Neurological examination

Example of a negative status

Skull and spinal cord are intact, with no sign of injury. Neck movements are free, there are no meningeal signs. Accurate vision, the visual field is full. Isocoria, mid-dilated pupils, maintained light reactions. Eye movements are free, with no double vision, no nystagmus. No trigeminal or facial nerve dysfunction. Symmetrical palatal arches, palatal and pharyngeal reflexes, no uvula deviation. The tongue is in the midline, its movements are free. The muscle tone is normal. Muscle trophy is normal. There is no paresis. Mid-brisk, symmetrical deep tendon reflexes. There are no pyramidal signs or pathological reflexes. No sensory loss. Coordination is precise. Normal posture, gait, and speech. Alert and oriented.

Examination of the skull, spine, and meningeal signs

• Skull
  • Skull intact?
  • Bruises or bumps?
• Spine
  • Spine straight? Lordosis/kyphosis/scoliosis?
  • No bruises
  • Paraspinal muscles have normal tone?
  • Spinal movements normal?
• Meningeal signs
  • Not examined in people with suspected cervical spinal injury!
    • May cause myelopathy
  • These tests are based on the fact that in meningitis, stretching the meninges are painful
    • These examinations stretch the meninges, causing pain and reflex movements which reduce the stretch of the meninges
  • Positive in:
    • Meningitis
    • Subarachnoid haemorrhage
    • Meningism
      • = presence of meningeal signs in systemic diseases without CNS involvement
  • Nuchal rigidity
    • Procedure
      • Patient lies supine
      • Passively lift patient’s head
    • Negative:
      • No resistance when lifting head
      • Pain may or may not be present
    • Positive:
      • Resistance when lifting head
      • Placing chin on chest is impossible
  • Kernig sign
    • Method 1
      • Procedure
        • Patient lies supine and bends their hips and knees to 90 degrees
        • Extend one leg passively while keeping the hip flexed
        • Repeat for other leg
      • Negative:
        • No pain or resistance when extending leg
      • Positive:
        • Pain or resistance when extending leg on both sides
    • Method 2 (similar to Lasègue)
      • Procedure
        • Patient lies supine with legs straight
        • Passively raise one leg while keeping knee straight
        • Repeat for other leg
      • Negative:
        • No pain, and patient doesn’t bend the knee on their own
      • Positive:
        • Pain, and patient bends the knee on their own
  • Brudzinski sign
    • Procedure
      • Patient lies supine with legs straight
      • Passively bend patient’s head forward
    • Negative
      • No flexion on the knees or hip
    • Positive
      • Patient flexes knees and hip

Examination of first and second cranial nerves (smell sensation, vision)

• CN I – olfactory nerve
  • Only tested if patient has complaints regarding smell (rare)
  • Procedure
    • Close patient’s eyes and one nostril
    • Let patient smell a non-irritating fragrance
  • Negative:
    • Patient can recognize that there is a smell (primary perception normal)
    • Patient can recognize the smell (cognitive function normal)
• CN II – optic nerve
  • Examination of visual acuity
    • Stand 5 meters from the patient
    • Hold up a number of fingers with your hand and ask the patient to say the number
    • If patient can’t see: repeat at 4 meter distance, and so on
    • Document: “patient can count fingers at X meter distance”
  • Examination of fundus
    • With ophthalmoscopy
  • Examination of visual field
    • Stand an arm’s length away from patient
    • Have your finger outside the visual field and move it slowly towards the visual field
    • Instruct patient to tell you when they see your finger
    • Examine the temporal, nasal, upper, and lower edges of the visual fields of each eye separately
  • Examination of pupillary light reflex
    • Direct pupillary reflex
      • Shining light into one eye causes myosis of that eye
    • Indirect pupillary reflex
      • Shining light into one eye causes myosis of the contralateral eye
  • Examination of oculopalpebral reflex
    • An object quickly approaching the eye elicits blinking
    • Used in unconscious patients (see topic 17)

Examination of ocular movements (cranial nerves III, IV and VI)

• Examination of ptosis
  • Drooping eyelid is due to CN III lesion
• Examination of diplopia
  • Ask patient whether they have diplopia (double vision)
• Examination of eye movement
  • Instruct patient to follow your finger as you move it vertically, horizontally, and diagonally
  • Observe for paresis, irregular movement, or nystagmus
  • CN III enables elevation, intorsion, adduction extorsion, and abduction
  • CN IV enables intorsion, depression, and abduction
  • CN VI enables abduction
• Examination of visual accommodation
  • Instruct patient to follow your finger as you move it toward the patient
  • Miosis, convergence, and accommodation should occur
• Examination of ciliospinal reflex
  • = pupils dilate if you pinch the skin of the neck
  • Not routinely examined (may be examined in unconscious patients)
  • Absent in Horner syndrome
• Examination of oculocephalic reflex (Doll’s eye reflex)
  • Used in unconscious patients
  • Absent in brainstem damage
  • Procedure
    • Open patient’s eyes
    • Quickly turn the head to each side
    • Observe the movement of the eyes
  • Negative (reflex is present)
    • Eyes look in the same direction even when the head is turned
    • (Eyes move in the opposite direction as the head)
  • Positive (reflex is absent)
    • Eyes remain in their fixed position, moving as the head moves

Examination of the trigeminal nerve

• Examination of somatosensory function
  • Lightly touch the area of each branch of the trigeminal nerve symmetrically with your thumb and index finger
    • Ophthalmic nerve – eyes and above
    • Maxillary nerve – between eyes and lips
    • Mandibular nerve – lips and below
  • Examine the pain sensation using something sharp in the same way, comparing both sides
• Examination of motor function
  • Ask: Do you get tired when chewing?
  • Palpate the temporal and masseter muscles while patient opens and closes their mouth
    • They should contract and have normal trophy (size)
• Examination of corneal reflex
  • Not routinely checked
    • Important in comatose patients, Bell’s palsy, patients with sensory loss on face
  • Touch the patient’s eye with a cotton tip
  • Normally, the patient will blink with both eyes in response
• Examination of masseter reflex
  • Ask patient to slightly, not completely, open their mouth
  • Place your finger on the patient’s chin and tap your finger with a reflex hammer
  • Normally, the jaw closes slightly in response

Examination of the facial nerve. Types of facial palsy.

• Examination of motor function
  • Inspect for asymmetry
  • Ask patient to:
    • Wrinkle forehead
    • Close eyes tightly
    • Wrinkle nose
    • Inflate cheeks
    • Smile with teeth
    • Whistle
• Examination of taste sensation
  • From anterior two-thirds of tongue (chorda tympani)
  • Not routinely examined
  • Ask patient whether they have normal taste perception
• Types of facial palsy
  • Central (supranuclear) facial palsy – forehead is unaffected
  • Peripheral facial palsy – whole face is affected
  • See topic 29

Examinations in case of vertigo (n. VIII, central vs. peripheral vestibular lesions)

• Patients with vertigo should be examined to determine whether the cause is central or peripheral (vestibular)
• Examination of nystagmus
  • See topic 13
• Examination of balance
  • Romberg test
    • Procedure:
      • Patient stands and closes their eyes
    • Negative:
      • Balance is just as good (or bad) with eyes closed as with eyes opened
      • This does not necessarily mean that the patient doesn’t sway, just that closing the eyes don’t change the amount of swaying
      • Healthy people will remain stable and not sway
      • People with cerebellar ataxia will sway regardless of eyes open or not
    • Positive:
      • Balance is worse with eyes closed (i.e., balance worsens, or patient starts swaying)
      • Indicates spinal sensory or vestibular problem on the side to which the patient sways
  • Unterberger test
    • Procedure:
      • Ask the patient to walk on the spot with their eyes closed for 30 seconds
    • Negative:
      • Patient does not rotate, or rotates less than 45°
    • Positive:
      • Patient rotates more than 45°
      • Indicates cerebellar or vestibular problem
• Differentiating central and peripheral causes of vertigo
  • See topic 30

Dix-Hallpike and Halmágyi-manoeuvre, alternation cover test and Epley – reposition manoeuvre

• Dix-Hallpike manoeuvre
  • Used in suspected BPPV
  • Procedure:
    • Patient sits on the examination table
    • Rotate the head 45 degrees to the side of the suspected BPPV
    • Keeping the neck rotated, quickly lay the patient in a supine position so that their head hangs slightly off the short end of the table
    • Hold this position for 20 seconds
    • Slowly reposition patient into the original seated position
  • Negative:
    • Patient experiences no vertigo
    • No nystagmus appears
  • Positive:
    • Patient experiences vertigo and nystagmus when supine, which spontaneously resolve within the 20 seconds
• (Halmágyi) head impulse test (HIT)
  • Determines whether the vestibuloocular reflex is intact
  • Procedure:
    • Patient sits or stands before you
    • Ask the patient to fix their gaze on your nose
    • Quickly turn the patient’s head to each side 15° multiple times and observe whether the patient loses the visual fixation
  • Negative:
    • Patient maintains visual fixation on your nose
  • Positive:
    • Patient’s eyes “turn away” when turned to the affected side, but is quickly corrected
    • Positive: Vestibular lesion on the affected side
• Alternating cover test
  • Determines whether there is skew deviation, a sign of central vestibular lesions
  • Procedure:
    • Ask the patient to fix their gaze on your nose
    • Cover one of the patient’s eyes for a while
    • Suddenly move the cover to the other eye
    • Examine the recently uncovered eye for movements
  • Negative:
    • The uncovered eye does not do any corrective movements
  • Positive:
    • The uncovered eye performs a small corrective movement
• Epley repositioning manoeuvre
  • Indicated if Dix-Hallpike is positive
  • This procedure moves the stone from the posterior semicircular canal into the utricle, improving symptoms
  • Procedure:
    • Patient sits on the examination table
    • Rotate the head 45 degrees to the side of the suspected BPPV
    • Keeping the neck rotated, quickly lay the patient in a supine position so that their head hangs slightly off the short end of the table
    • Hold this position for 30 seconds, or until the nystagmus disappears
    • Turn patient’s head by 90° towards the unaffected side
    • Hold this position for 30 seconds, or until the nystagmus disappears
    • Turn patient’s head another 90° towards the unaffected side, so that the patient is lying on their side with they head facing the ground
    • Hold this position for 30 seconds, or until the nystagmus disappears
    • Slowly bring patient back to a seated, upright position with the head in a neutral position
    • Ask patient to remain in this position for about 15 minutes

Examination of nerves IX, X, XI and XII

• Glossopharyngeal nerve (IX)
  • Mixed sensory, motor, and parasympathetic
    • Motor function is shared with the vagus nerve
  • Examination of the gag reflex
    • Not routinely examined
    • By touching the posterior wall of the pharynx with something
  • Examination of taste sensation
    • From posterior third of tongue
    • Not routinely examined
  • Examination of parasympathetic function
    • Stimulates parotid gland
    • Not routinely examined
• Vagus nerve (X)
  • Mixed sensory, motor, and parasympathetic
  • Examination of motor function
    • Pharyngeal muscles
      • Ask whether patient has problems swallowing
      • Observe the patient swallowing water
    • Soft palate and uvula
      • Check whether the uvula deviates to one side
        • In a palsy the uvula will deviate to the unaffected side
      • Check for symmetrical movement of soft palate when patient says “aah”
    • Vocal cords
      • Is the patient hoarse?
• Accessory nerve (XI)
  • Pure motor
    • Trapezius is innervated contralaterally
    • Sternocleidomastoid is innervated ipsilaterally
  • Examination of trapezius function
    • Ask patient to lift their shoulders
    • Apply resistance against the movement
  • Examination of sternocleidomastoid function
    • Ask patient to turn their head
    • Apply resistance against the movement
• Hypoglossal nerve (XII)
  • Pure motor
  • Examination of tongue muscles
    • Ask patient to protrude the tongue
    • In case of lesion it will deviate to the affected side
  • Examination of tongue trophy
    • Look for atrophy and fasciculations on the tongue
    • In case of lesion it will be apparent on the affected side
  • Examination of tongue spasticity
    • Ask patient to rapidly protrude and retract tongue
    • Observe for spasticity

Examination of deep tendon reflexes

• Radial reflex
  • C5-C6
  • Have patient sit at the edge of the table with their elbow in 90° flexion, palm facing medially
  • Hit the distal, radial part of the forearm with the hammer -> elbow flexion
• Biceps reflex
  • C5-C6
  • Have patient sit at the edge of the table with their elbow in 90° flexion, palm facing down
  • Hold your finger on the biceps tendon
  • Hit your finger with the hammer -> elbow flexion
• Triceps reflex
  • C7-C8
  • Have patient sit at the edge of the table with their shoulder abducted
  • Hold the patient’s upper arm for them and ask them to relax the forearm
  • Hit the triceps tendon with the hammer -> elbow extension
• Patellar reflex
  • L2-L4
  • Have patient sit at the edge of the table with their legs hanging freely
  • Hit the tendon of the quadriceps femoris, just below the patella -> knee extension
• Achilles reflex
  • S1 – S2
  • Have patient lying on their back
  • Sit next to the patient’s legs, flex the hip and knee
  • Fix the patient’s knee by squeezing it between your upper arm and your torso
  • Hold the patient’s foot in slight dorsiflexion by holding the ball of the foot
    • This puts some tension on the Achilles tendon
  • Hit the Achilles tendon with the hammer -> plantarflexion of ankle
  • Hit the middle of the plantar region of the foot -> plantarflexion of ankle

Examination of the pyramidal signs

• Babinski sign
  • Most important pyramidal sign
  • Procedure:
    • Ask patient to lie on their back
    • Scratch the lateral half of the sole of the foot from bottom to top
    • Response is usually not seen at the beginning of the movement but rather after some centimetres
  • Negative:
    • Plantarflexion, flexion of all toes
  • Positive:
    • Dorsiflexion of the big toe
    • The other toes spread out
• Triple flexion response/triflexion response
  • Same procedure as for Babinski sign
  • Can be felt more easily with one hand on the quadriceps muscle
  • Negative:
    • Plantarflexion of all toes
  • Positive:
    • Dorsiflexion of foot + flexion of knee + flexion of hip
• Achilles clonus
  • Procedure:
    • Ask patient to lie on their back
    • Dorsiflex the foot quickly
  • Negative:
    • No clonus in the gastrocnemius
  • Positive:
    • Clonus in the gastrocnemius
• Patellar clonus
  • Procedure:
    • Ask patient to lie on their back
    • Quickly thrust the patella downwards
  • Negative:
    • No clonus in the quadriceps
  • Positive:
    • Clonus in the quadriceps
• Hoffman sign
  • Procedure:
    • Hold the PIP joint of the middle finger, stabilizing it
    • Repeatedly flick down the distal phalanx of the middle finger
  • Negative:
    • No flexion of the distal phalanx of the thumb or the index finger
    • Bilateral response may be normal
  • Positive
    • Flexion of the distal phalanx of the thumb or the index finger
• Trömner sign
  • Procedure:
    • Hold the PIP joint of the middle finger, stabilizing it
    • Suddenly flick the volar aspect of the distal phalanx of the middle finger
  • Negative:
    • No flexion of the distal phalanx of the thumb or the index finger
    • Bilateral response may be normal
  • Positive
    • Flexion of the distal phalanx of the thumb or the index finger

Examination of the muscle tone and strength. Signs of central vs. peripheral lesion

• Examination of muscle tone
  • Muscle tone = resistance to passive movement
  • Both sides should be examined and compared
  • Movements should be performed slowly (to observe for rigidity) and quickly (to observe for spasticity)
  • Elbow
    • Passively flex and extend the patient’s elbow
  • Forearm
    • Passively supinate and pronate patient’s hand
  • Wrist
    • Passively flex and extend the patient’s wrist
  • Hip and knee
    • Passively flex and extend hip and knee
  • See topic 32 for pathological results
• Examination of muscle strength
  • Muscle strength = maximal force patient can produce during active movement
  • Both sides should be examined and compared
  • Examination of muscle strength of upper limbs
    • Proximal muscles
      • Ask patient to lift their arms up in supinated position and keep them there for 30 seconds while their eyes are closed. Then ask whether their arms feel equally heavy. Observe for pronation and drooping
    • Biceps
      • Ask patient to flex their elbow while you resist the movement
    • Finger muscles
      • Ask patient to make rings with the thumb and the little finger and try to “break” the ring. Repeat with the other four fingers
  • Examination of muscle strength of the lower limbs
    • Ankle
      • Ask patient to dorsiflex and plantarflex against your resistance
    • Ask patient to squat 10 times
      • (If they can’t perform this, ask “do you even lift bro?”)
    • Ask patient to walk 10 steps on their toes
    • Ask patient to walk 10 steps on their heels
  • Graded from 0 to 5 (based on MRC scale)
    • 5 – normal muscle strength
    • (4+ – submaximal movement against resistance)
    • 4 – moderate movement against resistance
    • (4- – slight movement against resistance)
    • 3 – can move against gravity but not against resistance
    • 2 – can move perpendicular to gravity but not against it
    • 1 – visible contraction, but no movement
    • 0 – no visible contraction (plegia)
  • Examine for decreased muscle trophy
    • Observe especially if there are side differences
  • Evaluation
    • Monoparesis = weakness of one limb
    • Hemiparesis = weakness of one side of body
    • Paraparesis = weakness of both legs
    • Tetraparesis = weakness of all limbs
    • (Biparesis = weakness of both arms (super rare))
• Signs of central vs peripheral lesion
  • See topic 21

Examination of Parkinsonism (muscle tone, hypo- and bradykinesia, alternating movements, gait, postural instability)

• Parkinsonism
  • = A set of symptoms seen in Parkinson disease, Parkinson-plus syndromes, other diseases
  • Examination of muscle tone
    • See topic 11
    • Rigidity is typical for Parkinsonism, especially cogwheel rigidity
  • Examination of bradykinesia
    • Bradykinesia = active movements are slow and have decreased amplitude
    • Observe patient’s active movements for slowness and decreased amplitude
      • Not only slow execution of the movement, but pauses occur too
  • Examination of alternating movements
    • Ask patient to perform quick, alternating movements
      • Touching thumb and index finger and spreading them again, repeatedly
      • Clenching and opening the fist repeatedly
      • Pronating and supinating the hand repeatedly
      • Dorsiflex and plantarflex the foot repeatedly
    • Observe for slowness
    • Negative:
      • Normal movements, no slowness
    • Positive:
      • Bradydiadochokinesia = alternating antagonistic movements are performed slowly
  • Examination of gait
    • Ask patient to walk
    • Negative:
      • Normal gait
    • Positive:
      • Short, narrow-based steps
      • Pauses when turning around
  • Examination of postural instability
    • Ask patient if they have had falls or experience postural instability
    • Pull test
      • Ask patient to stand upright
      • Pull the patient’s shoulders gently from behind
      • Observe the patient’s ability to regain their posture
      • Negative:
        • Can regain posture with 1 – 2 steps
      • Positive:
        • Posture only regained with 3 or more steps, or patient needs help to regain balance
  • Examination of tremor
    • Observe for tremors during rest and during active movements
    • Rest tremor is characteristic of Parkinson disease
  • See also topic 39

Examination of the cerebellar symptoms

• Symptoms manifest on the same side as the lesion
• Cerebellar ataxia
  • Gait ataxia
    • Wide-based, unsteady gait
    • Similar to the gait of drunk people
    • Observe patient’s gait
    • Observe whether the gait worsens or stays the same when patient closes their eyes
      • Worsening with eyes closed suggest sensory ataxia
      • Cerebellar gait ataxia does not worsen with closed eyes
    • Negative/inconclusive Romberg test
    • Positive Unterberger test (topic 6)
  • Limb ataxia
    • = uncoordinated movement of the limbs
    • Finger-to-nose test usually positive
    • Heel-to-shin test
      • Procedure
        • Ask patient to lie flat on their back
        • Ask them to place one heel on the opposite knee, and then move the heel smoothly down the shin to the ankle
        • Repeat on the opposite side
      • Negative:
        • Patient can perform the movement smoothly
      • Positive:
        • Patient is unable to perform the movement smoothly. Tremors appear
  • Trunk ataxia
    • = inability to sit or stand upright without support
    • Positive Romberg test (topic 6)
• Dysmetria
  • = overshooting or undershooting the intended movement
  • Finger-to-nose test
    • Procedure
      • Hold your finger out in front of the patient
      • Ask the patient to touch their nose, then your finger
      • Repeat this movement as you move your finger to new positions
    • Negative:
      • Patient can do movement normally, touching your finger every time
    • Positive:
      • Patient will miss your finger due to constantly overshooting or undershooting the precise movements
• Dysdiadochokinesia
  • = alternating antagonistic movements are irregular, uncoordinated
  • Ask patient to perform quick, alternating movements
    • Touching thumb and index finger and spreading them again, repeatedly
    • Clenching and opening the fist repeatedly
    • Pronating and supinating the hand repeatedly
    • Dorsiflex and plantarflex the foot repeatedly
  • Observe for irregularity and uncoordinated movements
• Dysarthria
  • = scanning speech
  • Words are broken down into separate syllables
  • See topic 16
• Intention tremor
  • = broad, coarse, slow tremor which occurs during purposeful movement
  • Tremor is at its worst right before reaching the target
  • Observed during finger-to-nose test
  • See also topic 33
• Examination of nystagmus
  • Try to provoke nystagmus by eliciting ocular movements
  • Does the patient have nystagmus?
  • Describe the type of the nystagmus
    • Horizontal/vertical/rotatory/combined
  • Which direction is the nystagmus?
    • The direction is named after the fast component
    • The nystagmus is directed toward the side of the lesion
  • Does visually fixating the gaze suppress the nystagmus?
    • Fixation does not improve nystagmus of cerebellar origin
  • See also topic 30

Examination of the sensation

• Compare both sides
• Show and tell the patient about the examination before you perform it with their eyes closed
• Examination of fine touch
  • Pathway: dorsal column
  • Procedure
    • Ask patient to close their eyes
    • Touch patient softly with finger or cotton pad
    • Tell patient to tell you when they feel it
  • Positive:
    • Hypoesthesia: decreased sensation
    • Anaesthesia: no sensation
    • Allodynia: painful sensation for a non-painful stimulus
• Examination of vibration
  • Pathway: dorsal column
  • Procedure
    • Hit a tuning fork and place it on the patient’s forehead, so they have a reference
    • Ask patient to close their eyes
    • Hit the fork again and place it on a bony prominence in the area to be examined
  • Positive:
    • Decreased or absence of vibration sensation
• Examination of proprioception (joint position)
  • Pathway: dorsal column
  • Procedure
    • Ask patient to close their eyes
    • Hold the patient’s hallux
    • Move the distal joint up and down randomly, and ask the patient at random times to identify the change in position
    • Perform the same movement for the 4th finger
  • Positive:
    • Decreased or absence of joint movement sensation
  • Note: Joint position sense is extremely sensitive, so even small movements can be felt by the patient
• Examination of pain sensation
  • Pathway: spinothalamic tract
  • Procedure
    • Ask patient to close their eyes
    • Prick the patient’s skin with a pointed object
  • Positive
    • Analgesia: No pain sensation
    • Hypoalgesia: Decreased pain sensation
    • Hyperalgesia: Increased pain sensation

Examination of the limb- and trunk ataxia

• See topic 13

Examination of the speech and the main types of disturbances

• Examination of speech
  • The speech can be examined while taking the history
• Main types of disturbances of speech
  • Dysphonia
    • Abnormal quality of voice
    • Due to mechanical abnormality of vocal cords
    • Examples
      • Laryngitis -> Hoarseness
      • Common cold -> nasal voice
  • Dysarthria
    • Abnormal articulation
    • Due to lesion to nervous pathways or muscles responsible for articulation
    • Examples
      • LMN lesion of soft palate -> paralytic dysarthria
        • (Nasal voice)
      • Spasticity of tongue, palate -> spastic dysarthria
        • (sounds like patient is talking with a plum in their mouth)
      • Cerebellar disease -> cerebellar dysarthria/scanning speech
      • Parkinsonism -> extrapyramidal/hyphonic dysarthria
        • (Slow, soft, monotonous)
  • Dysphasia/aphasia
    • Impaired language, either speaking or understanding
    • Due to hemispheric lesions
    • See topic 36

Examination of the unconscious patient

• Differentiate between cardiac, metabolic, and neurological causes
  • Most unconscious patients have underlying cardiac or metabolic problem; neurologic cause of unconsciousness is rare
  • Cardiac causes of unconsciousness
    • Most common
    • Suspicious features
      • Low heart rate
      • Low blood pressure
      • Abnormal ECG
  • Endogenous metabolic causes of unconsciousness
    • Etiology
      • Metabolic acidosis
      • Hypoglycaemia
      • Hyperglycaemic crisis
      • Hepatic encephalopathy
      • Uraemia
      • Hypercapnia
    • Suspicious features
      • Abnormal blood sugar
      • Kussmaul breathing (quick and deep)
      • Abnormal odour of breath
      • Hypotonia
      • Hyporeflexia
  • Exogenous metabolic causes of unconsciousness (intoxication)
    • Etiology
      • Opioids
      • Benzodiazepines
      • Alcohol
    • Suspicious features
      • Drugs or needles around the patient
      • Needle marks on the patient’s arms
      • Slow, superficial breathing
      • Extreme miosis (pinpoint pupils)
      • Low blood pressure
  • Neurological causes of unconsciousness
    • Etiology
      • Brainstem lesion (of the ascending reticular activating system)
        • Increased ICP -> foramen magnum herniation
        • Brainstem stroke
        • Trauma
      • Bilateral thalamus lesion
        • There’s a relatively frequent malformation where both thalami receive blood from same artery -> prone to bilateral ischaemia
      • Bilateral frontal lobe lesion
    • Suspicious features
      • Abnormal pupillary light reflex
        • Unilateral dilated fixed pupil – CN III palsy
        • Bilateral dilated fixed pupils – tectal lesion or atropine
        • Midpoint fixed pupils – midbrain lesion
        • Pinpoint fixed pupils – pons lesion, opioids
        • Small reactive pupils – thalamus lesion or metabolic
      • Abnormal conjugation
        • Conjugated and deviated eyes (deviate ipsilateral to cortical lesion)
        • Dysconjugated eyes (brainstem or CN III, IV, VI lesion)
        • Skew deviation (brainstem lesion)
      • High blood pressure
        • Increased ICP -> Cushing reflex
      • Decorticate posturing
        • Flexed elbows, adducted arms, flexed fingers and wrists
        • Indicates damage above the red nucleus, e.g. rostral midbrain, thalamus, internal capsule, hemispheres
      • Decerebrate posturing
        • Upper and lower extremities extended and internally rotated
        • Indicates damage below the red nucleus, e.g. caudal midbrain or pons
      • Absent oculocephalic reflex (brainstem lesion) (see topic 3)
      • Absent corneal reflex
      • Absent cough reflex (lower brainstem lesion)
      • Hyperreflexia
• History
  • From relatives or other witnesses
  • Did patient have any symptoms right before loss of consciousness?
  • Was loss of consciousness abrupt or gradual?
  • Patient’s recent health
  • Patient’s functional status
  • Previous medical history
  • Medication use
• Examination
  • General examination
    • ABC (airways, breathing, circulation)
      • Are the airways obstructed?
      • Breathing
        • Cheyne-Stokes breathing -> brainstem lesion, heart failure
        • Slow, superficial breathing -> drugs, narcotics
        • Quick, superficial breathing -> brainstem lesion
        • Kussmaul breathing -> acidosis, hyperglycaemic crisis
      • Circulation
        • Pulse
        • Temperature
          • Hyperthermia -> infection, heat stroke
          • Hypothermia -> cold exposure, sepsis, CNS disease
        • Skin colour
        • Blood pressure
          • Hypertension -> CNS haemorrhage
          • Hypotension -> circulatory shock
    • Smell of breath
      • Alcohol, ketone bodies, liver failure, uraemia, …
    • Bruises which can suggest a fall
  • Neurological examination
    • Determine Glasgow coma scale score
      • To what degree is the patient arousable?
        • Shout to them
        • Induce pain
          • Press on the exit point of the ophthalmic nerve
          • Press on fingernail
      • Observe eye opening, movement, and verbal response
    • Examination of meningeal signs (see topic 1)
      • Only examined if cervical trauma can be excluded
      • Meningeal signs can be present in subarachnoid haemorrhage
    • Examination of cough reflex
      • By suction or inserting endotracheal tube
    • Examination of pupil and pupillary reflexes
      • Unilateral, maximally dilated
      • Bilateral, maximally dilated
      • Mid-dilated, does not react to light
      • Tiny pinpoint pupils
      • Horner syndrome (see topic 41)
    • Examination of position of eyes
      • Conjugate deviation
      • Dysconjugate deviation
      • Skew deviation
    • Examination of spontaneous eye movements
      • Downward deviation of eyes
      • Repetitive horizontal movements
    • Examination of reflex eye movements
      • Oculocephalic (doll’s eyes) reflex
      • Oculovestibular reflex
    • Examination of corneal reflex
    • Examination of muscle tone
    • Examination of fundus
      • Papilloedema
      • Haemorrhage
    • Examination of pyramidal signs

Examination of the patient after a short-time loss of consciousness

• Differentiate between syncope and neurological causes
  • 90% are non-neurological
  • Syncope
    • Causes
      • Cardiac syncope
      • Reflex syncope
      • Autonomic dysfunction
      • Recent change in drugs
    • Suspicious features
      • Prodromal symptoms
        • Blurry vision, sight goes dark
        • Sweating
      • Lasts seconds
      • Patient is oriented immediately after
  • Neurological causes
    • Almost always seizures
    • Suspicious features
      • Prodromal symptoms
        • Often sudden blackout, no prodromal symptoms
        • Aura
      • Lasts minutes
      • Enuresis
      • Muscle soreness
      • Bitten tongue on lateral part
      • Patient has postictal period of tenebrosity and disorientation after
• History
  • Precipitating factor
  • Did the patient feel the episode coming?
  • What the patient was doing
  • How long did the episode last?
    • Seconds -> non-neurological
    • Minutes -> neurological
  • Did the patient bite his tongue?
    • Indicates seizure
  • Did the patient lose continence?
    • Indicates seizure
  • Did the patient regain full consciousness immediately or was it gradual?
    • A lasting post-ictal confusion is suggestive for a seizure
    • In true syncope full consciousness is immediately regained
  • Previous loss of consciousness
  • Drugs
    • Antidiabetics
    • Antihypertensives
  • Family history
  • Previous medical history
    • Diabetes
    • Hypothyroidism
    • Epilepsy
    • Known heart problems
  • Recent hydration status
• Examination of blood glucose
• Examination of cardiovascular system
  • Electrocardiogram
  • Heart auscultation
  • Turgor
• Neurological examination
  • Inspect for trauma

Examination of the patient with dementia

• (No good source, uncertain what it important)
• History
  • An informant who knows the patient well should be present
    • When did the informant first notice memory loss?
    • How has the memory loss progressed since then?
    • Recent changes in personality or mood?
  • Drugs
    • Opioids
    • Anticholinergics
    • Antidepressants
    • Sedatohypnotics (benzos, etc.)
  • Which daily activities can the patient perform now compared to previously?
  • Medical history
    • Stroke/TIA
    • Cardiovascular disease
    • Diabetes
  • Alcohol use
  • Sleep status
  • Other neurological symptoms
    • Loss of vision
    • Loss of motor function
    • Tremor
    • Poor balance and falls
    • Incontinence
• Cognitive testing
  • MMSE (mini mental state examination)
  • WAIS (Wechsler adult intelligence scale)
• Laboratory examination
  • B12 deficiency
  • Thyroid status
• Imaging
  • In cases of acute neurologic deterioration
  • Head CT or MRI
• Neurological physical examination
  • Examination for frontal release signs
    • See topic 54
  • Ocular examination (topics 2 and 3)
  • Examination of gait
  • Examination of extrapyramidal symptoms
    • Bradykinesia, rigidity, dystonia, akathisia, etc.
    • -> Dementia with Lewy bodies, Parkinson, vascular dementia, etc.
  • Examination of pyramidal signs
    • -> motor neuron disease
  • Examination of fundus
    • Papilloedema -> tumour, hydrocephalus

Examination of the confused patient

• ?
• No source