Basics of neuro-exam Neurology is: •Stroke •Vertebrogenic disorders •Craniocerebral and spinal traumas •Polyneuropathies, mononeuropathies •Epilepsy •Multiple sclerosis •Alzheimer´s disease and other dementias •Parkinson´s disease and other neurodegenerative disorders •Metabolic disorders •Neuroinfections •Toxic disorders of the brain •Nutritious deficiencies •Tumors •Migraine and other headaches •Myasthenia gravis •Neurologic complications of systemic diseases •……. Principles of neuro-exam •To enable the student to detect and record the physical signs of common and important disorders of the nervous system • •The student should understand the principle behind each test and what it is designed to detect. Neurologic exam •Anamnesis- history •Clinical exam •Other examinations (radiological, biochemical, haematological, laboratory, neurophysiological, etc.) • •Diagnosis: •Syndromological •Topical •Etiopathogenetical Neurological history •Current history (anamnesis) •Family history •Personal history •Past medical history •Pharmacological history •Physiological functions •Abusus •Occupational •Social •Alergies •Driving license •Gynecological and obstetrics history The Neuro Exam: History •History often provides the key since the neuro exam may be normal •Subarachnoid Hemorrhage •Carbon Monoxide Poisoning •Subdural Hematoma •Nonconvulsive Seizures • •Neuro complaints may be primary or secondary to other system disease •Infection •Overdose (elicit drugs, alcohol, etc.) •Metabolic Disorders • • Neurologic history •Time of Onset •Type of Onset •Progression •Trauma •Associated Symptoms •Factors that make it better/worse •Past Symptoms / Events •Past Medical History •Occupational / Environ Exposures • The order of neuro-exam •General appearance •Higher functions •Cranial nerves •Motor system •Reflexes (deep tendon reflexes, superficial reflexes) •Sensory system •Stance and gait Physical exam •Vital Signs •Head: Evidence of Trauma •Neck: Bruits, Rigidity •Heart: Murmurs •Lungs: Crepitation, Breathing frequency •Abdomen: Masses / Distention •Skin / Scalp: Lesions / Tenderness • Motor Exam •Strength •Tone •Hypertonia (upper motor neuron lesion) •Hypotonia (lower motor neuron lesion) •Rigidity (basal ganglia lesion) •Fasciculation (anterior horn cell lesion) •Tenderness •metabolic / inflammatory muscle disease • Motor Exam (strength) •0 = no movement •1 = flicker but no movement •2 = movement but can not resist gravity •3 = movement against gravity but can not resist examiner •4 = resists examiner but weak •5 = normal • Deep tendon reflexes •Eliciting a deep tendon reflex (DTR): •patient be relaxed with his/her limb in an appropriate position •to compare one side to the other— asymmetry • •When DTR’s are difficult to elicit: •testing after reinforcement (“Lock your fingers together and pull when I tell you to”; “Clench your teeth” ) Reflexes •Symmetry / upper vs lower –0 = absent –1 = hyporeflexia –2 = normal –3 = hyperreflexia –4 = clonus (usually indicates organic disease) •Superficial reflexes (corneal, pharyngeal, pharyngeal, abdominal, anal, cremasteric, bulbocavernosus) Deep Tendon Reflexes •Biceps (C5-C6) •Brachioradialis (C5-C6) •Triceps (C6-C8) •Flexor of hands and fingers (C7-C8) •Adductor (L2-4) •Patellar (L2-L4) •Medioplantar (L5-S2) •Plantar (L5-S2) •Achilles (L5, S1-S2) Superficial Reflexes •Elicited by cutaneous stimuli •Abdominal •Upper abdomen (T8-T10) •Lower abdomen (T10-T12) •Other •Corneal (trigeminus-facialis) •Gag (Glossopharyngeus, vagus- vagus) •Cremasteric (L1-L2) Pathologic Reflexes •Plantar reflex •the Babinski response (abnormal dorsiflexion of the great toe with fanning of the other toes) is a pathologic reflex indicative of UMN disease. •Frontal release signs •Blink reflex/Glabellar tap •Grasp reflex •Snout/sucking reflex Neuronatomy •Central versus peripheral –symmetrical vs asymmetrical •If central, what is the level: –Cerebrum („big brain“) –BrainStem –Spinal cord •If peripheral, is it –Nerve (nerve roots) –Neuromuscular junction –Muscle – • Impairment of the central versus peripheral motoneuron •Upper motor neuron lesion: •increased DTR •muscle tone increased •no fasciculations •Paresis (decreased strength) •Pathological reflexes (Babinski, etc.) • •Lower motor neuron lesion: •decreased DTR • tone decreased, atrophy •Fasciculations •Paresis (decreased strength) • • Pitfalls in neuroexam leading to misdiagnosis •Insufficient history, including history taking from the family members, other close relatives, co-workers etc. • •Insufficient performance of the systematical exam (lem just performing the exam where the problem is seen by the patient) • •Very preliminary diagnosis before the acquisition of all acquired data • •Misinterpretation of the „older“ lesions and current lesions • •Misinterpretation of the limiting factors- f.i. pain- misdiagnosed as the neurological deficit (like paresis, etc.) •