Erman Fandialan M.D.
Department of Clinical
Neurosciences
UERMMMC
To review the different parts of the
neurologic examination.
To review techniques of eliciting the
abnormalities.
Facilitates communication
Provides baseline
Directs testing
Localizes the lesion
The customary sequence of information
collection in the neurological interview is
outlined below:
Chief Complaint
History of Present Illness
Past Medical History
Review of Systems or Functional Inquiry
Family History
Social History
Accurate history often suggest correct
diagnosis
Chronological order and systematic
manner
Symptoms characterized in terms of:
severity, location, temporal profile,
aggravating and ameliorating factors
Includes complete general physical
examination + neurologic examination
Emphasis on:
Vital Signs
Head: Evidence of Trauma
Neck: Bruits
Heart: Murmurs, rhythm
Abdomen: Masses / Distention
Skin / Scalp: Lesions / Tenderness
MUST HAVES:
Neurological
hammer
Pen light
Pin / cotton
Tongue depressor
Stethoscope
BP apparatus
NICE TO HAVE:
Ophthalmoscope
Tuning Fork
Pocket Snellen
1.
2.
3.
4.
5.
6.
7.
Mental Status Exam
Cranial Nerves
Motor Exam
Sensory Exam
Reflexes
Cerebellar Exam
Meninges
Do the neurological examination in an
orderly fashion.
Finish the examination for one system
before starting another.
Always examine the left and the right
side of the body and compare.
Compare proximal against distal
findings.
1. Level of Alertness, Attention
and Cooperation
Awake, drowsy, stuporous, comatose
Best response
Spelling a short word forward and
backward (W-O-R-L-D / D-L-R-O-W is a
standard or naming the 12 months forward
and backward )
2. Orientation
Person
Place
Time
3. Memory
Immediate
recall
Recent Memory
Remote
Memory
4. Language
Spontaneous speech
Comprehension
Naming
Repetition
Reading
Apahasia
Brocas
Transcortical
Wernickes
Global
Conduction
5. Calculations, RightLeft Confusion, Finger
Agnosia, Agraphia*
Addition, subtraction,
multiplication, division
exercises
Identify right and left body
parts
Name and identify each
digit
Write the name and a
sentence
* Gerstmann's syndrome
dominant parietal lobe
6. Apraxia
Inability to follow a
motor command that
is not due to a primary
motor deficit or a
language impairment
Ideomotor apraxia
left inferior parietal
lobe lesion
Constructional Apraxia
non-dominant
parietal lobe lesion
Dressing Apraxia
7. Neglect and
Constructions
Hemineglect
Extinction on double
simultaneous
stimulation
Construction tasks
involving drawing
complex figures or
manipulating blocks
Anosognosia inability
to recognize ones body
part (non-dominant
parietal lobe lesion)
8. Sequencing
Tasks and Frontal
Release Signs
Continue drawing a
silhouette pattern of
alternating triangles
and squares
Frontal release signs:
the grasp, root, and
suck reflexes
Abulia
9. Logic and
Abstract thinking
Simple problem
solving
Proverb
interpretation
Similarity
comprehension
e.g. how are a car
and an airplane
alike?
FRONTAL LOBE:
Abstract thinking and
logic
Speech - Brocas area
Sequencing Tasks and
Frontal Release Signs
Concentration
Emotional expression
(abulia, apathy)
TEMPORAL LOBE:
DOMINANT:
Wernickes area
Memory,learning, orientation,
hearing
NON-DOMINANT:
Prosopagnosia (recognizes
persons by pictures)
Music, hearing
PARIETAL LOBE
DOMINANT :
Calculations, Right-Left Confusion,
Finger Agnosia, Agraphia
Naming,reading,stereognosis,
graphesthesia, somatognosia
NON-DOMINANT :
Apraxia, neglect, constructions
Stereognosis, graphesthesia
OCCIPITAL
LOBE:
Identify
objects and
colors
Use at least 3 substances
Do not use alcohol or
perfume
Cover one nostril
Ask the px to close his/her
eyes
While occluding each nostril,
patient is asked to sniff and
identify various odorants
Unilateral anosmia
hippocampus problem
A. Visual Acuity
Snellens or Jaeger
chart
Pinhole
B. Visual Fields
Confrontation test
C. Funduscopy
Red orange reflex
Media clear, hazy
Disc borders distinct, blurred
Cup disc ratio = 0.4 0.5
Arteriole/Venule ratio (AVR) =
2:3
Hemorrhages, Exudates
Papilledema
D. Pupillary Reflex
Afferent arm :optic nerve
Efferent arm: oculomotor
nerve
effector organ: pupillary
constrictor muscle
direct & consensual
CN III: MR, SR, IR, IO, levator palpebrae
CN IV: Superior oblique
CN VI: Lateral rectus
Mixed nerve
Sensory: corneal reflexes
Stimulate the corneoscleral junction
Afferent arm CN V
Efferent CN VII
Effector ms orbicularis oculi
Sensory V1, V2, V3
Test pain, temperature, vibration,
light touch
Compare areas
Report in %
Motor: jaw strength and muscle
bulk (masseter, temporalis)
Mixed nerve, predominantly
motor
Sensory: Taste anterior 2/3 of
tongue
Motor
Smile
Bury eyelashes
Nasolabial fold
Forehead has bihemispheric
innervation centrally
Central Vs Peripheral facial palsy
CENTRAL FACIAL PALSY
PERIPHERAL FACIAL PALSY
Gross hearing
Weber
No lateralization
Rinne
Compare air conduction
and bone conduction length
AC>BC
Normal
Sensorineural hearing loss
both are decreased
BC>AC
Conductive hearing loss
Taste / sensation
posterior pharynx
Swallow
Gag reflex
Without gag but
can swallow
normal CN IX & X
Sternocleidomas
toid - chin to the
opposite side
Trapezius raise
shoulder
Tongue
Stick out tongue
Tongue receives
bilateral innervation
from R and L CN XII
Tongue deviated
towards R - problem
on R CN XII
Check for atrophy and
fasciculations
Inspection: bulk, fasciculations
Palpation: tenderness
Tone
Hypertonia: subacute or chronic corticospinal lesion
Hypotonia: LMN lesion or acute UMN
Rigidity: basal ganglia disease
Muscle testing
Primary concern: can patient breathe
Key test: drift of extremity
Check both distal and proximal muscles
Grading:
0 - No muscle contraction is detected
1 - A trace contraction is noted in the muscle by
palpating the muscle while the patient attempts to
contract it.
2 - The patient is able to actively move the muscle when
gravity is eliminated.
3 - The patient may move the muscle against gravity but
not against resistance from the examiner.
4 - The patient may move the muscle group against
some resistance from the examiner.
5 - The patient moves the muscle group and overcomes
the resistance of the examiner. This is normal muscle
strength
Deltoid
Biceps
Wrist flexors
Finger flexors
Triceps
Thumb add.
Finger abd.
Dorsiflexors
Hip flexors
Hip abductors
Plantarflexors
Hip extensors
Hip adductors
Knee flexors
Toe extensor
Pain, Temperature: Lateral spinothalamic tract
Light touch, Pressure: Anterior spinothalamic tract
Vibration, joint position sense: Dorsal column
Medial lemniscal system
Cortical sensation
Graphesthesia
2 point Discrimination:
2-4 mm fingertips
4-6 mm dorsum of fingers
8-12 mm palm
20-30 mm dorsum of hand
Stereognosis
Tactile Extinction
REFLEXES GRADING
4+ Very brisk, hyperreflexive, with clonus
3+ Brisker or more reflexive than normally.
2+ Normal
1+ Low normal, diminished
0
No response
Biceps
brachii
tendon
reflex
C5-6
Triceps
tendon
reflex
C6-8
Brachioradia
lis tendon
reflex
C5-7
Patellar
tendon
reflex
L2-4
Corneal CN V, CN VII
Pharyngeal CN IX, X
Abdominal - T6-9, T10-12
Beevors sign
Anal S2-4
Cremasteric L1-2
Bulbocavernosus S3-4
Babinski
Chaddock
Oppenheim
Gordon
Schaefer
Hoffman
Myersons sign
Requires integration of cerebellar, motor, and
sensory functions
1. Appendicular Coordination
Rapid alternate pronation & supination
Dysdiadochokinesia
Ask patient to tap distal joint of thumb with tip of index
finger
Ask patient to tap your hand quickly with the ball of each
foot in turn
2. Point-to-point movements
Finger-to-nose pointing
Dysmetria
Heel-to-shin movement
3. Stance
With feet apart, then closed together
With eyes open, then eyes closed
4. Gait
Ask patient to walk across the room then turn and come
back
Ataxia when gait lacks coordination and unstable
Tandem Walking
Walk Heel-to-toe in a straight line
Walk on toes, then on heels
5. Nystagmus
Refers to involuntary rhythmic movements of
the eyes
Reflects an imbalance in one or more of the systems
that maintain stability of gaze:
Cerebellum and vestibular system
Supple or rigid neck
Kernigs
Brundzinskis
Not getting a complete history utilizing
family or observers
Not performing a systematic exam
Jumping to conclusions before gathering all
the data
Misinterpreting old lesions for new
Misinterpreting limitations from pain as
neurologic deficits
Lesions of the cerebral cortex and internal capsule
(supratentorial) sensory and motor defects confined to the
contralateral side of the body
Brain stem and spinal cord lesions ipsilateral as well as
contralateral defects due to varying patterns of crossover
Unilateral pain syndromes without motor deficits thalamic
pathology
A careful exam of CN II, III, IV and V is indicated in patients with
headache or suspected processes that cause increased ICP
Testing for pronator drift is the best screen for muscle weakness
of central origin
