Clinical Skills Tutorial -5

Peripheral Nervous System History Taking and Physical Examination

 Clinical Skills Tutorial -5
Tutorial_04/01-P5 to 20-P5 - Peripheral nervous system history taking and physical
examination

Overview: Taking a Neurological History

In addition to the normal history of the patients presenting complaint, there are specific closed
questions that form a neurological systems review. These questions do not take the place of
the detailed history you learned to take in semester one but rather add extra information
specific to the neurological system.

Objectives:
After participating in this class, it is expected that students will be able to:
1. Understand the steps and components of peripheral nervous system history
2. Integrate the anatomy of the peripheral nervous system with the patient presentation
3. Formulate a hypothesis of localization of lesions based on the patient history

Readings:
Prescribed pre-reading

Talley N & O’Connor S 2010 Clinical examination: A systematic guide to physical diagnosis
6th ed Elsevier Australia.

Epstein O, Perkin G, De Bono D & Cookson J 2008 Clinical Examination 4 th ed Mosby

Elsevier Limited

A SYSTEMATIC GUIDE TO PHYSICAL DIAGNOSIS. Nicholas J. Talley, MB BS. (Hons.)

(NSW), M.MedSc. (Clin Epi.) (Newc.), M.D. (NSW), Ph.D. (Syd.), FRACP, FAFPHM, FRCP
(Lond.), FRCP (Edin.), FACP, FACG, AGAF and Simon O’Connor, FRACP DDU FCSANZ
(7th Edition).

Tutorial plan:

1. Review of anatomy, surface anatomy and movement of the peripheral nervous

system 20 minutes

2. Review of peripheral nervous system history 60 minutes

3. Role play of peripheral nervous system history 30 minutes

Review of the neurological system:
You should ask the patient if they have experienced the following:
Dizziness
Vertigo
Headache
Seizures or fits
Paresthesia/anesthesia
Weakness (ask if on one side or both sides of the body)
Gait or movement problems
Visual, hearing, smelling disturbance
Neck stiffness
Disturbance of sphincter control (bowel, bladder)
Head injury with loss of consciousness (LOC)

Risk factors for peripheral neurological disease

Smoking
Diabetes
Hypertension
Alcohol
Diet (e.g. Vit. B12 deficiency)
Malabsorption
Infections (Shingles, Meningitis)
Cancer
Drug use and abuse
Injuries

Discuss with your tutor the relevance of

The past medical (including childhood illnesses), surgical and injuries history
The family history (e.g. benign essential familial tremor, Huntington’s Chorea)
The Drug history (medications, alcohol, smoking and recreational drugs)
Allergies
Social history including (diet, exercise, activities, support, occupation)

General Principles of Peripheral Neurological Examination

The aim of a neurological examination is to localize the anatomical site of the lesion (brain,
spinal cord, peripheral nervous system)
As with any other examination, start by introducing yourself to the patient, and then:
- explain what you intend to do (using appropriate language/NO jargon)
- obtain patient’s consent
- ask if the patient is currently in pain or discomfort
- ask the patient to properly expose the area you want to examine
- wash your hands before touching the patient and after the examination

• General
- Look – General appearance, Gait, tremor, spasm, abnormal
movements
 - Feel – spasm, fasciculation

• Motor System
- Muscle bulk, wasting, fasciculation
- Tone
- Power
- Reflexes
- Clonus (Lower limbs)
- Coordination

• Sensory System
- Pain (pinprick using neurotips)
- Temperature (using test tubes filled with hot/cold water – can use the tuning
fork to test for cold sensation)
- Vibration (using a 128Hz tuning fork)
- Proprioception (always with patient eyes closed)
- Light touch (using a wisp of cotton wool)
- Two point discrimination (using a paper clip)
- Stereognosis

** Always compare the two sides of the body

General:
• Inspection:
Make sure area to be examined is properly exposed.
Inspect for posture, muscle bulk, abnormal movements, fasciculation and skin
changes.
Muscle wasting can be a result of denervation, primary muscle disease or disuse.
Compare the muscle between sides.
Abnormal movements (involuntary) include tremor, which is a rhythmic distal
movement of the hands, feet or head and may be physiologically normal. It occurs at
a frequency of 10-14 cycles per second and may be worsened by exercise, caffeine,
alcohol and anxiety (like a hospital resident trying to insert an intravenous cannula
after having run up ten flights of stairs to an emergency). Tremor is assessed, by
asking the patient to hold out their hands with the fingers spread out.
Pathological tremor is often slower and may be the result of liver, thyroid or
neurological disease. Parkinsonian tremor is maximal at rest and reduced by
voluntary movement. Tremor, which is absent at rest and exacerbated by movement
(“intention tremor”) is principally due to cerebellar disorders.
Rarer movements include dystonia (slow twisting movements), chorea (dancing
movements) and hemiballismus (limb flung rapidly).
Fasciculations are irregular spontaneous contractions of individual motor units in an
arrhythmic pattern. While these may represent anterior horn cell disease, they may
also be benign.

Motor examination
• Tone:
Tone is an assessment of the freedom of movement of a joint when moved passively,
and is described as being normal, reduced (hypotonia) or increased (hypertonia).
 Lead pipe rigidity is associated with extra-pyramidal lesions. Cog wheel rigidity is
probably a manifestation of tremor (the rigidity in Parkinson’s disease is cog wheel
rigidity).

* Question: What is the difference between rigidity and spasticity?

• Power:
Power or muscle strength, is tested by pitting the examiner’s strength against the
patient’s full voluntary muscle resistance. Allowance must be made however for
differences in size and strength.
Grades of Muscle Power:
0. No muscle contraction visible
1. Muscle contraction visible but no movement of joint
2. Movement only when gravity excluded
3. Movement sufficient to overcome effect of gravity
4. Movement overcomes gravity plus added resistance
5. Normal power

Compare symmetry; look for specific muscle groups, proximal, distal or general and
between right and left.
• Reflexes:
Learn how to examine the reflexes of the upper and lower limbs.
Revise the reflex arc:
Place one finger on the tendon and tap this with the hammer, which should be
allowed to swing smoothly against gravity onto your finger. Reflexes can be normal,
increased or reduced and are always compared sequentially with the other side.
PRACTICAL POINT: Reflexes are best tested when the muscle is in the lengthened
position.
PRACTICAL POINT: Muscles and reflexes are usually served by the overlying
dermatome.
• Coordination:
The cerebellum controls coordination of muscle movements. The combination of
ataxia (walking on a broad based gait because the patient will tend to stagger to the
affected side), scanning speech (slurred speech pattern) and nystagmus are other
signs of likely cerebellar dysfunction.
Learn how to carry out the following tests of coordination:
1. Finger nose test and heel shin test:
Intention tremor (seen in cerebellar disease) increases as the target is
approached. If it is significantly worsened with eyes closed, this indicates a
contribution from proprioceptive dysfunction.
Dysmetria (what used to be known as past pointing) and dyssynergia
(decomposition of movement) may also be seen.
2. Rapidly alternating movements:
Ask your partner to pronate and supinate one hand on the dorsum of the
other as quickly as possible. Dysdiadochokinesia is when this movement is
very slow and clumsy in cerebellar disease and other disorders such as
pyramidal and extra-pyramidal lesions.
Rapidly alternating movements of the lower limbs are tested by the Foot-
tapping test.
3. Ballistic tracking
 Ask you partner to point towards your index finger. Move it suddenly in a
horizontal plane to a new position. In cerebellar disease, maximum
velocities are reduced and there is overshoot with rebound.
Note: It is always best to demonstrate these tests for the patient
Sensation:
Sensory examination is often subjective and inexact. Usually tests start proximally and move
distally down the limb and over each dermatome. Pain and temperature test the
spinothalamic pathway, vibration and proprioception the posterior columns. Light touch tests
both and is the least discriminatory.
Remember to; Ask your patient to close their eyes
Compare “right limb with left limb”
• Light touch
Be careful to touch and not stroke. Use a clean cotton ball.
• Pain
Ask your patient to close their eyes. Use a clean, disposable paper clip or neurotip
and ask them to identify “sharp or dull” each time they feel a touch. If an abnormal
area is found, test outwards from the area of dullness to the normal sensation. It is
unacceptable to pierce the skin.
• Temperature
This is rarely tested. Test tubes filled with hot and cold water are touched against the
skin.
• Vibration
Using a 128 Hz tuning fork, test by making the fork vibrate then deaden. Areas to be
tested are the ulnar head, olecranon, and shoulders starting distally. Vibration sense
has traditionally been tested over bony points, but it may be better to test over soft
tissue (Tally & O’Connor).
• Proprioception
For proprioception, use the distal interphalangeal joint, firstly demonstrating the
movements – center, up & down. Again start distally and if abnormality is
demonstrated, check at the wrists and elbows. Clarify with the patient first that
direction rather than position should be reported.
• Two point discrimination
The recognition of dual stimuli applied simultaneously. This can be done conveniently
using a bent clean paper clip.
• Stereognosis
Means being able to identify an object by feel e.g. a coin. Reduced stereognosis is a
sign of damage to the sensory part of the cortex, provided primary sensation is intact.