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Approach to examination of the
neurological system
Dr Nortina Shahrizaila
Consultant NeurologistUniversity of Malaya Medical Centre
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5 Possible Scenarios
• “Please examine this patient’s..”
1. Eyes
2. Cranial nerves excluding the eyes
3. Speech
4. Upper or Lower Limb
5. Cerebellar system
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Motor Nervous System
CEREBRAL HEMISPHERES
BRAINSTEM/CEREBELLUM
SPINAL
CORD SPINAL NERVES
CRANIAL NERVES
UMN LMN
N M J
HEAD + NECKMUSCLES
N M J
LIMBMUSCLES
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Cranial Nerves and Speech
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SCENARIO 1
• “Please examine this patient’s eyes”
• Examiners want to see if you can do a
thorough eye examination.
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System
• Inspection
• Optic nerve (II)
• Eye movements (III, IV, VI)
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Inspection
• Clues by bed
– Eyepatch: diplopia
– Magnifying glass: poor acuities
• Face
– Ptosis
– Pupil size / symmetry
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• TIP 1 – Whenever you see asymmetrical pupils, look
for ptosis
• TIP 2
– Whenever you see ptosis, look at pupil sizes
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–
small pupil and ptosis• Horner’s (sympathetic lesion)
– large pupil and ptosis• 3rd nerve palsy (eye usually ‘down&out’ aswell)
Pupil size and Ptosis : 4 Patterns
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- ptosis BUT equal pupils
Think Myasthenia Gravis
(levator palpebrae)
- unequal pupilsBUT no ptosis
Usuallly Holmes Adie pupil(parasympathetic lesion) –
large at onset–
shrinkswith age
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II
• Acuity
• Fields
• Fundoscopy
• Pupillary reflexes
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“I’
d like toformally
examine vision
with a Snellenchart”
60
36
24
18
12
9
6
5
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Optic Nerve
Chiasm
Optic Tract
3 3
L R
ANTERIOR
POSTERIOR Occipital Cortex
Visual
Fields
2. Bitemporal hemianopia
3. C/l Homonymous hemianopia
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Visual Fields
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“I’d like to assess the
fundi”
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Normal
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Optic Atrophy
Causes
1. MS
2. Chronic
raised ICP
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Papilloedema
Causes1. Raised ICP
2. Hypertension
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Pupil reflexes
• Light (direct + consensual) – Normal pupil
• constricts to light, dilates to dark
– Failure to constrict or dilate•
Implies severe optic nerve lesion – Relative failure to constrict in light (RAPD)
• Implies moderate optic nerve lesion
– Shine light on each eye in turn
– Consensual dilation to dark in an affected pupil overrides impaired
direct constriction to light => affected pupil dilates despite light
• Accommodation
– Failure suggests Holmes Adie or 3rd N palsy
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III, IV, VI
• Eye movements
– Range
– Diplopia
– Nystagmus
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6 3
4
33
3
ABduction ADduction
Eye Movements: Patient’s right eye
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Partial right-sidedptosis
R pupil >> left
R eye lookingdown +/- out
So this is a (partial)right-sided 3rd(oculomotor) nerve palsy
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Summary
• II Horner’s (CxR); RAPD (MRI)
•
III,VI Recognise; DM (BM, BP, MRI)
• Ptosis U/l: Horner’s (CXR)
B/l: Myasthenia (Ach R ab, EMG),
Myotonic dystrophy (gene test)
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Scenario 2
• “Please examine the cranial nerves
excluding the eyes”
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System
• Inspection
• I
• V
• VII
• VIII
•IX-X
• XI
• XII
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I
“Have you noticed any change in your sense
of smell?”
• If yes, may be due to frontal lesions (eg tumour), or
neurodegenerative conditions (Alzheimer’s, Parkinson’s)
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V
• Sensory
• Motor
• Reflex
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NB. V1 supplies tip
of nose
NB. V3 does not
supply angle of jaw
C2
Sensory supply of face
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• Test sensation in each division
–
Ideally with a pin
• Clench teeth
– Feel masseter & temporalis
• Ask to open mouth
– Watch for deviation (to weak side)
– Resist closure
• “I would like to examine the corneal reflexes”
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VII
• Motor
• Distinguish between UMN & LMN
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Inspection
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VIII
• Test with whispered numbers or finger rub
• Cover c/l ear
• If u/l hearing loss, say “I would like to
perform Rinne’s and Weber’s tests to
distinguish between sensorineural and
conductive deafness”
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Interpreting Rinne’s
• Normal
– AC > BC
• Sensorineural
– AC > BC
•Conductive – BC > AC
NB. Weber’s test just confirms conductive deafness
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IX - X
• IX
– Sensory (gag)
• X
– Motor (uvula)
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• “I would like to test the gag reflex”
• Ask patient to say ‘Aaah’
– Uvula pulled away from weak side
– Complete failure to elevate suggests b/l palatal
weakness
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XI
• Trapezius
– Shoulder shrug
• Sternocleidomastoid
– “Turn your head against my hand”
– Remember you are testing muscle on oppositeside
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XII
• Inspection (in mouth)
• Deviation
• Strength
• Speed
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Tongue deviates to left
Strong (R) side pushesweaker (L) side past themidline
So this is a left-sided
12th (hypoglossal) palsy
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Summary
• I, IX,X,XI very rare
• V stroke; MS
• VII UMN: stroke
LMN: Bell’s
•VIII sensorineural: age, neuroma
conductive: wax, otitis media
• XII stroke; MND
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Scenario 3
• “Please examine this patient’s speech”
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System
• Easy question (eg name, address)
• Free speech: listen carefully!
• Comprehension (increasing sophistication)• Naming (increasing sophistication)
• Consonants (p, t, k)
•Phrases (british constitution, baby
hippopotamus, west register st)
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• Fluent
– Comprehension intact• Normal
– Comprehension affected
• Receptive dysphasia
• Non-fluent
– Naming problems
•Expressive dysphasia
– Articulation problems
• Dysarthria
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Types of Dysarthria
• Cerebellar
– Explosive (poor control of volume)
– Staccatoed
• Bulbar/Pseudobulbar
– Nasal
– Strangled
• Parkinsonian
– Quiet
– Mumbled
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Summary
• Dysphasia Stroke (CT)
•Dysarthria – Consonant VII, IX-X, XII (MRI)
– Cerebellar MS (MRI), tumour
(CT), genetic (gene test)
– Bulbar/Pseudobulbar MND (EMG), Strokes (MRI)
Myasthenia (Ach R ab, EMG)
– Parkinsonian Parkinson’s! (clinical)
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Limbs & Cerebellum
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Scenario 4
“Please examine this patient’s
upper / lower limbs”
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Upper or Lower Limb
Aims
a) localise the lesion
– R or L
– Motor or sensory (or both)
– If motor, UMN or LMN (or both)
b) give a reasonable differential based onthat lesion site (s)
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• So you need an anatomical / structuraloverview of the nervous system
• And a list of 3-4 differentials for each site
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Structure of (motor) nervous system
• Brain
• Spinal cord
• Anterior horn cell
• Nerve root / plexus
• Peripheral nerve
• Neuromuscular junction
• Muscle
Structure
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Main differentials per part
• Brain and cord MRI – Vascular (stroke)
– Tumour
– Central demyelination (multiple sclerosis)
– Infection (herpes encephalitis, zoster myelitis) – Degenerative disease (Parkinson’s, Alzheimer’s)
• Anterior horn cell NCS/EMG
– MND
– Infection (polio)
(NCS / EMG = Nerve conduction studies / Electromyography)
Structure
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• Nerve root / plexus NCS/EMG
– Intervertebral disc
– Tumour
– Demyelination (Guillain-Barre)
– Infection (Lyme)
• Peripheral nerve NCS/EMG
– Diabetes
– Alcohol/drugs
– Genetic (Charcot-Marie-Tooth)
– Peripheral demyelination (Guillain-Barre)
– Infection (syphilis)
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• Neuromuscular junction (NMJ)
– Antibody (myasthenia, LEMS) AChR Ab
– Infection (botulism, diphtheria) Culture
• Muscle
– Genetic
• Muscular dystrophy Gene test
• Myotonic dystrophy Gene test
•Mitochondrial myopathy Muscle biopsy
– Myositis CK, ENA
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Conventional system of Examination
• Inspection
• Tone
• Power
• Reflexes
• Coordination
• Sensation
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Inspection
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• Bedside
– Walking aids
• Patient
– Wasting & Fasciculations (LMN)
– Spotters
• Parkinson’s
• Myasthenia gravis
• Myotonic dystrophy
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LMN
• Wasting
• Fasciculations
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Parkinson’s
• Reduced facial expression
• Rest tremor
• Bradykinesia ( if undertreated)
• Dyskinesia ( from treatment)
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Myasthenia gravis
• Ptosis (u/l or b/l)
• Difficulty rising fromchair with arms folded
Myotonic dystrophy
•Bilateral ptosis
• Grip myotonia
• Tent-shaped mouth
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Tips 1 and 2
Best ways to start a limb examination
• For UL exam
– First test arms outstretched
• For LL exam
– First test gait
UL exam
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Outstretched arms - 4 signs:
• Hemiparesis
•Pronator drift – Palms up
• Rebound
• Pseudoathetosis
• Gross weakness
•Subtle UMNweakness
• Cerebellar sign
• Proprioceptive loss
Funny walksLL exam
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Funny walks
• Broad base
• Shuffling
• Waddling
• Stamping
• High stepping
• Circumduction
• Antalgic
• Ataxic
• Parkinsonian
• Myopathic
• Neuropathic
• Foot drop
• UMN
• Non-neurological / functional
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Tone
• Upper Limbs
– Elbow: flexion / extension, feel
– Wrist: flexion / extension & rotation, feel
• Lower Limbs
– Knee: flex hip quickly, observe for heel lift from bed
– Knee: flexion / extension, feel
– Ankle: roll thigh, observe movement
– Ankle: rapidly flex knee and ankle, observe for clonus
Tone
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Abnormal tone
• Reduced (Flaccid)
– Difficult unless clear asymmetry
• Increased
– Clasp knife (Spastic)
– Lead Pipe / Cogwheel (Rigid)
Tone
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Clasp Knife vs Lead Pipe
Pyramidal Extrapyramidal
Sudden give/catch Even resistance
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Power
• Start proximally, work distally
• Compare R with L
• Isolate the joint when testing
• UL LL
SAB HF/HE
EF/EE KF/KE
WE DF/PF
FAB
Thumb abduction
Power
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MRC Grading
• 0 no muscle or joint movement
• 1 muscle contraction only
• 2 joint movement (gravity removed/aided)
• 3 joint movement (despite gravity)
• 4 joint movement (despite resistance)
• 5 full power
Power
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Tip 3
Interpreting power findings
•Look for patterns of weakness
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Patterns of Weakness
Focal v Diffuse
Nerve or nerve root Proximal v Distal?
Muscle Neuropathy Neither
Pyramidal (UMN) Non-specific
Patterns of Weakness
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Focal weakness
• Wrist drop
– Radial nerve palsy
– C7 radiculopathy
• Foot drop
– Common peroneal nerve palsy
– L5 radiculopathy
Patterns of Weakness
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Proximal v Distal
• Proximal
– Muscle / Neuromuscular junction
– EXCEPTION : Myotonic dystrophy
• Distal
– Peripheral Neuropathy – AND Myotonic dystrophy
UMNPatterns of Weakness
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UMN
• PostureFlexed,
Pronated arm
Extended,
Adducted
leg
Anti-Gravity
Muscles>
Antagonistic
muscles
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Reflexes
• Hold Tendon hammer loosely
• Compare sides
• Practice reinforcement
• Babinski – Scratch outside of foot and round below toes
– Observe the first movement of the big toe only
Reflexes
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Root levels
(1 2 3 4 5 6 7 )
• Ankle S1
•Knee L2,3,4
• Biceps C5,6
• Supinator C5,6
• Triceps C7
Reflexes
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Interpretation
• Absent (after reinforcement)
– LMN lesion
– Very helpful sign
– But remember acute UMN areflexia
• Brisk
– Normal: Young, anxious
– Abnormal: UMN
• Especially if asymmetrical
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Coordination (see later)
• Upper Limb
– Finger-nose
– Dysdiadochokinesia (DDCK)
• Lower Limbs:
– Heel-shin – Tandem gait
S i
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Sensation
• Difficult! This will be taken into account.
• Learn the dermatomes & practice them
• Ensure you test
– Pin Prick
– Proprioception (including Romberg’s test)
• “I’d like to test vibration sense using a tuning fork ”
• “I’d like to test temperature sense using hot and cold water insuitable containers”
Sensation
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Tip 4
Once again, look for patterns!
Sensation
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1. Glove and stocking
– peripheral neuropathy
2. Dermatomal
– root lesion
– cord lesion (sensory
‘level
’)
• T4 (nipples)
• T10 (umbilicus)
3. Romberg – Implies proprioceptive or vestibular failure, NOT
cerebellar disease
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Scenario 5
“Please examine this patient’s
cerebellar system”
Cerebellum
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System
• Speech
• Eyes
• Arms
• Legs
• Gait
Cerebellum
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Speech
• “How did you get here today”
• Repetition
– British Constitution
– West Register Street
– Baby hippopotamus
• Usually a mix of non-fluent, staccato,variable volume, monotone pitch
Cerebellum
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Eyes
• Nystagmus
– Increases towards side of cerebellar lesion
• Eye movements – Pursuit (slow ‘tracking’ movements)
– “Follow my finger”
• Broken, jerky
– Saccades (rapid ‘finding’ movements)
– Look “left”, “right”, “up”, “down”
• Overshoots
A
Cerebellum
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Arms
•Finger
– nose
– Tip of nose to tip of finger
– “as quickly and accurately as possible”
Observe past-pointing, intention tremor(NB,. If tremor seen, check rest & postural components)
• DDCK
– “Tap your hand like so” (demonstrate)
– “as fast as possible”
Observe errors
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Legs
• Heel-shin
– “Place your heel onto your knee
– “Then run it down your shin”
– “As quickly and accurately as possible”
Observe: overshooting
Cerebellum
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Gait
• First test truncal ataxia on bed
– Ability to sit upright unsupported
• Then stand them, observe base
• Then ask to walk normally, observe base
• Assess balance, especially on turns
• Ask to walk heel to toe (tandem), unless too
unsteady
Observe: broad base, unsteady turns & tandem
Cerebellum
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Causes?
Same as for rest of brain:
• Stroke
• MS
• Tumour
• Infection
• Degenerative (genetic)
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SUMMARY
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•Limited number of clinical scenarios – Eyes
– Cranial nerves except the eyes
– Speech
– Limbs
– Cerebellum
– Spotters (ptosis, mask-like face & gait)
Summary
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Tip 5
Don’t be too specific with the diagnosis
Identify the site of the lesion from the findings
Then reel off your pre-prepared differential
Motor summary
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Motor summary
UMN
(Cortico-
spinal)
Basal ganglia Cerebellar Anterior
horn, root,
nerve
Neuro-
muscular
junction
Muscle
Inspection UL flexed
LL extended
Rest tremor
Mask-like
face
Titubation Wasting
Fascics
Ptosis Ptosis
Wasting
Tone Spasticity Lead pipe/
cogwheeling
Reduced
Power Pyramidal
weakness
Distal
weakness
Proximal
weakness
Proximal
weakness
Reflexes Brisk
Babinksi+
Absent Absent
Co-
ordination
Ataxic
Gait Circumducts Festinant
Reduced
armswing
Broad based Waddling
Additional
Features
Pronator
Drift
Bradykinesia
Soft voice
Dysarthria
Nystagmus
Fatigueable