The Neurological Exam

Hi my name is Jessica Nishikawa I'm

going to be demonstrating a few of the
basic techniques of the neurologic
examination for you today these videos
are meant to supplement your learning
and are not intended to be completely
comprehensive or replace your readings
or lectures hi Connie
ok my name is Jessica I'm going to be
performing your neurologic exam today
I'm going to be speaking for the camera
so that students at home can also learn
from this experience okay thank you okay
okay
it's easiest to think of the neurologic
examination in about five different
areas Mental Status speech which is not
going to be discussed today at this at
this time and then cranial nerves which
we'll go over today the motor system
which includes coordination the sensory
system and then reflexes so we're going
to start with your cranial nerves okay
cranial nerve one is olfactory it is not
usually tested in clinical practice but
it's Connie's ability to smell so if you
were going to test this in your practice
you would include one side of her
nostril and have her smell a certain
scent you can buy little tubes of scent
lavender cinnamon coffee those things
are the normal ones that are generally
smelled but we're going to defer that
testing today Creole nerve to is optic
this is assessed by doing an optimal
optimal logic exam looking at the optic
nerve behind your eye there's more of
this in the video on head and neck but
basically you take your ophthalmoscope
go and remove your glasses from me go
ahead and look straight out into the
distance coming at a 15 degree angle
putting the scope to your eye finding
the red reflex and then following it in
to the patient eye
taking a look in the structures behind
her pupil looking at the optic disk and
the optic nerve cranial nerve two and
three are involved in pupillary
reactions so you shine a light in the
patient's pupil and watch for
constriction of that pupil and also
watch for constriction of
a consensual side so both direct and
consensual reaction so peoples are equal
round and reactive to light that is
innervated by crayon love to
again that's optic and crayon irve-3
which is ocular motor cranial nerves
three ocular motor cranial nerve four
which is cochlear and cranial nerve six
abducens are all involved in the extra
ocular movement so these are the six
cardinal views of gaze so I'm going to
have you follow my finger and try not to
move your head just move your eyes each
must or each cranial nerve three four
and six helps Connie move her move her
muscles that she's able to follow my
finger you'll note that I skipped
cranial nerve five cranial nerve 5 is
trigeminal this is has both sensory and
motor function to set to test the motor
function I'm going to put my hands on
your jaw and just have you tighten your
jaw good and move your jaw side-to-side
so cranial nerve innervates the motor
function of her jaw so clenching her
teeth and moving her jaw side-to-side
the sensory function is tested by taking
a q-tip splitting it in half and using
the dull and sharp edges and asking the
patient to be able to tell which ones
which Connie which one am i touching you
with soft good and how about now
sharp good ok crane the next one is
cranial nerve six which we already
discussed and cranial nerve seven then
is facial and this innervates your
facial movements so I'm going to have
you smile for me and frown and puff out
your cheeks very good like a monkey
that's cranial nerve seven crayon nerve
eight is acoustic we test this by your
hearing in clinical practice grossly
could be tested just by having
conversation if she's able to hear and
not say what huh a lot then you could
say that cranial nerve eight is probably
intact however you could do
the whisper test occlude one side of her
ear and whisper a common two syllable
phrase and have her repeat that Apple
Apple baseball baseball good
you could also test this by testing
lateralization and air conduction and
bow conduction this is called Weber's
test strike the tuning fork place it on
the top of her forehead and ask her if
she feels or hears it in both ears or
one ear more than the other rooms as you
should hear in both ears if there's no
conductive or since your neural hearing
loss the next test is the rent test and
this is a test to see if air conduction
is greater than bone conduction which it
should be strike the tuning fork place
the tuning fork behind on her masseter
muscle her excuse me sorry mastered bone
and ask her when she tell me when you
can no longer hear it just say no no and
then you should still hear it when it's
placed in front of your ear good do the
same thing on the other ear sled test
lateralization and air conduction bone
conduction so that's all for cranial
nerve number eight cranial nerve nine
which is the glossopharyngeal and
cranial nerve 10 which is vegas those
test your ability to swallow and the
soft palate movements in your mouth I'm
going to grab light here I'm going to
have you go ahead and swallow for me
good open up and say ah watching her
soft and hard palate move watching her
uvula seeing that its midline so you'll
note that some patients who have strokes
they will have some dysphasia or
inability to swallow afterwards and this
is part of the reason why
good cranial nerve 11 is accessory or
spinal accessory this can be tested by
placing your hands on the patient's
shoulders and having them shrug their
shoulders up towards you good against a
little bit resistance you can also place
your hand on the side of their chin and
have them try to move their neck against
your chin good and the other way good
and the last of the cranial nerves is 12
which is hypoglossal go ahead and stick
your tongue out for me and the tongue
should be midline if it deviates towards
one way or the other it gives you a clue
as to where the injury was in the spinal
canal because there's a phrase called
lick your wounds if your tongue deviates
to the right the wound within the wound
is in the the right cranial nerve if
your tongue deviates to the left and we
know it's the left side of your brain
that had had the injury that concludes
our cranial nerve assessment the next
step of the neurologic examination is
motor function and that includes
coordination so to begin with I would
have watched Connie as she entered the
room that's part of the motor watched
her gait and to see that it was even
that her stance was appropriate and and
you can always see that her posture is
pretty good right now - I'm also
observing for any involuntary tics any
gross deformity of her musculoskeletal
or neurologic systems right now then I'm
going to go ahead and start with looking
at the muscles themselves looking for
atrophy if her muscle is very atrophied
the big and you're looking mostly the
big muscle groups here the biceps
triceps forearms thighs and legs you're
not getting to fun although you can see
some atrophy of especially the thumb
muscle because of all the fingers gets
it's the larger one so you can see when
there's atrophy of the thumb muscles
pretty easily putting the patient do
some passive range of motion you're
going to get an assessment of the
patient's muscle tone and and muscle
bulk this is a pretty subjective finding
so it has to do with your ability to
assess
what their overall tone and bulk is so
you're going to have to get comfortable
by doing a number of these exams before
you can really make an assessment based
on you know how someone's muscle tone is
you should be able to tell if they're
rigid and spasmodic you know if it's
someone who has Parkinson's disease or a
contracture or you're not able to open
their arm even because that elbow is
really rigid and spastic versus someone
who is has flaccid tone you know they're
just in a coma and you pick up their arm
and it just drops
that's flaccid tone there's no basic
tone to their body but the tone in her
body is what's keeping her upright is
keeping her in an upright stance so
there's always the muscles are always
working a little bit so again that's
kind of a subjective finding but
something that you'll have to get used
to doing in your own clinical practices
okay so next I'm going to go through
each of the major muscle or areas and
and test your muscle strength range of
motion of the joints is a
musculoskeletal examination but the
strength associated with that is
neurologic so starting with your hands
I'm going to have you just keep them
rested and I'm going to try to keep them
together while you try to open them good
and now keep them open and I'm going to
try to close them but try keep them open
and I'm going to try to close them but
against resistance good and you should
be you should feel some resistance there
the patient shouldn't be you shouldn't
just be able to close the patient's hand
there should be some resistance there
and that's testing their finger muscles
with your wrist I'm going to have you
make a fist and turn palms down sorry
and I'm going to try to break your fist
so I'm going to try to bring your fist
down this way but try not to let me very
good good now elbows in to the side
don't let me press down good and now
don't let me press up very good good now
we're going to do shoulders arms
straight out and don't let me press down
good and don't let me press up good
shoulders at your side
and try to press out against my hand now
try to press in towards your body press
out against my hand press in towards
your body with all these major muscle
groups you're testing flexion and
extension abduction and adduction
against resistance moving down to her
knees and her quadriceps I'm going to
have her press out against my hands and
then press back in and they can also do
the same thing with the toes you can
with the feet you can dorsiflex and
Planner
dorsiflex on plantar flex the feet so
press up against my hands and now press
down against my hand good in this foot
too and go the most important thing is
that you're assessing one side compared
to the other so if you find that overall
the patient has a little bit of weakness
that's significant but what's more
significant is if is if one side is
grossly asymmetrical from the other
compared to the other okay so the next
major muscle group we're going to assess
is your hip so I'm going to have you lay
back okay lay down put your legs up on
the bed and again X we're going to be
testing flexion and extension so go
ahead and press up against my you can
bend your knee a little bit press up
against my hand good this need to just
this quad up against my hand good and
then put your hand down try to press
down against my good and press down
against my hand good with your knees up
try to keep me I'm going to try to open
your knees try to keep them closed
good now open them slightly and I'm
going to try to push them closed you try
to keep me from pushing them closed good
so I'm putting traction this way as
she's pressing against me and that's
testing the muscle function in her hips
the last part is internal and external
rotation go and relaxed once
this one goes up by extending me good
similarly I'm going to press down
against her I'm going to have her press
up against my hand good I'm going to
press and then press down very good
internal an external rotation we don't
need to the other side go ahead and sit
up and come to the side good so that is
the muscle testing of the major muscle
groups next we're going to move on to
coordination exams okay so go ahead and
stand up for me and turn to the side
okay so now we're going to do the
coordination exam with to test called
Romberg and pronator drift so to test
Romberg you have the patient's with
their eyes open go ahead and put both
arms out palms up and then have the
patient close their eyes and note that
they can stay in an upright position
without with minimal swaying and they're
not losing their balance good Connie
okay now open your eyes now to test
pronator you do the exact same position
you have the patient close their eyes
and while their eyes are closed your
take your hands and briskly press down
on their hands and note that they return
their hands to the extended position go
ahead open so that's
Romberg and pronator drift and
coordination exams part of the
coordination test is to observe gait and
related body movements I'm first going
to ask you to take a couple steps
forward using normal gait and turn
around and walk back I'm just observing
your gait for posture for balance and
swinging of the arms everything looks
good next I'm going to ask you to do
what we call tandem walking which is
where you walk your heel to toe in a
straight line so go ahead and take two
or three or four steps and then turn
around and return back heel to toe good
next I'm going to ask you to walk on
your heels then walk on your toe so take
the heel that turn around return on your
toes tiptoes very good now can you do a
shallow knee bend
very good right so those were all
coordination tests and part of the
neurologic examination going to have you
sit down one more time into a couple
more coordination exams this one is
called rapid alternating movements I'm
going to demonstrate it and then have
you demonstrate it for me with your
palms slap your hands lift up pronates
and then slap the back of your thighs
with your hands now to do that as fast
as you can and as fast as you can good
okay and stop note that it's a smooth
movement and it's not jerky and it's
it's the flow is is appropriate if there
was a brain stem problem or a brain
problem there would be jerkiness and she
wouldn't really be it as coordinated
with that the next test is called the
point-to-point movement so I'm going to
move my finger at different areas in
your visual field and I want you to
point to it and touch it and then touch
your nose and then point back to it so
let's start with you pointing to my
finger touch it and then touch your nose
good so again if there was a brain stem
problem or neurologic problem then she
wouldn't have the coordination to do
that as smoothly as she did that
concluded the motor punt the motor
function part of the neurologic exam the
next part is going to be the sensory
function for the sensory part of the
neurologic examination there's going to
be a couple things I'm going to ask you
to do but first of all note that you can
always test a sensation with sharp and
dull again with your broken q-tip and
the this being the dull side the sharp
side being the broken side you could do
this all over the body or you can ask
usually you reserve this for if there's
a place where there's some sensation
loss so in a diabetic it's important to
do the distal extremities the toes and
the feet you can also test sensation
with vibration so with a tuning fork you
can place that on the distal extremities
and do that as well
the first test is called stereo stereo
gnosis it's a test where you put a
fairly common object and an ordinary
object that the patient might come in
contact with and you have them close
their eyes and open your hand I'm going
to place an object in your hand and you
can feel it and tell me if you know what
that is it's a bobby pin that's correct
it's a bobby pin in someone who has
brain stem dysfunction neurologic
dysfunction they would not be able to
put together their sensation what
they're feeling the synapses into the
brain telling them what that is would
not be there the next test is called an
Graf especia this is where you ask the
patient to close their eyes and they
give you your palm and you write a
number in enlarged writing on their palm
close your eyes Connie three very good
okay point look localization is I should
preface by saying that all sensory
examinations are best done with patience
eyes closed so you hear me telling
quantity to close your eyes during all
these but really to do any sensation
examination there I should be closed I
also you get feedback from other areas
that you don't need so with point
localization you put he touched you have
the patient's eyes closed and you touch
an area and then you have the patient
open their eyes and point to where you
were touched and she's pretty darn close
sometimes the patients will not be close
at all two-point discrimination is
another test I'm going to use a bobby
pin since I have it on hand but you can
also use a paperclip that and pull the
edges apart with the patient's eyes
closed you separate the paperclip or the
bobby pin and put both sides on the
patient's arm or leg and and you do it
close together or separate and you ask
the patient if they feel one or two
points so in this case I'm going to try
this there's do you feel one or two
points I feel one
so in different areas that was - but in
different areas require a larger or
shorter distance so on the hand you
should be able to feel two points and
distinctly within a couple of
centimetres so close your eyes is this
one or two - good now I'm going to clip
close it and just do one and she should
just be able to fill one one if you're
doing the legs however you would need a
much wider bobby pin and able to before
she would be able to fill two separate
feelings so I'll try it like this and I
doubt she'll be she'll probably fill
this as one one yeah even though it's -
it's not it's the width isn't large
enough for her to fill it as - but if
you if you spread out the width and ask
her do you feel one or - yeah but was
that pretty easily felt as - or it was
not that easily yeah so on the legs and
in the distal extremities you need a
larger larger span in order to fill two
distinct pressure points even something
as as distinct as bobby pin the last
test is called extinction and you have
the patient close her eyes and touch the
patient on one side of the body asking
if they felt it and then repeat with the
opposite side and ask again then
simultaneously I would touch both sides
and ask her which side she felt it in
and stroke patients a lot of times
they'll know if you touch the right side
and they'll also know if you touch their
left side but if you touch them both at
the same time they'll probably only feel
it on the area where it was where their
lesion is not so on the side that they
don't have the hemiparesis so which side
okay go ahead and close your eyes looked
right good both good very good so that's
a sensory test called extinction that
sums up our sensory examination for this
part of the neurologic examination the
next part is the dependent and cutaneous
reflexes
okay the first part of the deep tendon
reflex I'm going to check your break
break break you'll radialis reflex with
the patient's arm relaxed place my thumb
over you can either strike the tendon by
itself or you can strike the tendon over
your thumb which is pressing on it and
you can note that her thumb and and
wrist which next I'm going to assess the
biceps tendon by having her relax her
arm again I'm going to press in on her
biceps and you can see again the thumb
twitching the triceps is a little bit
more difficult because the patient has
to be fairly relaxed and this is a hard
position to get the patient relaxed in
so I'm going to place your arm in my
hand and just try to completely relax
your shoulder and then behind the elbow
you're striking the tricep where the
tricep tendon inserts you should see a
slight movement in the arm good and you
can actually even feel the twitching in
the tricep in her upper arm next we're
going to move to the patella which is
the one that I rate thinks of when you
think of deep tendon reflexes when you
feel the patella there's a little
depression right beneath the the patella
that's where the patellar tendon runs
and that's where you want to aim for so
you want to strike your striking when
you when you're striking with the with
the hammer reflex hammer it should be
let your wrist do most of it you're not
actually hitting you're just actually
letting the weight of the hammer go down
into the patients go ahead and you
should see a little flicking of the knee
causing the need to jerk okay the last
one that we're going to be doing today
is the Achilles reflect for the Achilles
reflex you're going to gain your hammer
so that it hits the Achilles tendon here
behind the ankle and the posterior
aspect of the ankle and watch for the
foot to flick but you can alternatively
do this with the patient kneeling on a
chair so that their Achilles is up
in the air and you're hitting them and
you're striking it as they're as they're
kneeling on the chair
next is the cutaneous so that that's all
the deep tendon reflexes the next is the
cutaneous reflexes and there's just a
few of those to go over one is the
abdominal cutaneous reflex which I will
have Connie laid down for okay so for
the cutaneous reflexes the abdominal
cutaneous reflex with the patient's
belly exposed you take an object like
you could use the end of your hammer or
you could use the dull side of a q-tip
and just lightly stroke from the UM
blackish out towards the side and you're
watching the belly muscles contract they
may just flicker they may contract I can
see them easily in in Connie's abdomen
some patients with heavy musculature or
a lot of adipose tissue you're not going
to be able to see it all that well the
next reflex we're going to show you
demonstrate today is called babinski's
reflex take the bottom side of your of
your reflex hammer and you want to draw
a line from the heel up to the ball of
the foot drawing laterally and then
going across the ball medially and then
watching with their toe and with their
toes and and feet do so you note that
she plantar flexes which is a normal
response for an adult in child and
children who have positive Babinski
sometimes you'll see there you should
see their toes flare out and dorsiflex
but plantar flexion is a normal response
for an adult that concludes the
neurologic examination that we're going
to demonstrate for you today thank you
you
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