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Neurological exam outline
The function of the neurological system to coordinate both voluntary and involuntary actions of the human body; this is performed by nervous transmission of signals to and from different parts of the body via nervous tissue and structures. There are two main parts:
- The Central Nervous system (brain, spinal cord)
- The Peripheral Nervous system (nerves)
Let’s skip ahead to screening:
RED FLAGS:
- Sudden and severe headaches with or without head injury.
- Dizziness/vertigo, nausea and or vomiting.
- Seizures or tremors.
- Numbness and tingling without reproducible onset.
- Difficulty swallowing or speaking.
- Notable past histories of previous neuropathic disorders.
- Nystagmus (intentional tremor of the eye)
- Loss of consciousness.
General tips during the neuro-exam:
- Explain the tests to your patient. Many of these tests are dependent on command following (such as eyes closed, appropriate responses to give, etc.)
- Neuro exams are often subjective and can be difficult to interpret.
- Specifically map out the areas in which the sensory changes are found.
- Always compare bilateral sides, and distally to proximally.
Mental status:
- Alertness and orientation.
- History from family and friends if patient is unreliable or invalid.
- Memory and concentration: Name the president; three word recall; subtract 7 from 100 five times.
Cranial nerve screening:
- Smell (I Olfactory)
- Cardinal fields of gaze (III Occulomotor; IV Trochlear, VI Abducens)
- Accomodation (III Occulomotor)
- Peripheral vision (II Optic)
- Facial Expressions such as smile and frown (VII Facial)
- Stick out tongue (XII Hypoglossal)
- Trap/SCM testing (XI Spinal accessory)
- Consensual light reflex (II Optic, III Occulomotor)
- Take a peek in the mouth to examine oral mucosa.
- Say Ahhh test (IX Glossopharyngeal, X Vagus)
- Bite down on tongue depressor (V Trigeminal)
- Ophthalmoscopic exam (II Optic)
- Otoscopic and rhinoscopic exam
Cerebellum screening (RADAR):
- Rapid alternating movements (hand, finger or foot tapping; rapid supination/pronation)
- Accessory Movements (intentional tremors or nystagmus [tremor of the eye])
- Dysmetria (past pointing such as finger to nose, finger to finger)
- Ataxia (Gait heel to toe, or walking in a circle)
- Rebound phenomenon (Holme’s sign, elbow flexion MMT in supine causes person to hit themselves upon release)
Spinal cord and nerve screening
Sensory screening (posterior columns):
- Light touch (fasiculis gracilis (arms); cuneatus (legs))
- Vibration (128hz C tuning fork)
- Stereognosis (ID an object with touch only)
- Graphesthesia (ID a word or number written on skin)
- Proprioception (Dorsospinocerebellar tract)
Lateral columns (spinothalamic tract)
- Pain (sharp/dull)
- Temperature (hot/cold)
Motor testing (myotomes; corticospinal tract)
- Suboccipital flexors (C1, C2 nerve root)
- Cervical lateral flexors (C3 nerve root)
- Shoulder elevators (UT, LS) (C4 spinal nerve root)
- Deltoid (C5-6 axillary nerve)
- Brachioradialis (C5-6 radial nerve)
- Biceps (C5-6 musculocutaneous)
- Triceps (C6-7-8-T1 radial nerve)
- Wrist extensors (ECRL/B+ECU C6-7-8 radial nerve)
- Wrist flexors (FCU, FCR C6-7 median and ulnar nerve)
- Digit flexors (Flexor digitorums, C7-8, T1 median and ulnar)
- Innerossei (C7, C8, T1 ulnar nerve)
- Tibialis anterior (L4-5 deep peroneal nerve)
- Extensor hallicus longus (L4-5, S1 deep peroneal nerve)
- Peroneus longus (L5-S1, superficial peroneal)
Reflexes
Note; HYPOreflexia is often from peripheral neuropathy or radiculopathy at LMN level; HYPERreflexia is indicative of UMN level pathology.
- Deep tendon reflexes (DTR):
- Biceps (C5-6)
- Brachioradialis (C5-6)
- Triceps (C7)
- Patellar (L4)
- Hamstring (L5)
- Achilles (S1)
- Superficial reflexes:
- Abdominal (belly button moves to stimulus)
- Cremasteric, perianal wink
- Pathological reflexes
- Hoffman (Clawing of hand on finger flick)
- Babinski reflex.
- Nerve root tension testing:
- SLR, ULLT, Braggards, shoulder depression, brachial stretch, doorbell sign, Tinel’s.
Upper extremity nerve pathology
Radial nerve (C5, 6, 7, 8)
- Impingement at triangular space (triceps long head, teres major, humerus):
- Generally due to poorly adjusted crutches, humerus fractures and dislocations, falling asleep on arm a la Saturday Night Palsy.
- There is often a weakness of elbow and wrist extension (wrist drop)
- Diminished to loss of triceps reflex
- Loss of sensation to entire posterior arm and forearm (sans lateral forearm)
- Loss of sensation to posterior lateral 3.5 fingers to DIP joints.
- Radial groove impingement:
- Often due to compression from humerus fractures, or triceps muscle entrapments.
- Weakness of wrist extension or wrist drop.
- Loss of sensation to posterior lateral 3.5 fingers to DIP joints.
- Elbow impingement (at radial tunnel):
- Deep branch of radial nerve is compressed by either a fracture of the proximal radius or by crush by the supinator (less often the extensor carpi radialis brevis).
- Expect weakness of thumb and MCP extension.
Musculocutaneous nerve (C5, 6, 7)
- Only site of impingement is axillary fold of coracobrachialis muscle belly.
- Generally weakness of elbow flexion.
- Loss of cutaneous sensation to anterior and lateral forearm (lateral antebrachial cutaneous nerve)
- Loss of biceps reflex.
Axillary nerve (C5-6)
- Only site of impingement is Quadrangular Space (Teres major, minor, triceps long head and humerus), most often due to fractures of the humerus, dislocations and poorly adjusted crutches. The Quadrangular Space also contains the posterior humeral circumflex artery.
- Often weakness in deltoid and teres minor, resulting in poor abduction of arm.
- Loss of cutaneous sensation to superior posterior and lateral arm (deltoid shield area).
Median Nerve (C5, 6, 7, 8, T1)
- Elbow compression occasional due to sleeping on the elbow or medial supracondylar fractures.
- Often weakness of forearm pronation and wrist flexion.
- Ape hand deformity (atrophy of thenar muscles)
- Loss of sensation to palm and palmar surface of lateral 3.5 fingers.
- Impingement at the pronator teres caused by hypertonus of pronator teres (prontaror teres syndrome)
- Often with throbbing or aching pain in wrist and forearm.
- Poor grasp strength.
- Pain with forearm pronation and wrist flexion.
- Ape hand deformity
- Loss of sensation to palm and palmar surface of lateral 3.5 fingers.
- Importantly NOT associated with night pain.
- Impingement at the transverse carpal ligament at carpal tunnel.
- Ape hand deformity
- Loss of sensation to palm and palmar surface of lateral 3.5 fingers, sometimes only the latter!
Ulnar nerve (C7, 8, T1)
- Cubital tunnel of the elbow (cubital tunnel syndrome), likely from fracture at medial epicondyle, sustained pressure to the ligaments, or anomalies in the anconeus muscle. The cubital tunnel is formed by the tendonous arch jointing the humeral and ulnar heads of the flexor carpi ulnaris - inflammation of the flexor carpi ulnaris may compress the ulnar nerve.
- Expect claw hand deformity with normal PROM in severe cases.
- Loss of sensation to medial 1.5 fingers.
- Dysfunction at the wrist most often stems from defensive wounds from cuts, blunt trauma, or stab wounds.
- Bishops or claw hand deformity with normal PROM.
- Loss of sensation to medial 1.5 fingers.
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I haven't decided which topic will be next (read: I am procrastinating on muscle/bone evaluation because it is such a vast yet nuanced topic), so we'll just have to see :) This one is pretty dry, so the next one will also be more candid.
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