Introduction to Physical Diagnosis:

Neurology

Developed by Roger L. Weir, M.D.

Associate Professor of Neurology

OUTLINE

1. HISTORY AND PHYSICAL2. TECHNIQUE

– Courtesy– Routine– Actual / Practice

3. ILLNESSES/ DISORDERS / DIAGNOSES– * INTEREST– DIAGNOSIS– TREATMENT– (PREVENTION)– COUNSELLING– “N” common disorders– uncommon disorders

4. (NEWER DIAGNOSTIC TESTS / TOOLS)

NEUROLOGICAL HISTORY

• C/C or Presenting Illness (NP vs Consult) (see below)• HPI (see below)

• PMH includes tests done risk factors, HTN, Diab M.,Dyslipidemia

Head trauma, auto-accident previous surgery

c/c THE CHIEF COMPLAINT+or- other neurological problems

• HEADACHE. Onset, prior, severity, frequency, n or v, photophobia, fever ,phonophobia, age, confusion.

• LOSS OF CONSCIOUSNESS. seizure, syncope, other

• R WEAKNESS. Duration, onset, vision, sensation, headache,

• LOW BACK PAIN.duration,initial cause, rx

c/c contd

• DIZZINESS. Vertigo, tinnitus, double vision, faintness, ataxia, inducer, reliever, rising, flat, turning in bed, hearing.

• NUMBNESS OF HAND. Which fingers, neck pain

• DIFFICULTY WALKING. Pain, where pain

• DIFFICULTY SPEAKING. Understanding,

being understood

c/c contd.

• BLURRED/DOUBLE VISION one or two,

in which plane,

SEEING THINGS. ?hearing voices, threats, delusions, crawling in skin, drug use, FH.

History Present illness

• Onset date; recheck for a remote onset• Speed of onset• Prevalence/persistence/? Intermittent• Severity/ variations in severity• Precipitants• Relievers• Medication effect• Associated symptoms• Associated symptoms in the past

Neurological History

• FAMILY HISTORY

• Risk factors suggested

• Sickle Cell anemia

• Muscular Dystrophy

• Myocardial Infarction

• Spinocerebellar degeneration

Neurological History

• SOCIAL HISTORY

Alcoholism, Cocaine use Nicotine use,

Occupation

Living situation

Spousal/emotional status

ROS Multiple. See outline of Neuro exam.

THE NEUROLOGICAL EXAMINATION

• MENTATION AND SPEECH• CRANIAL NERVES (2 to 12)• MOTOR FUNCTION

– (Normal, Impaired, Abnormal movement)• COORDINATION (Cerebellar Function)• REFLEXES (DTR’s—deep tendon reflexes)• SENSATION• MENINGEAL SIGNS• STATION AND GAIT• SPINE / MUSCULO-SKELETAL

MENTATION AND SPEECH

• Level of Consciousness:– Awake, stupor, coma

• Memory:– Digit span (reverse versus forward), recent, remote, fund of

information

• Calculations:– Arithmetic, money (?education)

• Draw a clock• Draw a person• Copy a figure• Confusion• Denial / Inattention

MENTATION AND SPEECH

• Anosognosia

• Apraxia

• Distractibility

• Hallucinations:– Auditory, visual, other

• Mood:– anxiety, depression

• Appropriateness of interaction

MENTATION AND SPEECH

• Speech Production:– Quantity, flow, loudness, syllables, sounds, words

• Following Commands:– Verbal, written, gestures

• Naming• Repetition:

– sentence, word, counting, singing• Reading• Writing:

– spontaneously, copying, • Calculations / arithmetic

CRANIAL NERVES 1. 2*. 3*. 4. 5. 6*, 7*, 8*, 9, 10, 11, 12

• CN1CN1:: R/L nostril, non-irritant, diminution with age

• **CN2CN2:: Visual acuity, visual fields, light reflex, accommodation, optic disc

• **CN3CN3:: Light reflex, accommodation, EOM, lid opening, pupil size

• CN4CN4:: Depression of the adducted eye

• CN5CN5:: Facial sensation, jaw closure, side/side jaw movement

• **CN6CN6:: Abduction of the eye

• **CN7CN7:: Brow elevation, eyelid closure, smile facial droop +autonomic/sensory

• **CN8CN8:: Auditory acuity, dizziness, balance, tinnitus, nystagmus, Weber, Rinne

• CN9CN9: : Gag reflex, swallowing

• CN10CN10: : Vocal cord movement + autonomic

• CN11CN11: : Sternocleido-Mastoid, Trapezius

• CN12CN12: : Tongue deviation, atrophy, fasciculations

CRANIAL NERVES 1. 2*. 3*. 4. 5. 6*, 7*, 8*, 9, 10, 11, 12

MOTOR EXAMINATION

• WASTING / HYPERTROPHY (Duchenne muscular dystrophy)

• FASCICULATIONS (evidence of lower motor neuron dysfunction)

MOTOR EXAMINATION

• STRENGTH:– Proximal (characteristic of muscle problem),

distal (characteristic of periph. neuropathy), *Right vs. Left, upper limbs, lower limbs, nerve root distribution, nerve distribution, severity(0 to 5), pain effect, other.

MOTOR EXAMINATION

• RIGIDITY, SPASTICITY, OTHER

• SPEED OF MOVEMENT

• ABNORMAL INVOLUNTARY MOVEMENTS – eg tremor

• OTHER ABNORMAL MOVEMENTS – eg epileptiform.

COORDINATIONCerebellar function

• Reason for doing the strength test before coordination is to know if incoordination is due only to muscle weakness

• May apparently vary with strength

COORDINATIONCerebellar function

• **FINGER / NOSE testFINGER / NOSE test::– proximal, transitional, distal, moving target– ?past pointing, ?intention tremor

• RAPIDLY ALTERNATING MOVEMENTSRAPIDLY ALTERNATING MOVEMENTS::– supination/pronation, tapping rhythm

• **HEEL/SHIN testHEEL/SHIN test::– proximal, transit– ankle dorsiflexion

• **TANDEM WALKINGTANDEM WALKING:: (?mechanical impediment)– A little difficult in fat persons and mechanically impaired

• CHECK / REBOUNDCHECK / REBOUND:**:** – Cerebellar test…person with disfunction will have more rebound

• POSTUREPOSTURE• STANDING BASESTANDING BASE:: width, stability• GAITGAIT:: stable, asymmetric, ?type

REFLEXES

• Always compare the right with the left• Deep tendon, pathological, superficial

• SUPERFICIALSUPERFICIAL::– abdominal, cremasteric– Abdominal reflex disappears in the presence of upper motor neuron

(multiple sclerosis)• PATHOLOGICALPATHOLOGICAL::

– Babinski, snout, Hoffman, – Ankle clonus, other clonus– Oppenheim, Chaddock

• DEEP TENDON(R/L)DEEP TENDON(R/L)::– upper/lower, proximal/ distal– BJ, TJ, SJ KJ , AJ– Jaw jerk (corticobulbar test), pectoralis, adductor.

• GRADINGGRADING::– 0, 1, 2 , 3, 4– where 2 represents an average reflex.

SENSATION

• R/L, Prox/Distal, Upper/Lower, Nerve, Nerve root,• dorsal column, spinothalamic,• large fibre/ small fibre• CNS

• Light touch(acuity, subjective types)• Pin: metal, wood (NO reusable sharp points)• Temperature: cold metal vs. uncold wood; other

• Position sense( in 4 limbs), distal with or without proximal• Vibratory sense (requires judgement)

• Touch: Double simultaneous stimulation• Graphesthesia• Stereognosis• Two-point discrimination• Point localization

MENINGEAL SIGNSbacterial/ viral/other meningitis& subarachnoid hemorrhage

• NECK STIFFNESS• KERNIG• BRUDZINSKI• PHOTOPHOBIA• EYEBALL TENDERNESS (least

important)• (STRAIGHT LEG RAISING)• (?Headache, vomiting, lethargy)

SPINE/MUSCULO-SKELETAL

• Spine tenderness: – Cervical, Lumbar, Thoracic– Sacro-iliac joints

• Straight leg raising (for herniated disc?)• Muscle tenderness or tenseness of:

– Scalp muscles– Cervical paraspinals– Lateral neck muscles– Scapular region muscles– Lumbar paraspinals– Lateral sacrum

• Patrick’s Sign (for detecting hip problem)