Neurological Assessment

 

Emergency

 

Hx

Ex

Ix

Mx

 

Index

 

 

  

 

Neurological History

 

HPI

Dating

PMH

 

Social

 

 

Family

 

 

  

Neurological History of Presenting Illness (HPI)

 

-  Headache: brain tumour, meningits, SAH..

-  Faints/fits/funny turns: epilepsy, stroke, syncope

-  Dizziness

-  Vertigo: BPPV, stroke

-  Weakness: proximal myopathy, motor neuron disease, stroke

-  Tremors or involuntary movements

-  Gait problems

-  Visual problems

-  Hearing problems

-  Speech changes: cranial nerves, stroke

-  Mental state/cognition changes: delerium, dementia

-  Memory loss: dementia, head injury

          

 

 

  

Neurological Past Medical History (PMH)

 

-  Seizures

-  Stroke

-  Infections: encephalitis, meningitis, Guillian Barre, MS

-  Head or spinal injuries

-  Anticoagulants: intracranial bleed

          

 

 

  

Neurological Social History

 

-  Smoking: stroke

-  Alcohol: Wernickes encephalopathy, Korsakovs psychosis, depression (men)

-  ADLs: neuro impairment

 

 

 

  

Neurological Family History

 

-  Epilepsy, stroke, MS, hereditary spastic paresis

-  Mental illness/Psych Hx: dementia, schizophrenia, depression, bipolar disorder

 

 

 

 

Neurological Examination

 

General

Head

 

Arm

 

Chest

Abdo

 

Pelvis

Leg

 

 

Tone

Power

Reflexes + Clonus

LMN vs UMN

Dermatomes

Cuteneous Nerves

 

 

  

General Neurological Examination

 

-  GCS: head injury

-  MSE: dementia, delerium

-  Higher centres: handedness, orientation

-  Speech

-  Skin lesions

-  Facial capillary haemangioma: Sturge-Weber syndrome

-  Shingles: PHN

-  Nuerofibroma

 

Frontal Lobe Release Signs

- Cheek tap

- Palmomental reflex 

- Grasp reflex

- Pout & snout

- Hoffmans

 

Parietal Lobe

- Acalculia, agraphia, apraxia, agnosia

- Inattention, spatial neglect, left right disorientation

- 2 point discrimination

 

Temporal lobe

-  Memory

-  Glabella tap

-  Tap pts glabella

-  Normal pt stops blinking after 2nd or 3rd tap

-  Positive if patient blinks each time

-  Indicates PD or cerebellar degeneration

 

Observation

-  Tone

-  Rigidity (uniform increase in tome throughout motion): PD

-  Spasticity (increased tone which is velocity dependant, persistent): CP

-  Power 

-  Noted as x/5 for each muscle/group

-  0 = No movement

-  1 = Palpable contraction w movement

-  2 = Movement wo gravity

-  3 = Movement w gravity, nil resistance

-  4 = Movement w resistance, weaker than other side

-  5 = Nil weakness, normal

 

 

 

 

Reflexes

<Up>

 

 

Features

-  Test of afferent & efferent arcs

-  May be inhibited voluntarily by pt

-  Can be helped by mokey grip or jaw clenching (reinforcement)

-  Usually tested at same time as for clonus

 

Types

-  Corneal reflex

-  Masseter reflex (Jaw Jerk)

-  Upper Limb

-  Lower Limb

-  Epigastric (T7/8)

-  Abdominal (T9-12)

-  Patient supine

-  Draw across RUQ

-  Contraction of m. underneath stimulated skin

-  Cremasteric (L1/2)

-  Anal sphincter tone (S4/5)

 

 

 

LMN vs UMN Lesions

<Up>

 

 

 

UMN

LMN

Weak

Individual

Groups

Waste

++

N/+

Tone

Flaccid

N/spastic

Reflexes

Hypo

Hyper

Fasciculation

+

Nil

Contractures

++

Nil/+

Trophic

+

Nil/+

EMG

Denerve

 

 

 

 

  

Neurological Head & Neck Exam

 

-  MSE

-  GCS: head injury

-  Craniotomy

-  Cranial Nerve Examination

-  Eye Exam

-  Pupil changes

-  Opthalmoplegia

-  Carotid artery bruit: Stroke

-  Speech

-  Dysarthria

-  Dysphasia

-  Dysphonia

-  Ba Ba Ba: CN VII

-  Ka Ka Ka: CN IX

-  La La La: CN XII

 

 

 

  

Neurological Upper Limb Exam

 

Definition

-  Examination of the upper limb to assess neurological function

 

Features

-   

 

Components

-  Inspection

-  Tone

-  Power

-  Reflexes

-  Co-ordination

-  Sensory

-  Peripheral nerves

-  Ulnar nerve

-  Radial nerve

-  Median nerve

-  Cutaneous Innervation

-  Dermatomes

 

General Inspection

-  Muscle fasciculations

-  Symmetry, shape, wasting: myopathy

-  Thenar atrophy: Carpal tunnel syndrome

-  Posture

-  Spasticity: CP

-  Benedicts hand: ulnar nerve neuropathy

 

Tone

-  Shake hands & supinate/pronate

-  Bend elbow

-  Rigidity (uniform increase in tone throughout motion): PD

-  Cogwheel rigidity: PD

-  Spasticity (increased tone which is velocity dependant, persistent): CP

-  No test for clonus in upper limb

 

Power

-  Shoulder

-  Elevation: C3, C4

-  Abduction: Axillary nerve (C5, C6)

-  Adduction: C6, C7, C8

-  Elbow

-  Flexion: Musculocutaneous nerve (C5, C6)

-  Extension: Radial nerve (C6, C7, C8)

-  Wrist

-  Flexion: Ulnar & median nerves (C6, C7)

-  Extension: Radial nerve (C7, C8)

-  Finger

-  Extension: C7, C8

-  Flexion: C7, C8

-  Abduction: Ulnar nerve (C8, T1)

-  Adduction: Ulnar nerve (C8, T1)

-  Grip strength (2 fingers)

 

Reflexes

-  Biceps (C5, C6)

-  Flex elbow to 90o w hand supinated

-  Support releaxed forearm

-  Place your thumb over tendon

-  Tap your thumb with reflex hammer

-  Normal = bicep twitch or elbow flexion

-  Brachioradialis (C5, C6)

-  AKA Supinator Jerk

-  Flex elbow to 90o w hand semi-supinated (thumb to roof)

-  Tap tendon 4cm proximal to wrist

-  Normal = bicep twitch or elbow flexion

-  Triceps (C7, C8)

-  Flex elbow to 90o

-  Support releaxed forearm

-  Tap triceps tendon proximal to olecranon process

-  Normal = tricep twitch or elbow extension

-  Finger Jerks (C8)

-  Rest hand with palm facing upwards & slight finer flexion

-  Examiners finger on patients fingers

-  Lightly tap examiners fingers

-  Normal = slight flexion of fingers

 

 

Co-Ordination

-  Finger-nose

-  Patient to touch index finger to their nose

-  Then touch to examiners finger which

-  Move examiners finger each time

-  Briskly & slowly

-  Repeat several times

-  Abnormal = cerebellar disease

-  Intention tremor

-  Past pointing

-  Dysdydiokinesia

-  Rapid pronation & supination of patients hand into patients other hand

-  Abnormal = cerebellar disease

-  Duck beak

-  Rebound

-  Ask patient to rapidly raise arms from side then stop

-  Abnormal = cerebellar diseaes (hypotonia)

 

Sensory

-  Compare sides

-  Pin prick (spinothalamic pathway)

-  Use pin to touching to skin

-  Describe as sharp or dull

-  Map dermatomes

-  Compare sides

-  Temp (spinothalamic pathway)

-  Use hot 40-45o & cold 5-10o

-  Light touch

-  Vibration (posterior column)

-  Use 128Hz tuning fork

-  Patient to close eyes

-  Vibrate tuning fork & place on bone

-  Patient to inform when can no longer feel vibrations

-  Examiner to deaden tuning fork with hand

-  Test on

-  Acromioclavicular joint

-  Lateral epicondyle of humerus

-  Ulnar styloid

-  Thumb PIP joint

-  Proprioception (posterior column)

-  Thumb up/down

-  If abnormal test wrist & elbows

-  Impaired: Neuropathy

-  Paresthesia

-  Hand: Carpal tunnel syndrome

 

Dermatomes

 

Cutaneous Innervation

 

MSK Exam

-  Hand & Wrist

-  Elbow

-  Shoulder

 

 

 

References

 

Pic (dermatomes): www.instamedic.co.uk/exams/upperneuro

 

 

 

  

Neurological Chest Exam

 

-   

 

 

 

  

Neurological Abdominal Exam

 

-   

 

 

 

  

Neurological Lower Limb Exam

 

-  Inspection

-  Tone

-  Power

-  Reflexes

-  Co-ordination

-  Sensory

 

General Inspection

-  Gait Assesment

-  Fasciculations: UMN lesion

-  Symmetry, shape, wasting: myopathy

-  Scars/deformity

-  Posture: spasticity

 

Tone

-  Lift & drop knee

-  Flex/extend hip/knee

-  Clonus (patella & ankle)

 

Power

-  Hip flex/extension abd/adduction, knee flex/extension, foot dorsi/plantarflexion in/eversion, big toe

 

Reflexes

-  Patella (L2-4)

-  Patient seated w legs dangling, clear from floor

-  Tap patella ligament distal to patella

-  Normal = knee extension

-  Ankle (S1/2)

-  Ankle at 90o or less

-  May position patients ankle across contraletaral leg

-  +/- passive dorsiflexion

-  Tap gastroc tendon prox to calcaneus

-  Normal = plantar flexion

-  Foot (L5-S2)

-  Babinski (Plantar) (primitive) (S1/2)

-  Scratch lateral aspect of heel from bottom to top

-  Normal first response = plantar flexion of 1st toe

-  Abnormal = extension of 1st toe + other toe extension/fanning: pyramidal tract lesion

 

Co-Ordination

-  Tests cerebellar function

-  Heel-shin

-  Toe-finger

-  Flap foot

 

Sensory

-  Pin prick: pin

-  Temp: test tubes (hot & cold)

-  Light touch: cotton wool

-  Vibration: tuning fork on ASIS, patella, med. malleolus, DIP of 1st toe

-  Proprioception: 1st toe flexion/extension w eyes closed

 

 

 

Dermatomes

<Neuro Ex>

 

 

 

Segmental Levels

-  T4/5 = nipple level

-  T7/9 = xiphisternum

-  T10 = umbilicus

-  L1 = inguinal

-  S1/S4 = perineum

 

 

 

Cutaneous Nerves

<Neuro Ex>

 

 

 

 

 

 

 

 

 

Neurological Investigations

 

Path

Imaging

Proc

Micro

 

 

 

 

Neurological Management

 

General

Meds

Surgery

Proc