Author: Dr Paul Masiowski A handy guide The Neuro Exam for Non-Neurologists Date: 20 September 2013.

Author: Dr Paul Masiowski

A handy guide

The Neuro Exam for Non-Neurologists

Date: 20 September 2013


The neurological examinationThis handy guide will help you review and develop your neuro exam skills!

We will:

•Review the full neuro exam in overview

•Study the “Saskatoon Screening Exam”

(a 5 minute neuro exam sufficient to make most diagnoses)

•Study a faster screening exam

(a 2 minute neuro exam sensitive enough to rule out serious pathology in

most patients)

•Discuss tips and tricks for improving the sensitivity and reliability of the

exam

•Consider how and when to expand the screening exam screening for:

•dementia, headache, parkinsonism, tremor, myasthenia, myelopathy,

neuropathy, etc.

All that in 40 minutes (give or take)!

A handy guide

Objectives


•Queen’s Medicine, 2005

•USask Neurology residency, 2005-10

•FRCPC (Neurology) 2010

•Community practice at Lakeview Neurology

Associates

•Clinical Assistant Professor at USask

•SMA Section Rep

•Received honoraria from Allergan

•Interests: Migraine, Neuropsychiatry,

Movement Disorders

A handy guide

Biography and disclosures


One that tells you where the problem is

Like all tests, you need it to be reliable.

A handy guide

The neurological examination is a diagnostic test

• Find important abnormalities

• Recognize when something unusual is

actually normalYou need to know what the implications are of normal or

abnormal results


The overview

1.Mental Status

2.Cranial nerves

3.Motor

4.Reflexes

5.Sensory

6.Coordination & Gait

A handy guide

Outline of the neurological examination


Reviewed with JURSIs weekly at RUH since 1994

A handy guide

The Saskatoon Screening Exam

A 5 minute examination of the following:

1.Mental Status

2.Cranial nerves

3.Motor

4.Reflexes

5.Sensory

6.Coordination & Gait

This is as much of the neuro exam as you need to know,

most of the time


The Saskatoon Screening ExamAssessed during history taking (overall

impression)

If the patient can give a good history...

(well organized and detailed

demonstrating normal attention and

memory

with good language function)

...there’s little to be gained from any

further testing

A handy guide

Mental status exam



•Visual fields by confrontation (II)

•Pupils (II & III)Eye movements (III, IV &

VI)

•Facial strength (VII)Speech clarity (IX,

X, XII)

A handy guide

Cranial nerve exam



•Pronator driftStrength in arms and legs

(proximal & distal):

•Deltoids

•Finger extensors

•Hip flexors

•Tibialis anterior

A handy guide

Motor exam



•Brachioradialis, biceps,

tricepsKnee jerk, ankle

jerkBabinski

A handy guide

Reflexes exam


The Saskatoon Screening Exam • Lateralizing sensory loss:

•pin on both sides,

face/arm/leg

•vibration on both sides, in

toes

... or ...

•Distal sensory loss:

•pin ascending from toes

•vibration ascending from

toes

A handy guide

Sensory exam



•Finger to nose task

•Heel to shin task

•Rapid alternating

movements

•finger tapping

•open/close hands

•foot tapping

A handy guide

Coordination exam



•Normal gait

•Tandem gait (not in

elderly)

•Romberg? (not in elderly)

A handy guide

Gait exam


So easy, you can do it with any patient

1.Mental status: conversation / history (note speech)

2.Cranial nerves: visual fields, eye movements (look at pupils

too), grimace

2a. Fundi (if headache is a concern)

1.Strength: pronator drift, strength in 2 muscles in each limb

2.Reflexes: 2 per limb, Babinski

3.Sensation: skip it (!)

4.Coordination and gait: finger-nose, gait, tandem

A handy guide

The 2 minute screening exam


All opinions here are my ownPitfalls to the neuro exam:

•Subtle findings

•Unexpected findings

•Chronic findings

•Normally abnormal findings

•Findings not due to

neurological disease

•Patient cooperation

(sometimes)

Need to have reliable

techniques, so you can be

confident in the results

A handy guide

Tips and Tricks to improve your exam skills


Tips and Tricks•Most good historians have normal mental

status.

•Attention tests should be simple

(weekdays or months, backwards) -- avoid math

(serial 7s)

•Patients who can’t recall 3 words will think for a

moment or confabulate or distract; those who

say immediately

“I can’t remember” have a good prognosis

• A quick clock drawing can tell you whether or

not to worry

A handy guide

Mental status exam


Tips and Tricks

Not frequently tested by

neurologists:

•Smell

•Visual acuity

•Hearing

•Corneal reflex (except in coma)

•Gag reflex

•Strength in the neck

...unless the situation calls for it

A handy guide

Cranial nerves testing


Tips and TricksI use “static fingers”, testing by quadrant:

•Hold up 1 or 2 fingers in one quadrant

•Then on the opposite side

•Then test both sides at once (for visual extinction)

One eye or two?

•Both eyes at once is OK, except in headache patients

•Advantage of one-eye-at-a-time is catching pre-chiasmatic lesions

(pituitary etc)

•Disadvantage is time

Wiggling fingers in from periphery is unreliable, test macular (central

vision) instead

I show fingers for only a second or two, which is all it takes.

A handy guide

Visual fields testing


Tips and Tricks

Observe for symmetry in room light

If pupils equal, they’re normal

No need for flashlight!

A handy guide

Pupils testing

Normal variants:

•Physiologic anisocoria: pupil asymmetry preserved across spectrum of

light/dim

•Asymmetric pupil from trauma, surgery, etc

Subtle finding:

•Horner’s syndrome: miosis usually mild, goes with mild ptosis of upper

and lower lids.

Pupil asymmetry increases in the dark, so check in the dark


Tips and Tricks“Follow my finger”...

...all the way to one side, then the other

...then up, down and right at them (convergence)

•No need for “H” or other shapes

•Observe alignment, don’t ask about diplopia during test

Normal variants:

•Strabismus, usually congenital (ask).

Test each eye separately, movements should be ~normal

•Gaze evoked nystagmus: few beats, symmetric at extremes of

horizontal gaze. Very common with age, fatigue, mediations

(sedatives)

A handy guide

Eye movements testing


Tips and TricksLook for symmetry at rest and spontaneously

Grimace: show don’t tell what you want them to do

No need to test facial movements one by one

Normal variant:

•Some asymmetry of the face is normal (except in Hollywood)

Ask family if face is different than usual

Subtle finding:

•Symmetric facial weakness will be missed if you only check for

symmetry

Look for strength of eye closure (“squeeze them shut”) or lip

closure

A handy guide

Facial strength testing


Tips and Tricks

Is speech clear?

Can almost always decide during conversation

If not, test:

•Palate elevation (midline?)

•Tongue protrusion (midline?)

A handy guide

Speech testing


Tips and TricksVery sensitive test for mild weakness

Patient holds hands outstretched forward, palms up and fingers

straight

Eyes closed, wait 10+ seconds to rule out drift

Subtle findings:

•Abnormal drift is sometimes down, sometimes turning over

(pronating) and sometimes up (“sensory” drift)

Normal variant:

•Some patients will wave their hands up and down repeatedly

and may sway back and forth, even when encouraged to hold

still. (I scan them anyway)

A handy guide

Pronator drift testing


Tips and Tricks

Test muscles likely to be weak with mild deficits (screening test)

•Deltoids

•Finger extensors

•Hip flexors

•Ankle dorsiflexors

... are all weaker than their antagonists with an UMN lesion

(“corticospinal tract” distribution)

Normal variant:

•To detect variable effort (“giveway” weakness), make the patient move

first, to a target, then against resistance.

A handy guide

Strength testing


Tips and Tricks

Test pin and vibration, not light touch, temperature or proprioception

•Pin: broken tongue depressor

•Vibration: 128 Hz tuning fork (not audible)

Ask:

•Does this feel sharp?

•Do you feel the buzz?

•Is it the same on the other side?

Slight variations from side to side are OK.

•Move from left to right (screening for central problems)

•From distal to proximal (screening for neuropathy)

•From numb areas to normal areas (ask patient to show you where the transition is)

A handy guide

Sensory testing


Tips and Tricks

Finger/nose task

•Hold target still, no need to move it around

•Look for smooth, accurate movements

Heel/shin task

•Difficult to teach / learn

•Limited ROM (arthritis, pain) limits the value of the test

Rapid alternating movements:

•Finger tapping, open/close fist better than “clap-flip-clap-flip” task, which is difficult

Subtle finding:

•Mild dysmetria suggests mild weakness

Normal variant:

•“accurate” missing

A handy guide

Coordination testing


Tips and Tricks

Walk across the room (down the hall) and back. OK to repeat if needed

•Width of feet (should nearly touch)

•Leg swing

•Foot drop

•Arm swing

Walk on toes / heels (sensitive test of distal strength)

Tandem gait: not if elderly

Romberg: best done with distraction

•I tell them we’re doing a “concentration test”

A handy guide

Gait testing


Expanding your basic exam to answer harder questions1.Cerebrum: Does this patient have dementia? Aphasia?

2.Basal ganglia: Is this a Parkinsonian tremor?

3.Brainstem and cranial nerves: Does this patient have a central

cause of dizziness?

4.Cerebellum: Does this patient have a central cause of

imbalance?

5.Spinal cord: Does this patient have a spinal cord lesion?

6.Motor neuron: Does this patient have ALS?

7.Peripheral nerve: Is this numbness due to neuropathy?

8.Neuromuscular junction: Is this patient fatigued because of

myasthenia?

9.Muscle: Is this weakness due to myopathy?

A handy guide

Additional testing for specific situations


Expanding your basic exam to answer harder questions

Mental status quick screen (prefer this to MMSE or MoCA):

•orientation

•memory -- delayed recall of 3 word list

•attention -- months of the year backwards

•clock drawing

Language testing (simple --> complex):

•naming

•repetition

•comprehension (commands)

•fluency (in conversation)

A handy guide

Cerebrum: dementia, aphasia



Tremor:

•at rest? (usually in hands) -- worse with distraction

•with posture (hands, head)

•with activity (finger-nose)

Rigidity

•at wrist, elbow, knee -- worse with distraction

Bradykinesia

•finger tapping, open-close fists, foot tapping

•masked face, decreased blinking, hypophonic voice

Gait

•shuffling, decreased arm swing, flexed posture, en bloc

turns

A handy guide

Basal ganglia: tremor, parkinsonism


Expanding your basic exam to answer harder questionsCranial nerves:

•Horner’s syndrome

•eye movements, nystagmus

•dysarthria

•facial sensation, symmetry

Sensory and Motor:

•crossed findings (face on one side, arm/leg on the other)

Special test: Head Impulse test

Patient focuses eyes on tip of your nose. Gently but suddenly twist head 10-15 degrees to

one side, then the other.

If eyes remain fixed, normal. If corrective saccade brings them back to midline, vestibular

dysfunction.

A normal head impulse test in the setting of acute vertigo suggests stroke or other central

cause.

A handy guide

Brainstem and cranial nerves: vertigo



Ataxia:

•ataxia / dysmetria on finger-nose and/or heel-shin tasks

•clumsiness with rapid movements (finger tapping etc)

•slurred speech

•difficulty walking in tandem

Tremor: intention tremor with finger-nose

Eye movements: nystagmus (especially up or downbeating)

Gait: wide based, unable to walk in tandem

NB: Romberg is not a “cerebellar” test, it’s a test of

proprioception

A handy guide

Cerebellum: imbalance, clumsiness



xxx:

•ataxia / dysmetria on finger-nose and/or heel-shin tasks

•clumsiness with rapid movements (finger tapping etc)

•slurred speech

•difficulty walking in tandem

Tremor: intention tremor with finger-nose

Eye movements: nystagmus (especially up or downbeating)

Gait: wide based, unable to walk in tandem

NB: Romberg is not a reliable “cerebellar” test

A handy guide

Spinal cord: myelopathy



Strength testing:

•expect “corticospinal” pattern of weakness

•may be only in 1-2 limbs early in disease

Muscle atrophy

Fasciculations

•Look in larger muscles (calves, quads, triceps, deltoids,

pecs)

•Patient may be able to direct you

Reflexes: expect an “upper motor neuron” sign

(hyperreflexic, Babinski)

No sensory symptoms or signs

A handy guide

Motor neurons: ALS


Expanding your basic exam to answer harder questionsSensory loss / painful dysesthesiae

•in distribution of a single nerve (branch)

•in distribution of a single root

•distal symmetric (stocking-glove)

Weakness / atrophy

•in distribution of a single nerve (branch)

•in distribution of a single root

•distal symmetric (stocking-glove)

Requires enough neuroanatomy to be satisfied that other

nerves/roots are OK

...complex pictures can be hard to sort out (even for

specialists)cover_image.asp

A handy guide

Peripheral nerve: Neuropathy



“PD 3”:

•ptosis (usually asymmetric, variable)

•diplopia / eye movement abnormalities (esp upgaze)

•dysarthria (nasal speech)

•dysphagia (to liquids, on history)

May also have:

•facial weakness (symmetric)

•neck weakness (check flexors)

•limb weakness (proximal > distal, usually symmetric)

Test fatigability:

•prolonged upgaze (ptosis, upgaze)

•dysphagia (to liquids, on history)

A handy guide

Neuromuscular junction: myasthenia



Weakness:

•proximal > distal limbs

•usually symmetric

May have bulbar weakness:

•facial weakness (usually symmetric)

•dysarthria

•neck weakness (check flexors)

Ocular muscle weakness / ptosis not usually from myopathy

No fascics, usually not much atrophy

Reflexes and sensation normal

Gait can be myopathic (“waddling”, Trendelenburg)

A handy guide

Muscle: myopathy

Any questions?Thanks!

Feel free to email me with questions:

[email protected]

Author: Dr Paul Masiowski A handy guide The Neuro Exam for Non-Neurologists Date: 20 September 2013.

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Transcript of Author: Dr Paul Masiowski A handy guide The Neuro Exam for Non-Neurologists Date: 20 September 2013.