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The Basic Neurological Exam (Part I)
Physical Exam Curriculum
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Outline Lecture Review a brief version of the complete neurological exam Highlight the highest yield components of the neurological exam Focus on primary care Discuss how to focus a neurological exam based upon symptoms Practice! Ophthalmoscopic exam Any component of the neuro exam
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The Well-Visit Neurology Exam
Cognition Wakefulness and alertness Orientation Basic language and speech function Repeating phrases Naming objects Following commands (ascertained through rest of exam) Cranial nerves Pupillary exam Eye movements Facial strength Palatal elevation Shoulder shrug Tongue movements Motor Pronator drift Finger tapping Coordination Finger to nose Heel to shin Sensory Romberg testing Gait Normal walk and turn Stand on heels, Stand on toes Tandem gait
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The Well-Visit Neurology Exam
Cognition Wakefulness and alertness Orientation Basic language and speech function Repeating phrases Naming objects Following commands (ascertained through rest of exam) Cranial nerves Pupillary exam Eye movements Facial strength Palatal elevation Shoulder shrug Tongue movements Motor Pronator drift Finger tapping Coordination Finger to nose Heel to shin Sensory Romberg testing Gait Normal walk and turn Stand on heels, Stand on toes Tandem gait DISCLAIMER This is not a “rule out neurology” exam Please never just do this exam for anyone with neurologic complaints Please never just do this exam while rotating on neurology You still have to use your brain to figure out the necessary parts of the exam When in doubt, test more and/or refer to neuro
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The Complete Neurological Exam
Cognition Cranial Nerves Motor Function Deep Tendon Reflexes Sensation Coordination (cerebellar) Gait
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Mental Status and Cognition
Complete exam includes discussion of: Level of consciousness Alertness Language Speech Attention MMSE: orientation, attention, concentration, memory, language, construction abilities Sn 71-92%, Sp 56-96% not as good in MCI MOCA: useful for detecting mild cognitive impairment (MCI) Sn 90%, Sp 87% memory visuospatial processing executive functioning perceptual disturbances thought form/content Simmons, et al. Evaluation of Suspected Dementia Am Fam Physician Oct 15;84(8):
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Mental Status and Cognition
Complete exam includes discussion of: Level of consciousness Alertness Language Speech Attention MMSE: orientation, attention, concentration, memory, language, construction abilities Sn 71-92%, Sp 56-96% not as good in MCI MOCA: useful for detecting mild cognitive impairment (MCI) Sn 90%, Sp 87% memory visuospatial processing executive functioning perceptual disturbances thought form/content Simmons, et al. Evaluation of Suspected Dementia Am Fam Physician Oct 15;84(8):
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Mental Status and Cognition
Screening tests for Dementia Clock Draw (organization/planning) Sn 76%, Sp 81% Verbal Fluency (animal naming) (<15), Sn 88%, Sp 96% Mini-Cognitive Assessment Instrument (Mini-Cog), Sn 76%, Sp 89% Three item recall plus clock draw 0-2: high likelihood of dementia, 3-5: low likelihood of dementia Simmons, et al. Evaluation of Suspected Dementia Am Fam Physician Oct 15;84(8):
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The Complete Neurological Exam
Cognition Cranial Nerves Motor Function Deep Tendon Reflexes Sensation Coordination (cerebellar) Gait
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Cranial Nerves
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Cranial Nerves: How do I test?
Olfactory: smelling salts Optic: fundoscopic exam, visual fields, visual acuity, pupillary light reflex Oculomotor/Trochlear/Abducens: extraocular movements Trigeminal: sensation across three planes of face (V1, V2, V3), forced bite Facial: close eyes tightly, smile, grimace, puff out cheeks Vestibulocochlear: finger rub, tuning fork tests (Rinne, Weber) Glossopharyngeal/Vagus: gag reflex, “ahhh” Spinal Accessory: shrug shoulders, turn head Hypoglossal: tongue movement from side to side
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Cranial Nerves: How do I test?
Olfactory: smelling salts Optic: fundoscopic exam, visual fields, visual acuity, pupillary light reflex Oculomotor/Trochlear/Abducens: extraocular movements Trigeminal: sensation across three planes of face (V1, V2, V3), forced bite Facial: close eyes tightly, smile, grimace, puff out cheeks Vestibulocochlear: finger rub, tuning fork tests (Rinne, Weber) Glossopharyngeal/Vagus: gag reflex, “ahhh” Spinal Accessory: shrug shoulders, turn head Hypoglossal: tongue movement from side to side
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More Details on Extraocular Movement Testing
Strength of eye movements – testing patients for fullness of eye movements to assess for gaze paresis e.g. abducens nerve palsy, internuclear ophthalmoplegia Examining quality of eye movements Fast saccades Smooth pursuits Examining for nystagmus First test at primary gaze i.e. have the patient stare straight at your finger and observe eye movements. The eyes should not move. Look for nystagmus during and at the end of eye movements Physiologic nystagmus – 3-4 beats of lateral beating nystagmus at end gaze (e.g. look all the way to the right) that extinguishes Any other nystagmus is potentially abnormal! Vertical nystagmus is very, very bad and can indicate posterior fossa disease
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The Complete Neurological Exam
Cognition Cranial Nerves Motor Function Deep Tendon Reflexes Sensation Coordination (cerebellar) Gait
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Motor Exam Muscle Bulk: inspection
LMN: muscle wasting or atrophy Muscle Tone: resistance to passive movement Increased tone: “rachety” (cogwheel-->Parkinson’s), “clasp knife” (spasticity-- >UMN), “lead pipe” (basal ganglia) Decreased tone: indicative of lower motor neuron disease Muscle Strength: graded on scale 0=no movement, 1= flicker, 2=horizontal plane, 3= against gravity, 4= against some resistance, 5=normal Pronator Drift: helps elucidate subtle arm weakness (weaker arm “drifts”) Dexterity: finger taps, open/close hand, toe taps slowed movement suggests pyramidal/extrapyramidal issues Note any abnormal movements chorea, tremor
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Motor Exam Muscle Bulk: inspection
LMN: muscle wasting or atrophy Muscle Tone: resistance to passive movement Increased tone: “rachety” (cogwheel-->Parkinson’s), “clasp knife” (spasticity-- >UMN), “lead pipe” (basal ganglia) Decreased tone: indicative of lower motor neuron disease Muscle Strength: graded on scale 0=no movement, 1= flicker, 2=horizontal plane, 3= against gravity, 4= against some resistance, 5=normal Pronator Drift: helps elucidate subtle arm weakness (weaker arm “drifts”) Dexterity: finger taps, open/close hand, toe taps slowed movement suggests pyramidal/extrapyramidal issues Note any abnormal movements chorea, tremor
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The Complete Neurological Exam
Cognition Cranial Nerves Motor Function Deep Tendon Reflexes Sensation Coordination (cerebellar) Gait
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Deep Tendon Reflexes Reflexes: Grading: Babinski/Plantar Response:
Achilles: S1, S2 Patellar: (L2), L3, L4 Biceps: C5, C6 Triceps: (C6), C7, C8 Grading: Absent (0), Reduced (1+), Normal (2+), Brisk (3+), Clonus (4+) Hyperactive reflexes: UMN Brisk reflexes can be normal in young healthy people Reduced reflexes: LMN May be present in radiculopathies and mononeuropathies Babinski/Plantar Response: Normal: flexion of great toe with curling of toes Present: great toe extends and toes fan out <--UMN lesion
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The Complete Neurological Exam
Cognition Cranial Nerves Motor Function Deep Tendon Reflexes Sensation Coordination (cerebellar) Gait
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Sensation Dermatomes: Neuropathies: Modalities:
small-fiber = pain/temp DM large-fiber = vibration/proprioception B12 Modalities: light touch pain and temperature vibratory Proprioception (includes Romberg Test)
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Sensation Romberg Testing: Where to test
Patient stands with eyes closed Positive test: imbalance Where to test If unclear localization, test hands and feet If spinal cord localization is suspected, test for sensory level If spinal cord or nerve root is suspected, test for specific dermatomes
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Sensation Romberg Testing: Where to test
Patient stands with eyes closed Positive test: imbalance Where to test If unclear localization, test hands and feet If spinal cord localization is suspected, test for sensory level If spinal cord or nerve root is suspected, test for specific dermatomes
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The Complete Neurological Exam
Cognition Cranial Nerves Motor Function Deep Tendon Reflexes Sensation Coordination (cerebellar) Gait
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Coordination Involve multiple integrated systems: sensory, vestibular, pyramidal, extrapyramidal, basal ganglia, cerebellum Cerebellum combines proprioception with information from muscles to allow smooth limb/trunk movements Abnormalities results in ataxia (midline lesions cause truncal ataxia) Testing for appendicular ataxia: finger to nose heel to shin rapid alternating movements (rhythmic) Testing for truncal ataxia: stance gait
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Coordination Involve multiple integrated systems: sensory, vestibular, pyramidal, extrapyramidal, basal ganglia, cerebellum Cerebellum combines proprioception with information from muscles to allow smooth limb/trunk movements Abnormalities results in ataxia (midline lesions cause truncal ataxia) Testing for appendicular ataxia: finger to nose heel to shin rapid alternating movements (rhythmic) Testing for truncal ataxia: stance gait
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Gait Assessment: Assess for symmetry
Speed Stride Length Turning Associated Movements Assess for symmetry Testing: walk and turn, stand on heels/toes, tandem Types of abnormal gaits: Ataxic (cerebellar): wide-based, “drunk” Gait spasticity (UMN): stiffness Hemiparetic gait: favoring one side Parkinsonian: decreased arm swing, shuffling ASM
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Gait Assessment: Assess for symmetry
Speed Stride Length Turning Associated Movements Assess for symmetry Testing: walk and turn, stand on heels/toes, tandem Types of abnormal gaits: Ataxic (cerebellar): wide-based, “drunk” Gait spasticity (UMN): stiffness Hemiparetic gait: favoring one side Parkinsonian: decreased arm swing, shuffling ASM
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The Complete Neurological Exam
Cognition Cranial Nerves Motor Function Deep Tendon Reflexes Sensation Coordination (cerebellar) Gait
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The Well-Visit Neurology Exam
Cognition Wakefulness and alertness Orientation Basic language and speech function Repeating phrases Naming objects Following commands (ascertained through rest of exam) Cranial nerves Pupillary exam Eye movements Facial strength Palatal elevation Shoulder shrug Tongue movements Motor Pronator drift Finger tapping Coordination Finger to nose Heel to shin Sensory Romberg testing Gait Normal walk and turn Stand on heels, Stand on toes Tandem gait
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