1. Neurological Examination Dr Andrew Gale 23 Feb 2010

2. What do I need to do? Systematic neurological examination Selective examination “3-minute examination” None

3. During History OLAT Observe –Gait –General demeanour –Facial mobility, blink rate Listen –Speech quality and content Assess –Mental state –Memory –Reliability –Consistency Think –Provisional diagnosis –What do I want to know?

4. Systematic Neurological Examination 1.Mental state and higher function 2.Gait, posture and movement 3.Cranial nerves 4.Motor function 5.Coordination 6.Sensory function

5. 1. Mental state and higher function Mental state Cognitive function Speech Higher function deficit

6. 2. Gait, posture and movement Gait –Observe, particularly steps and arm swing and tremor –Heels and toes –Heel to toe –Romberg Rise from crouching

7. 3. Cranial Nerves Vision –VA, VF Fundi Ptosis, Proptosis, Pupils, Eye movts, nystagmus Facial sensation and corneal reflexes Facial weakness Hearing Tongue

8. Diagnosis of weakness Localisation depends on pattern of involvement and associated sensory impairment 1.Cortex 2.Internal capsule 3.Spinal cord 4.Anterior horn cell 5.Nerve root/Peripheral nerve 6.Neuromuscular junction 7.Muscle Pathology –What lesions occur at that site? –Time course of illness

9. Acute limb weakness Common causes

10. 4. Motor function Posture Rapid repetitive movts fingers Finger-nose coordination Symptomatic muscles –Wasting, fasciculation, tone, power Reflexes Plantars

11. 5. Coordination Finger-nose Heel-shin

12. 6. Sensory function Only test when relevant Focus on question that needs answering Unexpectedly finding loss of touch or reduction of pin-prick not likely to be relevant VS loss commonly asymptomatic Joint position loss most significant –Especially in ataxia or loss of balance without dizziness

13. Common neurological complaints Headaches Blackouts Dizziness (Vertigo) Weakness Numbness Tremor Loss of balance Memory loss Pain

14. During History Observe –Gait –General demeanour –Facial mobility, blink rate Listen –Speech quality and content Assess –Mental state –Memory –Reliability –Consistency Think –Provisional diagnosis –What do I want to know?

15. Examination in Headaches BP Visual fields Fundi Reflexes Plantars

16. Examination in Blackouts BP, heart Visual fields Fundi Reflexes Plantars

17. Examination in Vertigo Gait, Tandem walking Fundi Corneal reflexes Nystagmus Facial weakness Hearing Reflexes Plantars Ataxia Hallpike’s test (vertigo)

18. Examination in Weakness Wasting and fasciculation Tone Power Reflexes Plantars

19. Examination in Numbness Motor Sensory Modality –LT –VS –JPS –PP ( & Temp) –Dissociated Pattern of sensory loss to LT & PP –Peripheral nerve –Nerve root - dermatomal –Spinal - sensory level –Hemisensory

20. Examination in Tremor Observation of tremor at rest, walking, posture, action and activities Gait Facial movement Dexterity Muscle tone Coordination

21. Examination in Memory Loss Corroborative history MMSE Parkinsonian features Motor signs Sphincter disturbance

22. Examination in pain Anatomical localisation Appropriate exam for concomitant motor or sensory impairment

23. During History OLAT Observe –Gait –General demeanour –Facial mobility, blink rate Listen –Speech quality and content Assess –Mental state –Memory –Reliability –Consistency Think –Provisional diagnosis –What do I want to know?

24. “3 min exam” 1.Facial mobility & movt e.g. ptosis, facial weakness, Parkinson’s 2.Speech 3.Gait, H-T, walk on heels & toes, Rombergs 4.VF, eye movements, pupils 5.Face and tongue 6.Outstretched arms, tremor, pronator drift 7.Rapid finger movts 8.Reflexes and plantars 9.Fundoscopy