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The Exam from a
Neurologist's PerspectiveTracy W. Sax M.D.
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Neuro Exam Goals
• The neurological exam can be overwhelming and
time consuming. Break down into parts
• Think of the neuro exam as a tool to help localize
• The neuro exam actually starts with a good
history. This can help focus the exam
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Overview
• Brief neuro anatomy review
• History
• Neuro exam with common examples
• Clinical scenarios
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Central vs Peripheral
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Brain
• Cerebrum: lesions result in contralateral deficits of more
than one territory. Aphasia, contralateral visual
disturbance behavioral change
• Cerebellum: motor coordination/ balance can be ipsilateral
• Diencephalon: thalamus relay station for motor and
sensory impulses and hypothalamus homeostasis. Clinical
signs contralateral to lesion
• Brainstem: midbrain, medulla (can have mixed ipsilateral
and contralateral signs), pons
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Spinal cord
• Relay center for descending
motor control and ascending
sensory control
• Spinothalamic track: pain
temp and touch
• Dorsal columns: position,
proprioception, vibration and
fine touch
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Central Nervous System Signs
on Exam
• Hyper-reflexia
• Spasticity
• Sensory or motor loss face, arm and leg
• Sensory or motor loss bilaterally or unilaterally from
a certain level down with spinal cord lesions
• Cortical signs: Visual loss homonymous, language
disturbance, neglect, memory/ behavioral change
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Peripheral Nervous System
Signs on Exam
• Discrete nerve root territory
• Discrete peripheral nerve
territory
• Hypo-reflexia
• Atrophy
• Fasciculation
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Upper Motor Neuron (central) vs
Lower Motor Neuron
(peripheral)
• UMN increased DTR, LMN reduced DTR
• UMN muscle tone increased, LMN muscle tone
decreased and atrophy
• UMN no fasciculations, LMN fasciculations
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Myelopathy vs Radiculopathy
• Myelopathy=Spinal Cord Lesion= UMN.
Weakness, sensory changes below the level of the
lesion and hyper-reflexia
• L'Hermitte's sign cervical cord
• Electrical pulsation through body with neck
extension or flexion
• Radiculopathy follows distinct myotomal and
dermatomal pattern, hypo-reflexia
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Peripheral Nerve, Neuromuscular
Junction and Muscle
• Peripheral nerve: follows motor/sensory territory for a specific nerve. In generalized neuropathies, typically follows a stocking/glove pattern. Absent to trace reflexes. Atrophy, fasciculations
• Neuromuscular junction: No sensory loss, proximal weakness in arms/legs. Fatigable
• Muscle: Proximal weakness in arms/legs. No sensory loss
• Above may be diagnosed with nerve conduction studies and EMG.
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History
• Lateralization of symptoms
• Chronicity
• Paroxysmal?
• Associated symptoms help with localization
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The Neuro Exam
• Mental status
• Cranial nerves
• Motor
• Sensory
• Coordination (not necessarily cerebellum) includes
gait
• Reflexes
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Mental Status
• Many different screening tests to choose
(SLUMS, MMSE, MOCA)
• If a patient gives a very clear history and follows
commands you know language function is intact
and that they are attentive
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Mini Cog
Screening Test
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Cranial nerves
• CN2 acuity and visual fields
• CN3 pupil and adduction, elevation and depression of eye
• CN4 In torsion of eye
• CN6 abduction of eye
• CNV facial sensation
• CNVII facial muscles
• CNVIII hearing/ vestibular function
• CN11 trapezius
• CN12 tongue
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Bell's Palsy
• Sudden paralysis one side of
face
• Frontalis weakness
• Bell's phenomenon
• May present with pain behind
ipsilateral ear
• May later develop hemi facial
spasm
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Bell’s Palsy in Hollywood
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Stroke vs Bell's Palsy• Ipsilateral frontalis muscle is
spared when stroke causes
facial weakness
• Look for other neighboring
signs consistent with stroke
• Arm/leg weakness
• Numbness
• Aphasia
• Hyper-reflexia
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Motor Exam
• Tone
• Strength
• Look for patterns
• Common UMN weakness patterns
• Extensors of upper extremities vs flexors of lower
extremities
• Peripheral nerve vs myotomal weakness
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Myotome examples in lower
extremity
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Wrist Drop
• Examine the hand supported
• In the wrist drop position, the
other intrinsic hand muscles
will appear weak
• Numbness in discrete radial
territory
• Only radial nerve muscles
affected
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Stroke vs Radial Neuropathy
• This patient had wrist drop in
addition to true weakness of
the interossei and abductor
pollicis brevis
• No sensory loss
• Subtle hyper-reflexia on
affected side
• No obvious history of
compression in the affected
limb
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Sensory
• Check different modalities
• Pin/temp small fiber
• Vibration/proprioception large fiber
• Distribution
• Stocking distribution not specific to neuropathy
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Coordination
• Finger nose finger
• Heel to shin
• Fine movements
• Rapid alternating movements
• Gait regular tandem heel and toe
• Look at stride, initiation turning and arm swing
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Reflexes
• Hyper-reflexia vs hypo-reflexia
• Look for symmetry vs asymmetry
• Pathological: Jaw jerk, Hoffmann's and Babinski
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Clinical examples
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Parkinson's
• History: Typically starts with UNILATERAL tremor
• Increased tone
• Small amplitude fine movements
• Gait small steps reduced arm swing turns en bloc
• Masked facies
• Review medications
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Parkinson's Gait
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Parkinson's Tremor
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Essential Tremor
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Astasia-Abasia
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Approach to Patient Presenting
with Increased Falling
• History
• Light headed, loss of consciousness, dizzy,
weak, numb, ??? Medications
• Exam
• Orthostatics, mental status, strength, sensation,
coordination and gait
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Common Causes of Falls in the ElderlyAccident
Gait disturbance
Balance disorders or Weakness
Pain
Vertigo
Medications or Alcohol
Acute illness
Confusion
Postural hypotension
Visual disorder
Syncope, Epilepsy.
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Evaluate Feet
• The feet can be a key to
balance issues
• Sensory loss
• Abnormal reflexes
• Hygiene
• Callouses
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Small Fiber Neuropathy
• History: burning feet
• Loss of pin and temp preserved reflexes
• Normal strength and gait
• Symmetric involvement
• Preserved reflexes helps to differentiate from
spinal stenosis
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Challenging Case
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• 70 y.o. woman presents with a five year history
of increase numbness and burning in her feet.
• Exam notable for stocking distribution sensory
loss in the feet to the mid calf to pin and temp,
reduced vibration in the toes.
• Reflexes 2 at knees, 0 at ankles and toes down
going.
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• Labs revealed a low B12 of 189 and mild
hyperglycemia.
• Nerve tests showed mildly reduced sensory
response amplitudes.
• History, exam, nerve tests all consistent with a
diagnosis of polyneuropathy likely due to low B12
and hyperglycemia.
• She was treated with low dose Gabapentin and
B12 supplements
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• About 6 months after her initial visit, she reported
a rapid increase in symptoms
• She was falling at home
• She reported numbness to the upper thigh
• Her exam showed absent pin and temp to the
upper thigh
• Reflexes were 2 at knees, 0 at ankles, toes down
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• What happened?
• The tempo of her symptoms was not consistent
with peripheral neuropathy
• Imaging of the entire spine was performed
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Myelopathy
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Challenging Case• More than one neurologic problem occurring at
the same time
• Neuropathy prevented typical signs of
myelopathy (hyper-reflexia)
• The tempo of change in her symptoms was the
clue
• Cord lesions can be falsely localizing
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Take home points
• Unilateral, late onset tremor raises red flag for possible Parkinson's disease
• Review medications in patient with suspected Parkinson's disease
• Clock drawing can be a helpful screening test for memory loss
• Don't forget to look at the feet in a patient with unexplained falling
• Spinal cord lesions can be falsely localizing
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Call your local neurologist when in doubt!
Thank you!