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Neurology Exam Skills

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Neuro Exam

Mental Status

Alertness — Alert and oriented → Drowsy → Confused → Lethargic → Obtunded → Stuporous → ComaOrientation — Person, Place, Date.Attention — Count backwards from 20 to 1 or Months backwards or Serial 7s (100 minus 7, then minus 7 again, then again, etc)Repetition – “Today is a sunny day”Memory — immediate recall of three objects Short-term memory – ask for these objects after doing a few other tasks Short-term memory – ask for these objects after doing a few other tasks Remote memory (eg past presidents/events) Remote memory (eg past presidents/events)Language — fluencyNaming (including parts of objects – point to watch, to pen)Comprehension (three-step commands; syntax)Neglect —clock drawingPraxis — e.g. buttoning or unbuttoning a shirt. (If patient is weak or doesn't comprehend task, this does not count as apraxia)

Cranial Nerves

I — Test this with odorous sample, one nostril at a time. As most physicians don't carry odorants, the screening exam usually omits the first cranial nerve.II — Pupil reactivity to light and accommodation; visual acuity; fundoscopy; visual fieldsTest acuity with Snellen card. To screen field of vision, test by confrontation (patient looks at your nose while you move fingers).III — EOMs (except Lateral Rectus and Superior Oblique); nystagmus; ptosis; pupil reactivity to lightIV — Superior Oblique; head tilt away from lesion. Sup. Oblique is the “down and out muscle.”V — Sensation in three areas of face; muscles of mastication; corneal reflex (afferent)VI — Lateral RectusVII — Forehead wrinkle; palpebral fissure; nasolabial fold (NLF) – look for flattening. Corneal reflex (efferent). Remember UMN lesion spares forehead.VIII — Hearing; vertigo/nystagmus. Rinne and Weber tests.IX/X — Palate/uvula elevation; gag reflex (but usually don’t do gag in practice)XI — Trapezius (shoulder shrug), SCM (turn head from side to side)XII — Tongue deviates TOWARD weak side; check for atrophy

Motor

0 = no evidence of movement
1 = just a flicker of muscle action. muscle contracts, but produces no movement at the joint.
2 = only horizontal movement (ie, not anti-gravity)
3 = can overcome gravity, but NO ability to-overcome resistance
4 = weak; overcomes some resistance
5 = normal

Tone — increased in UMN lesions (spasticity) or in rigidity (eg Parkinsonian)Bulk — decreased in LMN lesions or in generalized cachexiaAbnormal movements — resting vs postural vs intention tremors; amplitude and frequencyPower — compare each sideLook specifically for and note Pronator drift

Coordination

Finger-nose-finger; Heel-knee-shin; Rapid alternating movements

Reflexes

0 = absent 1 = slightly reduced 2 = normal 3 = increased 4 = spreading/clonus

compare each side; try to relax Pt; increased in UMN lesions, decreased in LMN lesions and neuropathies. Note asymmetry!DTRs — biceps, brachioradialis, triceps, Hoffman's; knee jerk; ankle jerkPlantar reflex, Babinski signIf suspected frontal lesion, stroke, etc, check for “frontal release signs” (primitive reflexes) — glabellar; snout; rooting; grasp

Sensory

Temp/Pain — Use pin prick for pain, cold metal of tuning fork for cold. Tests small c fibers; anterolateral or spinothalamic tracts (cross in spinal cord)Vibration — Test with vibrating tuning fork. Large fiber; dorsal columns (cross at lower medulla)Proprioception – Test by moving finger/toe up or down while patient can’t see and ask them to tell you which direction you moved it. Large fiber, dorsal columnsCortical sensation — two-point discrimination, stereognosis, graphesthesia, double simultaneous stimulationGait: Base — wide based usually means cerebellar (vermian); may indicate proprioceptive lossGait: Station — circumduction (UMN); waddling (proximal myopathy); shuffling (Parkinsonian); steppage (foot-drop) ; antalgic (pain)Test tandem, toe, heel walking!Posture — titubation (cerebellar); stooped (Parkinsonian)Arm swing — unilateral decrease (UMN); bilateral decrease (Parkinsonian)Romberg — positive indicates proprioceptive loss usually (can be vestibular also)And don’t forget vitals and to examine other organ systems as part of the general exam...

A note on the Mini Mental Status Exam
The mini mental status examination or MMSE is a quick, validated examination to evaluate mental status. It is used often with suspected dementia. Score varies substantially with educational level; well educated people with mild dementia can compensate and do well on the MMSE.
A score of less than 20 (out of a possible 30) has an 87% sensitivity for detecting dementia.

Adapted from Standford Medical School’s “Annotated Neuro Exam” stanford.edu

MRI 101

T1-weighted MRI
Bright white = fresh blood, fat, gadolinium
Dark = Fluid/water, dense bone, air

T2-weighted.
Bright white = Fluid/water/CSF. (T2 is more helpful in detecting pathological change. Helpful in detecting cerebral edema that often occurs in pathological states.)
Dark = Fluid/water, dense bone, air

FLAIR. Stands for “fluid attenuated inversion recovery.” The same as T2 but this mode suppresses areas that normally have fluid in them (such as ventricles), which makes it easier to see pathology.

Diffusion Weighted Image (DWI): Can pick up acute ischemia. Enhancement can be seen within 5–10 minutes of the onset of stroke symptoms

Dermatomes

20150502_dermatome

Glasgow Coma Scale

Eye Opening

Spontaneous: 4
To speech: 3
To pain: 2
No Response: 1

Verbal Response

Oriented: 5
Confused speech: 4
Inappropriate words, jumbled: 3
Incomprehensible sounds: 2
No Response: 1

Motor Response

Obeys: 6
Localizes movement in response to stimulation: 5
Withdraws to pain: 4
Abnormal Flexion to pain (Decorticate): 3
Extensor Response to pain (Decerebrate): 2
No Response: 1

Score: 15 is normal. 3 * 8 = coma, requires intubation.