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INTRODUCTION
How to use this book
Anatomical
Syndromal
Aetiological
The interpretation of the neurological history and the synthesis of the neurological examination require experience and background knowledge. However, using this book you should be able to describe most of the common neurological abnormalities using appropriate terms and you will begin to synthesize and interpret them.
Neurological terms
Throughout the book, the patient and examiner are assumed to be male, to avoid the awkward use of he/she. Cranial nerves will be referred to by their name, or by their number in Roman numerals.
HISTORY AND EXAMINATION
HISTORY
The neurological history
Initially, establish some basic background information—the age, sex, handedness, and occupation (or previous occupation) of the patient. Determine if the patient has had any headaches, seizures, fainting, blackouts, episodes of numbness, tingling, or weakness, any sphincter disorder (urinary or fecal incontinence, urinary retention, and constipation), or visual symptoms, including double vision, blurred vision, or loss of vision.
Conventional history Past medical history
If they turn out to be right, you know they've already thought about the possibility. For example, if they have migraines but were concerned that they had a brain tumor, it is helpful to specifically discuss this differential diagnosis.
GENERAL EXAMINATION
It's helpful to take the history before moving on to the exam—at least in your mind—and trying to arrive at a differential diagnosis. If you think about the difference at this stage, then be sure to use the examination to try to reach a diagnosis.
SPEECH
BACKGROUND
Dysphonia
Dysarthria
APHASIA WHAT TO DO
If the problem is less serious, he may be able to slowly tell you his name and address. Ask him to say all the words he can think of, starting with a certain letter, usually 'f' or 's' (abnormal = less than 12 in 1 minute for each letter).
Further tests
Start with easily named objects and later ask about less frequently used objects that will be more difficult.
WHAT YOU FIND See Figure 2.2
WHAT IT MEANS
DYSPHONIA WHAT TO DO
WHAT YOU FIND AND WHAT IT MEANS
DYSARTHRIA WHAT TO DO
WHAT YOU FIND Types of dysarthria
MENTAL STATE AND HIGHER FUNCTION
MENTAL STATE BACKGROUND
WHAT TO DO AND WHAT YOU FIND Appearance and behaviour
Mood
Vegetative symptoms
Delusions
Hallucinations and illusions
Organic psychoses
Functional psychoses
Bipolar depression: episodes of depression as above, but also episodes of mania - elevated mood, grandiose delusions, speech and thought pressure.
Neuroses
Personality disorder
HIGHER FUNCTION BACKGROUND
The tests cannot be interpreted if the patient is not paying attention as this will clearly interfere with all other aspects of the testing.
WHEN TO TEST HIGHER FUNCTION
WHAT TO DO Introduction
- Attention and orientation Orientation
- Memory
- Calculation Serial sevens
- Abstract thought
- Spatial perception
- Visual and body perception Tests for parietal and occipital lesions
- Apraxia
Take a newspaper or magazine by the bed and ask the patient to recognize the faces of famous people. If the patient cannot do this with normal motor function: apraxia of the limb.
WHAT YOU FIND
Ask the patient to copy your hand movements and demonstrate: (1) make a fist and tap it on the table with the thumb up; (2) then straighten your fingers and tap the table with your thumb up.
Patterns of focal loss
If accompanied by finger agnosia (inability to name fingers), left-right agnosia (inability to distinguish left from right) and dysgraphia = Gerstmann syndrome - indicates a dominant parietal lobe syndrome. Ideomotor apraxia: lesions of either the dominant parietal lobe or the premotor cortex, or a diffuse brain lesion.
Diffuse or multifocal abnormalities Common
Focal deficits
GAIT
WHAT TO DO AND WHAT YOU FIND Ask the patient to walk
Disjointed as if the patient has forgotten to walk and often appears rooted to the spot: apraxic.
FURTHER TESTS
Apraxic gait: Indicates that the cortical integration of the movement is abnormal, usually with frontal lobe pathology. May be mistaken for the gait in chorea (especially in Huntington's disease), which is shuffling, trembling, and spasmodic and has associated findings on examination (see Chapter 24).
Non-neurological gaits
Romberg's test What to do
He stands with his eyes open; falls with eyes closed = Romberg's test is positive: loss of joint position sense.
GENERAL
CRANIAL NERVES
The nuclei of the cranial nerves within the brainstem serve as markers for the level of the lesion (Fig. 5.2. Sometimes, when summarizing neurological examination, people divide it into 'cranial nerves' and examination of the.
OLFACTORY NERVE
WHAT TO DO
WHAT YOU FIND
CRANIAL NERVE I
THE EYE 1 – Pupils, Acuity, Fields
- Pupils
- Acuity
- Fields
- GENERAL WHAT TO DO
- PUPILS
The organization of the visual pathways means that different patterns of visual field abnormalities arise from lesions in different locations. The visual fields are divided vertically by the fixation point into the temporal and nasal fields.
WHAT YOU FIND See Figure 7.2
FURTHER TESTING Swinging light test
ACUITY
WHAT TO DO AND WHAT YOU FIND Can the patient see out of both eyes?
FIELDS WHAT TO DO
Assess major field defects
Test each eye individually What to test with?
Imagine that there is a plane, like a vertical sheet of glass, halfway between you and the patient (Fig. 7.5A). Bring a white pin toward the fixation line along an arc of a sphere centered on the patient's eye (Fig. 7.5B).
WHAT YOU FIND See Figure 7.7
If the pin is seen before it reaches the midline, there is macular sparing. If the pin is first seen, when it crosses the midline, there is no macular sparing.
Bring the pin horizontally from the side with the defect to the point of fixation.
Classified according to degree of functional preservation in the affected field (eg, ability to see moving targets), whether congruent or incongruent and macula-sparing or not.
WHAT IT MEANS See Figures 7.6 and 7.7
THE EYE 2 – Fundi
The focus ring is used to correct (1) for your vision and (2) for the patient's vision. If you are nearsighted or nearsighted (myopic) and do not wear glasses or contact lenses, you will need to turn the focus knob counterclockwise to focus to see a normal eye; turn it clockwise if you are nearsighted or farsighted (hyperopic.
Look at the blood vessels
Look at the retinal veins as they turn into the optic disc and see if they pulsate and go from convex to concave. This is best assessed by looking along the vein that runs into the optic cup.
Look at the retinal background
WHAT YOU FIND 1. Optic disc
Myopic fundus: myopic eye is large, so the disc appears paler; this may be mistaken for optic atrophy. Myelinated nerve fibers: Opaque white fibers that usually radiate from the intervertebral disc and may be mistaken for papilledema.
WHAT IT MEANS 1. Optic disc
Blood vessels and retinal background
EYE MOVEMENTS
CRANIAL NERVES III, IV, VI
The cover test What to do
Test the eye movements to pursuit
Test saccadic eye movements
Test convergence
Vestibulo-ocular reflex (doll's eye manœuvre)
Single cranial nerve palsy (III, IV or VI): lesions along the course of the nerve or a core lesion. Surgical (N.B. pupil involvement in third nerve palsy): tumor, aneurysm, trauma, a false localizing sign or uncal hernia (third nerve).
NYSTAGMUS
Special test: optokinetic nystagmus (OKN)
WHAT IT MEANS
Ataxic nystagmus: nystagmus of abductor eye >> adductor eye, associated with internuclear ophthalmoplegia (see Chapter 9). Ocular bobbing: eyes that float up and down in the vertical plane—associated with pontine lesions.
THE FACE
BACKGROUND Facial nerve: VII
Trigeminal nerve: V Sensory
What to do
CRANIAL NERVES V AND VII
FACIAL NERVE: WHAT TO DO Look at the symmetry of the face
Other functions of the facial nerve
FACIAL NERVE: WHAT IT MEANS
TRIGEMINAL NERVE: WHAT TO DO Motor
Sensory
Apply a piece of cotton wool twisted so that it touches the cornea from the side. Failure to contract one side of the face = V 1 lesion • Failure to contract only one side = VII lesion • Subjective reduction in corneal sensation = partial.
TRIGEMINAL NERVE: WHAT YOU FIND Motor
TRIGEMINAL NERVE: WHAT IT MEANS
Loss of pinprick and temperature with associated contralateral loss of these modalities on the body: ipsilateral brainstem lesion. Loss of sensation in muzzle distribution: lesion of descending spinal sensory nucleus with the lowest level outer syringomyelia, demyelination.
CRANIAL NERVE VIII
AUDITORY NERVE
The vestibular system is not easily examined at the bedside because it is difficult to test one part of the system, or even one side, in isolation. In some respects this is fortunate, as it is this ability of the vestibular system that allows patients to recover even from severe unilateral vestibular lesions by learning to operate on only one functioning vestibular system.
Gait
Nystagmus
Head impulse test
Caloric test
With complete sensorineural deafness in one ear, bone conduction from the other ear will be better than air conduction. This is repeated in the other ear and then in each ear with warm water (44°C).
CALORIC TESTING: WHAT YOU FIND
CALORIC TESTING: WHAT IT MEANS
FURTHER TESTS OF VESTIBULAR FUNCTION Hallpike's test
The patient lies down with his head on a pillow at a 30-degree angle so that the lateral semicircular canal is vertical. Ask him to walk on the spot; if he does this, he should.
THE MOUTH
Glossopharyngeal nerve: IX
Vagus nerve: X
Hypoglossal nerve: XII
MOUTH AND TONGUE: WHAT TO DO Ask the patient to open his mouth
CRANIAL NERVES IX, X, XII
Small tongue: with fasciculations = bilateral lower motor neuron lesion; motor neuron disease (progressive bulbar palsy), basal meningitis, syringobulbia. Small tongue: with fasciculations and reduced movement speed = mixed bilateral lesions of the upper and lower motor neurons; motor neuron disease (progressive bulbar palsy).
PHARYNX: WHAT TO DO Look at the position of the uvula
GAG REFLEX: WHAT TO DO
PHARYNX AND GAG REFLEX: WHAT YOU FIND
LARYNX: WHAT TO DO Ask the patient to cough
Direct visualization of the vocal cords can be achieved with laryngoscopy, which allows the position and movement of the vocal cords to be assessed.
LARYNX: WHAT YOU FIND
PHARYNX AND LARYNX: WHAT IT MEANS
Bilateral lower motor neuron
ACCESSORY NERVE
WHAT TO DO Look at the neck
CRANIAL NERVE XI
Upper motor neuron (UMN): increased tone, increased reflexes, pyramidal pattern of weakness (weak extensors in the arm, weak flexors in the leg). Mixed UMN and LMN lesions: motor neuron disease (with normal sensation), or combined cervical myelopathy and radiculopathy and lumbar radiculopathy (with sensory abnormalities).
MOTOR SYSTEM
Examples of brainstem signs (all contralateral to upper motor neuron weakness): third, fourth and sixth paralysis, seventh lower motor neuron loss, nystagmus and dysarthria.
General comments Always
TONE
Arms
Legs
Resistance suddenly increases ("catch"); heel leaves bed easily when knee is raised quickly: spasticity.
Special situations
ARMS
Basic screening examination
Close your fingers on the patient's fingers, palm to palm, so that both sets of fingertips are on the other's metacarpal phalanges. Ask the patient to take your fingers and then try to open the patient's grip (Fig. 17.6).
FURTHER TESTS OF ARM POWER
Stand behind the patient, hold his elbow against his side with the elbow bent, and ask him to keep his elbow in and move his hand to the side. Hold the patient's forearm and wrist with the forearm semi-pronated (as if shaking hands).
LEGS
Power testing screening Compare the left with the right
Ask the patient to bend the knee and bring the heel towards the bottom. Ask the patient to turn the ankle back and bring the toes toward the head.
REFLEXES
With the patient's legs straight, place your hand on the ball of his foot with the ankles at 90 degrees. For the arms, ask the patient to clench his teeth as you swing the hammer.
Further manœuvres Demonstration of clonus
The spread of the reflex indicates an upper motor neuron lesion that occurs above the level of innervation of the muscle to which the reflex has spread. This indicates a lower motor neuron lesion at the level of the absent reflex (C5 in this case) with an upper motor neuron lesion below, indicating spinal cord involvement at the level of the absent reflex.
ABDOMINAL REFLEXES What to do
Pendular reflex: this is usually best seen in the knee, where the reflex continues to oscillate for several beats. Slow relaxing reflex: This is especially seen with the ankle reflex and can be difficult to notice.
PLANTAR RESPONSE What to do
No response: may occur with marked weakness of the upper motor neuron (the toe cannot be extended); can occur if there is a sensory abnormality that interferes with the afferent part of the reflex. A plantar extensor response that surprises you (one that doesn't fit the rest of the clinical picture) should be interpreted with caution—it could be a withdrawal response.
WHAT YOU FIND AND WHAT IT MEANS
WHAT YOU FIND Remember
- Weakness in all four limbs
- Weakness in both legs
- Unilateral arm and leg weakness
- Syndromes limited to a single limb
- Variable weakness
- Weakness that is not really there
Sensory loss: middle finger (Chapter 21). iv) C8 root: finger flexion weakness; loss of finger reflex. Sensory loss: lateral shin and dorsum of the foot (Chapter 21). ii) L4 root: weakness of knee extension and leg flexion.
WHAT IT MEANS Myopathy (rare)
Sensory loss: lateral tibia and dorsum of foot (Chapter 21). iv) S1 root: weakness in plantar flexion and foot eversion. Loss of sensation: lateral border of the foot, sole of the foot (Chapter 21). i) Weakness appears to wear off with exertion and then recover: consider myasthenia gravis. ii) Fluctuating, with effort collapsing at times and full force at other times: consider functional weakness.
Myasthenic syndromes (rare) Causes
Mononeuropathies (very common) Common causes
Radiculopathies (common) Common causes
Peripheral neuropathies (common)
Mononeuritis multiplex (rare)
Polyradiculopathy (rare)
Spinal cord syndromes (common)
Brainstem lesions (common)
Hemisphere lesions (common)
Functional weakness
Vibration sense and joint position sense are usually quick and easy and require little concentration, so test them first. In all parts of sensory testing, it is essential to first teach the patient about the test.
SENSATION
The relevant sensory loss is illustrated in the fingers for the median nerve, ulnar nerve, radial nerve, and axillary nerve (Fig. 21.2A–C). The dermatomal representation in the arms can be easily remembered if you remember that the middle finger of the hand is supplied by C7.
Dermatomes
WHAT TO DO Vibration sense
Joint position sense
Be sure to hold the toe or toe sideways (as in Fig. 21.8) and not the nail and ball; otherwise you will test the pressure rating as well as the joint position feel.
Pinprick
Light touch
Special situations
Temperature sensation Screening
Other modalities Two-point discrimination
Test: Gradually reduce the distance between the pins, touching either one or two pins. Note the setting where the patient cannot distinguish a hook from two legs.
FURTHER TESTS Sensory inattention
WHAT YOU FIND AND WHAT IT MEANS
Patterns of sensory loss
Brainstem: loss of pain and temperature in the face and on the opposite side of the body. TIP The different etiologies available for each of the patterns of sensory loss reinforce the importance of the history in understanding the clinical findings.
COORDINATION
Ask the patient to tap the back of his right hand alternately with the palm, and then the back of his left hand. Ask him to lift his leg and place the point of his heel on his knee and then pass it to the point of his leg (Fig. 23.2) (demonstrate.
Trunk
Ask the patient to twist the hand as if opening a door or unscrewing a light bulb (demon.
With outstretched arms
Finger–nose test
Repeated movements
Heel–shin test
ABNORMAL MOVEMENTS
Terms used in movement disorders (Fig. 24.1)
When testing tone in one arm, it is sometimes helpful to ask the patient to raise the other arm up and down. Ask the patient to perform any maneuvers that he reports may cause the abnormal movement.
WHAT YOU FIND Face
Head
Arms and legs Positive phenomena
Akinetic–rigid syndromes (parkinsonism) (common)
Tremors (common)
Chorea (uncommon) Common cause
Hemiballismus (rare)
Dystonia (uncommon)
Tic (uncommon)
Myoclonic jerk (rare)
Others
SPECIAL SIGNS AND OTHER TESTS
PRIMITIVE REFLEXES Snout reflex
Palmo-mental reflex What to do
Grasp reflex What to do
SUPERFICIAL REFLEXES Cremasteric reflex
Anal reflex What to do
TESTS FOR MENINGEAL IRRITATION Neck stiffness
The neck moves easily in both planes, with the chin easily reaching the chest when the neck flexes: normal.
Testing for Kernig's sign What to do
Resistance to knee straightening: Kernig's sign - bilaterally indicates meningeal irritation; if unilateral, can occur with radiculopathy (cf. straight leg lift).
Head jolt test
TESTS OF RESPIRATORY AND TRUNK MUSCLES Respiratory muscles
