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Neurological examination

in psychiatry
Abid rizvi
Junior resident 3
Department of psychiatry
Major section of neurological
examination
Mental status
Cranial nerves
Motor
Sensory
Reflexes
Cerebellar functions and co-ordination
Gait and station
Abnormal movements
Mental Status Exam
1. level of consciousness
2. attention and concentration.
3. Orientation
4. Speech and language
5. Memory
6. Calculation skills
7. Logic and abstractions
8. test for agnosia and apraxia
9. judgement and insight
Level of consciousness
ability to relate to both self and
surrounding
Quantitative lowering of
consciousness
fully alertness to coma
Clouding of consciousness to
drowsiness to coma
Clouding of consciousness-
deterioration in thinking, attention,
perception and memory.
Drowsiness- patient is awake but drift
into sleep if not stimulated.
Coma-unconscious (no verbal, motor
or response to painful stimuli.
Glassgow coma scale
Eye opening Verbal response Motor response
Spomntaneous (4) Oriented (5) Obeys (6)
To speech (3) Confused (4) Localizes (5)
To pain (2) Inappropriate words Withdraws (4)
(3)
Nil (1) incomprehensible (2) A flexiuon
(decorticate) (3 )
Nil (1) A.Extension
decerebrate (2)
Nil (1)
Quanlitative change in consciousness
Delirium
Fluctuation of consciousness
confusion
Twilight state
Abrupt onset and end
Variable duration, few hrs to weeks.
Voilent emotional outburst and acts.
Disturbance in the continuity of
consciouness
Epilepsy, brain tumor, alcohol intox,
neurosyphillis
Dream like state (oneiroid state).
delirium
Stupor
Doesn't fall on continuum from
alertness to coma
Mutism + akinesia
Patient may appear awake and alert.
Attention and
concentration.
Attention: ability to attend to a
specific stimuli without being
distracted by external or internal
stimuli.
Sustained attention is concentration.
Tests for attention
Digit repetition tests
Digit span forward- 7 +_2
Digit span backwards 5 +_1

Difference between the two should not


be more than 2
Tests of concentration;

A random letter tests.

7 serial subtraction tests


Counting WORLD BACKWARDS
ORIENTATION
Orientation to time, place, person
and their situation
Speech and language
1. Patient is conscious but making no attempt to
speak MUTISM
2. Patient is trying to speak but whispers
APHONIA.
3. Volume of sound and the content of speech is
normal ,but the articulation and enunciation of
individual words distorted DYSARTHRIA.
4. Disorder of language - APHASIA
Examination of speech
1. Listen
2. British constitution, royal Devonshire
constabulary, triruvanathpuarm, Muzzafarpur,
chakravarthy rajgopalchary..(my baby ate a
cupcake on the train)
3. Read a paragraph
4. Count till 30.
Listen to the words for
Slurring
Rhythm (jerky, explosive, or monotonous)
Loud or too soft.
Particular letters presenting with difficulty.
Nasal tone
Disturbance constant or intermittent, increasing or
decreasing
Correct co ordination of lips, tongue, palate,
larynx, and muscle of respiration.

Upper motor neuron, lower motor neuron,


actual muscle, the coordinating system,
cerebellum and EPS.
Speech abnormal

language fn abn- aphasia


language function n

voice,volume,pitch,timbre
normal abnormal
dysphonia

hoarse,whispery,mute high pitched

adductor
spasm

cough abnormal cough normal


voice,volume,pitch,timbre normal

Speech rhythm prosody abnormal speech rhythm prosody normal

hypernasal (Palatal

Weakness)
Speech slurred drunken speech flat monotonous ab labial (papa ma
Scanning no emotional tone facial weakness)
Cerebellar EP ,RIGHT FL

abn lingual(daddy

Abn velar (coke kuh ) palatal post tongue weak anterior tongue weak
Cerebellar dysarthria
Speaks slowly, deliberately syllable by
syllable as if scanning.

Flow of words is lost and each word is given


equal emphasis.
Pseudobulbar dysarthria
Individual syllables are slurred and presision
of consonant production is lost.

Brizh conshishushon
APHASIA
DEF defect in the power of expression or
comprehension by speech, writing, reading, or
gesture.

? Any localizing value.


Dr BROCA the diagram maker
Rt or left dominance natural; or enforced.
Spontaneous speech
Comprehension
Naming object
Repeatition
Reading
Writing
Calculation
Spontaneous speech: Note the patient's fluency, including phrase length,
rate, and abundance of spontaneous speech. Also note tonal modulation and
whether paraphasic errors (inappropriately substituted words or syllables),
neologisms (nonexistent words), or errors in grammar are present.
Comprehension: Can the patient understand simple questions and
commands? Comprehension of grammatical structure should be tested as
well
Naming: Ask the patient to name some easy (pen, watch, tie, etc.) and some
more difficult (fingernail, belt buckle, stethoscope, etc.) objects

Repetition: Can the patient repeat single words and sentences (a standard is
"no ifs ands or buts")?
Reading: Ask the patient to read single words, a brief passage, and the front
page of the newspaper aloud and test for comprehension.
Writing: Ask the patient to write their name and write a sentence.
BROCAS APHASIA
FLUENCY- impaired
COMPREHENISON - normal
REPEATITION - impaired
NAMING - impaired
WRITING - impaired (only small
sentences)
READING - impaired (only simple
sentences).
Wernickes aphasia
FLUENCY normal (jagron or
neologism)
COMPREHENISON -impaired
REPEATITION - impaired
NAMING - impaired
WRITING - impaired)
READING - impaired
Conduction aphasia repetition
impaired.
Transcortical aphasia repetition
normal
Anomic aphasia - naming impaired.
MEMORY
Immediate recall (short term
memory)
digit recall test.
Recent memory.
orientation and
ability to learn new material.
Remote memory.- tests patients fund
of knowledge
APRAXIA
failure to carry out well organised
voluntary movement correctly
despite intact motor, sensory and
co=ordinatory function.
Method of testing
Simple movements- put out your
tongue,close your eyes,(if impaired
look for automatic mov)
More complex- how to use
comb,pen,scissors.
3 steps task lightening a cigarette,
hammering a nail. (both with and
without object.)
Types
Ideomotor apraxia
Ideational apraxia
Constructional apraxia
Dressing apraxia
IDEOMOTOR APRAXIA
Patient can perform automatic
movements (blowing nose, runing
back hand in hair)
Can describe and plan the action.
Cannot carry out the motor
movement.
Most comman.
Ideational apraxia
Part of the whole movement can be
carried out but the whole act not,
Can carry out each step correctly but
not the whole movement.
Constructional apraxia
Drawing geometrical figures and
clock face and marking time on it.
Dressing apraxia.
Lesion in the parietal lobe.
AGNOSIA
failure to recognise familiar object
by one or more senses.
Agnosia for smell and taste unknown.
Calculation skills
Logic and abstractions
Cranial nerve examination
I olfactory VII - facial
II optic VIII - vestibulocochlear
III occulomotor IX - glossopharyngeal
IV trochlear X - vagus
V trigeminal XI spinal accessory
VI abducens XII hypoglossal
CN I - Olfactory
Ask for any changes in sense of smell
bottles of smells
Test each nostril separately
Avoid noxious stimuli
CN II - optic
Visual acuity
Visual fields
Fundoscopy
Color vision
CN III, IV, & VI
CN III (oculomotor)
Most extraocular movements
Pupillary reflex
Eyelid opening

CN IV (trochlear)
Supplies superior oblique
(SO4)
Downward and inward eye movement
Test full range of
movement of
CN VI (abducens) extraocular muscles
Supplies lateral rectus
(LR6) Check for double
Lateral eye movement vision (by asking
patient)
CN V - trigeminal
Three divisions
CN V1 ophthalmic (sensory)
CN V2 maxillary (sensory)
CN V3 mandibular (sensory and motor)
Motor to muscles of mastication
Sensation
Fine touch (cotton wool tip)
Pain (neurotip)
Motor
Clench teeth to assess mastication muscles
Corneal and jaw jerk reflexes
not done routinely
CN VII - facial

Motor Assessment:
muscles of face, Look at face
scalp and ears Elevate eyebrows
Sensory Scrunch up eyes
Taste to anterior (try to open)
2/3 tongue
Show teeth/smile
Ear
canal/postauricular (sensation not
routinely assessed)
(Autonomic)
CN VIII - vetibulocochlear
Hearing and balance

To test:
Crude hearing test (whisper double digit
number in one ear)
Rinne
Weber (lateralisation)
(Rombergs)
CN IX - glossopharyngeal
Motor To assess:
Open mouth, look at
Pharyngeal palate (lesion deviates
muscles soft palate to opposite
side)
Sensory
Assess swallow
Taste to (gag reflex, mucosal
posterior 1/3 anaesthesia)
tongues
Pharynx,
tonsils, fauces,
TM, posterior
ear canal
CN X - vagus
Motor, autonomic and sensory to:
Palate, pharynx, larynx, neck, thorax,
abdomen

To assess:
Listen to voice
(gag reflex)
CN XI spinal accessory
Motor to
Sternocleidomastoid
Upper trapezius

To assess:
Shrug against resistance
Head rotation and movement
against resistance
CN XII - hypoglossal
Motor to tongue

To assess:
Look for muscle wasting,
fasciculations, deviation
Assess strength
(Lesion deviates tongue
towards affected side)
Motor system
Bulk
Tone
Power
Sensory system
Pain, touch and temperature
Propioceptive sensation
Graphaesthesia and two point
discrimination.
REFLEXES
Present or absent
If present, is it normal or abnormal.
If absent, defect at the sensory or
motor level.
Abnormality are unilateral or
bilateral. Can any level can be
appreciated.
Prerequesites

1. Comforetable relaxed patient


2. A good hammer
3. Flexible wrist
4. Knowledge of the reflex arch
Classification of reflex
Deep tendon reflex
Superficial reflex
Pathological reflexes
Deep tendon reflexes.
Bicep jerk:
Midway between flexion and
extension, slightly pronated and arm
resting on lap of the patient.
C5-C6
Tricep jerk:
midway between flexion and
extension and resting in the patients
lap.
C6-C7
Supinator jerk:
forearm in semiflexion and
semipronation
Stike at the base of the styloid
process
Flexion of the forearm
Muscle tested is brachioradialis.
C5-C6
The patellar reflex:
Various ways to elicit the
jerk.
L2-L4
THE ANKLE JERK :
DIFFERENT POSITIONS
SI S2
SUPERFICIAL REFLEXES
PALMAR REFLEXES
SCAPULAR OR INTERSCAPULAR
REFLEXES
SUPERFICIAL ABDOMINAL REFLEXES
THE CREMASTERIC REPLEX.
ANAL REFLEX
THE PLANTAR REFLEX
POSITION
supine hips and knee in full extension and
heel resting on the bed.
sitting knee extended and foot held either
in examiners hand or on knee.
OBJECT
blunt point, applicator stick, handle of
reflex hammer, a broken tongue blade, thumbnail,
key
HENRY MILLER bentley key.
babisnski- goose quill.
Technique
- a delibirate firm stimulus which is not
too painful nor too light.
- Lateral side of sole starting from heel
towards the little toe (as described
by Babinski).
- Medial movement across the
metatarsal pad (not described by
Babinski). All such movement should
stop short of great toe.
Normal response- plantarflexion of great toe.
Abnormal response- dorsiflexion of great
toe.
Warm foot more response
Triple response
See first movement at metatarsophalangeal
joint
Absent in anxious individual.
Babinski negative no such term
Some of the other methods to test
extensor-planter response :

Babinski sign
Chaddock sign
Oppenheim sign

Gordon sign
Schaefer sign
Disorder Of
Gait
Normal physiology of gait
Brainstem and spinal cord- Central
pattern generator.
Subthalamus and midbrain
(pedunculopontine nucleus).
Gait cycle heel strike heel
stike
Stance phase
To bear weight
Swing phase
To advance the limb
One limb support double
limb support
Stance phase (60%).-initial ct,
loading, mid stance and terminal
stance.
Swing phase(40%)-pre swing, initial
contact,mid swing,and terminal
stance.
80m p/m,113 steps /m ,stride length of 1.41m
Base of feet-2 inches(1st compensatory effort)

C.G- ANTERIOR TO S 2

An efficient gait minimizes the displacement of the


central of mass by roatating and tilting the pelvis and
felxing and extending the various joint involved

Abnormal gait-Increased energy expenditure ,and


falling.
Abnormal gait

Parkinsonism
Stooped posture-(head and neck forward).
Knee flexed
Flexion - elbow shoulder & wrist but fingers
extented.
freezing- as start hesitation, or threshold
akinesia (even during talking or eating)
Small ,slow, flat footed shuffles.
festination {latin-festinaire- to hurry}

Difficulty in stopping and turning en block

Impaired postural reflexes and tendency to


fall forward (propulsion) countered by
festination.

Souques leg sign


PSP (progressive supranuclear palsy)
CBD (corticobasal degeneration)
PPD (primary pallidial degeneration)
Wilsons disease
Multisystem atophy
Frontal gait disorder
Gait apraxia- lack of ability to use
the legs without deficit in sensory,
motor or cordination.
Marche a petis pas(walk of little
steps).
slow, short,shuffling
gait.
Magnetic gait and Lower body
parkinsonism
Greatest difficulty in initiation- gait
ignition failure and start hesitation.
Small feeble stepping movement
with minimal forward progress.
Unable to lift the feet(as if glued)
After few shuffles- stride length
increase- slipping clutch gait.
Turn hesitation
Diffuse frontal lobe envolvement
Normal pressure and other
hydrocephalous.
Vascular disease in frontal lobe ,
(subcortical small vessel disease)
Cerebellar ataxic gait
Wide based, clumsy, unsteady,
lurching & irregular.
Staggering and drunken gait.
Tendency to sway, eratic and
unpredictible stride length.
Romberg sign +/_
Difficulty in walking tandem.
Hemispheric lesion- deviates towards
the side.
Vermis-grossly unstable, reels ion
both direction, need 2 people
support.
Stroke, trauma, tumor,
neurodegenerative changes and
cerebellar degeneration.
Gait of sensory ataxia
Normal balance
vestibular system
proprioception
vision
looses the awareness of lower
extremity or whole body in space.
Depend upon visual input.( incred on
eye clos)
Walks with eyes down.
steppage or double tap gait.(heel first)
to increase the
proprioceptive feedback.
Foot drop gait.
lift leg ,to clear the toe.
unable to stand on heel
Toe first touch
Toe end of the shoe is worn out..
+
Gait of spastic hemiperesis.
loss of normal arm swing and
circumduction of leg.
Scissoring gait.
Tightness of hip adductors so that
knees cross one in front of other with
each step.
Seen in cronic myelopathies as in
MS. And cervical spondilosis,
Herperkinetic gait.
synderham chorea,huntingtons
disease,and other athetosis, dystonia
and other abnormal movement
accentuate during.
Walking accentuate not only
movement but also postural
instability
Abnormal
movements
Answer these :
Part of body affected,
Constant or episodic,
At rest or on movement or both,
Voluntary movement suppress or
increases it,
Positional alteration,
Altered by emotion,enviroment or
temperature,
Effect of eye closure
Is the patient aware of it
Effect of attention
Abnormal involuntary movement as
a spectrum
Regular /predictible Intermediate Fleeting
/unpredictible
Tremor Dystonias Fasciculation
Hemibalism Athetosis Myoclonus
Partial myoclonus Tic Chorea
Myokymia Dyskinesia
Steriotypy
TREMOR:
involuntary, relatively, rhythmic, purposeless, oscillatory
movement.
Define its:
location, rate amplitude, rhythmicity, relationship to rest
and activity,
Underlying pathology and etiology.
Tremor-
slow- 3 to 5 hz
medium- 5 to 10 hz
fast 10 to 20 hz
Fine, coarse, and medium
Rest tremor- decreases on use of
part.(P.syn)
Action tremor
Postural tremor limbs
maintained in an antigravity position.
(ET & enhanced physiological tremor)
Kinetic tremor
intentional tremor.
Rest tremor
Disappear or atleast decreases on
activity.
Most commanly- distal extremity but
can also affect leg arm, tongue jaw
head , eyelids or rarely entire body.
Parkinsonian tremor-
resting, nonintentional, slow and coarse.
4 to 5 hz (slow).
Repititive contraction of agonist and antagonists.
Initially unilateral in one digit, eventually becoming
bilateral.
Disappears on sleeping and exercebated by
anxierty and fatigue.
Classically pill rolling.
action tremors
Postural tremors
Physiological tremors-
8 to 12 hz.(slower in children and young
adult)
hand in postural tension
Anxiety,fright,fatigue,
hyperthyroidism- enhanced physiological
tremor(fine,rapid at outstreached fingers)
Essential tremors,.
Commanest of all
Familial, appear in second decade t0
sixth decade and worsons.
Senile tremor is a form of ET.
ETOLOGY OBSCURE.
MADE WORSE BY ANXIETY
ESSENTIAL TREMOR PARKINSONS TREMORS
MOST PROMINENT AT SUSTAINED AT REST
PSTURE NO SPILLAGE
HENCE PATIENT MAY SPILL WATER
WHILE DRINKING
HEAD AND VOICE INVOLVED RARELY INVOLVED,(ONLY IN LATE
STAGE
ALCHOHAL AND BETA BLOCKER NO EFFECT
IMPROVES
INTENTIONAL TREMOR.
Cerebellar disease.
Appear when precision is required to
touch a object.
Finger shaking perpendicular to the line
of travel.
Amplitude of oscillation increases
towards the end of the motion.
Finger nose test.
wing beating tremor of:
wilsons disease
chorea
Involuntary, irregular, random nonrhythmic,
hyperkinetic movement which are abrupt,
brief, jerky and ill sustained.
Individual movement discrete,but variable
in type and location.
Chaotic, multiform constantly changing
movement
seems to flow from one part of the body to
another.
Movement seems voluntary but are
involuntary.
Persists at rest ,are increased by
activity and tension and disappears
in sleep.
One extremity,trunk, face, tongue,
lips.
Piano playing movement and
milkmaid grip.
Parakinesia
Huntingtons chorea and synderhams
chorea.
Huntingtons- facial grimacing more
marked, chorea more slow and less
jerky and more bizzare
Bizzare prancing gait due to chorea.
Athetosis(a thetosis without fixed
position.)
Slow, somewhat sustained,
involuntary, irregular, coarse writhing
movement.
Face, neck, trunk, fingers, hand and
toes.
Any combination of flexion,
extention, abduction and adduction.
Flow from one part of the body to
Usually congenital- perinatal injury to
basal ganglia.
Pseudoathetosis( sensory athetosis).
asterixis
A- not ; sterixis fixed
An irregular sharp brief loss of
posture especially evident in the
outstreched hand.
Occurs in decompensated hepatic
failure and uremia, poisoning with
hypnotic drugs and respiratory
failure.
hemibalism
Hemibalismus
Wild flinging continuous movement
that occur on one side of the body.
Infarction or hemorrhage in contra
lateral subthalamic nucleus,
Continuous throughout waking
disappear only in deep sleep

dyskinesia
All hyperkinetic movement-
technically dyskinesia.
Term reserved for dyskinesia duie to
drug.
Comman problem in patients of PD
treated with lecvodopa.
Orofacial dyskinesia.
Involuntary movement of the mouth,
face, jaw or tongue consist of
incessant chewing , pursing of the
lips, tongue thrusting, licking and
incessant chewing movement
Tardive dyskinesia dopamine
antagonists
More common in old females
Difficult to treat.
Other tardive phenomenon can also
occur- tardive tremor, tardive
dystonia, tardive tics, tardive
chorea./
`
dystonia
spontaneuos, involuntary, sustained
muscle contraction forcing affected
part of the body in abnormal
posture
Any part can be affected.
Can be generalized, focal,
intermittent, segmented and
hemidistribution.
Writers cramp, blepharospasm,
spasmodic totticolis, belly dancer
myoclonus
repetitive, abrupt, brief, rapid,
lightening like jerky movement of
one muscle or a group of muscle.
Usually occurs in paroxysms at
irregular intervals, during rest or
active movement .often precipritated
by emotional, mental state,
tactile,visual or auditory stimuli.
Can be physiological- hiccups, hypic
jerks.
Often the myoclonic jerks are quite
voilent.
Seen with epilepsy (JME, WEST
SYNDROME)
Myoclonus without prominent seizure
seen in- CZ disease, Hallervorden
Spatz syndrome,WD, SSPE, AD.
Tics
Some degree of awareness of
movement, but make movement in
response to some urge or compelling
inner force.
Tension and restlessness
Unvoluntary.
Co-ordinated repititive seemingly
purposeful act involving a group of
muscle in their normal synergistic
relationship.
Tics are exagerated during emotional
tension and disappear during sleep.
When under scrutiny patient may
supress their tics, but they reaapear
when their attention get divided.
Giiles de la tourrete- multiple tics
type, motor as well as vocal.
( including obscenities).
akathesia.
Inner restlessness and urge to move.
Type of seizure ?
Region of the brain involved ?
thank
you
Questions ??????????????