The Neurological Exam

Lecture from: Dr. Javier 08-09

Neurological Illness
Signs of Increased Intracranial
pressure
Headache, Vomiting,
Papilledema
Signs of Meningeal irritation
Neck rigidity, Kernigs sign,
Brudzinski
Focal Neurologic Deficits
One learns by doing the thing; for though
you think you know it, you have no
certainty until you try. Sophocles
you learn how to listen to and examine
patients thoroughly and confidently. It is
the most precious and durable skill you
have;
the more you use it, the better it
becomes.
It is unique.

pinal Cord
Peripheral Nerve
Neuromuscular
Muscle

Junction

At all times one must treat patients with

respect and kindness. When you enter the
room, identify yourself and tell the patient
why you are there. Do not persist with the
history or examination past the point at
which the patient is tired or uncooperative.
Patients are most cooperative with students
and doctors who are clean, neat, and polite.
Have a system of examination and learn to
follow it in the same way each time.
Level of lesion
Cerebral
Brainstem
Midbrain
Pons
Medulla
Cerebellum

Sequence of Examination
1. Mental Status examination
2. Cerebellar function/coordination
3.Cranial Nerves
4. Motor system
5. Sensory system
6. Reflexes
Mental Status Examination
Difficulties with communication
Determine whether recall & insight
into recent & past events are intact
1. Level of consciousness
2. Orientation
3. Memory

4. Language
5. Speech
6. Insight & Judgement
7. Abstract thinking
8. Calculation
Bare Essentials:
Difficulties with communication
Determine whether recall &
insight into recent & past events
are intact
Cranial Nerve Examination
Assess the following:
1. Pupillary size and reactivity
2. Fundi
3. Visual fields
4. Ocular motility
5. Facial
movements/Symmetry/Sensation
CN I (Olfactory):
Usually neglected/omitted
Ask patient to sniff a mild stimulus
(e.g. coffee, cigarette)
Inferior frontal lobe disease (e.g.
meningioma)
Foster-Kennedy Syndrome
Significant if unilateral anosmia is
detected
CN II (Optic):
Check visual acuity using Snellens
chart
Optic disk should be examined
Test visual fields by confrontation
Further Tests:
1. Perimetry
2. Tangent screen
3. Visual evoke potential

CN III, IV, VI (Oculomotor, Trochlear,

Abducens):
Minimum Requirement
1. Describe size & shape of pupils
2. Check reactivity of pupils to light and
accommodation
3. Check extraocular movements and
observe for any paresis and
nystagmus

CN II (Optic):
Optic disk examination

CN V (Trigeminal): Minimum Essential

A. Sensory testing to light touch &

temperature/or pain involving:
1.
Ophthalmic
2.
Maxillary
3.
Mandibular
B. Motor Testing Jaw clench
C. Corneal reflex is done if patient is unable
to follow commands or has altered
sensorium

Look at symmetry of the face

Ask the patient to:
Show you his teeth /gums

Smile

Close your eyes tightly as if you

had soap in them

Look up the at the ceiling

The Corneal Reflex

Tool : Use Sterile COTTON (w/o alcohol)

In general, taste is perceived
better on the more posterior
aspects of the
tongue, palate, and pharynx
rather than on the anterior.
CN VII (Facial):
Search for facial symmetry at rest
and with movement
Test for the following:
1. eyebrow elevation
2. forehead wrinkling
3. eye closure
4. smiling
5. cheek puff

Evaluation of FACIAL NERVE

CN VIII (Vestibulo-cochlear):
Check ability to hear a finger rub or
whispered voice with each ear
Rinnes (air vs. bone conduction)
Webers (laterality of lesion)
Further test: Audiometry
CN IX, X (Glossopharyngeal
& Vagus):
Position & symmetry of palate &
uvula at rest and with phonation
Gag reflex is checked by stimulating
posterior pharyngeal wall on each
side
Gag reflex is often absent in normal
individuals

CN XI (Spinal Accessory):
Shoulder shrug
Head rotation to each side against
resistance
A. The wrong way to
examine the left
sternomastoid. The
patient attempts to turn
his head to his right
against resistance.
B. The correct way to
examine the left sternomastoid.
The patient turns his head to the
right unresisted. The examiner
then attempts to bring the head back to the
forward position as the patient resists.

CN XII (Hypoglossal):
Minimum requirement is to inspect:
tongue for atrophy or fasciculation
Position with protrusion
Strength when extended against
inner surface of the cheek on each
side
Motor System
Look for muscle atrophy
Check extremity tone
Assess upper ext. strength & look for
pronator drift
Check for strength of wrist and finger
extensors (Rapid finger taps)
Ask patient to walk
Bulk
Atrophy: Diminished muscle bulk,
most marked with lower motor
neuron disease, but also seen with
chronic upper motor neuron disease.
Fasciculations: Seen with lower
motor neuron disease and
amyotrophic lateral sclerosis
Tone
Spasticity: initial resistance to quick
movement of a joint which then
diminishes by the end of the
movement.
Rigidity: steady resistance through
the entire movement of a joint.
Flaccidity: markedly diminished
tone; suggests lower motor neuron
disease, but may be observed
acutely following upper
motor neuron disease, such as
stroke.

Abnormal movements
Bradykinesia w/tremors
Athetosis - slow, sinuous, writhing
movements in distal limbs
Chorea - semipurposeful, flowing
movements that flit from one part of
the body to another
Hemiballismus - wild flinging/flailing
movements that represent large
amplitude proximal movement
Dystonia - sustained contractions of
both agonist and antagonist muscles,
frequently causing twisting and
repetitve movements or abnormal
postures
Myoclonus - brief, sudden shock-like
jerk
Manual Muscle Testing/Grading:
0 = no movement
1 = flicker or trace of contraction but no
associated movement
2 = movement with gravity eliminated
3 = movement against gravity but not
against resistance
4 = movement against moderate
resistance
5 = full power
Coordination/Cerebellar Test
Limb ataxia - hemisphere
Truncal & gait ataxia - midline
I. Finger-to-Nose Test
- intention tremors
- past pointing
II. Pronation-Supination Test

- Rapid-rhythmic alternating
movements
- Dysdiadochokinesia
III. Heel to Knee to Shin Test
- slide the heel up & down the front
of
the shin
- look for side to side tremor or
buckling

Finger-to-nose test.
a Normal.
b Ataxia.
c Intention tremor

Tests of rapid alternating movements.

A. Finger-nose-finger testing. B. Pinching
the thumb and the little finger together
(the thumb and the index finger can also
be used). C. Tapping one hand on the
back of the other D. One-hand
clapping.

Rapid alternating prone-supine-prone

positions of the hand on the thigh
Lower limb
coordination.
A. Heel tapping.
B. Heel sliding.

Elicitation of the rebound phenomenon

in cerebellar dysfunction.
a Technique. b Normal finding: prompt
braking of movement.
c Pathological rebound phenomenon with
insufficient braking due to an ipsilateral
cerebellar lesion
Reflexes
Deep Tendon Reflex:
Muscle Stretch Reflex
Reflex muscle contraction mediated
by Lower motor reflex arc
Hyperreflexia = UMN lesion
Hyporeflexia = LMN lesion
Clonus = severe hyperreflexia
repeated rhythmic contraction
elicited
by striking
a tendon/dorsiflexing the ankle
Common Reflexes Tested

DTRs or MSRs

Plantar Reflex:
Pathologic reflex
1. Babinski sign
2. Chaddocks sign
3. Gordons sign
4. Bings sign
- Extension of the big toe & flexion of the
small toes
- fanning

Check for the babinski

Use key, not ballpen !
Sensory Examination
Ask patient whether he can feel light
touch, temp of cool object, pin prick
in each distal extremity
Vibration and position sense.
Check double simultaneous
stimulation using light touch on the
hands, face, legs
Most difficult & unreliable due to
subjectivity
Wartenberg Pin-wheel

Tips for Sensory Examination:

1. Do not ask leading questions
2. When mapping a region of sensory
loss, move from the affected area
into the normal region
3. Beware of fatigue

The
Gait /Station
Observe the patient while walking
normally, on heels & toes following a
straight line
Rombergs Test
Ex. Hemiparetic gait
Ataxic gait
Parkinsonian gait
Typical gait
disturbance of a
hemiparetic patient.
Circumduction of the
spastically
paretic leg
with
predominantly extensor
tone, and flexion of the
spastically paretic arm at
the elbow because of
predominantly flexor tone.
WORST
Headache of
his life !!!
Check for
Nuchal Rigidity

Reminders
Screening for Neurological problems
Complicated but achievable in 5
minutes
Follow a sequence that is
comfortable
Practice makes perfect

Have a system of examination and learn to

follow it in the same way each time.

Decorticate (a) and decerebrate (b)

posturing.

TENDON REFLEX Grading System

GRAD REFLEX
E
Zero
Absent
1
Hypoactive
2
Normal
3
4

Hyperactive w/o
clonus
Unsustained Clonus

Sustained Clonus

5 Indices derived from MMSE

(What the MMSE tested)
I.
Total Orientation Index (range 010): Summing temporal and physical
orientation indices
a.
Temporal Orientation Index
(range 0-5): 5 items that
assess orientation to time
(year, season, date, day and
month)
b.
Physical Orientation Index
(range 0-5): 5 items that
assess orientation to place
(state/country,
country/province, town/city,
hospital, floor)
II.
Language Index (range 0-4):
items that assess language abilities
a.
Naming watch and pen
b.
Repeating the phrase no ifs,
and no buts
c.
Following written command to
close your eyes

III.

Declarative Memory Index (range

0-3): noted how many words patient
recalled after a delay
a.
Ball
b.
Flag
c.
Tree
IV.
Working Memory Index (range: 08):
a.
Spell backwards WORLD
b.
Carrying out three-step
command
I.
Take this paper with
your right hand
II.
Fold it in half
III.
Place it on the floor
V.
Motor/Constructional
Index (range 0-2):
2 items requiring motor response
a.
Copying intersecting
pentagons
b.
Producing a written sentence
to command
Neuro Exam in Psychiatry
1. To elicit signs pointing to focal,
circumscribed cerebral dysfunction
2. To elicit signs suggesting diffuse,
bilateral cerebral disease

Avelyn Lim
http://maidencircuits.multiply.com