Clinical Neurological Examination and Localization 1st ed. 2021
Bedside Neurological examination is an important tool in diagnosing neurological disorders. Despite significant advances in the investigations available for diagnosing neurological disorders bedside neurological examination remains the cornerstone in diagnosing neurological disorders and should not only be conducted prior to the investigations but should be actually be utilized to plan the appropriate investigations. The ebook provides a focused account of various aspects of the neurological examination leading to clinical localization and hence obtaining the neurological diagnosis. It includes topics like how to obtain an appropriate neurological history’, ‘higher mental system examination’, examination of speech and various cranial nerves, and examination of other systems including motor system, sensory system, reflexes, cerebellar, and autonomic nervous system. The ebook also includes certain interesting topics like ‘neurological examination of the unconscious patient ‘and ‘tricks and tips of neurological localization. The ebook is easy to read and memorize due to multiple self-explanatory illustrations and important aspects being highlighted in bulleted format. The book will be of extreme help for MD and DNB students of Internal Medicine as well as DM and DNB students of Neurology and DNB and MCH Neurosurgery students, hence covering a fairly large readership base. It will also be read by practicing Internal medicine physicians, neurologists, and neurosurgeons who may want to revise the basics and tricks of neurological examination and localization.
About the Author
Dr. Vinit Suri is one of the most eminent neurologists in India with more than 30 years of experience in the field. He is a graduate of University College of Medical Sciences, Delhi University, and stood first in the Final MBBS examination with several gold medals to his credit and obtained his D.M. Neurology from G.B.Pant Hospital in 1992. He has been involved in teaching graduate and postgraduate students for the last 30 years and this is something very close to his heart. He is extremely sought after by his students for teaching neurological examination methods and skills of localization in a simple and easy-to-understand manner.
He has been working at Indraprastha Apollo Hospital, New Delhi as Senior Consultant Neurologist and Coordinator of the department since 1996 and has been a pioneer in spearheading the Stroke Thrombolysis program in India.
He has served the Indian Stroke Association as the Secretary, Treasurer, and President and is the current President of the Delhi Neurological Association.
Neurological evaluation is similar to solving a complex mathematical equation. It is similar because neurological localization is extremely accurate
when components of the equation are selected appropriately. This exercise involves the accurate selection of the components of the equation from the history and elicitation of appropriate clinical signs as well as understanding the “neurological language” so as to arrange the components appropriately. An experienced neurologist can take an appropriate though detailed and focused history and conduct an appropriate and focused neurological examination and resulting in localizing the lesion within a few minutes when the inexperienced beginner may not get anywhere even after spending hours.
In this era of sophisticated neurological investigations including MRI, PET MRI, and functional MRI, electrophysiology, and genetic and serological markers clinical localization continues to be important and relevant and should not only precede these investigations but also should guide the diagnostic evaluation process.
This book is planned to provide a concise though a focused overview of methods of neurological examination enabling a focused clinical approach for localization in patients with neurological disorders.
Important components of the neurological diagnosis include:
1. Site of lesion:
(a) Central or peripheral nervous system with specific localization site—determined by localization from both history and clinical examination.
2. Etiology of lesion:
(b) Determined predominantly from the history with clues from:
I. Onset-acute, subacute, or chronic
II. Course of the illness-monophasic, relapsing, progressive, or spontaneous improvement
III. Other comorbidities and family history
IV. Therapeutic responses and failures
A Differential Diagnosis in order of priority is then prepared using the components of the SITE of lesion and ETIOLOGY at that site.
Table of Contents:
1.1 Basic Neuroanatomy
2- The Neurological History
2.1.2 History of Present Illness.
2.2 Specific Questions
2.3 Negative History
2.4 Past Medical History
2.5 Family History
2.6 Social History
2.7 Neurological Examination
2.8 The Neurological Kit
3- Higher Mental Function.
3.1 Higher Mental Function.
3.2 Screening Tests of Higher Mental Function
3.2.1 Attention Span and Vigilance.
3.2.5 Abstract Thinking and Judgment.
3.2.6 Visuospatial Tests.
3.2.9 Appearance, Behavior, Mood, Delusions, and Hallucinations
3.3 Specific Lobar Function.
3.4 Frontal Lobe.
3.4.1 Functions and Tests According to Functional Regions of Frontal Lobe
3.4.2 Premotor Area
3.4.3 Supplementary Motor Area (Area 6)
3.4.4 Frontal Eye Field Area (Area 8)
3.4.5 Broca’s Area (Area 44)
3.4.6 Prefrontal Lobe
3.5 Parietal Lobe
3.5.1 Functions of Parietal Lobe and Tests According to Functional Regions of the Parietal Lobe
3.6 Temporal Lobe
3.6.1 Functions and Tests According to Functional Regions of the Temporal Lobe
3.7 Occipital Lobe
3.7.1 Functions and Tests According to Functional Regions of Occipital Lobe
4- Cranial Nerve Examination
4.1 Olfactory Nerve: 1st Cranial Nerve
4.1.2 Clinical Testing
4.1.3 Clinical Interpretation
4.2 Optic Nerve: 2nd Cranial Nerve
4.2.3 Clinical Testing
4.2.4 Fluorescein Angiography
4.2.5 Optical Coherence Tomography (OCT).
4.3 Oculomotor (3rd), Trochlear (4th), and Abducens (6th) Cranial Nerves
4.3.2 Supranuclear Ocular Movements.
4.3.6 Vestibular Eye Movements
4.3.8 Non-nystagmus Ocular Oscillatory Movements
4.4 Ooculomotor or 3rd Cranial Nerve
4.5 Trochlear Nerve 4th Cranial Nerve
4.6 Abducens or 6th Cranial Nerve
4.6.1 Clinical Evaluation
4.6.2 Clinical Interpretation
4.7 Trigeminal or 5th Cranial Nerve
4.7.2 Sensory Component.
4.7.3 Motor Component
4.7.4 Clinical Evaluation.
4.7.5 Localization of 5th Nerve According to Signs.
4.8 Facial Nerve or 7th Cranial Nerve
4.8.2 Intracranial Course.
4.8.3 Extracranial Course
4.8.4 Clinical Testing
4.8.5 Upper Motor Facial Palsy (UMN)
4.8.6 Lower Motor Facial Palsy
4.8.7 Sites of LMN 7th Palsy
4.9 Vestibulocochlear or 8th Cranial Nerve
4.9.2 Clinical Testing
4.9.3 Electronystagmography (ENG)
4.10 The Glossopharyngeal (IXth) and Vagus (X) Nerves
4.10.3 Clinical Testing
4.11 Spinal Accessory Nerve: 11th Cranial Nerve
4.11.2 Clinical Testing
4.12 The Hypoglossal Nerve or XIIth Cranial Nerve
4.12.2 Clinical Testing
5- Examination of Speech
5.1 Language Disorders or Aphasia
5.1.1 Spontaneous Speech
5.1.2 Comprehension of Speech
5.1.4 Paraphasic Errors
5.1.5 Naming: Word Finding Difficulty (Anomia)
5.1.6 Reading (Alexia)
5.1.7 Writing (Agraphia)
5.2.1 Clinical Evaluation
6- Motor System Examination
6.1 Muscles of Head, Neck, and Face
6.2 Muscles of Upper Limb
6.3 Muscles of Trunk
6.4 Muscles of Lower Limb
7.1 Superficial Reflexes
7.1.1 Abdominal Reflex (T1–T12)
7.1.2 Cremasteric Reflex (L1)
7.1.3 Anal Reflex (S4/5)
7.1.4 Bulbocavernosus (S3/4)
7.1.5 Plantar Response or Babinski Response (S1)
7.2 Deep Tendon Reflexes
7.2.1 Reinforcement of Reflex
7.2.2 Grading of Deep Tendon Reflex
7.2.3 Components of a Brisk Reflex
7.2.4 Inverted Reflex.
7.2.5 Hung Up Reflex
7.2.6 Pendular Jerk
8 Sensory System Examination.
8.1 Exteroceptive Sensations
8.2 Proprioceptive Sensations
8.2.1 Pain and Temperature Pathway
8.2.2 Sensory Areas According to Peripheral Nerves
8.2.3 Sensory Loss Patterns
8.3 Clinical Testing
9 Cerebellar Examination and Examination of Posture, Stance, and Gait
9.1 Cerebellar Signs.
9.1.2 Hemispherical cerebellar signs
9.2 Clinical Tests
9.2.4 Intention tremor
9.2.5 Truncal Ataxia
9.2.6 Pendular Knee Jerk
9.2.7 Holmes Rebound phenomenon
9.3 Posture, Stance, and Gait
9.3.1 Posture and Stance
9.4 Common Gait Disorders
9.4.1 Asymmetrical Gait.
9.4.2 Symmetrical Gait
10- Involuntary Movements
10.1 Types of Movement Disorders
10.1.1 Hypokinetic Disorders
10.1.2 Hyperkinetic Disorders
11- Examination of Skull, Spine, Nerves, and Neurocutaneous Markers
11.3 Thickened Nerves
11.4 Neurocutaneous Markers
11.4.2 Sturge Weber Syndrome
11.4.3 Tuberous Sclerosis
11.4.4 Ataxia telangiectasia
11.4.5 Hypomelanosis of Ito
11.4.6 Von-Hippel-Lindau Disease
12 Autonomic Nervous System Examination
12.2 Tests for Autonomic Nervous System
12.2.1 Inspection of skin.
12.2.2 Cardiovascular Reflexes.
12.2.3 Sweating Tests or Sudomotor Tests
12.2.6 Pupillary Signs.
12.2.7 Laboratory Tests.
13 Examination of the Unconscious Patient
13.1 Q 1. What Is the Level of Consciousness?
13.2 Q 2. Is the Neurological Examination Focal or Generalized?
13.3 Q3 What Is the Possible Site and Etiology of the Lesion?
13.3.1 Pattern of Respiration
13.3.2 Motor Status.
13.3.4 Ocular Movements.
13.3.6 Sensory Evaluation
13.3.7 Other Aspects of Neurological Evaluation
14 Summary of Localization
14.1 LMN Lesions
14.2 UMN Lesion and Sites.