Introduction to Physical Diagnosis:
Neurology
Developed by Roger L. Weir, M.D.
Associate Professor of Neurology
OUTLINE
1. HISTORY AND PHYSICAL
2. TECHNIQUE
Courtesy
Routine
Actual / Practice
3. ILLNESSES/ DISORDERS / DIAGNOSES
* INTEREST
DIAGNOSIS
TREATMENT
(PREVENTION)
COUNSELLING
N common disorders
uncommon disorders
4. (NEWER DIAGNOSTIC TESTS / TOOLS)
NEUROLOGICAL HISTORY
C/C or Presenting Illness (NP vs Consult)
(see below)
HPI (see below)
PMH
includes tests done
risk factors,
HTN, Diab M.,Dyslipidemia
Head trauma, auto-accident
previous surgery
c/c THE CHIEF COMPLAINT
+or- other neurological problems
HEADACHE. Onset, prior, severity,
frequency, n or v, photophobia, fever
,phonophobia, age, confusion.
LOSS OF CONSCIOUSNESS. seizure,
syncope, other
R WEAKNESS. Duration, onset, vision,
sensation, headache,
LOW BACK PAIN.duration,initial cause, rx
c/c contd
DIZZINESS. Vertigo, tinnitus, double
vision, faintness, ataxia, inducer, reliever,
rising, flat, turning in bed, hearing.
NUMBNESS OF HAND. Which fingers,
neck pain
DIFFICULTY WALKING. Pain, where pain
DIFFICULTY SPEAKING. Understanding,
being understood
c/c contd.
BLURRED/DOUBLE VISION one or two,
in which plane,
SEEING THINGS. ?hearing voices,
threats, delusions, crawling in skin, drug
use, FH.
History Present illness
Onset date; recheck for a remote onset
Speed of onset
Prevalence/persistence/? Intermittent
Severity/ variations in severity
Precipitants
Relievers
Medication effect
Associated symptoms
Associated symptoms in the past
Neurological History
FAMILY HISTORY
Risk factors suggested
Sickle Cell anemia
Muscular Dystrophy
Myocardial Infarction
Spinocerebellar degeneration
Neurological History
SOCIAL HISTORY
Alcoholism, Cocaine use
Nicotine use,
Occupation
Living situation
Spousal/emotional status
ROS
Multiple. See outline of Neuro exam.
THE NEUROLOGICAL
EXAMINATION
MENTATION AND SPEECH
CRANIAL NERVES (2 to 12)
MOTOR FUNCTION
(Normal, Impaired, Abnormal movement)
COORDINATION (Cerebellar Function)
REFLEXES (DTRsdeep tendon reflexes)
SENSATION
MENINGEAL SIGNS
STATION AND GAIT
SPINE / MUSCULO-SKELETAL
MENTATION AND SPEECH
Level of Consciousness:
Awake, stupor, coma
Memory:
Digit span (reverse versus forward), recent, remote, fund of
information
Calculations:
Arithmetic, money (?education)
Draw a clock
Draw a person
Copy a figure
Confusion
Denial / Inattention
MENTATION AND SPEECH
Anosognosia
Apraxia
Distractibility
Hallucinations:
Auditory, visual, other
Mood:
anxiety, depression
Appropriateness of interaction
MENTATION AND SPEECH
Speech Production:
Quantity, flow, loudness, syllables, sounds, words
Following Commands:
Verbal, written, gestures
Naming
Repetition:
sentence, word, counting, singing
Reading
Writing:
spontaneously, copying,
Calculations / arithmetic
CRANIAL NERVES
1. 2*. 3*. 4. 5. 6*, 7*, 8*, 9, 10, 11, 12
CN1: R/L nostril, non-irritant, diminution with
age
*CN2: Visual acuity, visual fields, light reflex,
accommodation, optic disc
*CN3: Light reflex, accommodation, EOM, lid
opening, pupil size
CN4: Depression of the adducted eye
CN5: Facial sensation, jaw closure, side/side
jaw movement
*CN6: Abduction of the eye
CRANIAL NERVES
1. 2*. 3*. 4. 5. 6*, 7*, 8*, 9, 10, 11, 12
*CN7:
Brow elevation, eyelid closure, smile
facial droop +autonomic/sensory
*CN8: Auditory acuity, dizziness, balance,
tinnitus, nystagmus, Weber, Rinne
CN9: Gag reflex, swallowing
CN10: Vocal cord movement + autonomic
CN11: Sternocleido-Mastoid, Trapezius
CN12: Tongue deviation, atrophy, fasciculations
MOTOR EXAMINATION
WASTING / HYPERTROPHY
(Duchenne muscular
dystrophy)
FASCICULATIONS (evidence of lower
motor neuron dysfunction)
MOTOR EXAMINATION
STRENGTH:
Proximal (characteristic of muscle problem),
distal (characteristic of periph. neuropathy),
*Right vs. Left,
upper limbs, lower limbs,
nerve root distribution,
nerve distribution,
severity(0 to 5),
pain effect,
other.
MOTOR EXAMINATION
RIGIDITY, SPASTICITY, OTHER
SPEED OF MOVEMENT
ABNORMAL INVOLUNTARY MOVEMENTS
eg tremor
OTHER ABNORMAL MOVEMENTS
eg epileptiform.
COORDINATION
Cerebellar function
Reason for doing the strength test before
coordination is to know if incoordination is
due only to muscle weakness
May apparently vary with strength
COORDINATION
Cerebellar function
*FINGER / NOSE test:
proximal, transitional, distal, moving target
?past pointing, ?intention tremor
RAPIDLY ALTERNATING MOVEMENTS:
supination/pronation, tapping rhythm
*HEEL/SHIN test:
proximal, transit
ankle dorsiflexion
*TANDEM WALKING: (?mechanical impediment)
A little difficult in fat persons and mechanically impaired
CHECK / REBOUND:**
Cerebellar testperson with disfunction will have more rebound
POSTURE
STANDING BASE: width, stability
GAIT: stable, asymmetric, ?type
REFLEXES
Always compare the right with the left
Deep tendon, pathological, superficial
SUPERFICIAL:
abdominal, cremasteric
Abdominal reflex disappears in the presence of upper motor neuron
(multiple sclerosis)
PATHOLOGICAL:
Babinski, snout, Hoffman,
Ankle clonus, other clonus
Oppenheim, Chaddock
DEEP TENDON(R/L):
upper/lower, proximal/ distal
BJ, TJ, SJ
KJ , AJ
Jaw jerk (corticobulbar test), pectoralis, adductor.
GRADING:
0, 1, 2 , 3, 4
where 2 represents an average reflex.
SENSATION
R/L, Prox/Distal, Upper/Lower, Nerve, Nerve root,
dorsal column, spinothalamic,
large fibre/ small fibre
CNS
Light touch(acuity, subjective types)
Pin: metal, wood (NO reusable sharp points)
Temperature: cold metal vs. uncold wood; other
Position sense( in 4 limbs), distal with or without proximal
Vibratory sense (requires judgement)
Touch:
Double simultaneous stimulation
Graphesthesia
Stereognosis
Two-point discrimination
Point localization
MENINGEAL SIGNS
bacterial/ viral/other meningitis
& subarachnoid hemorrhage
NECK STIFFNESS
KERNIG
BRUDZINSKI
PHOTOPHOBIA
EYEBALL TENDERNESS (least
important)
(STRAIGHT LEG RAISING)
(?Headache, vomiting, lethargy)
SPINE/MUSCULO-SKELETAL
Spine tenderness:
Cervical, Lumbar, Thoracic
Sacro-iliac joints
Straight leg raising (for herniated disc?)
Muscle tenderness or tenseness of:
Scalp muscles
Cervical paraspinals
Lateral neck muscles
Scapular region muscles
Lumbar paraspinals
Lateral sacrum
Patricks Sign (for detecting hip problem)
