The Nervous System Flashcards
1
Q
Neurological history: An approach to neurological symptoms
A
Symptoms can vary wildly in neurology. The exact nature of the symptom. The onset (sudden? slow- hours? days? weeks? months?). Change over time (progressive, intermittent, episodes of recovery). Precipitating factors. Exacerbating and relieving factors. Previous episodes of the same symptom. Previous investigations and treatment. Associated symptoms. Any other neurological symptoms.
2
Q
Neurological history: Dizziness
A
Narrow the exact meaning down without appearing aggressive or disbelieving.
A sense of rotation = vertigo.
Swimminess or lightheadedness- a non-specific symptoms which can be related to pathology in many different systems.
Pre-syncope- the unique feeling prior to fainting.
Incoordination- many will say they are dizzy when they can’t walk straight due to either ataxia or weakness.
3
Q
Neurological history: Headache
A
This should be treated as any other type of pain.
Establish character, severity, site, duration, time course, frequency, radiation, aggravating and relieving factors, and associated symptoms.
Ask about facial and visual symptoms.
4
Q
Neurological history: Numbness and weakness
A
These 2 words are often confused by patients- describing a leg as ‘numb’ when it is weak with normal sensation.
May report numbness when they are experiencing pins and needles or pain.
5
Q
Neurological history: Tremor
A
Does the tremor occur only at rest, only when attempting an action, or both?
Is it worse at any particular time of day?
Severity can be established in terms of its functional consequence (can’t hold a cup/ put food to mouth?).
Establish what is being described- a tremor is a shaking, regular, or jerky involuntary movement.
6
Q
Neurological history: Common symptoms
A
Dizziness Headache Numbness and weakness Tremor Syncope Seizures Visual symptoms Falls and loss of consciousness
7
Q
Neurological history: Falls and loss of consciousness
A
An eyewitness account is vital.
Establish also whether the patient actually lost consciousness or not.
People often describe ‘blacking out’ when in fact they simply fell to the ground (drop attacks have no LOC).
‘Can you remember hitting the ground?’
Ask about preceding symptoms and warning signs- may point towards a different organ system (sweating or weakness could be a marker of hypoglycaemia, palpitations may indicate a cardiac dysrhythmia).
8
Q
Neurological history: Seizures
A
Establish early on if there was any impairment of consciousness and seek collateral histories.
Syncopal attacks can often cause a few tonic-clonic kegs which may be mistaken for epilepsy.
True tonic-clonic seizures may cause tongue-biting, urinary and faecal incontinence, or both.
People presenting with pseudoseizure can have true epilepsy, as well as vice versa.
9
Q
Neurological history: Visual symptoms
A
Commonly visual loss, double vision, or photophobia (pain when looking at bright lights).
Establish what is being experienced- ‘double vision’ (diplopia) is often complained of when the visit is blurred or sight is generally poor (amblyopia) or clouded.
10
Q
Neurological history: Direct questioning for specific symptoms
A
Headaches.
Faints, fits and ‘funny turns’, and ‘blackouts’.
Visual symptoms.
Pins and needles, tingling.
Numbness.
Weakness.
Incontinence, constipation, or urinary retention.
11
Q
Neurological history: Past medical history
A
A birth history is important here, particularly in patients with epilepsy- brain injury at birth has neurological consequences. Hypertension- if so, what treatment? Diabetes mellitus- what type? what treatment? Thyroid disease. Mental illness (e.g. depression). Meningitis or encephalitis. Head or spinal injuries. Epilepsy, convulsions, or seizures. Cancers. HIV/AIDs.
12
Q
Neurological history: Drug history
A
Anticonvulsant therapy (current or previous)? Oral contraceptive pill? Steroids? Anticoagulants? Anti-platelet agents? Tobacco, alcohol?
13
Q
Neurological history: Family history
A
Ask about neurological diagnoses and evidence of missed diagnoses (seizures, blackouts, etc.).
14
Q
Neurological history: Social history
A
Occupation: neurological disease can impact significantly on occupation so ask about this at an early stage- some suggest right at the beginning of the history; also ask about exposure to heavy metals or other neurotoxins.
Driving?- many neurological conditions have implications here.
Ask about the home environment thoroughly (will be very useful when considering handicaps and consequences of the diagnosis).
Ask about support systems- family, friends, home-helps, day centre visits, etc.
15
Q
Neurological history: Characteristic headaches
A
Tension Subarachnoid haemorrhage Sinusitis Temporal (giant cell) arteritis Meningitis Cluster Raised intracranial pressure Migraine
16
Q
Neurological history: Characteristic headaches, tension
A
Bilateral- frontal, temporal.
Sensation of tightness radiating to neck and shoulders.
Can last for days.
No associated symptoms.
17
Q
Neurological history: Characteristic headaches, subarachnoid haemorrhage
A
Sudden, dramatic onset ‘like being hit with a brick’.
Occipital initially, may become generalised.
Associated with neck stiffness and sometimes photophobia.
18
Q
Neurological history: Characteristic headaches, sinusitis
A
Frontal, felt behind the eyes or over the cheeks.
Ethmoid sinusitis is felt deep behind the nose.
Overlying skin may be tender.
Worse on bending forwards.
Lasts 1-2 weeks, associated with coryza.
19
Q
Neurological history: Characteristic headaches, temporal (giant cell) arteritis
A
Diffuse, spreading from the temple- unilateral.
Tender overlying temporal artery (painful brushing hair).
?jaw claudication whilst eating.
?blurred vision- can lead to loss of vision if severe and untreated.
20
Q
Neurological history: Characteristic headaches, meningitis
A
Generalised.
Associated with neck stiffness and signs of meningism.
Nausea, vomiting, photophobia.
Purpuric rash is caused by septicaemia, not meningitis per se.
21
Q
Neurological history: Characteristic headaches, cluster
A
Rapid onset, usually felt over one eye.
Associated with a blood-shot, watering eye, and facial flushing.
May also have rhinorrhoea.
Last for a few weeks at a time.
22
Q
Neurological history: Characteristic headaches, raised intracranial pressure
A
Generalised headache, worse when lying down, straining, coughing, on exertion, or in the morning.
Headache may also wake the patient in the early hours.
May be associated with drowsiness, vomiting, and focal neurology.
23
Q
Neurological history: Characteristic headaches, migraine
A
Unilateral- rarely crosses the midline.
Throbbing/pounding headache.
Associated with photophobia, nausea, vomiting, and neck stiffness.
May have preceding aura.
24
Q
Neurological examination: Framework
A
Inspection, mood, conscious level. Speech and higher mental functions. Cranial nerves II-XII. Motor system. Sensation. Coordination. Gait. Any extra tests. Other relevant examinations, e.g. skull, spine, neck stiffness, ear drums, blood pressure, anterior chest, carotid arteries, breasts, abdomen, lymph nodes.
25
Neurological examination: General inspection and mental state
Are they accompanied by carers- and how do they interact with those people?
Do they use any walking aids or other forms of support?
Any abnormal movements?
Observe the gait as they approach the clinic room, if able.
Any speech disturbance?
What is their mood like?- ask the patient how they feel. what is the state of their clothing, hair, skin and nails? restlessness, inappropriately high spirits, pressure of speech? obviously depressed with disinterest? denying disability?
26
Neurological examination: Cognitive function, The Abbreviated Mental Test Score
AMTS (10 points) is a brief screening tool.
Neurological diseases may affect function such that patients' appearance or communication skills are at odds with their educational level- formal assessment allows for any future change to be noted and monitored.
Explain the purpose of the questions and ask their permission to proceed.
1) Date of birth: 'What is your date of birth?'
2) Age: 'How old are you?'
3) Time: 'What time is it?'
4) Year: 'What year is it now?'
5) Place: 'Where are we?' or 'What is this place?'
6) Head of state: 'Who's the Prime Minister at the moment?' or 'Who is the current monarch?'
7) War II: 'What year did the second world war start?
8) 5-minute recall: Tell the patient an address (e.g. 42 West Street) and ask them to repeat it back to you to ensure they've heard it correctly. Ask them to remember it. 5 minutes later, ask them to recall the address- must remember in full to score the point.
9) 20-1: 'Count backwards from 20 to 1. Patients sometimes need a prompt, 'follow on from me: 23, 22, 21...'
10) Recognition: 'What job do I do?' and 'What job does this person do?' - both must be correct to score the point.
27
Neurological examination: Speech and language
Speech and language problems may be evident from the start of the history and require no formal testing.
You should briefly test language function by asking the patient to read or obey a simple written command (e.g. close your eyes) and write a short sentence.
If apparently problematic, speech can be tested formally by asking the patient to respond to progressively harder questions: yes/no questions, simple statements or instructions, more complicated sentences, and finally by asking them to repeat complex phrases or tongue-twisters.
Before jumping to conclusions, ensure that the patient is not deaf (or that their hearing aid is working) and that they can usually understand the language you are speaking.
28
Neurological examination: Speech and language, dysarthria
A defect of articulation with language function intact (writing will be unaffected).
There may be a cerebellar lesion, an LMN lesion of the cranial nerves, an extrapyramidal lesion, or a problem with muscles in the mouth and jaws or their nerve supply.
Listen for slurring and the rhythm of speech.
Test function of different structures by asking the patient to repeat: 'yellow lorry' or words with 'd', 'l' and 't' (tongue function); 'peter piper picked a pickle' or words with 'p' and 'b' (lip function).
Cerebellar lesions: slow, slurred, low volume with equal emphasis on all syllables ('scanning').
Facial weakness: speech is slurred.
Extrapyramidal lesions: monotonous, low volume and lacking in normal rhythm.
29
Neurological examination: Speech and language, dysphonia
Defective volume- huskiness.
Usually from laryngeal disease, laryngeal nerve palsy or, rarely, muscular disease such as myasthenia graves.
May also be 'functional' (psychological).
30
Neurological examination: Speech and language, dysphasia
This is a defect of language, not just speech, so reading and writing may also be affected (some patients attempt to overcome speaking difficulties with a notepad and pen only to be bitterly disappointed).
Types: expressive, receptive, conductive, nominal, and global.
31
Neurological examination: Speech and language, expressive dysphasia
'Anterior', 'motor', 'Broca's' dysphasia.
Lesion in Broca's area (frontal lobe), involved in language production.
Understanding remains intact.
Unable to answer questions appropriately.
Speech is non-fluent, broken with abnormal word ordering.
Unable to repeat sentences.
32
Neurological examination: Speech and language, receptive dysphasia
'Posterior', 'sensory', 'Wernicke's' dysphasia.
Lesion in Wernicke's area creates problems understanding spoken or written language (dyslexia) and problems with word-finding.
Unable to understand commands or questions.
Speech is fluent with lots of meaningless grammatical elements.
May contain meaningless words.
Unable to repeat sentences.
Patients are often unaware of their speech difficulty and will talk nonsense continually- although may become frustrated with other people's lack of understanding.
33
Neurological examination: Speech and language, conductive dysphasia
Lesion in the arcuate fascicles and/or other connections between the 2 primary language areas.
Patient can comprehend and respond appropriately.
Unable to repeat a sentence.
34
Neurological examination: Speech and language, nominal dysphasia
All language function is intact except for naming of objects.
Caused by lesion at the angular gyrus.
Patient may function with 'circumlocution', e.g. says 'that thing I write with' instead of 'pen'.
35
Neurological examination: Speech and language, global dysphasia
Both Broca's and Wernicke's areas affected.
| The patient is unable to speak or understand speech at all.
36
Neurological examination: Cranial nerve I, olfactory, applied anatomy
Sensory: smell.
Motor: none.
Fibres arise in the mucous membrane of the nose.
Axons pass across the cribriform plate to the olfactory bulb.
The olfactory tract runs backwards below the frontal lobe and projects, mainly, in the uncut of the ipsilateral temporal lobe.
37
Neurological examination: Cranial nerve I, olfactory, examination
Not routinely tested unless the patient complains of a loss of sense of smell (anosmia) and exhibits other signs suggestive of a frontal or temporal lobe cause (e.g. tumour).
'Have you noticed any change in your sense of smell or taste recently?'
Casual: take a nearby odorous object, e.g. coffee or chocolate, and ask the patient if it smells normal.
Formal: a series of identical bottles containing recognisable smells are used, the patient is asked to identify them, e.g. coffee, vanilla, camphor, vinegar.
Test each nostril separately and determine if any loss of smell is uni- or bilateral.
38
Neurological examination: Cranial nerve I, olfactory, findings
Bilateral anosmia: usually nasal, not neurological; causes include upper respiratory tract infection, trauma, smoking, old age, Parkinson's disease, tumours of the ethmoid bone or congenital ciliary dysmotility syndromes.
Unilateral anosmia: mucus-blocked nostril, head trauma, subfrontal meningioma.
39
Neurological examination: Cranial nerve V, trigeminal, applied anatomy
Sensory: face sensation in 3 branches: ophthalmic (V1), maxillary (V2), mandibular (V3).
Motor: muscles of mastication.
Nerve originates in the pons, travels to trigeminal ganglion at the petrous temporal bone and splits.
V1 passes through the cavernous sinus with III and exits via the superior orbital fissure.
V2 leaves via the infraorbital foramen (also supplies the palate and nasopharynx).
V3 exits via the foramen oval with the motor portion.
40
Neurological examination: Cranial nerve V, trigeminal, inspection
Inspect the patient's face- wasting of the temporalis will show as hollowing above the zygomatic arch.
41
Neurological examination: Cranial nerve V, trigeminal, testing motor function
Ask the patient to clench their teeth and feel both sides for the bulge of the masseter and temporalis.
Ask the patient to open their mouth wide- the jaw will deviate towards the side of a V lesion.
Again ask them to open their mouth but provide resistance by holding their jaw closed with one of your hands.
42
Neurological examination: Cranial nerve V, trigeminal, testing sensory function
Assess light touch for each branch and ask the patient to say 'yes' if they can feel it. Forehead, cheek, and midway along the jaw, like-for-like.
For each branch, compare left to right: 'does it feel the same on both sides?'
Test pin-prick sensation at the same spots using a sterile pin.
43
Neurological examination: Cranial nerve V, trigeminal, findings
Wasting of muscles: long term V palsy, MND, myotonic dystrophy.
Loss of all sensory modalities: V ganglion lesion (?herpes zoster).
Loss of light touch only, with loss of sensation on ipsilateral side of the body: contralateral parietal lobe (sensory cortex) lesion.
Loss of light touch in V only: lesion at the sensory root pons.
Loss of pin-prick only, along with contralateral side of body: ipsilateral brainstem lesion.
Loss of sensation in a 'muzzle' distribution (nose, lips, anterior cheeks): damage to the lower part of the spinal sensory nucleus (syringomyelia, demyelination).
44
Neurological examination: Cranial nerve V, trigeminal, reflexes
Jaw jerk.
| Corneal reflex.
45
Neurological examination: Cranial nerve V, trigeminal, reflexes, jaw jerk
Explain to the patient what is about to happen as this could appear rather threatening.
Ask the patient to let their mouth hang loosely open.
Place your finger horizontally across their chin and tap your finger with a patella hammer.
Feel and watch jaw movement- there should be a slight closure of the jaw but this varies widely in normal people; a brisk and definite closure may indicate an UMN lesion above the level of the pons (e.g. pseudobulbar palsy).
46
Neurological examination: Cranial nerve V, trigeminal, reflexes, corneal reflex
Afferent = V1. Efferent = VII.
Ask the patient to look up and away from you.
Gently touch the cornea (overlies the iris) with a wisp of cotton wool.
Bring this in from the side so it cannot be seen approaching.
Watch both eyes. A blink is a normal response.
No response = ipsilateral V1 palsy.
Lack of blink on 1 side only = VII palsy.
47
Neurological examination: Cranial nerve VII, facial, applied anatomy
Sensory: external auditory meatus, tympanic membrane, small portion of skin behind ear, taste anterior 2/3 of tongue.
Motor: muscles of facial expression, stapedius.
Autonomic: parasympathetic supply to lacrimal glands.
The nucleus lies in the pons, the nerve leaves at the cerebellopontine angle with VIII.
The nerve gives off a branch to the stapedius at the geniculate ganglion whilst the majority of the nerve leaves the skull via the stylomastoid foramen and travels through the parotid gland.
48
Neurological examination: Cranial nerve VII, facial, muscles of facial expression
Test both left and right at the same time.
Some patients have difficulty understanding the instructions- quickly demonstrate to allow the patient to mirror you.
Look at the patient's face at rest. Look for asymmetry in the nasolabial folds, angles of the mouth, and forehead wrinkles.
Ask the patient to raise their eyebrows ('look up') and watch the forehead wrinkle. Attempt to press their eyebrows down and note any weakness.
Ask the patient to 'close your eyes tightly'. Watch, then test against resistance with your finger and thumb. 'Don't let me open them'.
Ask the patient to puff out their cheeks. Watch for air escaping on one side.
Ask the patient to bare their teeth, 'show me your teeth'. Look for asymmetry.
Ask the patient to purse their lips, 'whistle for me'. Look for asymmetry. The patient will always smile after whistling.
49
Neurological examination: Cranial nerve VII, facial, the 'whistle-smile' sign
A failure to smile when asked to whistle (whistle-smile negative) is usually due to 'emotional paresis' of the facial muscles, synonymous with Parkinsonism.
50
Neurological examination: Cranial nerve VII, facial, external auditory meatus
This should be examined briefly if only VII is examined- can be done as part of VIII if examining all the cranial nerves.
51
Neurological examination: Cranial nerve VII, facial, taste
Rarely tested outside specialist clinics.
Each side is tested separately using cotton buds dipped in solutions applied to each side of the tongue in turn.
Swill the mouth with distilled water between each taste sensation.
Test: sweet, salty, bitter (quinine), and sour (vinegar).
52
Neurological examination: Cranial nerve VII, facial, findings
Upper motor nerve lesion: will cause loss of facial movement on the contralateral side but with preservation of forehead wrinkling- both sides of the forehead receive bilateral nervous supply. Unilateral = CVA, etc. Bilateral = pseudobulbar palsy, motor neurone disease.
Lower motor neuron lesion: will cause loss of all movement on the ipsilateral side of the face. Unilateral = demyelination, tumours, Bell's palsy, pontine lesions, cerebellopontine angle lesions. Bilateral = sarcoid, GBS, myasthenia gravis.
Bell's palsy: idiopathic unilateral LMN VII paresis.
Ramsay-Hunt syndrome: unilateral paresis caused by herpes at the geniculate ganglion (look for herpes rash on the external ear).
53
Neurological examination: Cranial nerve VIII, vestibulocochlear, applied anatomy
Sensory: hearing (cochlear), balance/equilibrium (vestibular).
Motor: none.
The 8th nerve comprises 2 parts: the cochlear branch originates in the organ of Corti in the ear, passes through the internal auditory meatus to its nucleus in the pons.
Fibres pass to the superior gyrus of the temporal lobes.
The vestibular branch arises in the utricle and semicircular canals, joins the auditory fibres in the facial canal, enters the brainstem at the cerebellopontine angle, and ends in the pons and cerebellum.
54
Neurological examination: Cranial nerve VIII, vestibulocochlear, examination
Enquire first about symptoms- hearing loss/changes or balance problems.
Peripheral vestibular lesions cause ataxia during paroxysms of vertigo but not at other times.
Begin by inspecting each ear.
Test hearing.
Test vestibular function.
55
Neurological examination: Cranial nerve VIII, vestibulocochlear, hearing
```
Test each ear separately.
Cover one by pressing on the tragus.
Simple test of hearing: rub your fingers together at the external auditory meatus with patient's eyes closed, ask which side the sound is on and if it's the same on both sides.
Rinne's test.
Weber's test.
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56
Neurological examination: Cranial nerve VIII, vestibulocochlear, hearing, Rinne's test
Tap a 512Hz tuning fork and hold adjacent to the ear (air conduction).
Then apply the base of the tuning fork to the mastoid process (bone conduction).
Ask the patient which position sounds louder.
Normal = air conduction > bone conduction = 'Rinne's positive'.
In neural (or perceptive) deafness, Rinne's test will remain positive.
In conductive deafness, the findings are reversed (bone >air).
57
Neurological examination: Cranial nerve VIII, vestibulocochlear, vestibular function, turning test
Ask the patient to stand facing you, arms outstretched.
Ask them to march on the spot, then close their eyes (continue marching).
Watch.
The patient will gradually turn towards the side of the lesion, sometimes 180 degrees.
58
Neurological examination: Cranial nerve VIII, vestibulocochlear, vestibular function, Hallpike's manoeuvre
A test for benign positional vertigo (BPV).
Do not test those with known neck problems or possible posterior circulation impairment.
Warn the patient what is about to happen.
Sit the patient facing away from the edge of the bed such that when they lie back their head will not be supported (over the edge).
Turn their head to one side and ask them to look in that direction.
Lie them back quickly- supporting their head so that it lies about 30 degrees below the horizontal.
Watch for nystagmus (affected ear will be lowermost).
Repeat with the head turned in the other direction.
No nystagmus = normal.
Nystagmus, with a slight delay (~10secs) and fatiguable (can't be repeated successfully for 10-15mins) = BPV.
Nystagmus, no delay, and no fatiguing = central vestibular syndrome.
59
Neurological examination: Cranial nerves IX and X, glossopharyngeal and vagus, applied anatomy
The 9th and 10th nerves are considered together as they have similar functions and work together to control pharynx, larynx, and swallow.
IX, sensory: pharynx, middle ear, taste on posterior 1/3 of tongue.
IX, motor: stylopharyngeus.
IX, autonomic: parotid gland.
IX originates in the medulla, passes through the jugular foramen.
X, sensory: tympanic membrane, external auditory canal, and external ear, proprioception from thorax and abdomen.
X, motor: palate, pharynx, and larynx.
X, autonomic: carotid baroreceptors.
X originates in medulla and pons, leaves the skull via jugular foramen.
60
Neurological examination: Cranial nerves IX and X, glossopharyngeal and vagus, applied anatomy
The 9th and 10th nerves are considered together as they have similar functions and work together to control pharynx, larynx, and swallow.
IX, sensory: pharynx, middle ear, taste on posterior 1/3 of tongue.
IX, motor: stylopharyngeus.
IX, autonomic: parotid gland.
IX originates in the medulla, passes through the jugular foramen.
X, sensory: tympanic membrane, external auditory canal, and external ear, proprioception from thorax and abdomen.
X, motor: palate, pharynx, and larynx.
X, autonomic: carotid baroreceptors.
X originates in medulla and pons, leaves the skull via jugular foramen.
61
Neurological examination: Cranial nerves IX and X, glossopharyngeal and vagus, examination, pharynx
Ask the patient to open their mouth and inspect the uvula (use a tongue depressor if necessary).
Is it central or deviated to one side? which side?
Ask the patient to say 'ahh'. Watch the uvula. It should move upwards centrally. Does it deviate to one side?
62
Neurological examination: Cranial nerves IX and X, glossopharyngeal and vagus, examination, gag reflex
This is unpleasant for the patient and should only be tested if a IX or X nerve lesion is suspected (afferent signal = IX, efferent = X).
With the patient's mouth open wide, gently touch the posterior pharyngeal wall on one side with a tongue depressor or other sterile stick.
Watch the uvula (it should lift up).
Repeat on the opposite side.
Ask the patient if they felt 2 touches- and was there any difference in sensation?
63
Neurological examination: Cranial nerves IX and X, glossopharyngeal and vagus, examination, larynx
Ask the patient to cough- normal character? gradual onset/ sudden?
Listen to the patient's speech- note volume, quality, and whether it appears to fatigue (quieter as time goes on).
Test swallow.
At each stage, watch the swallow action- 2 phases or 1 smooth movement? delay between fluid leaving mouth (oral phase) and pharynx/larynx reacting (pharyngeal phase)? any coughing/choking? any 'wet' voice?
Terminate the test at the first sign of the patient aspirating.
Offer the patient a teaspoon of water to swallow, repeat x3.
Offer the patient a sup of water, repeat x3.
Offer the patient the glass for a mouthful of water, repeat x3.
64
Neurological examination: Cranial nerves IX and X, glossopharyngeal and vagus, findings, uvula
Moves to one side = X lesion on the opposite side.
No movement = muscle paresis.
Moves with 'aah' but not gag and decreased pharyngeal sensation = IX palsy.
65
Neurological examination: Cranial nerves IX and X, glossopharyngeal and vagus, findings, cough
Gradual onset of a deliberate cough = vocal cord palsy.
'Wet', bubbly voice and cough (before the swallow test) = pharyngeal and vocal cord palsy (X palsy).
Poor swallow and aspiration = combined IX and X or lone X lesion.
66
Neurological examination: Cranial nerve XI, accessory, applied anatomy
Sensory: none.
Motor: sternocleidomastoids and upper part of trapezii.
The accessory nerve is composed of 'cranial' and 'spinal' parts.
The cranial accessory nerve arises from the nucleus ambiguus in the medulla.
The spinal accessory nerve arises from the lateral part of the spinal cord down to C5 as a series of rootlets.
These join together and ascend adjacent to the spinal cord, passing through the foramen magnum to join with the cranial option of the accessory nerve.
It leaves the skull via the jugular foramen.
The cranial portion joins with the vagus nerve (X).
The spinal portion innervates the sternocleidomastoids and the upper fibres of the trapezii.
Each cerebral hemisphere controls the ipsilateral sternocleidomastoid and the contralateral trapezius.
67
Neurological examination: Cranial nerve XI, accessory, examination
The cranial portion of the accessory nerve cannot be tested separately.
Inspect the sternocleidomastoids- look for wasting, fasciculation, hypertrophy, and any abnormal head position.
Ask the patient to shrug their shoulders and observe.
Ask the patient to shrug again, using your hands on their shoulders to provide resistance.
Ask the patient to turn their head to each side, first without then with resistance (use your hand on their cheek).
68
Neurological examination: Cranial nerve XI, accessory, findings
Isolated accessory nerve lesions are very rare.
XI lesions usually present as part of a wider weakness or neurological syndrome.
Bilateral weakness: with wasting caused by muscular problems or motor neuron disease.
Unilateral weakness (trapezius and sternomastoid same side): suggests a peripheral neurological lesion.
Unilateral weakness (trapezius and sternomastoid of opposite sides): usually with hemiplegia suggests an UMN lesion ipsilateral to the weak sternomastoid.
The action of the sternocleidomastoid is to turn the head to the opposite side, so poor head turning to the left indicates a weak right sternocleidomastoid.
69
Neurological examination: Cranial nerve XII, hypoglossal, applied anatomy
Sensory: none.
Motor: muscles of the tongue.
Nucleus lies on the floor of IV ventricle.
Fibres pass ventrally, leaving the brainstem lateral to the pyramidal tracts.
Leaves the skull via the hypoglossal foramen.
70
Neurological examination: Cranial nerve XII, hypoglossal, examination
Ask the patient to open wide and inspect the tongue on the floor of the mouth. Look for size and evidence of fasciculation.
Ask the patient to protrude the tongue. Look for deviation or abnormal movements.
Ask the patient to move the tongue in and out repeatedly, then side to side.
To test for subtle weakness, place your finger on the patient's cheek and ask them to push against it from the inside using their tongue.
71
Neurological examination: Cranial nerve XII, hypoglossal, findings
A LMN lesion will cause fasciculation on the affected side and a deviation towards the affected side on protrusion, and weakness on pressing the tongue away from the affected side.
A unilateral UMN lesion will rarely cause any clinically obvious signs.
A bilateral UMN lesion will give a small, globally weak tongue with reduced movements.
A bilateral LMN lesion (e.g. motor neuron disease) will also produce a small, weak tongue.
A rapid 'in and out' movement on protrusion (trombone tremor) can be caused by cerebellar disease, extra-pyramidal syndromes, and essential tremor.
72
Neurological examination: Motor, applied anatomy, cortex
The primary motor area is the precentral gyrus of the cerebrum and it is here, along with adjacent cerebral areas, that imitation of voluntary movement occurs.
Muscle groups are represented by areas of the cortex from medial to lateral.
The size of the area dedicated to muscle corresponds with the precision of movement (= the number of motor units) that are involved.
73
Neurological examination: Motor, applied anatomy, pyramidal (direct) pathways
These are concerned with precise, voluntary movements of the face, vocal cords, hands and feet.
The simplest pathways consist of 2 neutrons.
The first 'upper motor neuron' originates in the cerebral cortex, passes down through the internal capsule, brainstem, and spinal cord where it synapses with a 'lower motor neuron'.
This leaves the cord to synapse with skeletal muscle fibres.
There are 3 pyramidal tracts: lateral corticospinal, anterior corticospinal, and corticobulbar.
Lateral corticospinal: control of precise movement in the hands and feet, represents 90% of UMN axons, these decussate (cross over) in the medullar oblongata before continuing to descend so that thieves from the right side of the brain control muscles on the left of the body and vice versa.
Anterior corticospinal: control of the neck and trunk, holds 10% of UMN axons, these do not cross in the medulla but descend in the anterior white columns of the spinal cord, decussate at several spinal levels and exit at the cervical and upper thoracic segments.
Corticobulbar: voluntary muscles of the eyes, face, tongue, neck, and speech, terminate at nuclei in the pons and medulla, some crossed, others not, control of cranial nerves III-VII and IX-XII.
74
Neurological examination: Motor, applied anatomy, extrapyramidal (indirect) pathways
All the other descending pathways.
These are complex circuits involving the cortex, limbic system, basal ganglia, cerebellum, and cranial nerve nuclei.
There are 5 major tracts controlling precise movements of the hands and feet, movement of the head and eyes in response to visual stimuli, muscle tone, and truncal stability and balance.
Basal ganglia/nuclei: complex circuits concerned with the production of autonomic movement, planning movement sequences, also appear to inhibit intrinsically excitable circuits.
75
Neurological examination: Motor, tone
The aim is to test resting tone in the limbs.
Arms: take the patient's hand in yours as if shaking it, and hold their elbow with your other hands. From this position, you can pronate and supinate the patient's forearm, roll the patient's wrist through 360 degrees, and flex and extend the patient's elbow.
Legs, hip: with the patient lying flat, legs straight, hold on to the patient's knee and roll it from side to side.
Legs, knee: with the patient in the same position, put your hand behind the patient's knee and raise it quickly, watch the heel- it should lift from the bed slightly if tone is normal.
Legs, ankle: holding the foot and the lower leg, flex and dorsiflex the ankle, and check for clonus.
76
Neurological examination: Motor, tone
The aim is to test resting tone in the limbs.
Arms: take the patient's hand in yours as if shaking it, and hold their elbow with your other hands. From this position, you can pronate and supinate the patient's forearm, roll the patient's wrist through 360 degrees, and flex and extend the patient's elbow.
Legs, hip: with the patient lying flat, legs straight, hold on to the patient's knee and roll it from side to side.
Legs, knee: with the patient in the same position, put your hand behind the patient's knee and raise it quickly, watch the heel- it should lift from the bed slightly if tone is normal.
Legs, ankle: holding the foot and the lower leg, flex and dorsiflex the ankle, and check for clonus.
77
Neurological examination: Motor, inspection and tone, findings, reduced tone
'Flaccid' due to LMN or cerebellar lesions or myopathies.
78
Neurological examination: Motor, inspection and tone, findings, increased tone
Spasticity (clasp-knife rigidity): the limb appears stiff; with increased pressure, there is a sudden 'give' and the limb moves; seen in UMN lesions.
Lead-pipe rigidity: the limb is equally stiff through all movements.
Cogwheel rigidity: an extrapyramidal sign, caused by a tremor superimposed on a rigid limb; the limb moves in a stop-go halting fashion.
Gegenhalten (paratonia): seen in bilateral frontal lobe damage and catatonic states; tone increased with increased pressure from the examiner, the patient appears to be resisting movement.
Myotonia: a slow relaxation after action- when asked to make a fist, the patient is unable to release it quickly and will be slow to let go of a handshake, e.g. myotonic dystrophy.
Dystonia: the limb or head has an abnormal posture that looks rather uncomfortable.
79
Neurological examination: Motor, inspection and tone, findings, increased tone
Spasticity (clasp-knife rigidity): the limb appears stiff; with increased pressure, there is a sudden 'give' and the limb moves; seen in UMN lesions.
Lead-pipe rigidity: the limb is equally stiff through all movements.
Cogwheel rigidity: an extrapyramidal sign, caused by a tremor superimposed on a rigid limb; the limb moves in a stop-go halting fashion.
Gegenhalten (paratonia): seen in bilateral frontal lobe damage and catatonic states; tone increased with increased pressure from the examiner, the patient appears to be resisting movement.
Myotonia: a slow relaxation after action- when asked to make a fist, the patient is unable to release it quickly and will be slow to let go of a handshake, e.g. myotonic dystrophy.
Dystonia: the limb or head has an abnormal posture that looks rather uncomfortable.
80
Neurological examination: Motor, upper limb power, overview
Demonstrate each movement, mirroring the patient.
Each muscle group should be graded from 0-5 according the the MRC system.
Examining the upper limbs allows for both sides to be tested at once, allowing a direct comparison between left and right.
81
Neurological examination: Motor, upper limb power, shoulder
Abduction, C5: ask the patient to abduct their arms with elbows bent, 'arms up like a chicken', ask them to hold still as you attempt to push their arms down.
Adduction, C6-7: the patient should hold their arms tightly to their sides with elbows bent, you attempt to push their arms out.
82
Neurological examination: Motor, upper limb power, elbow
Flexion, C5-6: the patient should hold their elbows bent and supinated in front of them 'like a boxer', hold the patient at the elbow and attempt to extend their arm, 'don't let me straighten your arm'.
Extension, C7: patient holds same position as you resist extension at the elbow by pushing on their distal forearm/wrist, 'push me away'.
83
Neurological examination: Motor, upper limb power, wrist
Flexion, C6-7: with arms supinated, the patient should flex the wrist and hold as you attempt to extend it by pulling from your own wrists.
Extension, C6-7: the opposite manoeuvre, patient holds their hand out straight and resists your attempts to bend it.
84
Neurological examination: Motor, upper limb power, fingers
Flexion, C8: ask the patient to squeeze your fingers and resistance your attempts to pull away.
Extension, C7-8: ask the patient to hold their fingers out straight, support their wrist with one hand and attempt to push their fingers down with the side of your hand over their first interphalangeal joints.
Abduction, T1: ask the patient to splay their fingers out and resist your attempts to push them together.
Adduction: ask the patient to make an 'ok' sign and resistance you breaking the circle, or hold a piece of paper between their fingers and resist you pulling it out.
85
Neurological examination: Motor, MRC power classification
```
5 = normal power.
4 = movement against resistance but not 'full' normal power.
3 = movement against gravity, but not against resistance.
2 = movement with gravity eliminated, e.g. can move leg side to side on bed but not lift it.
1 = muscled contractions but no movement seen.
0 = no movement or muscular contraction.
```
86
Neurological examination: Motor, upper limb power, pronator drift
A useful test of subtle weakness.
Ask the patient to hold their arms outstretched in front, palms upwards and eyes closed.
If one side is weak, the arm will pronate and slowly drift downwards.
87
Neurological examination: Motor, upper limb power, pronator drift
A useful test of subtle weakness.
Ask the patient to hold their arms outstretched in front, palms upwards and eyes closed.
If one side is weak, the arm will pronate and slowly drift downwards.
88
Neurological examination: Motor, lower limb power, overview
The patient should be seated on the bed with their legs outstretched in front of them.
The limbs should be exposed as much as possible so that contractions of the muscles can be seen.
Power is tested for each muscle group on one side then the other, comparing right with left and scored according to the MRC scale.
89
Neurological examination: Motor, lower limb power, hip
Flexion, L1-3: with the lower limbs lying on the bed, the patient is asked to raised each leg, keeping the knee straight, the examiner can oppose the movement by pushing down on the thigh just above the knee, 'stop me pushing down'.
Extension, L5-S1: ask the patient to keep their leg pressed against the bed as you attempt to lift it, either with a hand beneath the calf or the ankle, 'stop me lifting your leg up'.
Abduction, L4-S1: ask the patient to move their leg out to the side as you oppose the movement with a hand on the lateral thigh, 'stop me pushing your legs together'.
Adduction, L2-4: with the legs central, put your hand on the medial thigh and attempt to pull the leg out to the side against resistance, 'don't let me pull your legs apart'.
90
Neurological examination: Motor, lower limb power, knee
Flexion, L5-S1: take hold of the patient's knee with one hand and their ankle with the other and flex the leg to about 60 degrees, 'pull your knee in towards your bottom', 'stop me straightening your leg'.
Extension, L3-4: with the patient's leg in the same position, ask the patient to extend their leg, 'push me away', 'straighten your leg out' as you oppose it.
91
Neurological examination: Motor, lower limb power, ankle
Plantar flexion, S1-2: with the patient's leg out straight and ankle relaxed, put your hand on the ball of the foot and ask the patient to push you away, 'push down against my hand and stop me pushing back'.
Dorsiflexion, L4-5: from the same position, hold the patient's foot just above the toes and ask them to pull their foot backwards, 'stop me pushing your foot down', support at the ankle and push with the side of your hand.
92
Neurological examination: Motor, tendon reflexes, theory
The sudden stretch of a muscle is detected by the muscle spindle which initiates a simple 2 neuron reflex arc, causing that muscle to contract.
Tendons are struck with a tendon hammer (causing a sudden stretch of the muscle) and the resultant contraction observed.
In LMN lesion or myopathies, the reflex is reduced or absent, but increased or brisk in UMN lesions.
93
Neurological examination: Motor, tendon reflexes, technique
For each reflex, test the right, then left, and compare.
The hammer should eld at the far end of the handle and swung in a loose movement from the wrist.
The patient should be relaxed and can be distracted- e.g. 'grit your teeth on the count of 3...'
94
Neurological examination: Motor, tendon reflexes, biceps
C5-6.
With the patient seated, lie their arms across their abdomen.
Place your thumb across the biceps tendon and strike it with the tendon hammer.
Watch the biceps for contraction.
95
Neurological examination: Motor, tendon reflexes, supinator
```
C5-6.
The muscle tested is brachioradialis.
With the patient's arms lying loosely across their abdomen, put your fingers on the radial tuberosity and tap with the hammer.
The arm will flex at the elbow.
If brisk, the fingers may also flex.
```
96
Neurological examination: Motor, tendon reflexes, triceps
C7.
Taking hold of the patient's wrist, flex their arm to 90 degrees.
Tap the triceps tendon about 5cm superior to the olecranon process of the ulna.
Watch the triceps.
97
Neurological examination: Motor, tendon reflexes, knee
L3-4.
With the patient's leg extended, use one hand behind their knee to lift their leg to ~60 degrees.
Tap the patella tendon and watch the quadriceps.
98
Neurological examination: Motor, tendon reflexes, ankle
S1-2.
With the hip flexed and externally rotated and the knee flexed to ~90 degrees, hold the foot and tap the Achilles tendon.
Watch the calf muscles for contraction/ankle flexion.
Alternatively, with the leg extended and relaxed, place your hand on the ball of the foot and strike your hand with the hammer.
99
Neurological examination: Motor, other reflexes, plantar response
L5-S2.
Babinski reflex.
The patient should be lying comfortably, legs outstretched.
Warn the patient that you are about to touch the sole of their foot.
Stroke the patient's sole with an orange stick or similar disposable item, from the heel up the lateral aspect of the sole to the base of the 5th toe, along the ball of the foot to the base of the big toe.
Watch the big toe for its initial movement.
Normal response is plantar flexion of the big toe.
UMN lesions will cause the big toe to dorsiflex- 'Babinski response'.
If the leg is withdrawn and the hell moves in a ticklish reaction, this a a withdrawal response and the test should be repeated.
100
Neurological examination: Motor, other reflexes, ankle clonus
A rhythmical contraction of a muscle when suddenly stretched- a sign of hyperreflexia due to UMN lesion.
With the patient lying on the bed, knee straight and thigh slightly externally rotated, suddenly dorsiflex the foot.
More than 3 beats of clonus is abnormal.
101
Neurological examination: Sensory, applied anatomy, spinal roots and dermatomes
A spinal nerve arises at each spinal level, containing sensory and motor neurons serving a specific segment of the body.
The area of the skin supplied by the sensory neutrons corresponding to each spinal level can be mapped out- each segment is a dermatome.
There is considerable overlap and variation.
102
Neurological examination: Sensory, applied anatomy, somatic sensory pathways
There are 2 main spinal pathways for sensory impulses: posterior columns and spinothalamic tract.
Posterior columns: these convey light touch, proprioception, and vibration sense, stereognosis, weight discrimination, and kinaesthesia; nerves from receptors extend up the ipsilateral side of the spinal cord to the medulla, their axons forming the 'posterior columns' (fasciculus gracilis and fasciculus cuneatus); the 2nd order neurons decussate at the medulla and travel in the medial lemniscus to the thalamus; from there, the impulse is conveyed to the sensory cortex.
Spinothalamic tract: this carries pain and temperature sensation; 1st order neurons synapse in the posterior grey horn on joining the spinal cord; 2nd order neurons then decussate and ascend the contralateral side of the cord in the spinothalamic tract to the thalamus.
103
Neurological examination: Sensory, applied anatomy, the sensory cortex
This is located at the post-central gyrus, just posterior to the motor cortex.
Much like the motor strip, the areas receiving stimuli from various parts of the body can be mapped out.
A lesion affecting one area will cause sensory loss in the corresponding body area on the contralateral side.
104
Neurological examination: Sensory, light touch
With the patient's eyes closed, touch their skin with a wisp of cotton wool and ask them to say 'yes' when it is felt.
Test on the sternum first to let them know what it will feel like, then in each dermatome.
'Did it feel the same on each side?'
105
Neurological examination: Sensory, vibration sense
A 128Hz tuning fork is used.
As always, demonstrate on sternum first.
Ask the patient to close their eyes, tap the tuning fork and place the base on a bony prominence- ask if the patient can feel the vibration.
If 'yes', confirm by taking hold of the tuning fork with your other hand to stop the vibration after asking the patient to tell you when the vibration ceases.
Compare left to right and work in a systematic fashion, starting most distally.
Finger tip, wrist, elbow, shoulder, ASIS, tibial tuberosity, metatarsophalangeal joint, and toes may be tested.
106
Neurological examination: Sensory, proprioception
Loss of position sense is usually distal.
Start by testing the patient's big toe or thumb.
The technique can be used at any joint.
With the patient's eyes closed and leg relaxed, grasp the distal phalanx from the sides.
Whilst stabilising the rest of the hand/foot, move the finger/toe up and down at the joint, telling the patient which direction is which, and checking that they can actually feel it.
Ask the patient to close their eyes and to tell you which direction you are moving their finger/toe in.
Flex and extend the joint, stopping at intervals to ask the patient whether it is up or down.
If proprioception is absent, test other joints, working proximally.
107
Neurological examination: Sensory, pin-prick
Use a disposable pin e.g. neurotip.
Test as you would for light touch in each dermatome after demonstrating on the sternum and asking the patient to close their eyes, gently pressing the pin on the skin.
Test each dermatome in a systematic way, mapping out abnormalities.
On each touch, ask the patient whether it feels sharp or dull.
Occasionally use the blunt end to test the patient's reliability with a negative control.
108
Neurological examination: Sensory, temperature
Not routine.
Loss of temperature sensation may be evident from history, e.g. accidental burns.
When tested, test tubes or similar vessels containing hot and ice-cold water are used, and each dermatome tested.
109
Neurological examination: Coordination, upper limbs
Finger-nose test.
Rapid alternating movements.
(Rebound).
110
Neurological examination: Coordination, upper limbs, finger-nose test
Ask the patient to touch the end of their nose with their index finger.
Hold your own finger out in front of them, at arm's reach from the patient, and ask them to then touch the tip of your finger with theirs.
Ask them to move between their nose and your finger.
Look for intention tremor (worse as it approaches the target) and 'past-pointing' (missing the target entirely).
The test can be made more difficult by moving the position of your finger each time the patient touches their nose.
111
Neurological examination: Coordination, upper limbs, rapid alternating movements
Ask the patient to repeatedly supinate and pronate their forearm, keeping the other arm still such that they clap their hands palm-to-palm, then back-to-palm, and so on.
Slow and clumsy = dysdiadochokinesis.
112
Neurological examination: Coordination, upper limbs, rebound
From a resting position (arms at sides), the patient should be asked to quickly abduct their arms and stop suddenly at the horizontal.
In cerebellar disease, there will be a delay in stopping and the arm will oscillate about the intended final position.
113
Neurological examination: Coordination, lower limbs
Heel-shin test.
| Foot tapping.
114
Neurological examination: Coordination, lower limbs, heel-shin test
With the patient sitting, legs outstretched, ask them to slide the heel of one foot up and down the shin of the other leg at a moderate pace, and kick up to meet your hand.
A lack of coordination will manifest as the heel moving side to side about the intended path.
In sensory, as opposed to cerebellar, ataxia (lack of proprioception), patients will perform worse with their eyes closed.
115
Neurological examination: Coordination, lower limbs, foot tapping
The patient taps your alternate hands with their alternate feet as fast as possible.
Non-dominant side performs poorly in normal individuals.
116
Neurological examination: Cerebellar syndrome, findings
Eye movements show a loss of smooth pursuit.
Nystagmus- note the direction of the gaze and the direction of the nystagmus.
Dysarthric- or classic monotonous 'scanning' speech.
Reduced tone- reduced in pure cerebellar disease but may be increased if cerebellar signs coexist with other disease (e.g. posterior circulation stroke, MS).
Intention tremor- perform finger-nose test.
Dysdiadochokinesis.
Trunkal unsteadiness- ask the patient to sit forward with their arms across their chest.
Lower limb incoordination- heel-shin test.
117
Neurological examination: Cerebellar syndrome, gait
Unsteady, broad-based gait.
| If the patient is steady, assess tandem gait.
118
Neurological examination: Peripheral nerves, upper limb, median nerve
C6-T1.
Motor: muscles of the anterior forearm, except flexor carpi ulnaris, and 'LOAF' (lateral 2 lumbricals, opponens pollicis brevis, and flexor pollicis brevis).
Sensory: thumb, anterior index and middle fingers, some of the radial side of the palm.
119
Neurological examination: Peripheral nerves, upper limb, ulnar nerve
C8-T1.
Motor: all the small muscles of the hand except LOAF (lateral 2 lumbricals, opponens pollicis brevis, and flexor pollicis brevis) and flexor carpi ulnaris.
Sensory: ulnar side of hand, little finger and half of ring finger.
120
Neurological examination: Peripheral nerves, upper limb, radial nerve
C5-C8.
Motor: triceps, brachioradialis, and extensors of the hand.
Sensory: small area over the anatomical snuff box.
121
Neurological examination: Peripheral nerves, upper limb, median nerve palsy, inspection
Inspect the forearm carefully, looking for signs of rheumatoid arthritis, osteoarthritis, and any scars.
Wasting of the thenar eminence?
Sign of benediction?- the index and middle fingers are held out straight despite flexion of the other fingers, like a Catholic blessing; due to paralysis of flexor digitorum profundus.
The thumb is held in abduction in the plane of the palm- 'simian thumb', 'monkey paw'.
122
Neurological examination: Peripheral nerves, upper limb, median nerve palsy, tone
Normal.
123
Neurological examination: Peripheral nerves, upper limb, median nerve palsy, power
Weakness of the thenar eminence: abduction, flexion, and opposition of the thumb.
Weakness of flexion at the terminal IP joint of the index finger.
The pen-touching test: place the patient's hand flat, palm up; hold your pen or similar just above the thumb and ask the patient to lift the thumb vertically to touch the pen, without moving the rest of the hand; in median nerve palsy, they will not be able to do this.
Oschner's clasping test: ask the patient to clasp their hands together with fingers interlocking; the index finger will fail to flex in median nerve palsy.
124
Neurological examination: Peripheral nerves, upper limb, median nerve palsy, sensation
Loss of sensation over the thumb, anterior index and middle fingers, and the radial side of the palm.
125
Neurological examination: Peripheral nerves, upper limb, median nerve palsy, Tinel's test
Percussion over the median nerve at the carpal tunnel causes tingling in the distribution of the nerve.
Tinel's sign is paraesthesia in a nerve distribution caused by percussion of that nerve and applies to any nerve.
126
Neurological examination: Peripheral nerves, upper limb, median nerve palsy, Phalen's test
Ask the patient to hold both wrists flexed for 60 seconds.
| This produces an exacerbation of the paraesthesia- relieved by relaxing the wrist (positive in 50% of patients).
127
Neurological examination: Peripheral nerves, upper limb, median nerve palsy, tourniquet test
A sphygmomanometer pumped to just above systolic pressure on the ipsilateral arm for 1-2 minutes reproduces the symptoms.
128
Neurological examination: Peripheral nerves, upper limb, ulnar nerve palsy, inspection
Wasting of the dorsal interossei and hypothenar eminence, if the neuropathy is long-standing.
'Ulnar claw'- extension at the phalangeal-metacarpal joints and flexion aaa the interphalangeal joints, usually little finger first, then ring finger.
The patient may be complaining of pain, usually in the forearm or elbow.
129
Neurological examination: Peripheral nerves, upper limb, ulnar nerve palsy, tone
Normal.
130
Neurological examination: Peripheral nerves, upper limb, ulnar nerve palsy, power
Weakness of all the small muscles of the hand, except LOAF (lateral 2 lumbricals, opponens pollicis brevis, and flexor pollicis brevis).
Weak abduction of the index finger.
Ulnar muscles in the forearm may be weak: flexor digitorum profundus of the 4th and 5th digits, which flexes the distal phalanges; flexor carpi ulnaris which flexes the wrist in the medial direction.
Froment's sign: ask the patient to pinch a piece of paper between thumb and index finger or make a fist- this will be weak and the thumb will flex as it is unable to abduct.
Test thumb abduction to rule out a C8/T1 nerve root lesion.
131
Neurological examination: Peripheral nerves, upper limb, ulnar nerve palsy, reflexes
Normal tendon reflexes.
132
Neurological examination: Peripheral nerves, upper limb, ulnar nerve palsy, sensation
Loss of sensation over the medial aspect of the hand, little finger and medial half of the ring finger.
133
Neurological examination: Peripheral nerves, upper limb, radial nerve palsy, inspection
Carefully inspect the upper limbs.
| Radial nerve palsy is the classic cause of wrist drop.
134
Neurological examination: Peripheral nerves, upper limb, radial nerve palsy, tone
Normal.
135
Neurological examination: Peripheral nerves, upper limb, radial nerve palsy, power
Weakness of triceps (elbow extension) in very proximal lesions.
Weakness of brachioradialis (elbow flexion with the forearm partially pronated).
Test power in the extensor muscles of the wrist, fingers at the MCP joints, and thumb- weakness in some or all of these, sparing of finger abduction and thenar eminence muscles (thumb abduction at right angles to the palm).
To test finger abduction, fingers must be extended- place hand on a flat surface to test if there is finger drop.
136
Neurological examination: Peripheral nerves, upper limb, radial nerve palsy, reflexes
Absent or weak triceps reflex in very proximal lesions, and also C7 root lesions.
137
Neurological examination: Peripheral nerves, upper limb, radial nerve palsy, sensation
Sensory loss in a small area over the dorsal aspect of the hand at the anatomical snuff box- hard to test.
138
Neurological examination: Peripheral nerves, lower limb, lateral cutaneous nerve of the thigh
L2-3.
Motor: none.
Sensory: the lateral aspect of the thigh.
Examining a lesion: there may be some sensory loss as indicated but this is very hard to test in practice.
139
Neurological examination: Peripheral nerves, lower limb, common peroneal nerve
L4-S2.
Motor: anterior and lateral compartments of the leg
Sensory: the dorsum of the foot and anterior aspect of the leg.
Examining a lesion: 'foot-drop' with corresponding gait, weakness of foot dorsiflexion and eversion, preserved inversion.
140
Neurological examination: Peripheral nerves, lower limb, femoral nerve
L2-4.
Motor: quadriceps.
Sensory: medial aspect of thigh and leg.
Examining a lesion: weakness of knee extension is only slightly affected, hip adduction preserved; stretch test positive if pain is felt in thigh/inguinal region when, lying prone, patent abducts the hip, flexes the knee, and plantar-flexes the foot.
141
Neurological examination: Peripheral nerves, lower limb, sciatic nerve
L4-S3.
Motor: all the muscles below he knee and some hamstrings.
Sensory: posterior thigh, ankle and foot.
Examining a lesion: foot drop and weak knee flexion, knee jerk reflex preserved but ankle jerk and plantar response are absent; stretch test positive if pain felt at the back of the thigh when, lying supine, the leg is lifted by the ankle straight to 90 degrees and the foot dorsiflexed.
142
Neurological examination: Gait, examination
Ask the patient to walk a few metres, turn, and walk back to you.
Use of walking aids.
Symmetry.
Size of paces.
Lateral distance between the feet.
How high the feet and knees are lifted.
Bony deformities.
Disturbance of normal gait by abnormal movements.
Ask the patient to walk on tip-toes (inability = S1 or gastrocnemius lesion).
Ask the patient to walk on their heels (inability = L4/5 lesion, foot-drop).
143
Neurological examination: Gait, examination, findings
```
Hemiplegia
Scissoring
Parkinsonism
Cerebellar ataxia
Waddling
Foot drop
Apraxic
Marche a petit pas
Painful gait
Functional
```
144
Neurological examination: Gait, examination, findings, hemiplegia
One side weaker than the other with the patient tilting pelvis to lift the weak leg which may swing out to the side.
Gait may be unsafe without the use of walking aid.
145
Neurological examination: Gait, examination, findings, scissoring
If both legs are spastic (cerebral palsy, MS), toes drag on floor, trunk sways from side to side, and legs cross over on each step.
146
Neurological examination: Gait, examination, findings, Parkinsonism
Flexed posture with small, shuffling steps.
No or little arm-swing.
Difficulty starting, stopping, and turning.
Gait seems hurried ('festinant') as legs attempt to prevent body falling forwards.
147
Neurological examination: Gait, examination, findings, cerebellar ataxia
Broad-based (legs wide) gait with lumbering body movements and variable distance between steps.
Difficulty turning.
148
Neurological examination: Gait, examination, findings, sensory ataxia
Loss of proprioception.
Patient requires more sensory input to be sure of leg position so lifts leg high ('high-stepping') and stamps feet down with a wide-based gait.
May also watch legs as they walk.
Romberg's positive.
149
Neurological examination: Gait, examination, findings, waddling
Weakness of proximal lower limb muscles.
Patient fails to tilt pelvis as normal so increased rotation to compensate, also at the shoulders.
May also see increased lumbar lordosis.
150
Neurological examination: Gait, examination, findings, foot drop
L4/5 lesion, sciatic, or common peroneal nerves.
Failure to dorsiflex the foot leads to a 'high-stepping' gait with increased flexion at the hip and knee.
If bilateral, may indicate peripheral neuropathy.
151
Neurological examination: Gait, examination, findings, apraxic
Usually frontal lobe pathology such as normal pressure hydrocephalus or cerebrovascular disease.
Problems with gait even if all other movements may be normal.
Patient may appear frozen to the spot and unable to initiate walking.
Movements are disjointed once walking.
152
Neurological examination: Gait, examination, findings, marche a petit pas
Diffuse cortical dysfunction.
| Upright posture, small steps with normal arm-swing.
153
Neurological examination: Gait, examination, findings, painful gait
The cause will normally be obvious from the history.
| The patient limps with asymmetrical gait due to painful movement.
154
Neurological examination: Gait, examination, findings, functional (hysterical)
Gait problems will be variable and inconsistent, often with bizarre and elaborate consequences.
May fall without causing injury.
Often worse when watched.
155
Neurological examination: Gait, examination, Romberg's sign
A further test of proprioception.
Usually tested at the time of gait examination, as the patient will be standing at this point.
When proprioception is lost in the lower limbs, patients can often stand and move normally as long as they can see the limb in question.
Perform this with care- only if you are able to prevent the patient falling and injuring themselves.
Ask the patient to stand. You stand facing them.
Ask the patient to close their eyes.
If there is loss of proprioception, the patient will lose their balance and start to fall- if so, ask them to open their eyes immediately, if they haven't already done so, and help them regain their balance without injury.
156
The unconscious patient: history
Eye witness account?
State of clothing- loss of continence?
Look for alert necklace/bracelet in wallet, purse, etc.
157
The unconscious patient: examination, overview
```
ABC.
Skin.
Movements/posture.
Consciousness.
Neck.
Head.
Battle's sign.
Ears/nose.
Tongue/mouth.
Eyes.
Rest of the body.
Other bedside tests.
```
158
The unconscious patient: examination, ABC
Airway patent? Should the patient be in the recovery position?
Measure respiratory rate, note pattern of breathing.
Is O2 needed?
Cyanosis?
Feel pulse.
Listen to chest.
Measure heart rate, BP.
159
The unconscious patient: examination, skin
Look for injury, petechial haemorrhage, evidence of IV drug use.
160
The unconscious patient: examination, movements/posture
Watch. Is the patient still or moving? all 4 limbs moving equally?
Any abnormal movements- fitting, myoclonic jerks?
Test tone and compare both sides.
Squeeze the nail bed to test the response to pain (all 4 limbs).
Test tendon reflexes and plantar response.
Decorticate posture: lesion above the brainstem, flexion and internal rotation of the arms, extension of the lower limbs.
Decerebrate posture: lesion in the midbrain, extension at the elbow and wrist, pronation of the forearm, lower limbs extended.
161
The unconscious patient: examination, consciousness
Attempt to wake the patient by sound.
Ask their name.
If responsive, are they able to articulate appropriately? note the best response.
Be aware of possible dys- or aphasia which may cause an inappropriate response in an otherwise alert individual.
Score level of consciousness according to GCS or AVPU.
162
The unconscious patient: examination, neck
Do not examine if there may have been trauma.
| Test for meningeal irritation- these signs reduce as coma deepens.
163
The unconscious patient: examination, head
Inspect for signs of trauma and facial weakness.
| Test pain sense.
164
The unconscious patient: examination, Battle's sign
Bruising behind the ear = a base of skull fracture.
165
The unconscious patient: examination, ears/nose
Look for CSF leakage or bleeding.
Test any clear fluid for glucose (positive result = CSF).
Inspect eardrums.
166
The unconscious patient: examination, tongue/mouth
Look for cuts on the tongue (seizures), corrosive material around the mouth.
Smell breath for alcohol or ketosis.
Test the gag reflex- absent in brainstem disease or deep coma.
167
The unconscious patient: examination, eyes
Pupils: measure size in mm. are they equal? test direct and consensual light responses. pupils dilated with atropine, TCAs, and amphetamine. pupils constricted with morphine and metabolic coma.
Test corneal reflex.
Fundi: look especially for papilloedema and retinopathy.
Doll's head manoeuvre: take the patient's head in your hands and turn it from side to side- the eyes should move to stay fixed on an object, indicates an intact brainstem.
168
The unconscious patient: examination, rest of the body
A brief but thorough exam.
| Look especially for trauma, fractures, signs of liver disease, and added heart sounds.
169
The unconscious patient: examination, other bedside tests
Test urine, capillary glucose, and temperature.
170
The unconscious patient: Glasgow Coma Scale (GCS)
Objective score of consciousness.
Repeated testing is useful for judging whether coma is deepening or lifting.
Lowest possible score is 3.
Eye opening (max. 4 points):
- spontaneously open = 4
- open to any verbal stimulus = 3
- open in response to painful stimulus = 2
- no eye opening at all
Best verbal response (max. 5 points):
- conversing and orientated (normal) = 5
- conversing but disorientated and confused = 4
- inappropriate words (random words, no conversation) = 3
- incomprehensible sounds (moaning, etc.) = 2
- no speech at all = 1
Best motor response (max. 6 points):
- obeying commands (e.g. raise your hand) = 6
- localising to pain (moves hand towards site of stimulus) = 5
- withdraws to pain (pulls hand away from stimulus) = 4
- abnormal flexion to pain (decorticate posturing) = 3
- abnormal extension to pain (decerebrate posturing) = 2
- no response at all = 1
171
The unconscious patient: Glasgow Coma Scale (GCS), eye opening
```
Max. 4 points:
Spontaneously open = 4
Open to any verbal stimulus = 3
Open in response to painful stimulus = 2
No eye opening at all
```
172
The unconscious patient: Glasgow Coma Scale (GCS), best verbal response
```
Max. 5 points:
Conversing and orientated (normal) = 5
Conversing but disorientated and confused = 4
Inappropriate words (random words, no conversation) = 3
Incomprehensible sounds (moaning, etc.) = 2
No speech at all = 1
```
173
The unconscious patient: Glasgow Coma Scale (GCS), best motor response
Max. 6 points:
Obeying commands (e.g. raise your hand) = 6
Localising to pain (moves hand towards site of stimulus) = 5
Withdraws to pain (pulls hand away from stimulus) = 4
Abnormal flexion to pain (decorticate posturing) = 3
Abnormal extension to pain (decerebrate posturing) = 2
No response at all = 1
174
The unconscious patient: AVPU
```
A much more simplified score used in rapid assessment of consciousness and often by non-specialist nurses in monitoring conscious level.
A = Alert.
V = responds to Voice.
P = responds to Pain.
U = Unresponsive.
```
