves. Also: frown, show teeth, puff out cheeks. Corneal reflex already done. See CN V.

CN VIII: Vestibulocochlear Dr's hands arms length by each ear of pt. • Rub one hand's fingers with noise on one side, other hand noiselessly. • Ask pt. which ear they hear you rubbing. • Repeat with louder intensity, watching for abnormality. Weber's test: Lateralization • 512/ 1024 Hz [256 if deaf] vibrating fork on top of patients head/ forehead. • "Where do you hear sound coming from?" • Normal reply is midline. Rinne's test: Air vs. Bone Conduction • 512/ 1024 Hz [256 if deaf] vibrating fork on mastoid behind ear. Ask when stop hearing it. • When stop hearing it, move to the patients ear so can hear it. • Normal: air conduction [ear] better than bone conduction [mastoid]. If indicated, look at external auditory canals, eardrums.

CN IX, X: Glossopharyngeal, Vagus Voice: hoarse or nasal. Pt. swallows, coughs (bovine cough: recurrent laryngeal). Examine palate for uvular displacement. (unilateral lesion: uvula drawn to normal side). Pt says "Ah": symmetrical soft palate movement. Gag reflex [sensory IX, motor X]: • Stimulate back of throat each side. • Normal to gag each time.

CN XI: Accessory From behind, examine for trapezius atrophy, asymmetry. Pt. shrugs shoulders (trapezius). Pt. turns head against resistance: watch, palpate SCM on opposite side.

CN XII: Hypoglossal Listen to articulation. Inspect tongue in mouth for wasting, fasciculations. Protrude tongue: unilateral deviates to affected side.

Coordination Gait Tandem walking Limb coordination Rapid alternating movement Finger - nose Finger – finger Heel - shin

Motor examination Muscle status Muscle tone Muscle power Tendon reflexes Gait & coordination

Deep tendon Jerks

Sensory system Cortical sensation Superficial sensation (pain, temp, light touch) Deep sensation (joint movement, position & vibration sensation)