Neurologic Exam (Part 2)

P.Diagnosis 2010/01/29 Dr. Josephine Guitierrez

A. NEUROLOGIC EXAMINATION
The Neurologic examination allows an astute clinician to be able to pinpoint the lesion with a significant
degree of precision

B. OUTLINE OF THE NEUROLOGIC EXAMINATION

1. Mental Status Examination*
2. Cranial Nerve examination
3. Motor Examination
4. Reflex Examination
5. Sensory Examination
6. Cerebellar Functions*
7. Autonomic Functions
8. Meningeal Tests
9. Higher Cortical Functions

A. GOALS OF THE NEUROLOGIC EXAMINATION

1. Is there a lesion?
2. Where is the lesion?
3. What is the Lesion

A. NEUROLOGIC EXAMINATION IN DETAIL

1. MENTAL STATUS EXAMINATION

 Global appreciation of a global function of a patient’s state

 Much from the data comes from the observations made during the interview for history
taking
 Has to be probed unobstrusively
 This part of the exam is delicate and subjective
 Tact and technique is everything!
 The physician should act as a sounding board for the patient’s thoughts and experiences
 Do not try to learn too much too fast. Be sensitive to the patient’s readiness to disclose
information.

a. General behavior and appearance

b. Stream of talk
c. Mood and affective responses
d. Content of thought
e. Intellectual capacity
f. Sensorium
1) Consciousness
2) Attention span
3) Orientation
4) Memory (remote, recent, immediate)
5) Fund of information
6) Insight, Judgment, Planning

a. General behavior and appearance

• Mainly through observation
• Are his movements normal or immobile? Hyperactive? Agitated? Restless?
Quiet? Neat? Slovenly?
• Is he dressed according to his age, peers, sex, background, and occasion?

a. Stream of talk
• Amount and character of verbal output of the patient
• Does he respond to conversation normally? Is his speech rapid? Incessant?
Under great pressure? Is he very slow and difficult to draw into a spontaneous
conversation? Is his verbal output scarce? Verbose?
• Can he discuss things? Able to reach conversation goals?
• Observe: rate, rhythm, coordination
• Repeat: “no”, “ifs”, “ands”, or “buts”

• Aphasia or Dysarthria?
○ Expressive (Broca’s: frontal, nonfluent aphasia)
○ Receptive (Wernicke’s: superior temporal lobe, fluent aphasia)

[LimeNotes] P.Diagnosis / Neurologic Exam (Part 2) Total Pages: 5 / Filesize: 31.00kb

Batch 2012: 2009-2010 (2nd Year) Date: 02/02/2010
Printed on: 02/02/2010
 LimeNotes
Neurologic Exam (Part 2)

○ Dysarthria: motor dysfunction of the muscles of articulation

○ Paraphasias, ‘word salads’, neologisms

a. Mood/Affective Responses
• Not elicited by direct injury but by observing and comparing reactions of patient
to common or normal reactions in similar situations
• Is the patient euphoric, agitated, inappropriately gay, giggling, or is he silent,
weeping, angry?
• Does his mood swing in a direction appropriate to the subject matter of the
conversation?
• Is he emotionally labile? How much provocation does he need to start crying or
laughing? How much time does he need to get over it?

a. Content of thought
• Checks for the realism of the thinking
• Does the person have illusions (seeing an object as another thing)?
Hallucinations (perception of a stimulus in the absence of one, visual or
auditory)? Delusions (false sensory of perception not based on natural situation
of a sensory perception)? Misinterpretations?
• Is he preoccupied with bodily complaints, fears of cancers, or heart disease?
• Does he feel that society is maliciously trying to give him difficulty?

a. Intellectual capacity
• Is he bright, average, dull, or obviously demented or mentally retarded?
• Educational attainment has to be considered

a. Sensorium
• The mechanism by which the body receives and integrates all the senses, the
memories, all hopes, and desires into a stream of consciousness.
• Defined as the ability to perceive and process ongoing events in the light of past
experiences…

1) Consciousness
○ Defined as an awareness of the self and the environment
○ Is the patient fully aware of himself and his environment?

○ Levels of consciousness
 Awake – fully aware of himself and the environment and is
able to respond intelligently to environmental stimuli
 Drowsy – may have moments when he is awake but has
longer periods of sleeping; however, when adequately
aroused, can respond purposefully but briefly, attention span is
shortened and lapses back to sleep
 Obtunded – may appear awake but is not aware of and does
not respond to external stimuli
 Stuporous – appears asleep but responds to stimuli with non-
purposeful reactions (like breathing rapidly, random
movements, pursing of lips, etc.) and only when stimuli is
present; lapses back to unconsciousness when stimuli is
stopped
 Comatose – complete unresponsiveness even with stimulus
1) Attention span
○ Refers to attentiveness
○ Can the patient focus to stimulus sufficiently to comprehend them?
○ Short / adequate / intact?

1) Orientation
○ Patient’s understanding in his place in time, space, in relation to
others/person?
○ If the patient is conscious and attentive, can he comprehend who he is,
where he is, and when it is?
○ Should test orientation to time, person, and place
○ As to person: recognizes himself, his role, other people and their roles?
○ As to place: does he know he is in the hospital, its name, the name of
the city and province?
○ As to time: does the patient know the time of day, the day of the week,
month, year?

1) Memory (remote, recent, immediate)

○ Observe how well he recalls and relates the events in his medical
history
○ Have you ever been concerned about your memory? How has your
memory been? Suppose we try out your memory?
○ Recall of three objects

P.Diagnosis / Neurologic Exam (Part 2)

Page 2 of 5
02/02/2010
 LimeNotes
Neurologic Exam (Part 2)
○ Technique
 Immediate memory: give him 3 objects to remember, and
then after several minutes ask him to name them again.
 Recent memory: ask him what he had during his latest meal.
 Remote memory: Ask him to tell you his birthday.
1) Fund of information
○ Reflects what the patient knows about what is going on in the world
○ Ask him the name of the president, a few of the latest headlines, give
some coherent viewpoint about some current problems

1) Insight, Judgment, and Planning

○ Does the patient recognize his illness and its implications? Do his goals
and plans match his physical and mental capabilities?
○ Ask him: “What do you plan to do once you are already out of this
hospital?”
○ Give him a hypothetical situation where a reaction needs to be elicited
and see how he reacts to it.

1. CEREBELLAR FUNCTION

a. Balance and equilibrium

1. Ataxia – inability to maintain postural equilibrium and balance
○ Truncal ataxia – observe the patient’s balance when he is seated or
standing. Patients with cerebellar lesions will fall to one side,
corresponding to the side of cerebellum affected
○ Tandem walk – ask the patient to walk along an imaginary line with
steps close to each other like doing a tightrope walking. Patients with
cerebellar dysfunction can walk with a wide-based gait or frequently
falls.

Patients with cerebellar dysfunction can walk with a wide

based gait or fall to the side of the lesion.

○ Romberg’s test – evaluates peripheral positional sensation or dorsal

column function (proprioception) as well as midline cerebellar function)
 Ask the patient to stand still with feet together, arms raised
forward, with eyes closed. Observe for balance or falling to
one side or swaying
 Patients with cerebellar ataxia will fall or sway eyes open or
closed
 Patients with sensory ataxia will sway only when eyes are
closed (eyes are helping with balance by showing the position
in space) but can balance better with eyes open because of
the added visual correction to position sense

a. Coordination and precision:

• Dysmetria – inability to execute movements with extreme precision
○ Finger-to-Nose test:
 Ask the patient to point to the tip of nose and the tip of your
index finger, alternately, while moving your fingers in different
directions each time. The patient should be able to land his
finger exactly on tip of the nose and your finger.

 patients with cerebellar disease may experience terminal

tremors or hesitation as they try to hit the ‘targets’ or may miss
target altogether and point past the target (past-pointing)
○ Heel-to-shin test:
 Legs of the patient should be extended or straight. Ask the
patient to tap his heel to his other knee 3x and then move the
heel firmly from the knee down along the shin.
 He should be able to do this straight movement without losing
control or incoordination of the feet. The other leg should also
be checked.
 Abnormal response: heel is ‘swerving’

a. Coordination:
• Dysdiadokokinesia – inability to execute movements with coordination and
grace; test with rapid alternating movements

○ Tests for coordination

 Pronation-supination test: ask the patient to use both hands
in alternate pronation and supination. Observe the symmetry of
force exerted, rhythm, grace and coordination.

P.Diagnosis / Neurologic Exam (Part 2)

Page 3 of 5
02/02/2010
 LimeNotes
Neurologic Exam (Part 2)

 Foot-tapping test: ask the patient to tap each foot several

times on the floor. Observe whether the amount of force,
rhythm, and coordination is appropriate.
 Patients with cerebellar disease: may show the affected arm of
leg to be lacking in direction, slower, more incoordinated or
clumsy, less or excessively more forceful than the normal side.
The side of the manifestation is ipsilateral to the cerebellar lobe
affected.

a. Muscle tone and posture:

1. Rebound phenomenon
○ With eyes closed and arms outstretched in front, press downward and
release the arms.
○ Observe whether the patient is able to return arms to original position
without overshooting (goes way beyond the original position)

1. Hypotonia
○ Observe for ‘ragdoll posture’; Test for muscle tone

1. Nystagmus – abnormal ocular movement;

○ ask the patient to look to the extreme left and right, up and down.
○ Observe for rhythmic, jerky involuntary movements of the eyeball.

 Midline cerebellar function

• Tandem walking-
• Heel-shin test
 Hemispheric Cerebellar Function
• Finger-to-nose test
• Dysmetria, Rapid alternating hand movements

a. Meningeal Signs
1. Passive neck flexion – with the patient lying down, put your hand behind her
head or neck and rapidly flex the neck. Observe for any resistance or rigidity.
2. Kernig’s maneuver – start with holding the flexed knee of your patient, slowly
extend the knee. Observe and ask whether there is pain in the nuchal area.
3. Brudzhinki’s maneuver – use your hands on the nape to flex the neck of the
patient lying down. Observe for response: sudden flexion of both knees.

b. Autonomic Function Tests

• Urinary/Fecal Incontinence or retention: rectal examination gives you information
on anal sphincter tone
• Horner’s syndrome: ptosis, myosis, anhydrosis
• Postural hypotension: sitting and standing BP recordings
• Sweating patterns, iodine-starch test

1. TESTS FOR HIGHER CORTICAL FUNCTION

 Should be done last, requires an intact sensorium, motor and sensory systems to be fairly
intact to allow the patient to respond appropriately to the tests
 Need not be done in routine tests except when symptoms or other signs suggest cerebral
pathology.
1. Agnosia
2. Apraxia
3. Aphasia
4. Calculation

1. Agnosia
○ ‘not knowing’ defined as the inability to understand the import or
significance of a sensory stimulus even though the sensory pathways
and sensorium are intact
○ Necessary conditions in diagnosing agnosia previous skills that enable
him to know the significance of a particular stimulus, intact sensorium,
intact sensory pathways
○ e.g. astereognosia, agraphognosia, finger agnosia, astognosia,
atopognosia, anosognosia

a. Astereognosia – inability to recognize objects by touching its shape

and dimensions. Ask the patient to close his eyes. In one hand, put in a
common object and ask the patient to identify it. Manifested in non-
dominant parietal lobe abnormality.
b. Agraphognosia – inability to recognize written alphabet or numbers
written on the palm (dominant lobe abnormality)

P.Diagnosis / Neurologic Exam (Part 2)

Page 4 of 5
02/02/2010
 LimeNotes
Neurologic Exam (Part 2)

c. Finger agnosia – inability to recognize fingers (dominant lobe

abnormality)
d. Atopognosia – inability to recognize position of limbs or body parts.
Common in patient with phantom limbs.
e. Asomatognosia -

1. Apraxia
○ Inability to do; defined as the inability of the patient to perform a
volitional act even though the motor system and sensorium are intact
○ Requirements for the diagnosis – adequate previous skills, intact
sensorium, intact motor system

a. Constructional apraxia – inability to draw; ask the patient to copy the

drawing of a cross without lifting the pen or intersecting pentagons
b. Dressing apraxia – ask the patient to show how to put on his pajama
top or shirt
c. Indeomotor apraxia – ask the patient to show how he lights a cigarette
or brushes his teeth
d. Tongue apraxia – ask the patient to stick out his tongue
e. Gait ataxia – ask the patient to walk, he is unable to walk in spite of
good motor function and balance

1. Aphasia
○ Inability to understand or express words even though his sensory
systems, mechanism of phonation and articulation, and sensorium are
relatively intarct
○ Will be apparent once you start the interview with the patient
○ Give the patient a picture and ask him to tell a story about it
○ Ask him to read a simple written command and ask him to perform it
○ Ask him to repeat “Methodist Episcopal”, “Massachusetts General
Hospital”
○ Ask him to write his name, or copy a sentence.
○ Ask him to name objects like a pen, watch, shapes.

a. Anomic aphasia – patient is unable to name an object seen

○ Folstein Mini Mental Status Examination
 10 items on orientation
 3 items on immediate reacall
 5 items on attention/calculation
 3 items on short term memory
 1 item on repetition
 2 items on naming
 3 items on three-command comprehension
 1 item on reading or comprehension
 1 item on drawing
1. Calculation

END OF NOTES

P.Diagnosis / Neurologic Exam (Part 2)

Page 5 of 5
02/02/2010