The Neurologic Examination

1. The Neurologic Examination Jason Schwartz APRN, BC, NP Ann Arbor Neurology

2. Objectives Learn the components of the neurologic examination Become familiar with normal findings Determine the significance of some abnormal findings Learn some PEARLS related to the neurologic examination Keys on localization and temporal profile

3. Components of Neurologic Examination Mental Status exam Cranial Nerves Motor exam Deep Tendon Reflexes Cerebellar Examination Sensory Examination Gait and Station

4. Mental Status Examination MMSE CDT Other More Involved Tools Formal Neuropsychiatric Testing

5. Cranial Nerve Examination I-smell-rarely tested unless c/o decreased smell- may be caused by brain tumor II-visual acuity, fundus exam, visual fields, afferent pupillary response

6. Cranial Nerve Exam Cont�d III �sup/inf rectus, inf oblique, efferent pupillary response, ptosis IV-superior oblique muscle-look down and in VI- lateral rectus muscle � lateral gaze

7. Cranial Nerve Exam Cont�d V- muscles of mastication, sensory-ophthalmic, maxillary, mandibular, jaw jerk, corneal reflexes VII � facial strength and asymmetry, taste, speech, �mi, mi, mi�-lips VIII � hearing, balance, Weber/Rinne Testing

8. Cranial Nerve Exam Cont�d IX, X-swallowing, soft palate elevation, gag reflex, taste, �kuh, kuh, kuh�-soft palate XI � shoulder shrug, trapezius and sternocleidomastoid XII � tongue protrusion-atrophy or fasiculations �la, la, la� tongue

9. Upper Motor Neuron vs Lower Motor Neuron lesions Upper Motor Neuron-lesion is in the brain or the spinal cord Lower Motor Neuron-lesion is in the nerve roots, peripheral nerves, or neuromuscular junction.

10. Motor Examination 0-5 rating scale 0-none, 1-trace, 2-no gravity, 3-gravity, 4-some resistance, 5-full resistance UMN � UE-distribution of weakness in deltoids, triceps, wrist extensors, finger extensors; LE � hip flexors, hamstrings, ankle dorsiflexors are weak. Spasticity may be present. LMN � think of peripheral nerves or nerve roots, neuromuscular diseases, atrophy, fasiculations

11. Deep Tendon Reflexes Rating scale 0-4 - 0-none, 1-hypo, 2-nl, 3-brisk, 4-brisk w/ clonus Hyperreflexia - UMN lesion Hyporeflexia - LMN lesion

12. Cerebellar Examination Finger nose finger testing Heel knee shin testing Rapid Alternating Movements Tandem Walking Gait Ataxia

13. Sensory Examination Pain/temperature/light touch Vibration/position sense/light touch Graphesthesia, stereognosis, Double simultaneous stimulation Romberg Sign

14. Gait and Station Look at arm swing, quality of turns, width of gait, and stride Functional testing-heels, toes, squats Spasticity, weakness, circumduction-outward swinging of leg associated w/ weakness and spasticity

15. Functional Findings on Exam Giveway weakness Sensory findings that cross midline Band like sensory loss Monocular Diplopia-usually functional but could be retinal detachment

16. Some Exam Pearls Pearl #1-Afferent pupillary defect or Marcus Gunn Pupil swinging flashlight test-pupil dilates when light is shined onto affected eye-seen with optic neuritis Pearl #2 � optic neuritis causes decreased visual acuity in affected eye and causes optic disc pallor Pearl #3 �visual defects- hemianopic vs amaurosis fugax Pearl #4 � 3rd nerve palsy-eye deviated laterally, mydriasis-b/c parasympathetic control is impaired Pearl #5 � Horner�s syndrome-ptosis, miosis, and anhydrosis � sympathetic control is impaired

17. Some Exam Pearls Pearl # 6 � trigeminal neuralgia- 1 of 3 distributions on the ipsilateral side of face-short bursts of electrical type pain Pearl #7 � Bell�s Palsy vs Stroke- tears, ears, taste, face - often preceded by retroauricular pain. Sometimes associated w/ Herpes Zoster-rash in ear Pearl #8 - BPV- inner ear problem, Dix-Hallpike maneuver Pearl #9 - Babinski Response-abnormal response is extension of great toe and spreading of other toes w/ scratching of plantar surface of foot-indicates UMN lesion Pearl #10-testing for dysarthria, �Pa Pa Pa�-labial, �Ta Ta Ta�-hard palate, �Ka Ka Ka�-soft palate

18. Other Pearls Left handed or Right handed? Speech center-dominant side of brain Left brain-right side; right sided visual field defect Right brain � left side; left sided visual field defect Cortical lesion � contralateral CN deficits and arm/leg symptoms; look at lesion-gaze palsy - think of cortical stroke Brain Stem lesion � ipsilateral CN deficits and contralateral arm/leg symptoms; look away from lesion-gaze palsy - think of brainstem stroke

19. Localization Where�s the lesion? Focal--strictly confined to a single circumscribed area, usually unilateral Diffuse--two or more focal lesions distributed randomly or non-randomly

20. Temporal Profile How did symptoms begin/progress over time? Transient/persistent Rapidity Acute: evolve over minutes to hours Subacute: evolve over hours to weeks Chronic: evolve over months to years

21. Localization/Temporal Profile

22. Are we done yet? How about some case studies?

23. Case Studies 1. 65 yo RH male w/ sudden onset right facial weakness, right arm weakness, right sided numbness, aphasia a. focal or diffuse? b. temporal onset? c. what is the likely cause? d. acute workup and treatment e. hospital workup and secondary prevention f. education and risk factor management

24. Case Studies cont�d 2. 50 yo male w/ onset left facial weakness over 1 hour with h/o URI week before. Associated symptoms include change in taste, pain behind the left ear, sound sensitivity in left ear (everything sounds very loud) a. focal or diffuse? b. temporal profile? c. neurologic exam findings and likely cause d. stroke or no stroke? e. what are the clues to help with diagnosis

25. Case Studies Cont�d 3. 62 yo male presents to your office c/o gradual worsening over the last 4 months of right sided arm weakness and aphasia. 1 month ago he was seen in the ER for new onset seizures. a. focal or diffuse? b. temporal profile? c. given age and above answers, likely etiology? c. details of seizure d. diagnostic workup e. Safety rules/laws

26. Case Studies cont�d 4. 27 yo woman with gradual onset of various symptoms over the last week including right hand numbness, loss of vision in the left eye, weakness in the left leg, and slurred speech. a. focal or diffuse? b. temporal profile? c. what is the likely etiology? d. important history components-s/s in the past, family history, preceded by infection e. diagnostic tests-MRI brain, lumbar puncture f. treatment options-immunomodulator therapy-injections

27. Case Studies cont�d 5. 60 yo man w/ 5 year onset and progression of worsening tremor in the right arm and difficulty walking. a. focal or diffuse? b. temporal profile? c. what is the likely diagnosis? d. clues to help w/ diagnosis e. treatment options

28. Case Studies cont�d 24 yo woman w/ headache, nausea, photophobia-left sided lasting 4 hours 3-4 times per week 60 yo man w/ headaches, left sided numbness during the headache and blurred vision. Exam-mild left sided weakness. 50yo woman w/ h/o headaches since teenager-always preceded by seeing flashing sparkles in vision and right sided numbness occurring 4-5x/year.

29. THE END Any Questions?