Neurologic examination
China Medical University Hospital
Department of Neurology
敖瑀 Yu Aoh MD
Consciousness
loss
Headache Confusion
Imbalance
Weakness
Coma
Vertigo Choking
Numbness
Memory Drooling
loss PAIN
Gait Incontinence
abnormality
Brain
•Cerebrum
Cortical
Spinal Cord
•Motor
function
•Sensory
Cons. nerves
Peripheral
Temp.
•Brainstem
•Motor
Pain nn.
Cranial
•Sensory
Light
Reflex Touch
Temp.
Vibration
Cons.
Pain
•BasalLevel
ganglia
Light Touch
•Autonomic
•Cerebellum
Vibration
•Autonomic
•Pattern
Conscious level
Arousal or wakefulness Jennett 1992
(i.e. eyes open to command)
Alertness and awareness
(i.e. orientation and communication)
Appropriate voluntary motor activity
(i.e. obeying commands)
GCS JOMAC
GCS Glasgow Coma Scale
• Eyes Open • Verbal • Motor
4 – Spontane
response response
ous 5 – Oriented
6 – Obey
3 – To verbal 4 – Disoriented
3 – Words only 5 – Localize
2 – To pain
1 – None 2 – Moaning 4 – Withdrawal
1 – None 3 – Decorticate
2 – Decerebrate
Range: 3-15 1 – None
JOMAC
• Judgment : Fire, lost-found
• Orientation: Persons/Time/Place
• Memory: immediate/short/long-term
• Abstract thinking: proverbs
• Calculation: 100-7 or 20-3
http://teachmeanatomy.info/head/cranial-nerves/summary/
一嗅
二視
三動眼
四滑
五叉
六外旋
七顏
八聽
九舌咽
十迷走
十一副
十二舌下
Cranial nerves
Cranial nerves
Cranial Clear Comatose
1 olfaction X
Pupil/Visual acuity/Visual field Pupil size/Light reflex
2
Confrontation test Threaten test
3 Medial, up/down gaze Doll eye
4 Inferior-medial gaze Doll eye
5 Facial sensation/Mastication Corneal reflex
6 Lateral gaze Doll eye
7 Facial palsy Judge by appearance
8 Hearing Caloric test
9, 10 Swallowing, drooling Gag/ sputum suction
11 SCM/Trapezius muscle X
12 Tongue movement X
EYES
• Visual acuity 2
• Visual field 2
• Pupil 2 3
• Gaze 3 4 6
– Position (是否在正確位置)
– Limitation (是否能正常轉動)
– Diplopia (是否有複視)
• Orbital (swelling? Edema?)
• Eyelids (ptosis? Retraction? Closure?) 3 7
Confrontation test
Pupil examination
• Circumstances
• Size (1mm +/-)
Anisocoria
– Anisocoria: PATHOLOGIC!
• Pupillary Reflex
Pinpoint pupils 2 >>> 3
Response rate
Consensus
Unilateral
miosis + ptosis
Horner’s syndrome Bilateral dilated
Extraocular muscles
L’t CN VI
R’t CN IV L’t CN III
EOM Horizontal Gaze Conjugation
Trigeminal nerve (CN V)
Facial n.
(CN VII)
Ask the patient to
1. Smile
2. Close your eyes
Simple Two-step test to know
the types of facial palsy
Peripheral type Central type
R’t Central type R’t peripheral type R’t hemifacial spasm
R’t Hemifacial spasm
Vestibulo-cochlear nerve (CN VIII)
Vestibular division (Balance) Cochlear division (Hearing)
Patient clear
Patient unclear
Doll eye
COWS
Glossopharyngeal, Vagus nn.(CN IX, X)
Leave this til the end of the exam
Accessory n. (CN XI) Hypoglossal n. (CN XII)
Check muscle power of Check muscle power of
• SCM tongue
• Trapezius • Tongue protrusion
• Tongue movement in
the mouth
Motor system
Brain
Muscle
Cord Nerve
Neuro-
Muscular
junction
Motor system (cont.)
• Muscle power
•MRC
Muscle bulk
– Atrophy Clinical presentation
grading
– Hypertrophy
5– Fasciculation
Full power
• 4MuscleCould
toneovercome partial resistance
3– Spasticity V.S. Rigiditygravity
Could overcome
• 2Deep Horizontal
tendon reflex
movement only
• Other important reflexes
1– Babinski
Muscle twitching but no movement
– Hoffman
0– Jaw-jerk
None
• Muscle bulk
– Atrophy
– Hypertrophy
– Fasciculation
• Upper limbs DTR • Lower limbs DTR
– Pectoralis major – Knee jerks
– Biceps brachii – Ankle jerks
– Triceps brachii
– Bracheoradialis
– Finger jerks
• Important reflexes
– Babinski sign
– Hoffman
– Jaw-jerk 5
Central v.s. Peripheral
Romberg test
Sensory system
溫痛
震動/本體覺
Different Crossing sites
Coordination
• Gait (taxis, Ataxia)
– Base
• Cerebellar function testing
– Dysdiadochokinesia
– Finger-Nose-Finger test
– Heel-Knee-Shin test
– Finger-chasing
– Tandem gait
Extrapyramidal system
• Bradykinesia
• Rigidity
• Posture instability
• Involuntary movement
– Tremor
– Dystonia
– Chorea
– Myoclonus
High Cortical function
• Frontal:
– Luria test
– Stroop test
• Parietal:
– Gerstmann syndrome
– Simultanagnosia
– Anosognosia
• Temporal:
– Memory
• Occipital:
– Visual field
咖啡
黃 粉紅
綠
藍
紫
紅 橘 墨綠
Consciousness Motor system
GCS JOMAC Muscle power 0-5
Neck Muscle Bulk Atro./Hyper.
Brudzinski Carotid bruits Muscle tone Spas./Rig.
Kernig DTR -/+/++/+++/++++
Cranial nerves
Sensory system
1 Olfaction
Pain/Temperature Pinprick
2 Pupil size, Confrontation
Vib./Proprioception Joint-
3,4,6 EOM, diplopia? position/Fork
5 Facial sensory, mastication muscle
Coordination
7 Facial palsy
Gait Balance, gait base
8 Hearing
Cerebellar FNF, HKS, Tandem
9,10 Swallowing, speech gait
11 SCM, Trapezius
Extrapyramidal sys.
12 Tongue protrusion
工欲善其事
Welcome to the world of Neurology
• Luria test, neglect • Sensory:
• Romberg, Proprioception
• Cranial:
– Pupil
• Coordination:
– Confrontation
• FNF, HKS
– EOM • Tandem gait
• Motor:
– Muscle power • EPS:
– Muscle tone • Finger tapping
– DTR • Posture instability
– Babinski/Hoffman/Jaw-jerk
