Semiologie Neurologique: Medical Observations

• Semiologie Neurologique is for 2nd year Medical Students
• The content below discussed medical observations in neurology, interrogation, neurological examination and reasoning, and the overall synthesis

Observation Medicale en Neurologie

• The interrogatory is an essential time for observation and is done with care
• The clinical exam is carried out systematically by a precise order
• Neurological reasoning passes through different stages: Syndromic grouping, topographical discussion, pathophysiological mechanisms and etiologies.

L'interrogatoire

• The patient's identity and laterality (right or left handed) should be noted.
• Record past medical history
• Record habitual history (tuberculosis, cardiovascular risks, etc)
• Record genital chancres
• Record buccal or genital aphthosis
• Record prior neurological episodes.
• Special attention to the pregnancy, health at birth, psychomotor development and social integration of children
• Record family medical history
• Note consanguinity
• Note neurological diseases or similar cases.
• History of Illness
• The reason for seeking treatment is an important detail to note
• The physician needs to know the primary symptom
• Any accompanying signs are essential pieces of information
• The manner of the onset: sudden, acute, subacute or chronic(>6months)
• The mode of evolution: continuous aggravation, stationary, flare-ups/remissions

L'examen Neurologique

• Neurological exam occurs after history/interview
• Examination is done function after function in the following order:
• Gait
• Muscular strength
• Tonus
• Reflexes
• Sensations
• Motor coordination
• Cranial nerves
• Higher functions
• The Somatic exam is a complete cardio-vascular, abdominal, pleuro-pulmonary, osteoarticular, ganglionic area, thyroid area, and cutaneous examination.

La Synthese

• Syndromic grouping of neurological signs found on exam indicate onset mode, evolutionary mode and pertinent med history.
• The base of Diagnostic Reasoning passes through several stages:
• Topographical Diagnosis
• Discussion of the pathophysiologic mechanism
• Etiological Discussion
• Additional Exams

Raisonnement Diagnostique

• Diagnostic topographical considerations:
• Affected Muscles
• Neuromuscular Junction
• Peripheral Nerve
• Roots
• Bone Marrow
• Cerebral Trunk
• Cerebellum
• Encephalon
• Diagnosis conditions the diagnostic approach and indications of complementary examinations.
• Discussion of pathophysiologic mechanisms considers onset and evolution of impairments
• Brutal Installations indicate vascular mechanisms
• Regressive Deficits indicate inflammatory cause
• Progressive evolution indicates possible hereditary illness
• Additional extra-neurological signs include:
• General signs, that may indicate infectuous mechanisms
• Systemic signs with neurological implications
• Discussion of Etiologies considers topography(s) and mechanisms
• Example: Cortical encephalic topography of abrupt installation might indicate a cerebrovascular accident.
• Additional Exams (2 Types)
• Confirm level of neurological attack (cerebral scan, MRI)
• May provide diagnostic information

L'examen Neurologique

• General Neurological Examination
• Gait and Stance
• Muscle Tone
• Muscle Strength
• Reflexes
• Sensations
• Motor Coordination
• Cranial Nerves
• Higher Functions

I. Examen de la Marche

• The patient is observed walking back and forth
• There are 5 types of abnormal gaits:

Types of Abnormal Gait

• Ataxic or Unbalanced Gait
• The patient struggles to maintain balance
• The patient cannot walk in a straight line
• The patient separates the legs and arms, and the half-turn is broken down into steps
• There the thee pathological situations include cerebellar ataxia, vestibular ataxia, and proprioceptive ataxia
• Spastic Gait
• Caused by hypertonia predominating the extensor muscles of the lower member prevents folding go the knee
• The patient moves by “felling,” moving the rotation laterally
• The felling may be unilateral or bilateral
• Spastic hypertonia is a sign of pyramidal syndrome
• Steppage
• Paralysis of the elevator muscles of the foot
• Is characteristic of peripheral nervous system event
• Akinetic or Parkinsonian Gait
• Automatic movements and trouble initiating movement is a characteristic
• Presents with small steps and the arms glued to the body
• Waddling Gait
• Weakness of the muscle in the pelvic girdle leads to failure of the hips and core during walking
• Patient balances basin alternatively from on side while stepping
• Affliction is linked to muscular disease

Examen de la Station Debout

• Patient stands with feet together, searching for difficulty balancing
• Investigation of Romberg sign, with patient standing with eyes closed
• Sign of Romberg is positive, with a tendency to fall.
• This is the case for vestibular and proprioceptive syndromes

Examen du tonus Musculaire

• Muscle tone is the permanent state of tension of the striated muscle that persists during its voluntary relaxation.
• Tone depends on a medullary reflex activity and is under the supramedullary centers
• Examinations include patient lying done, with muscles relaxed
• Mobilization involved resistance moderately that limits muscle extensibility

Semiologie du Tonus

• Hypotonia is a diminishing of muscle tone
• Complete absence of resistance to passive muscle mobilization
• The muscle is flaccid, with accented extensibility
• Cases of Hypotonia are linked to peripheral nervous system and acute cerebral attacks.
• Occurs during spinal shock phase
• Seen in acute lesions of pyramidal pathway
• Hypertonia is an augmentation of muscle resistance
• Can be classified to spastic or plastic hypertonia
• Spastic Hypertonia, with increases resistance to the muscles of inférior extensors: resistance is released abruptly

Examen des Muscles et de La Force Musculaire

• The patient undresses to assess volume
• Atrophy or Amyotrophy: decrease in muscle volume, seen in peripheral affections
• Hypertrophy: localized or diffused muscle growth, typically seen in children with myopathies. Experiencing spontaneous contractions: is of the of the peripheral nervous system trembling.

Examen de la Force Musculaire

• Global force is determined
• Barre and Mingazzini maneuvers are used to assess global force of patient

La maneuver de Mingazzini

• Segmental Muscle Force
• The force in the face, neck, limbs and trunk are evaluated bilaterally.
• Comparison in strength is conducted bilaterally
• Evaluating to assess is that how is fighting force of the patient against the examiner.
• Force is graded from 0 to 5
• Absence of force results in a 0 evaluation
• Contraction with no displacement results in 1
• Displacement without gravity results in 2
• Displacement against gravity results in 3
• Partial displacement of resistance of gravity results in 4
• Normal displacement results in 5
• Topographies involved with Muscle motor failure: can be due to paralysis affecting various body areas
• Hemiplegia = paralysis of the muscles in one side of the body
• Paraplegia = paralysis in the lower muscles of the limbs
• Tetraplegia = paralysis where all limbs of are paralyzed
• Monoplegia = paralysis where one limb is paralyzed
• Radicular = Paralysis of muscle innervated through a root
• Tronculaire = paralysis of muscle via neurological root

Étude des Reflexes

• Indicates metamere is affected
• Reflex points to center of the spinal chord or cerebral trunk, the sign of the integrity of area of affected.

Reflexes Osteo-Tendineux (ROT)

• Monosynaptic reflexes that localize metameric medulla
• Performed on a relaxed patient
• Percussion is done using a reflex hammer
• Response is a contraction of the corresponding muscle
• Analyzed by amplitude
• Compared controlaterally
• Symmetry is the rule
• The major tendons
• Bicipital reflex can be located in C5
• Tricipital reflec located in C7
• Stylo-radial reflex located in C6
• Cubito-pronateur (C8)
• Rotulian reflex located in L4
• Achillean relfex is loccated in S1

ROT Semiologie

• Under Normal conditions, Reflexes Osteo-Tendineux exist and are symmetric in terms of amplitude
• Two types of pathological aspects exist
• Abolished during SNP or severe aiguettes
• Exaggerated duering pyramidal syndromes
• During the phase of a central attack
• ROT’s = vifs, polycinetiques
• Crossed or diffued= stimulates response from the contralateral muscles

Reflexes Cutaneo-Muqueux

• They are polysynaptic.
• Cutaneous Plantar Reflex
• If the patient is flexible the RCP is bent. An alternate reaction may cause a Babinski Sign.
• Abdominal Reflexes
• metameres medullaires are D6 to D12. Normal response would result in. contraction of. abdominal. muscle and slight. movement toward. stimulus. They are not present during, pyramidal conditions
• Cremaster Reflex
• Contraction resulting from internal, lower thigh stimulation of lower parts of the thighs and associated organs
• Metameres L1-L2
• Avolition results in pyramidal symptom
• Anal Reflex
• Stimulation of. anus resulting in, S3-S4 Contraction. This. will not occur. if the PNS or there is an Central attack
• Other skin surface reflections (corneal, visual, soft palate, nausea) will be studied in the chapters consacrés for examination of CRANIAL NERVES.