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Neurological Practical Examination - Complete Study Guide

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1. MMSE - Mini-Mental State Examination

Domains Tested & Maximum Scores (Total = 30 points)

Interpretation of Scores

• 27-30: Normal cognition
• 21-26: Mild cognitive impairment
• 11-20: Moderate impairment
• 0-10: Severe impairment

Important Limitations (from Kaplan & Sadock's Synopsis of Psychiatry)

• Does NOT assess executive functions (frontal lobe) - a major gap
• Underestimates deficits in highly educated individuals with early Alzheimer disease
• Overestimates deficits in individuals with little education
• Cutoff scores must be adjusted for age and education
• Cannot differentiate the specific etiology of cognitive impairment - not a substitute for neuropsychological testing

Practical Tips for MMSE Administration

• Ensure the patient can hear you and understands the language
• No time pressure, but note if responses are slow
• Do not prompt or help with answers
• Score strictly - partial credit is not given for most items
• Document the total score AND note which domains were impaired

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2. Motor System Examination

Step 1 - Inspection

• Look for muscle wasting/atrophy (UMN vs LMN distinction)
• Look for fasciculations (fine muscle twitching - LMN sign)
• Note posture and involuntary movements (tremor, chorea, dystonia)

Step 2 - Tone Assessment

• Normal tone: smooth resistance throughout range
• Hypotonia (flaccidity): decreased resistance - LMN lesion, cerebellar disease
• Hypertonia - Spasticity: velocity-dependent resistance, "clasp-knife" quality - UMN (corticospinal) lesion
• Hypertonia - Rigidity: uniform resistance throughout range ("lead-pipe" or "cogwheel" in Parkinson's) - basal ganglia lesion

Step 3 - Power/Strength Testing (MRC Scale)

• Upper limb: shoulder abduction (C5), elbow flexion (C5/C6), wrist extension (C6/C7), finger extension (C7), finger abduction (T1)
• Lower limb: hip flexion (L1/L2), knee extension (L3/L4), ankle dorsiflexion (L4/L5), big toe extension (L5), ankle plantarflexion (S1/S2)

Step 4 - Coordination

• Finger-nose test: finger to own nose, to examiner's finger - tests cerebellar function
• Heel-shin test: heel along opposite shin
• Rapid alternating movements (dysdiadochokinesia): pat hand rapidly
• Romberg's test: stand feet together, eyes open then closed (positive = sways/falls with eyes closed = dorsal column/proprioceptive loss)

Step 5 - Gait

• Observe: stride length, arm swing, base width, turning
• Hemiplegic gait: circumduction of leg (UMN lesion)
• Cerebellar/ataxic gait: wide-based, staggering
• Parkinsonian gait: shuffling, festinating, reduced arm swing
• Steppage gait: foot drop, high stepping (LMN/peroneal nerve)
• Scissor gait: legs cross each other (bilateral spastic paresis)

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3. Sensory System Examination

Primary Sensory Modalities

Cortical/Higher Sensory Modalities (if primary intact)

• Two-point discrimination: Distinguish two simultaneous points (tests parietal cortex)
• Stereognosis: Identify object by touch with eyes closed (coin, key)
• Graphesthesia: Identify number/letter written on palm
• Point localization: Identify where you were touched

Practical Method

1. Always explain the test to the patient first with eyes open, then test with eyes closed
2. Work from areas of reduced sensation outward to normal
3. Compare left vs. right, proximal vs. distal, upper vs. lower limbs
4. Map the deficit - is it dermatomal (nerve root), peripheral nerve territory, or hemisensory (central)?

Patterns of Sensory Loss

• Glove and stocking: Peripheral polyneuropathy (e.g., diabetic neuropathy)
• Dermatomal: Nerve root compression
• Hemisensory loss: Contralateral thalamus or cortex lesion
• Dissociated (pain/temp lost, vibration intact): Syringomyelia, Brown-Sequard syndrome
• Vibration/proprioception lost, pain/temp intact: Dorsal column lesion (subacute combined degeneration, tabes dorsalis)

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4. Reflexes - Names and Reflex Arc Levels

Deep Tendon Reflexes (DTRs) - Complete List

Reflex Grading Scale

• 0: Absent (abnormal)
• 1+: Hypoactive / diminished
• 2+: Normal (brisk)
• 3+: Hyperactive without clonus
• 4+: Hyperactive with transient clonus
• 5+: Hyperactive with sustained clonus

Biceps Reflex Arc - Closed Loop (C5, C6)

1. Tap biceps tendon → stretches biceps brachii
2. Muscle spindle (Ia fiber) activated → afferent signal up C5/C6 dorsal root
3. Synapse in spinal cord at C5-C6 level
4. Efferent via C5/C6 ventral root → musculocutaneous nerve → biceps contracts

Patellar Reflex Arc - Closed Loop (L2-L4)

1. Tap patellar tendon → stretches quadriceps femoris
2. Muscle spindle (Ia fiber) activated → afferent up L2-L4 dorsal root
3. Monosynaptic synapse in spinal cord at L2-L4 level
4. Efferent via L2-L4 ventral root → femoral nerve → quadriceps contracts (knee extends)
5. Simultaneously, inhibitory interneurons relax the antagonist (hamstrings)

Superficial Reflexes

• Abdominal reflex: Stroke abdomen toward umbilicus - T8-T12
• Cremasteric reflex: Stroke inner thigh - L1, L2
• Plantar reflex (Babinski): Stroke lateral sole of foot
  • Normal: plantarflexion (toes curl down)
  • Abnormal (Babinski sign): dorsiflexion of big toe + fanning of other toes = UMN lesion

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5. Multiple Sclerosis (MS) - Symptoms

Cardinal Features by System

Optic Nerve (Optic Neuritis - most common first presentation)

• Acute/subacute unilateral visual loss with pain on eye movement
• Decreased color vision
• Relative afferent pupillary defect (Marcus Gunn pupil)
• Central scotoma on visual field testing
• 90% recover vision over 2-6 months

Brainstem / Cranial Nerves

• Internuclear ophthalmoplegia (INO) - hallmark of MS in a young adult
  • Impaired adduction of one eye with nystagmus in the abducting eye
  • Caused by lesion in medial longitudinal fasciculus (MLF)
• Nystagmus (acquired pendular nystagmus is characteristic)
• Diplopia (double vision)
• Dysarthria (slurred speech)
• Vertigo (in 30-50% of patients)
• Facial numbness or trigeminal neuralgia in young adults
• Facial myokymia (undulating facial twitching)

Spinal Cord Symptoms

• Lhermitte's sign: Electric shock sensation down spine/limbs on neck flexion - pathognomonic of posterior column involvement
• Motor: spastic weakness of limbs (UMN pattern - hyperreflexia, spasticity, Babinski sign)
• Sensory: numbness, tingling, pins and needles, "MS hug" (band-like chest tightness)
• Impaired vibration and joint position sense (posterior column)
• Bladder dysfunction: urgency, frequency, retention, incontinence (neurogenic bladder)
• Bowel dysfunction: constipation, urgency
• Sexual dysfunction

Cerebellar Symptoms (Charcot's Triad)

1. Intention tremor
2. Nystagmus
3. Scanning/staccato dysarthria

• Ataxic gait
• Dysmetria (past-pointing)
• Dysdiadochokinesia (inability to perform rapid alternating movements)

Cognitive & Psychiatric

• Cognitive slowing, memory problems
• Depression (very common)
• Euphoria (less common)
• Fatigue (most disabling complaint in >90% of patients)

Heat Sensitivity (Uhthoff's Phenomenon)

• Temporary worsening of symptoms with heat (hot shower, exercise, fever)
• Classic and characteristic of MS

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6. Guillain-Barré Syndrome (GBS) - Symptoms

Classic Presentation

• Onset: Often 2-4 weeks after respiratory or GI infection (esp. Campylobacter jejuni, CMV, EBV)
• Weakness: Begins in legs, ascends proximally ("ascending paralysis")
  • Symmetric weakness of lower limbs first, then arms
  • Can progress to quadriplegia
  • In severe cases: respiratory muscle failure (requires ventilation in 9-30% of cases)
• Areflexia/Hyporeflexia: Invariable feature - absent deep tendon reflexes
• Sensory symptoms: Paresthesias (tingling, pins and needles) worse in hands and feet, but sensory loss is often mild compared to motor loss
• Pain: Moderate-severe pain in extremities, back, interscapular area in ~70% during acute phase

Autonomic Dysfunction (65% of hospitalized patients)

• Orthostatic hypotension
• Hypertension (episodic or sustained)
• Sinus tachycardia or bradycardia
• Cardiac arrhythmias
• Urinary retention
• Gastrointestinal atony (ileus)
• Sweating abnormalities

Cranial Nerve Involvement (45-75%)

• Bilateral facial palsy (most common cranial nerve involvement)
• Dysphagia, dysarthria (bulbar involvement)
• Ophthalmoplegia (in Miller-Fisher variant)

Diagnostic Criteria (Required)

1. Progressive weakness of both legs and arms
2. Areflexia or hyporeflexia

CSF Finding (Hallmark)

• Albuminocytological dissociation: Elevated protein (>45 mg/dL) with < 10 cells/μL (no pleocytosis)

GBS Subtypes

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7. Other Neurological Disorders - Symptoms

7a. Parkinson's Disease

1. Resting tremor - "pill-rolling" 4-6 Hz, disappears with movement
2. Rigidity - cogwheel or lead-pipe resistance to passive movement
3. Bradykinesia - slowness of voluntary movement (most disabling)

• Postural instability (later feature) - retropulsion, festinating gait
• Hypomimia (mask-like face, reduced blinking)
• Micrographia (progressively smaller handwriting)
• Hypophonia (soft, monotone speech)
• Shuffling gait with reduced arm swing
• Non-motor: depression, constipation, REM sleep disorder, anosmia (often precedes motor symptoms by years), dementia (Parkinson's dementia, 30-40% of patients)

7b. Myasthenia Gravis

• Fatigable weakness - gets worse with activity, improves with rest
• Ptosis and diplopia - most common first presentation (ocular myasthenia)
• Bulbar weakness: dysarthria, dysphagia, nasal regurgitation
• Limb weakness (proximal > distal)
• Respiratory failure in myasthenic crisis
• Normal reflexes and sensation (pure motor, NMJ disease)
• Positive Tensilon (edrophonium) test
• Ice pack test: ptosis improves when ice applied to eye (cold improves NMJ function)
• Thymoma association (10-15%)

7c. Stroke (CVA)

• MCA territory (most common): contralateral hemiplegia (face + arm > leg), hemisensory loss, homonymous hemianopia, aphasia (dominant hemisphere), neglect (non-dominant)
• ACA territory: contralateral leg weakness > arm, urinary incontinence, behavioral changes
• PCA territory: homonymous hemianopia, memory deficits, cortical blindness
• Lacunar infarcts: pure motor hemiplegia, pure sensory stroke, ataxic hemiparesis, dysarthria-clumsy hand syndrome

7d. Meningitis

1. Fever
2. Severe headache ("worst headache of life" if subarachnoid hemorrhage/meningeal irritation)
3. Neck stiffness (nuchal rigidity)

• Photophobia and phonophobia
• Kernig's sign: Flex hip 90°, then attempt to extend knee - pain/resistance = positive
• Brudzinski's sign: Passive neck flexion causes involuntary flexion of hips and knees
• Jolt accentuation of headache: Horizontal head rotation at 2-3 Hz worsens headache
• Non-blanching petechial/purpuric rash (meningococcal septicaemia - emergency)
• Altered consciousness (bacterial meningitis more severe)
• Seizures

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Summary - UMN vs LMN Differentiation (Practical Examination Key)

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• Kaplan & Sadock's Synopsis of Psychiatry - MMSE and neuropsychological assessment
• Bradley and Daroff's Neurology in Clinical Practice - MS, GBS clinical features
• Ganong's Review of Medical Physiology, 26e - Reflex arcs and DTR grading
• Medical Physiology (Boron & Boulpaep) - Motor system, stretch reflex arc

Neurological Examination - Quick Summary with Important Tests

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1. MMSE (30 Points Total)

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2. Motor System - Key Tests

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3. Sensory System - Key Tests

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4. Important Reflexes

Babinski Sign = Big toe goes UP + other toes fan out = UMN lesion (ABNORMAL in adults)

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5. Multiple Sclerosis - Key Signs & Tests

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6. Guillain-Barré Syndrome - Key Signs & Tests

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7. Other Disorders - Key Tests Summary

Parkinson's Disease

Myasthenia Gravis

Meningitis

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UMN vs LMN - The Most Important Distinction

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Memory aid for reflex levels: "C5-6 pick up sticks (biceps), C7 lay them straight (triceps), L3-4 kick the door (patellar), S1-2 stamp the floor (Achilles)"