Neurological Examination Made Easy, 6e

Description

Neurological clinical examinations are some of the most intimidating procedures medical students, junior doctors and residents have to perform. This book's clear, succinct explanations and simple/memorable line drawings, along with top tips/common mistakes boxes, combine to demystify the subject and offer straightforward guidance. The spectacular success of the book over many years demonstrates that it succeeds more than any other resource available. This 6th edition will ensure the content remains as fresh, current and easy to interpret as ever. A concise and lucid explanation of how to examine the nervous system. Copiously illustrated with clear line diagrams and flow charts. Instructions are clear and systematic - what to do, what you will find, and what it means. New simplified line drawings have been added. The new edition contains an expanded summary of how to perform a complete neurological examination. The book will be available on the StudentConsult library. Front Cover IFC NEUROLOGICAL EXAMINATION: MADE EASY NEUROLOGICAL EXAMINATION: MADE EASY Copyright CONTENTS PREFACE ACKNOWLEDGEMENTS How to Use this Book 1. Anatomical (where?) 2. Syndromal (what?) 3. Aetiological (why?) GLOSSARY OF NEUROLOGICAL TERMS 1 - HISTORY AND EXAMINATION HISTORY The neurological history Basic background information Present complaint Conventional history Past medical history Drug history Family history Social history Toxin exposure Systemic inquiry Patient’s perception of illness Anything else? Synthesis of history and differential diagnosis GENERAL EXAMINATION 2 - SPEECH BACKGROUND 1. Aphasia 2. Dysphonia 3. Dysarthria 1. APHASIA WHAT TO DO Assess understanding Test understanding Assess spontaneous speech Ask further questions Assess word-finding ability and naming Assess repetition Assess severity of impairment of speech Further tests Test reading and writing WHAT YOU FIND WHAT IT MEANS 2. DYSPHONIA WHAT TO DO WHAT YOU FIND AND WHAT IT MEANS 3. DYSARTHRIA WHAT TO DO WHAT YOU FIND Types of dysarthria With abnormal rhythm With normal rhythm WHAT IT MEANS 3 - MENTAL STATE AND HIGHER FUNCTION 1. MENTAL STATE BACKGROUND WHAT TO DO AND WHAT YOU FIND Appearance and behaviour Mood Vegetative symptoms Delusions Hallucinations and illusions WHAT IT MEANS Organic psychoses Functional psychoses Neuroses Personality disorder 2. HIGHER FUNCTION BACKGROUND WHEN TO TEST HIGHER FUNCTION WHAT TO DO Introduction 1.Attention and orientation Orientation 2.Memory b. Short-term memory or episodic memory c. Long-term memory or semantic memory 3.Calculation Serial sevens Alternative test: doubling threes Further tests 4.Abstract thought What you find What you find 5.Spatial perception Clock face Five-pointed star What you find 6.Visual and body perception Facial recognition: ‘famous faces’ Body perception Sensory agnosia 7.Apraxia Three-hand test WHAT YOU FIND Patterns of focal loss WHAT IT MEANS Diffuse or multifocal abnormalities Common Rarer Nutritional Infective Structural Focal deficits Degenerative Vascular Neoplastic Infective Demyelinating 4 - GAIT BACKGROUND WHAT TO DO AND WHAT YOU FIND If symmetrical If small paces If normal paces If asymmetrical FURTHER TESTS WHAT IT MEANS Non-neurological gaits Romberg’s test What to do What you find and what it means 5 - CRANIAL NERVES: GENERAL BACKGROUND 6 - CRANIAL NERVE I: OLFACTORY NERVE WHAT TO DO WHAT YOU FIND WHAT IT MEANS 7 - CRANIAL NERVES: THE EYE 1 – PUPILS, ACUITY, FIELDS BACKGROUND 1. General The eyes are usually symmetrical 2. Pupils The pupillary light reaction Accommodation reaction 3. Acuity 4. Fields 1. GENERAL WHAT TO DO WHAT IT MEANS 2. PUPILS WHAT TO DO IN A CONSCIOUS PATIENT WHAT YOU FIND FURTHER TESTING Swinging light test What to do What you find and what it means WHAT IT MEANS 3. ACUITY WHAT TO DO AND WHAT YOU FIND Can the patient see out of both eyes? (i) Using Snellen’s chart (ii) Using a near vision chart (Fig. 7.3) (iii) Using bedside material such as newspapers A new development WHAT IT MEANS 4. FIELDS WHAT TO DO Assess major field defects Test each eye individually What to test with? Using a red pin (recommended) Alternative technique using a white pin (a less sensitive test) Once you find a field defect When there is a homonymous hemianopia WHAT YOU FIND (i) Defect limited to one eye Constricted field (ii) Defect affecting both eyes WHAT IT MEANS 8 - CRANIAL NERVES: THE EYE 2 – FUNDI BACKGROUND WHAT TO DO 1. Look at the optic disc 2. Look at the blood vessels 3. Look at the retinal background WHAT YOU FIND 1. Optic disc 2. Blood vessels 3. Retinal background (Fig. 8.7) General background Red lesions White/yellow lesions Black lesions WHAT IT MEANS 1. Optic disc 2. Blood vessels and retinal background 9 - Cranial Nerves III, IV, VI:Eye Movements BACKGROUND Double vision rules WHAT TO DO The cover test What to do What you find What it means Test the eye movements to pursuit Test saccadic eye movements Test convergence Vestibulo-ocular reflex (doll’s eye manœuvre) WHAT YOU FIND Other common abnormalities WHAT IT MEANS 10 - CRANIAL NERVES: NYSTAGMUS BACKGROUND WHAT TO DO Special test: optokinetic nystagmus (OKN) WHAT YOU FIND WHAT IT MEANS 11 - Cranial Nerves V and VII: The Face BACKGROUND Facial nerve: VII Trigeminal nerve: V Sensory Motor What to do FACIAL NERVE: WHAT TO DO Other functions of the facial nerve FACIAL NERVE: WHAT YOU FIND FACIAL NERVE: WHAT IT MEANS TRIGEMINAL NERVE: WHAT TO DO Motor Test muscles of mastication (trigeminal nerve: motor) Sensory TRIGEMINAL NERVE: WHAT YOU FIND Motor Jaw jerk Sensory TRIGEMINAL NERVE: WHAT IT MEANS 12 - CRANIAL NERVE VIII: AUDITORY NERVE AUDITORY WHAT TO DO Test the hearing Rinne’s test Weber’s test WHAT YOU FIND WHAT IT MEANS VESTIBULAR BACKGROUND Gait Nystagmus Head impulse test Caloric test CALORIC TESTING: WHAT YOU FIND CALORIC TESTING: WHAT IT MEANS FURTHER TESTS OF VESTIBULAR FUNCTION What you find and what it means Turning test What you find and what it means 13 - Cranial Nerves IX, X, XII: The Mouth BACKGROUND Glossopharyngeal nerve: IX Vagus nerve: X Hypoglossal nerve: XII MOUTH AND TONGUE: WHAT TO DO To assess weakness Test repeated movements Test speech MOUTH: WHAT YOU FIND AND WHAT IT MEANS PHARYNX: WHAT TO DO Additional testing GAG REFLEX: WHAT TO DO PHARYNX AND GAG REFLEX: WHAT YOU FIND LARYNX: WHAT TO DO LARYNX: WHAT YOU FIND PHARYNX AND LARYNX: WHAT IT MEANS 14 - CRANIAL NERVE XI: ACCESSORY NERVE BACKGROUND WHAT TO DO Look at the neck Look at the shoulders Sternocleidomastoid Trapezius WHAT YOU FIND AND WHAT IT MEANS 15 - MOTOR SYSTEM: INTRODUCTION KEY ANATOMY GENERAL WHAT TO DO General comments 16 - MOTOR SYSTEM: TONE BACKGROUND WHAT TO DO Arms Legs Tone at the hip Tone at the knee Tone at the ankle WHAT YOU FIND Special situations WHAT IT MEANS 17 - MOTOR SYSTEM: ARMS BACKGROUND WHAT TO DO Look at the arms Basic screening examination Shoulder abduction Elbow flexion Elbow extension Wrist extension Finger extension Finger flexion Finger abduction Finger adduction Thumb abduction FURTHER TESTS OF ARM POWER Serratus anterior Rhomboids Supraspinatus Infraspinatus Brachioradialis Long flexors of little and ring finger WHAT YOU FIND 18 - MOTOR SYSTEM: LEGS BACKGROUND WHAT TO DO Power testing screening Hip flexion Hip extension Knee extension Knee flexion Foot dorsiflexion Plantar flexion of the foot Big toe extension Extension of the toes Hip adductors Foot inversion Foot eversion 19 - MOTOR SYSTEM: REFLEXES BACKGROUND WHAT TO DO Biceps Supinator Triceps Finger reflex Knee reflex Ankle reflex Ankle reflex alternatives Reinforcement Further manoeuvres Demonstration of clonus WHAT YOU FIND AND WHAT IT MEANS ABDOMINAL REFLEXES What to do PLANTAR RESPONSE What to do What you find What it means Alternative stimuli (all trying to elicit the same responses) 20 - MOTOR SYSTEM: WHAT YOU FIND AND WHAT IT MEANS WHAT YOU FIND Remember Weakness in all four limbs With increased reflexes and extensor plantar responses With absent reflexes Mixed upper motor neurone (in the legs) and lower motor neurone weakness (in the arms) Normal reflexes Weakness in both legs With increased reflexes and extensor plantar responses With absent reflexes in the legs Unilateral arm and leg weakness Upper motor neurone lesion in the high cervical cord, brainstemor above Syndromes limited to a single limb Upper limb Hand Arm Lower limb Variable weakness Weakness that is not really there WHAT IT MEANS Myopathy (rare) Causes Myasthenic syndromes (rare) Causes Mononeuropathies (very common) Common causes Radiculopathies (common) Common causes Rare causes Peripheral neuropathies (common) Mononeuritis multiplex (rare) Polyradiculopathy (rare) Spinal cord syndromes (common) Brainstem lesions (common) Hemisphere lesions (common) Functional weakness 21 - SENSATION: GENERAL BACKGROUND Arms Legs Dermatomes WHAT TO DO Vibration sense Joint position sense Pinprick Screening test Assessing a lesion Assessing a hypothesis Light touch Special situations Temperature sensation Screening Formal testing Other modalities Two-point discrimination FURTHER TESTS Sensory inattention What you find What it means 22 - SENSATION: WHAT YOU FIND AND WHAT IT MEANS WHAT YOU FIND Patterns of sensory loss WHAT IT MEANS 23 - COORDINATION BACKGROUND WHAT TO DO Arms Finger–nose test Repeated movements Legs Heel–shin test Trunk Other tests of cerebellar function WHAT YOU FIND With outstretched arms Finger–nose test Repeated movements Heel–shin test Trunk WHAT IT MEANS 24 - ABNORMAL MOVEMENTS BACKGROUND Terms used in movement disorders (Fig. 24.1) WHAT TO DO WHAT YOU FIND Face Positive phenomena Negative phenomena Head Arms and legs Latent phenomena Negative phenomena WHAT IT MEANS Akinetic–rigid syndromes (parkinsonism; common) Tremors (common) Chorea (uncommon) Hemiballismus (rare) Dystonia (uncommon) Tic (uncommon) Myoclonic jerk (rare) Others 25 - SPECIAL SIGNS AND OTHER TESTS 1. PRIMITIVE REFLEXES Snout reflex What to do What you find Palmo-mental reflex What to do What you find Grasp reflex What to do What you find What it means 2. SUPERFICIAL REFLEXES Cremasteric reflex What you find Anal reflex What to do What you find What it means 3. TESTS FOR MENINGEAL IRRITATION Neck stiffness What to do What you find and what it means Testing for Kernig’s sign What to do What you find and what it means Head jolt test What to do What you find What it means 4. TESTS OF RESPIRATORY AND TRUNK MUSCLES Respiratory muscles Bedside testing Axial and trunk muscles 5. MISCELLANEOUS TESTS AND SIGNS Tinel’s test Lhermitte’s phenomenon Straight leg raising (Fig. 25.3) Hoover’s sign Head impulse test What to do (Fig. 25.5) What you find and what it means 26 - THE AUTONOMIC NERVOUS SYSTEM BACKGROUND Sympathetic system: ALARM system Parasympathetic system: HOLIDAY system Outflow WHAT TO DO WHAT YOU FIND Pupils Skin WHAT IT MEANS 27 - THE UNCONSCIOUS OR CONFUSED PATIENT BACKGROUND Level of consciousness: assessment of the unconscious and confused patient Herniation or coning 1. Uncal herniation What happens Physical signs 2. Central herniation What happens Physical signs WHAT TO DO Resuscitation EXAMINATION Position and movement What to do What you find Best verbal responses What to do What you find Head and neck What to do and what you find Eyelids What to do and what you find Pupils What to do Fundi Eye movements What to do What you find What to do Tendon reflexes What you find WHAT YOU FIND AND WHAT IT MEANS COMMON CAUSES OF COMA 1. Diffuse and multifocal processes Toxin-induced Infectious Vascular Trauma Epilepsy Temperature regulation Infectious 2. Supratentorial lesions (CT or MRI brain scan) 3. Infratentorial lesions (CT or MRI brain scan) THE CONFUSED PATIENT—DELIRIUM Background What to do What you find What it means 28 - SUMMARY OF STANDARD NEUROLOGICAL EXAMINATION STANDARD NEUROLOGICAL EXAMINATION 29 - PASSING CLINICAL EXAMINATIONS BACKGROUND WHAT TO DO Stage 1: examine a patient neurologically, observed by an examiner Systematic, practised and reliable Appropriate and thorough Professional Stage 2: describe your findings, coming to some sort of conclusion Stage 3: discuss the further investigation or managementof the patient’s problem LEARNING NEUROLOGICAL EXAMINATION IN A CRISIS BIBLIOGRAPHY FOR FURTHER READING AND REFERENCE Small neurology textbooks Large neurology textbooks Reference sources General examination INDEX A B C D E F G H I J K L M N O P Q R S T U V W