Neurologic PE Flashcards
Motor Neurological Examination
Case 1: Your next patient is a 50 year old lady who has come to you complaining of one-sided weakness in her arms and legs, and a slurred speech for 15 minutes. She is feeling well now. Her vital signs are stable.
Case 2: Your next patient is a 30 year old man who is a known case of epilepsy. He is complaining of weakness in the right arm and leg.
Task:
1. Explain upper limb and lower limb MOTOR neurologic examination to the medical student. Sensory has already been done
Inspection: wasting, tremor, fasciculations
UMN: (-) wasting, hypertonia, hyperreflexia, (+) Babinski
LMN: (+) wasting, hypotonia, hyporeflexia, (+) fasciculations
Power:
- active movement against resistance
- muscle grading
- upper limb myotomes
C5: shoulder abduction
C6: elbow flexion
C7: elbow extension
C8: grip strength
T1: finger spread
- upper limb special test: drift test (pronator drift
- lower limb myotomes
L2: hip flexion
L3: knee extension
L4: knee flexion
L5: ankle dorsiflexion
S1: ankle plantar flexion
- lower limb special test: gait (asymmetry, ask to squat, walk on heels (L5) then toes (S1))
Tone:
- passive movement: check if normal or rigid (hypertonia)
- upper limb: wrist, elbow, shoulder
- lower limb: ankle, knee, hip
- special test: clonus
Reflexes
- biceps reflex (C5,C6)
- triceps reflex (C7, C8)
- knee jerk reflex (L3, L4)
- ankle reflex (S1, S2)
- Babinski (L5, S1, S2)
Coordination
- finger to nose
- dysdiadochokinesia
- heel to shin
Chemotherapy-induced Neuropathy Examination
Your next patient is a 50 year old lady who is a known case of breast cancer and was scheduled to receive 8 weeks of chemotherapy with Cisplatin. On week 6 of her treatment, she developed numbness in her legs and chemo was stopped. She also has pain on walking. Her GP told her it can be the side effect of chemotherapy.
Task:
1. Explain your sensory neurological examination to the medical student with anatomical landmarks
Inspection: ulcers, deformities
Check Pain
1. Dermatomes
- L1: groin
- L2: anterior thigh
- L3: anterior knee
- L4: medial side of leg to big toe
- L5: lateral side of leg to dorsum of foot
- S1: sole and heel
2. Sensory level
Check temperature
- same dermatomes and sensory level
Vibration
- 128Hz tuning fork
- on bony prominences
- start distally: big toe, medial malleolus, tibial tuberosity, ASIS
Proprioception
- hold big toe on sides of IPJ
- Romberg test
Fine Touch
- cottonwool
-same dermatomes and sensory level
Monofilament test
- 10g monofilament
- tip of big toe
- head of metatarsals
- heel
Reflexes
- knee jerk (L3, L4)
- ankle reflex (S1, S2)
Diabetic Sensory Neuropathy Examination
Your next patient is a 48 year old man who is a known case of Diabetes Type 2. He has presented to you complaining of numbness in both legs.
Task:
1. Explain sensory neurological examination of the upper limbs and lower limbs to the medical student
Inspection: ulcers, deformities
Check pain & light touch
1. Dermatomes
Upper limb:
C5 - outer part of upper arm/deltoid
C6 - lateral aspect of forearm
C7 - middle finger
C8 - little finger
T1 - medial aspect of forearm
Lower limb:
L1 - groin
L2 - upper anterior thigh
L3 - anterior knee
L4 - medial aspect of leg and big toe
L5 - lateral aspect of leg and dorsum of foot
S1 - sole and heel
S2 - posterior aspect of thigh
- Sensory level
Check vibration
128Hz tuning fork
Upper limb:
IP joint of thumb, radial styloid, olecranon
Lower limb: big toe, medial malleolus, tibial tuberosity, ASIS
Monofilament test: 10g monofilament
- tip of big toe
- head of metatarsals
- heel
Proprioception
- sides of IPJ of big toe and thumb
Reflexes:
-Biceps reflex (C5, C6)
-Triceps reflex (C7, C8)
-Knee reflex (L3, L4)
-Ankle reflex (S1, S2)
Check temperature
-dermatomes
-sensory level
Cerebellar Examination
Old Case: Your next patient is a 45 year old man who presents to you complaining of an unsteady gait. He has difficulty in walking and has a history of a wrist fracture after a fall while he was drunk. He drinks 8-10 beers everyday. Power, tone, reflexes are done and normal.
Tasks:
1. Explain PE to the medical student
2. Explain your diagnosis and differentials
New Case: Your next patient is a 45 year old man who is a chronic alcoholic patient. He has a history of a fall when he was drunk and has an ulcer on his leg.
Task:
1. Explain your PE to the medical student focusing on the cerebellar effects of alcohol
GA: level of consciousness, abnormal movements, tremors, use of walking aids
Gait:
- broad-based gait
- heel to toe walking
- Romberg test
Head:
Eyes: nystagmus, fundoscopy for papilledema
Speech: staccato speech “Hippopotamus” “West Register street”
Upper limb
1. Coordination
- finger to nose test
- dysdiadochokinesia
- rebound phenomenon
2. drift test
3. Tone
Lower limb
1. Knee reflex
2. Coordination
- heel to shin test
- toe tap test
- toe to finger test
- truncal ataxia
Differentials for Unsteady Gait
- Alcoholic cerebellar degeneration
- Alcoholic sensory neuropathy
- Diabetic sensory neuropathy
- Vitamin B12 deficiency
- Brain tumors
- Stroke/TIA
- Vestibular problems: Meniere’s disease
Pediatric Headache Examination
Your next patient is a 10 year old boy who has been complaining of headache for 6 months. His headache is worse on bending forward. Vital signs are stable.
Tasks:
1. Explain the steps of examination to the mother
2. Explain what instruments you will be using
Explain your PE to the medical student focusing on neurological examination
GA: LOC, tremors, involuntary movements, facial asymmetry
Cranial Nerves:
1. CN 1 - ask if noticed any changes in smell. ask to smell chocolate/coffee
2. CN 1 - visual acuity - Snellen; Fundoscopy - Papilledema; Pupils - direct & indirect light reflex
3. CN 3,4,6 - Eye movements with red pin; nystagmus, double vision, restricted eye movements
4. CN 5 - light touch on forehead, cheeks, jaw; clench teeth to check bulk & tone of masseter & temporalis
5. CN 7 - raise eyebrows, wrinkle forehead, close eyes - don’t let me close it, puff cheeks - don’t let me empty it
6. CN 8 - whisper test, Rinne & weber
7. CN 9, 10 - uvular deviation, soft palate for symmetric rise, speech, voice, cough
8. CN 11 - shoulder shrug, turn head to one side for SCM
9. CN 12 - tongue deviation and wasting
Upper & Lower Limb
1. Power
- Upper limb
C5 - shoulder abduction
C6 - elbow flexion
C7 - elbow extension
C8 - grip strength
T1 - finger spread
- Lower limb
L2 - hip flexion
L3 - knee extension
L4 - knee flexion
L5 - dorsiflexion
S1 - plantar flexion
- Sensory
- Upper limb
C5 - deltoid
C6 - lateral aspect of forearm
C7 - middle finger
C8 - little finger
T1 - medial aspect of forearm
- Lower limb
L1 - groin
L2 - upper anterior thigh
L3 - anterior knee
L4 - medial aspect of leg and big toe
L5 - lateral aspect of leg and dorsum of foot
S1 - sole, heel
S2 - posterior aspect of thigh - Tone - passive movements of joints checking for hypertonia and normal tone
- Coordination: finger to nose test
- Reflexes: biceps reflex (C5, C6), knee reflex (L3, L4)
Pediatric Headache Examination
Your next patient is a 10 year old boy who has been complaining of headache for 6 months. His headache is worse on bending forward. Vital signs are stable.
Tasks:
1. Explain the steps of examination to the mother
2. Explain what instruments you will be using
3. Explain your PE to the medical student focusing on neurological examination
Explain steps: I’ll be looking at his face, arms and legs, checking his eyes, and movement of his face, and at the end I’ll check sensation of his arms and legs
For this examination, I will be using a pen torch, ophthalmoscope, Snellen chart, red top pin, reflex hammer, and a cottonwool
GA: LOC, tremors, facial asymmetry
Cranial Nerves examination
Upper and Lower limb examination
- inspection: wasting, fasciculations, tremors
-Power
-Sensory
*if you still have time: tone, coordination, reflexes
Trigeminal Neuralgia Examination
Your next patient is a 40 year old lady who presents to you complaining of facial pain. You have made the diagnosis of trigeminal neuralgia.
Task:
Explain your physical examination to the medical student
GA: Ptosis, pupil inequality, wasting of temporalis & masseter muscle
Neurological Examination
- Cranial nerves
-Trigeminal nerve examination
1. Sensory branch - check pin on all 3 divisions (frontal, maxillary, mandibular)
2. Motor branch - wasting of temporalis & masseter muscle, clench teeth to check tone and bulk; pterygoid muscle - hold mouth open, shut it (palsy: deviation to weak side)
3. Corneal reflex
4. Jaw reflex
Upper & Lower limb examination
- Inspection
- Power: myotomes
- Sensory: dermatomes
If still have time: tone & reflexes
7th, 9th, 10th, 11th Cranial Nerve Examination
Case 1: Your next patient is a 40 year old man who presents to you complaining of right-sided facial weakness. He has been diagnosed with Bell’s Palsy
Case 2: Your next patient is a 37 year old man presenting with right-sided weakness
Task:
1. Explain your physical examination of the 7th, 9th, 10th, 11th cranial nerves to the medical student with anatomical landmarks and expected findings
Cranial Nerve 7: Facial Nerve
Anatomy: exits the pons with 8th, exits the cerebellopontine angle then facial canal. leaves skull through stylomastoid foramen, to parotid gland
Inspection: ptosis, loss of nasolabial fold, drooping of corner of mouth
Involvement of forehead: UMN (-), LMN (+)
Power: wrinkle forehead, close eyes tightly, puff cheeks
UMN: muscles affected on opposite side
LMN: muscles affected on same side
Check taste on anterior 2/3 of tongue
Cranial Nerve 9 & 10: Glossopharyngeal & Vagus
Anatomy: exits medulla, moves out through jugular foramen
9th: sensory fibers to nasopharynx, pharynx, middle & inner ear, posterior 1/3 of tongue; secretory fibers to parotid
10th: sensory fibers to pharynx & larynx; motor fibers to pharynx, larynx, palate
PE: uvular deviation, rise of soft palate, gag reflex, hoarseness (recurrent laryngeal nerve palsy), bovine cough, swallow water, taste of posterior 1/3
Cranial Nerve 11: Accessory nerve
Anatomy: central portion from medulla, spinal portion from 5 cervical segments. moves through jugular foramen; central gives motor fibers to vagus nerve, spinal gives motor fibers to trapezius and SCM
PE: shrug shoulders, turn head to side
Weakness & Tingling in Lower Limb Examination
Patient presents to you complaining of weakness and tingling in his right leg (after squatting/ injured himself while squatting)
Task:
1. Explain physical examination to the medical student
Differentials:
- lumbar radiculopathy
- nerve entrapments: common peroneal nerve, meralgia paraestetica
GA: protective posture
Gait: ask to walk
- able to bear weight?
- antalgic gait?
- steppage gait?
Lower limb examination
Inspection: fasciculation, wasting, trauma signs
Palpation: temp, CRT, pulse, Tenderness - ankle (Ottawa locations), knee, fibular head, hip
Movement: passive & active: hip, knee, ankle
Neurological examination
Motor - myotomes
Sensory - dermatomes
Reflexes
Special tests
- SLR: 30-60 degrees
- Lateral cutaneous nerve of thigh
- Common peroneal nerve entrapment
