Physical Exam

The Neurological Exam

Summary

MS:        GCS 15 A&O x 3 lang fluid & app (good repeat)

Mentation seems nl (MMSE 30/30)

CN:        VA 20/20 OU VF full disc sharp without pap

PERRL 3mm OU EOMI without nystagmus

Face c nl sensation, symmetry, strength

Hearing intact; t/p midline

(shoulder shrug, gag, corneal, caloric, jaw jerk)

Motor:   nl bulk and tone 5/5 strength throughout

No invol movements

D, B, T, WF, WE, HI, IP, Q, H, AT, G

Sens:       nl PP vib and proprio

Coord:    F-N and H-S nl, RAM and Finger tap nl

DTR: +2 sym throughout, plantar is flexor

Gait: nl good tandem, no romberb

 

Mental status: Always start with the Glasgow Coma Scale Score

  • Glasgow Coma Scale
    • Eye- 1- Don’t open; 2- Open to Pain; 3- Open to voice; 4- Open spontaneously
    • Verbal- 1- No verbal; 2- Incomprehensible sounds; 3-Inappropriate words; 4-Confused; 5-Oriented (x3)
    • Motor- 1- No motor; 2- Extensor/Decerebrate posturing; 3- Flexor/Decorticate posturing; 4- Withdrawal to pain; 5-Localizes; 6-Follows
  • Limbic and global functions (memory), testing of dominant hemisphere frontal language function and parietal function (Gerstmann’s syndrome), right parietal dysfunction (neglect and constructions), and frontal dysfunction (sequencing tasks and frontal release signs).
    • Alertness, Attention, Cooperation, Orientation: Person, Place, Time, Consequence followed by attention (W-O-R-L-D-D-L-R-O-W)
    • Memory- 3 items: Damaged medial temporal or medial diencephalon
    • Language- Spontaneous, comprehension, naming, repetition (no, ifs ands or buts- lost in lesion to arcuate fasciculus), reading, writing
    • Gerstmann syndrome- “touch your right ear with your left thumb”: defect in dominant parietal lobe: Calculations, R-L confusion, Finger agnosia, agraphia Note: You can get a hemineglect with a Nondominant parietal lesion
    • Apraxia- “pretend to comb your hair”- often present in lesions affecting language areas / dominant hemisphere
    • Frontal release signs- perseveration, motor impersistence, go-no-go testing, grasp reflex

Cranial nerves

  • CN II-

o   VA

o   Color vision- red desaturation- often seen in optic neuritis

o   VF

o   Visual extinction- double simultaneous stimulation: a form of neglect often seen on the left (right sided lesion)

  • Pupillary responses- CN II and III: Mainly tested by evaluating for a RAPD. Do not be confused with hippus- brief oscillations of papillary size (by paying special attention on the very first swing of the light)
    • Edingner-Westphal nucleus- parasymp innervates pupillary sphincter muscle and ciliary bodies (accommodation)
    • Direct response- Lesions: ipsi optic nerve, pretectal area, ipsi parasym c CN III, or pupillary constrictors
    • Consensual response- Lesion: contra optic nerve, pretectal area, ipsi parasym, pupillary constrictors
    • Accommodation- Lesion: ipsi optic nerve, ipsi parasymp, pupillary constrictors, bilateral optic tract lesions: SPARED with pretectal lesions
  • Vestibular Nuclei (medulla) à CN VI nucleus & lateral gaze (Pons) à CN III nucleus & vertical gaze (midbrain) [this helps r/o infratentorial lesions; Also Abducens nucleus contains VI and lateral gaze but a tumor here will also affect VII b/c of overlying fibers]
    • Pupil Lesions:
    • Metabolic- small reactive
    • Diencephalon/thalamus- small reactive
    • Tectal- large fixed c hippus
    • CN III (uncal)- fixed and dilated
    • Pons- pinpoint
    • Midbrain- midposition and fixed pupil
  • Isolated CN III palsy- high risk of PCom or distal basilar aneurysm especially with complete loss of parasympathetic function (ptosis and mydriasis) c some ocular motor dysfunction
    • Pupil sparing III- diabetic neuropathy, atherosclerosis, vasculitis
    • Pupil involving III- tumors (chordoma, meningioma), aneurysms
  • EOM- LR 6, SO4, R3
    • Internuclear ophthalmoplegia- lesion of MLF: contralateral loss of adduction (medial rectus CN III) on lateral gaze but not on convergence: Ispi 6 Contra 3
  • Nystagmus
    • Horizontal- parietal lobe, CN VIII, PPRF, blindness
    • Vertical- often at cervicomedullary junction (downbeat)
  • Abducens nucleus- contains CN VI and lateral gaze center; a tumor here will also affect CN VII 2/2 overlying fibers
  • CN V- facial sensation, corneal reflex (CN V and VII), and jaw jerk (both afferent and efferent limbs mediated by CN V)
  • CN VI palsy- 2/2 ­ICP or clival fracture
  • CN VII-
    • Facial expression- UMN spare forehead
    • Taste- affected in lesions of gustatory nucleus (nucleus solitarius)
  • CN VIII- hearing crosses at multiple levels and ascend bilaterally to the thalamus and auditory complex
    • Peripheral vertigo- hearing loss; unidirectional, torsional nystagmus (Dix-Hallpike maneuver)
    • Central vertigo- rarely hearing loss, nystagmus (bidirectional, vertical, pure horizontal common)
  • Palate elevation and Gag reflex (CN IX and X)
  • Muscles of articulation- CN V, VII, IX, X, XII
  • CN X- uvula goes to side opposite lesion
  • CN XI- SCM, Trapezius
  • CN XII- deviates toward weak side

Cranial nerve syndromes

Syndrome CN Involved Location of Lesion Typical cause:
Foix III, IV, V1, VI Sphenoid fissure Mass, aneurysm
Tolosa-hunt III, IV, V1, VI; sym Cavernous sinus, superior orbital fissure Sinus thrombosis, aneurysm, inflammation
Gradenigo VI, VI Petrous apex Inflammation
Vernet IX, X, XI Jugular foramen Mass lesions
Collet-Sicard IX, X, XI, XII Occipital condyle Mass lesions
Villaret IX, X, XI, XII Occipital condyle Mass lesions involving ICA

 

 

 

Motor exam

  • Observation- involuntary movements/tremors associated with lesions of basal ganglia or cerebellum

o   LMN lesions- weakness, atrophy, fasciculations, hyporeflexia

o   UMN lesions- weakness, hyperreflexia, increased tone

o   Functional testing: pronator drift, rapid alternating movements, bike wheel

o   Pronator drift- pronation or slight curling of fingertips is abnormal

o   Finger extensors- hold fingers extended and examiner tries to flex them: Corticospinal tract damage generally spares flexors relative to extensors (extensors- relatively weak anyway with large cortical representation)

o   Strength:

  • 0/5- no contraction
  • 1/5- flicker (potentially your imagination). You can often feel the movement
  • 2/5- movement (gravity eliminated)
  • 3/5- movement against gravity
  • 4/5- movement against some resistance
  • 5/5- normal

 

Action Muscles Nerves Root
Finger Extension Extensor digitorum, indicis, digiti minimi Radial nerve C7, C8
Thumb abduction Abductor pollicis longus Radial nerve C7, C8
Finger abduction Dorsal interossei, abductor digiti minimi Ulnar nerve C8, T1
Finger Adduction Adductor pollicis, palmar interossei Ulnar nerve C8, T1
Thumb opposition Opponens pollicis Median nerve C8, T1
Flexion DIP 2,3 Flexor digitorum profundus Median nerve C7, C8
Flexion DIP 4,5 Felxor digitorum profundus Ulnar nerve C7, C8
Wrist flexion/abd flexor carpi radialis Median nerve C6, C7
Wrist flex/add flexor carpi ulnaris Ulnar nerve C7, C8
Wrist ext/abd extensor carpi radialis radial nerve C5,C6
Elbow flexion biceps, brachialis musculocutaneous C5,C6
Elbow extension Triceps radial nerve C6, C7,C8
Arm abd deltoid Axillary nerve C5, C6
       
Hip flexion iliopsoas Femoral nerve, L1-L3 L1-4
Knee extension Quadriceps Femoral nerve L2,3(m),4(L)
knee flexion Semitendinosus, semimembranosus, biceps femoris Sciatic Nerve L5(m),S1(L)
Leg Abduction Glutius medius, gluteus minimus, tensor fasc lat Superior gluteal nerve L4,5, S1
Leg adduction obt externus, add longus, magnus, gracilis Obturator nerve L2,3,4
Toe dorsiflexion extensor hallucis longus, extensor dig longus deep peroneal nerve L5,S1
Foot dorsiflexion tibialis anterior deep peroneal nerve L4,5
Foot plantar flex Gastrocnemius, soleus Tibial nerve S1,S2
Foot eversion Peroneus longus, brevis superficial peroneal nerve L5,S1
Foot inversion tibialis posterior Tibial nerve L4,L5

With Knee extension and Flexion the higher root (IE lower number) is medial: So with extension the L3 root controls the medial muscle  and L4 controls lateral

Patterns of Weakness that Aid in Localization

Distribution of Weakness Location of Lesion
Limbs and lower face on same side (spastic hemiparesis, UMN) Contralateral cerebral hemisphere
All four limbs (spastic tetraparesis, UMN), speech (spastic dysarthria), swallowing with hyperactive jaw and facial jerks (pseudobulbar palsy, UMN) Bilateral cerebral hemispheres
Hemiparesis (UMN) plus cranial nerve signs (LMN) Brain stem
Tetraparesis (UMN) plus cranial nerve signs (LMN) Brain stem
All four limbs (spastic tetraparesis, UMN) Mid- or upper cervical cord
Lower limbs (UMN) and hands (LMN) Low cervical cord
Lower limbs (spastic paraparesis, UMN) Thoracic spinal cord Bilateral, medial motor cortex
All limbs, proximal > distal (LMN) Muscle (myopathy or dystrophy)
Legs, distal > proximal (LMN) Nerve (polyneuropathy)
Ocular muscles, eyelids, jaw, face, pharynx, tongue (LMN) Neuromuscular junction
Jaw, face, pharynx, tongue; sparing ocular muscles, eyelids (UMN and LMN) Motor neuron disease
Specific muscle groups in one limb (LMN) Nerve root, plexus or peripheral nerve

 

Reflexes

  • Grading: 0-absent, 1+ trace, 2+ normal, 3+ brisk, 4+ nonsustained clonus, 5+ sustained clonus
Reflexes Segment Nerve  
Achilles tendon S1 Sciatic
Patellar L4 Femoral
Biceps C5 Musculocutaneous
Brachioradialis C6 Radial
Triceps C7 Radial
  • Also possible to test L3/L5 by striking medial quad/hamstring respectively
  • Gait:
    • Spastic gait- unilateral or bilateral corticospinal tracts
    • Ataxic gait- cerebellar vermis or other midline cerebellar structures
    • Vertiginous gait- vestibular nuclei/nerve, semicircular canals
    • Frontal gait (apraxic)- frontal lobes or frontal subcortical white matter
    • Parkinsonian- SN
    • Dyskinetic gait- STN (choreix/ballistic/athetoid)
    • Tabetic- posterior columns or sensory nerve fibers
    • Paretic- nerve roots, NMJ, or muscles
    • Antalgic- painful
  • Sensory dermatomes

 

  • Signs
    • Lhermitte’s sign- dorsal column lesion à neuralgia, ataxia, dysarthria, painful tetanic posturing
    • Laseque’s sign- Sciatica
    • Kernig’s sign- pain of flexing hip, knee, ankle (Kernig – Kick)
    • Brudzinski sign- touch chin to chest and pt will bend knees
    • Spurling’s sign: radicular pain reproduced on tilting head toward ipsilateral side.
    • Straight Leg Raise (SLR): tests L4 to S1. Positive if it produces sciatic pain, NOT back pain. Reverse SLR positive for L3.
    • Crossed straight leg- elevating the contralateral leg cause Sx in affected leg: 90% spec for lumbosacral nerve root impingement
    • Percussion of the spine c pain- metastatic dz, MM, epidural abscess, osteomyelitis
    • Pace test- Piriformis syndrome- pain c resisted hip abd/ext rotation
    • FABER- flexion, abduction, external rotation = Hip pathology
    • Axial manual traction and shoulder abduction- Sx diappear 2/2 herniated cervical disk
    • Trendelenburg- pelvis tilts toward lifted leg = weak contralateral thigh adductors (L5)
    • Inverted radial reflex- flexion of digits with brachioradialis reflex: Pathognomonic of cervical stenosis
    • Uhthoff’s phenomenon- worsening of neurological signs/symptoms in MS or other demyelinating conditions when the body is overheated (temperature related neurologic decline)

 

Joseph MillerPhysical Exam

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