Neurological Examination
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2 Neurological Examination Adam Zeman Professor of Cognitive and Behavioural Neurology University of Exeter Medical School
3 History rules!
4 History rules! and you are very good at it
5 History rules! and you are very good at it History yields hypotheses
6 History rules! and you are very good at it History yields hypotheses Where?
7 History rules! and you are very good at it History yields hypotheses Where? What?
8 Neurological history taking Diagnostic hypothesis where, then what? Where? Muscle NMJ Peripheral nerve Spinal cord Brain Brain stem Cerebellum Thalamus basal ganglia Lobe or network
9 Neurological history taking Some common symptom patterns: NMJ Fatiguable weakness LMN Distal weakness and numbness Dysarthria, dysphagia UMN Dexterity, dragging foot, exertional worsening, clonus, spasms and sphincter disturbance Extrapyramidal Aching, slowing up, shuffling, dexterity, handwriting Cerebellar Slurring of speech, clumsiness, unsteadiness
10 Neurological history taking Diagnostic hypothesis where, then what? What? eg spinal cord syndrome: Compression Disc tumour Demyelination Stroke
11 Neurological history taking Whats Inherited vs acquired Vascular Inflammatory Neoplastic Traumatic Allergic Metabolic Endocrine Drugs Iatrogenic Psychiatric Mechanical/Structural Degenerative Deficiency Sleep-related Physiological
12 Examination tests the hypotheses framed from the history It rarely surprises So why do it?
13 It s expected
14 It s expected Helps to build a relationship
15 It s expected Helps to build a relationship Allows some more history taking
16 It s expected Helps to build a relationship Allows some more history taking Buys time for thought
17 It s expected Helps to build a relationship Allows some more history taking Buys time for thought Allows you to recognise normal
18 It s expected Helps to build a relationship Allows some more history taking Buys time for thought Allows you to recognise normal May provide confirmatory signs
19 It s expected Helps to build a relationship Allows some more history taking Buys time for thought Allows you to recognise normal May provide confirmatory signs Occasionally springs a surprise
20 It s expected Helps to build a relationship Allows some more history taking Buys time for thought Allows you to recognise normal May provide confirmatory signs Occasionally springs a surprise Therapeutic ritual
21 Neurologists have two advantages
22 Neurologists have two advantages Calibration by many normal examinations
23 Neurologists have two advantages Calibration by many normal examinations Knowledge of neurological disorders:
24 Neurologists have two advantages Calibration by many normal examinations Knowledge of neurological disorders: the eye will not see what the mind does not know
25 Focus on aspects that are Most robust
26 Focus on aspects that are Most robust Most revealing especially in neuropsychiatry
27 Useful patterns of signs Neuromuscular junction fatiguable weakness (eg ptosis)
28 Useful patterns of signs Neuromuscular junction fatiguable weakness (eg ptosis) Lower motor neuron Wasting, fasciculation Decreased tone Weakness Reduced or absent reflexes +/- accompanying sensory loss, often distal
29
30 Useful patterns of signs Upper motor neuron Spastic posture Clasp-knife increase in tone Pyramidal pattern of weakness Excessively brisk reflexes Extensor plantars +/- accompanying sensory loss sensory level hemisensory loss
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34 Useful patterns of signs Extrapyramidal (pathology in basal ganglia) Reduced spontaneous movement if akinetic rigid syndrome (eg Parkinson s) chorea if hyperkinetic (eg Huntington s) Rigid increase in tone if akinetic Power near normal once mobilised Reflexes normal Decrementing bradykinesia in Parkinson s disease
35 Cortico-striatal loops
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38 Useful patterns of signs Cerebellar DANISH Dysdiadochokinesia Ataxic gait Nystagmus Intention tremor Slurred speech Hypotonia
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40 Useful patterns of signs Functional weakness ( hysterical ) Hoover s sign (voluntary hip extension weak, automatic hip extension on flexion of opposite leg normal) - Fluctuating or collapsing weakness acrobatic gait
41 Informal observation Muscle bulk Posture Spastic Dystonic Involuntary movements Tics, choreoathetosis, tremor, myoclonus Paucity of movement
42 Informal observation Gait Stiff Ataxic Bradykinetic Lurching
43 Gait Ordinary Heel-toe Romberg s Heel, toe walking Rise from squat Hopping on one leg at a time
44 I eg head injury II Acuity eg optic neuropathy Fields eg tumour Fundi postpone III, IV, VI eg PSP, MS Pursuit Saccadic Convergence Fundi eg papilloedema, atrophy pupillary responses eg Syphilis
45 V eg Sjogren s syndrome Motor Sensory VII eg Lyme disease VIII eg mitochondrial cytopathy IX/X eg MND XI XII eg cerebellar, spastic, extrapyramidal
46 Limbs Neurological examination Observation Tone Power Reflexes Sensation Temperature or pin-prick Vibration or joint position Coordination hunting for the patterns.
47 History rules Yields hypotheses Where? What? Examination tests these Much of this is informal LMN, UMN, cerebellar, extrapyramidal patterns are (relatively) robust Some signs are especially revealing Calibration and knowledge are keys
48 ps Ask your neurologist to perform a mental state examination
49 An example
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