NEUROLOGICAL EXAM

Clinical Reasoning II: 2010 John G. Quinlan, M.D.

NEUROLOGICAL EXAM

MENTAL STATUS II-XII MOTOR SENSORY GAIT

Mental Status Exam

Level of consciousness Orientation Specific evaluation of language Memory and Attention

Cranial Nerves II-XII (General Comments)

We skip CN-I Certain nerves are bundled (e.g. eye movements and speech production). Reflexes allow us to evaluate brain stem function, even in comatose patients.

Cranial Nerve II

Cranial Nerve II

Pupils and More

Cranial Nerves III, IV and VI

Diplopia worsens in gaze direction of the action of the paretic muscle. The outer image is always the pathological image.

Oculocephalic Reflex

Eye Control Circuits

Cranial Nerves V and VII

Check V with light touch and by palpating the masseter. Check VII by testing frontalis, oculi and oris muscles. Corneal reflex is tested in comatose patient.

Cranial Nerve VIII

Eyes must be closed. Rubbing fingers creates mid to high frequencies. Be random in delivering the stimuli.

Cranial Nerves VII, IX, X, XII (Tested by analyzing speech)

Phonation Pa, Ta and Ka Spastic dysarthria (strangled phonation and slowed rates) Flaccid dysarthria (breathy phonation and fairly normal rates)

Motor Examination: Muscle Strength Testing

Use mechanical advantage. Use your own weight. Watch out for muscle substitutions (what muscle(s) is this examiner testing?). Well cover specifics in the small groups.

Motor Examination: Muscle Stretch Reflex Testing

Patient must be relaxed and well positioned. You must know roots and nerves for reflexes (and muscles).

Motor Examination: RAMs and the Babinski response

Upper motor neuron pathology slows rapid alternating movement (RAM) rates. Watch the great toe carefully (Babinski and triple-flexion.

Motor Examination: Cerebellar Function

I like finger-nose-finger and toe-finger testing. Heel-shin maneuver. Limb dysmetria is seen with IPSILATERAL cerebellar hemishere disease.

Sensory Examination

Pin and vibratory sense are nice tools for evaluating the nerves, cord and brainstem. Know your cortical sensations (e.g. stereognosis and graphesthesia)

Gait and Station

Rhomberg test Regular walking (a fine way to test for early parkinsonism). Tandem walking (rigorous testing for ataxia).

Neurological Exam PRS Cases

Young Man with Weakness

A 28 year old man noted that he was stumbling as he walked home from work yesterday evening. This morning, his legs were so weak that he fell on the way to the bathroom. He has not been able to void for more than 12 hours. He felt his arms were strong. He complained of moderately-severe mid back pain. He has no significant medical problems.

Young Man with Weakness Exam 1

He has tenderness to percussion in his mid back. There is less than antigravity strength (2/5) in both legs. He has normal reflexes. Rapid alternating movements (RAMS) are very slow and the patient has bilateral Babinski responses. Joint position sense and vibration sense are absent in toes bilaterally. He can only feel sharpness at the level of his umbilicus. The remainder of neurological exam is normal.

Where do you localize the lesion?

100%
1. 2. 3. 4.

5.

Right frontal lobe Right pons Left frontal lobe Left pons None of the above are correct.

0%
1

0%
2

0%
3

0%
4 5

Where do you localize the lesion?

1.

2. 3. 4. 5.

Bilateral parasagital cortex Thoracic cord Peripheral nerves Medial pons Non-neurological

81%

4%
1 2

8%
3

8% 0%
4 5

Where do you localize the lesion?

98%
1.

2.
3. 4. 5.

Bilateral parasagital cortex C5 cord level T5 cord level T10 cord level Non-neurological

0%
1

0%
2

2%
3 4

0%
5

What is the most likely cause of the patients symptoms?

45%
1. 2. 3. 4.

5.

Ischemia Hemorrhage Tumor Inflammation None of the above

30%

15% 4%
1 2 3 4

6%

Which test would you order?

1.
2. 3. 4.

5.

MRI scan of the spine. EEG (Electroencephalogram) Nerve conduction studies. Cerebral angiogram. None of the above.

77%

21% 0%
1 2 3

0%
4

2%
5

Young Man with Weakness

A 28 year-old man noted that he was stumbling as he walked home from work yesterday evening. This morning, his legs were so weak that he fell on the way to the bathroom. He denied loss of bladder control. He felt his arms were strong. He complained of moderately-severe mid back pain. He has no significant medical problems.

Young Man with Weakness: Exam 2

There is less than antigravity strength (2/5) in both legs. Reflexes are absent in legs and arms. Foot speed (RAMS) is normal. Both great toes are flexor to plantar stimulation. Absent JPS and vibration sense in toes and fingers. Remainder of the neurological exam is normal.

Where do you localize the lesion?

1.

2.
3. 4. 5.

Bilateral parasagital cortex Thoracic cord Peripheral nerves Medial pons Non-neurological

68%

18% 11% 2%
1 2 3 4

0%
5

What is the most likely cause of the patients symptoms?

1. 2.

3.
4. 5.

Ischemia Hemorrhage Tumor Inflammation None of the above

0%
1

88%

13% 0%
2

0%
3 4 5

Which test would you order?

1. 2. 3. 4. 5.

MRI scan of the spine. EEG (Electroencephalogram) Nerve conduction studies. Cerebral angiogram. None of the above.

91%

5%
1

0%
2 3

0%
4

4%
5

A Woman in Pain
A 41 year-old woman had the fairly sudden onset of moderate neck pain about two weeks ago. Yesterday, she sneezed several times and afterward noted: 1) the pain has worsened and radiated to her left shoulder, 2) she has left hand numbness, and 3) left arm weakness. She has no significant medical problems and takes no medications. She works as a waitress.

A Woman in Pain: Exam

She has restricted range of motion of her neck and shoulder. Otherwise, her general exam was normal. She has weakness in the left deltoid and biceps muscles and an absent left biceps reflex. Her sharp sensation is reduced over her left thumb. Otherwise, her neurological exam was normal.

Where would you localize the lesion?

1.
2. 3. 4.

5.

Left median nerve. Right frontal lobe Left C5 root Left C7 root None of the above.

83%

13% 4%
1

0%
2 3 4

0%
5

What is the most likely cause of the patients symptoms?

58%
1. 2. 3. 4.

5.

Ischemia Hemorrhage Tumor Inflammation Trauma

14% 9% 9%

11%

Which test would you order?

1.
2. 3. 4. 5.

MRI scan of the cervical spine. EEG (Electroencephalogram) Nerve conduction studies. Cerebral angiogram. None of the above.

82%

14% 0%
1 2 3

0%
4

5%
5

Questions