Neurological Examination Overview

Neurological Examination Overview

• A fundamental process for diagnosing and managing disorders affecting the nervous system.
• Focuses on localizing lesions, identifying signs of normal and abnormal neurological function, and guiding diagnostic and management decisions.

Goals of the Neurological Examination

• Localization of the lesion
• Assessment of the level of neurologic function
• Guiding diagnostic and management strategies.

Review of History- Present Illness

• Onset, duration, and progression of symptoms.
• Character, location, and intensity of symptoms.
• Associated symptoms, aggravating, and relieving factors.

Review of History- Past Medical History

• Previous neurological disorders, surgeries, or trauma.
• Chronic medical conditions, including diabetes, hypertension, and thyroid disease.
• Past medications, including neuropsychiatric drugs.
• Family history of neurological disorders.

Indications for Neurological Examination

• Suspected neurological disorders
• Evaluating neurological symptoms
• Monitoring the progression of existing neurological conditions.

Mental Status Testing

• Mini-Mental State Examination (MMSE) is a screening tool for cognitive impairment.
• The MMSE comprises 30 questions.

Cranial Nerve Examination

• Assessment of all 12 nerves (CN I-XII) considering sensory, motor, and reflex functions.
• CN I (Olfactory): Test for smell.
• CN II (Optic): Test for visual acuity, visual fields, and fundoscopic exam.
• CN III (Oculomotor), CN IV (Trochlear), CN VI (Abducens): Evaluate pupillary reflexes, eye movements, and convergence.
• CN V (Trigeminal): Test for facial sensation, corneal reflexes, and jaw movements.
• CN VII (Facial): Assess facial expressions and taste.
• CN VIII (Vestibulocochlear): Examine hearing and balance.
• CN IX (Glossopharyngeal) and CN X (Vagus): Evaluate swallowing, gag reflex, and vocal cord function.
• CN XI (Accessory): Assess trapezius and sternocleidomastoid muscle strength.
• CN XII (Hypoglossal): Examines tongue movements and speech.

Motor System Examination - Muscle Bulk, Tone, & Strength

• Muscle Bulk: Assess for muscle atrophy or hypertrophy.
• Muscle Tone: Evaluate resistance to passive movement.
• Muscle Strength: Test the strength of different muscle groups using a grading system.

Motor System Examination - Motor Strength Testing

• Upper Motor Neuron (UMN) lesions: spastic, rigid, and hyperreflexive.
• Lower Motor Neuron (LMN) lesions: flaccid/hypotonic, distal muscle atrophy, and decreased reflexes.

Reflex Testing - Deep Tendon Reflexes (DTR)

• Assess reflexes in biceps, triceps, brachioradialis, patellar, and Achilles tendons.
• Grading scale: 0 (absent), 1+ (decreased), 2+ (normal), 3+ (brisk), 4+ (hyperactive).

Sensory Testing

• Evaluate light touch, pain, temperature, vibration, and proprioception.
• Assess for sensory deficits, including numbness, tingling, or loss of sensation.

Coordination and Gait Examination - Coordination Testing

• Finger-to-nose test: Tests coordination in the upper extremities.
• Heel-to-shin test: Tests coordination in the lower extremities.
• Rapid alternating movements: Tests the ability to perform alternating movements quickly.

Coordination and Gait Examination - Gait and Balance Testing

• Observe gait for abnormalities like ataxia, spasticity, or weakness.
• Perform Romberg test and tandem gait to assess balance.

Head Impulse Test

• Detects vestibular dysfunction, moving the patient's head and observing for corrective saccades.

Nystagmus Observation

• Identifies spontaneous nystagmus and its direction by asking the patient to gaze left and right.

Skew Deviation Test

• Checks for ocular misalignment by covering and uncovering one eye and observing for corrective movements.

Diagnostic Linkage - Interpretation

• Analyze the findings from each component of the neurological examination.

Diagnostic Linkage - Clinical Conditions

• Identify potential causes of neurological symptoms and suggest further investigations.

Week 8, Headache Article - Primary Headaches

• Migraine is the most disabling and prevalent primary headache disorder.
• Tension-type Headache (TTH) is the most common headache type.
• Trigeminal Autonomic Cephalalgias (TACs) present with unilateral pain and autonomic symptoms.

Week 8, Headache Article - Secondary Headaches

• Caused by underlying medical conditions, such as vascular, infectious, or neoplastic causes.

Week 8, Headache Article - Management

• Acute treatment options include over-the-counter analgesics, triptans, and newer agents like gepants.
• Preventive treatments for migraines include antihypertensives, antidepressants, antiepileptics, botulinum toxin, and monoclonal antibodies.

Week 8, Headache Article - Diagnostic Approach

• Diagnosing headaches involves a thorough history and examination.
• Diagnostic imaging or lumbar puncture is recommended in certain high-risk cases.

Week 8, Headache Article - Emerging Therapies

• Neuromodulation devices and behavioral therapies are becoming increasingly recommended.

Concussions - Key Symptoms

• Headache
• Dizziness
• Nausea
• Vomiting
• Cognitive impairment
• Balance problems
• Sensitivity to light and sound.

Concussions - Mechanism of Injury

• Direct or indirect impact to the head.

Concussions - Initial Evaluation

• On-field assessment: Assess consciousness, orientation, and basic neurological function.
• Sideline evaluation: Conduct a more comprehensive evaluation, including a neurological exam.
• Hospital or clinic evaluation: Conduct a thorough neurological exam and consider neuroimaging if necessary.

Concussions - Management

• Immediate Management: Rest, observation, and monitoring for signs of worsening symptoms.
• Gradual return to activity: Progress through a graded return-to-play protocol.
• Prolonged symptoms and special considerations: Individualized management based on symptom severity and duration.
• Preventive strategies: Use appropriate safety equipment and promote concussion awareness.

Week 9, Musculoskeletal Examination - General Principles

• Thorough history of the present illness.
• Review of systems.
• Past medical history, including previous injuries, surgeries, and medications.
• Physical examination, including inspection, palpation, range of motion, and special tests.

Week 9, Musculoskeletal Examination - Specific Joint Examinations

• Shoulder Examination: Inspect for deformities, palpate for tenderness, assess range of motion, and perform specific tests.
• Elbow Examination: Inspect for deformities, palpate for tenderness, assess range of motion, and perform specific tests.
• Hand and Wrist Examination: Inspect for deformities, palpate for tenderness, assess range of motion, and perform specific tests.
• Hip Examination: Inspect for deformities, palpate for tenderness, assess range of motion, and perform specific tests.
• Knee Examination: Inspect for deformities, palpate for tenderness, assess range of motion, and perform specific tests.
• Foot and Ankle Examination: Inspect for deformities, palpate for tenderness, assess range of motion, and perform specific tests.

Common Musculoskeletal Disorders

• Case Studies and Clinical Scenarios:
  • Rotator Cuff Tear:
    • Pain, weakness, and limited range of motion in the shoulder.
    • Positive impingement and drop-arm test.
  • Carpal Tunnel Syndrome:
    • Numbness, tingling, and pain in the thumb, index, and middle fingers.
    • Positive Tinel's and Phalen's test.
  • Tendonitis:
    • Pain and inflammation in a tendon, such as Achilles tendonitis or De Quervain's tenosynovitis.
    • Palpable tenderness over the affected tendon.
  • Osteoarthritis:
    • Pain, stiffness, and decreased range of motion in a joint, such as the knee or hip.
    • Crepitus on joint movement.
  • Low Back Pain:
    • Pain in the lower back, radiating to the legs in some cases.
    • Possible limitation in movement and spinal tenderness.
  • Scoliosis:
    • Lateral curvature of the spine.
    • May cause back pain, uneven shoulders, and uneven hips.
  • Spinal Stenosis:
    • Narrowing of the spinal canal, causing pain, numbness, and tingling in the legs.
    • Neurological deficits, such as weakness or bowel/bladder dysfunction.

Common Childhood Orthopedic Disorders

• Metatarsus Adductus (MTA): Forefoot turning inwards, usually resolves spontaneously.
• Calcaneovalgus Foot: Foot pointing outwards, often due to ligament laxity, resolves spontaneously in most cases.
• Vertical Talus: Foot bent upwards, requires bracing and surgery in severe cases.
• Cavus Foot Anomaly (High-Arched Foot): High arch, may require orthotics or surgery if causing pain or functional issues.
• Flatfeet: Flat arch, may require orthotics and stretching exercises.

Kyphosis

• Causes: Scheuermann's disease, postural kyphosis, osteoporosis.
• Management: Conservative treatment with bracing or physiotherapy or surgical correction if severe.

Common Causes and Risk Factors for Low Back Pain

• Mechanical low back pain: Resulting from stress, strain, or injury to the spine.
• General Risk Factors: Age, obesity, smoking, lack of physical activity, heavy lifting, vibration exposure.

Identification of Red Flags in Clinical History - Age-Specific Concerns

• Back pain with fever: Infectious processes.
• Back pain with weight loss: Malignancy.

Identification of Red Flags in Clinical History - Use of Anticoagulants

• Back pain with anticoagulants: Potential spinal epidural hematoma.

Identification of Red Flags in Clinical History - Constitutional Symptoms

• Fever
• Weight loss
• Night sweats
• Suggesting potentially serious causes of back pain such as infection or malignancy.

Key Physical Examination Findings - Neurological Evaluations

• Motor weakness: Possible nerve root compression.
• Sensory loss: Potential nerve root compression.
• Increased reflexes: Possible UMN lesion.

Key Physical Examination Findings - Genitourinary Symptoms

• Urinary retention: Cauda equina syndrome.
• Incontinence: Cauda equina syndrome.

Specific Conditions Associated with Red Flags

• Spinal Epidural Abscess: Fever, back pain, constitutional symptoms.
• Cauda Equina Syndrome: Urinary retention, fecal incontinence, bilateral leg weakness.
• Vertebral Compression Fractures: Trauma, osteoporosis, cancer.
• Malignancies and Metastatic Disease: Weight loss, night sweats, constitutional signs.

Musculoskeletal Examination - Recognizing Potentially Life-Threatening Conditions

• Red Flags for Immediate Evaluation: Severe pain, tenderness over spine, neurological deficits, signs of infection or systemic illness.
• Conditions Requiring Urgent Attention: Spinal epidural hematoma, cauda equina syndrome, spinal epidural abscess.

Musculoskeletal Examination - Evaluation Sequence for Musculoskeletal Complaints

• General Examination Steps:
  • Medical history and review of systems.
  • Physical examination to evaluate posture, gait, and range of motion.
  • Assess muscle strength.
  • Palpate for tenderness, swelling, and crepitus.
  • Conduct special tests to evaluate specific joint structures or conditions.
  • Determine the need for imaging or further testing based on the findings.
  • Educate patients about their diagnosis and management plan.
  • Follow up to monitor progress and adjust treatment as needed.

This quiz covers the essential components of a neurological examination, including the process of diagnosing and managing nervous system disorders. It emphasizes the importance of localizing lesions and assessing neurologic function. Additionally, it delves into the review of patient history to guide diagnostic and management strategies.