Neurologic examination

Dr. Cristian Alexander

Central nervous vs peripheric nervous system
The neurological examination, approached in
a systematic and logical fashion by the
clinician is leading to the anatomical
location of the patient's problem!
Every neurological sign has an
neuroanatomical equivalence
Mental status
A. Confusion:
a. Name?
b. Orientation in time (year, season, month, day)
c. Orientation in space (country, city, place, floor)
B. Attention (immediate recall): you tell 3 word and the patient have to
repeat them
C. Calculation: repetition of series of digits, or calculation substractions 100
-7,-7,-7, -7, -7 etc.
D. Memory
• Grades of altered mental status: drowsiness, stupor, deep stupor, coma
Memory
• Registry memory (attention): repeating function (ex.:house, fish, car)
• Recent memory: rembering the 3 word after a time period of 1-5 minutes
within the patient is distracted by other activities
• Short-term memory disturbances: you ask the patient for events and
information within the last 1-2 weeks
• Long-term memory disturbances: you ask the patient for events and
activities happend for example in his childhood
Anterograde amnesia: the patient can not learn new information after onset
of the lesion
Retrograde amnesia: is imapird memory of events immediately before onset
of the lesion, but earlier memories are preserved
Involuntary movements
• Tremor
• Myokimia
• Fasciculations
• Athetosis
• Choreea
• Dystonia
• Myoclonia
• Tics
Meningeal signs
• Nuchal rigidity
• Kernicke sign
• Brudzinsky sign

Meningeal iritation= menigeal signs

Meningism= meningeal iritation+fever
Meningitis= meningism+CSF changes (+/-headache, photophobia or
other focal signs)
Cranial nerves examination
• 1 Olfactive nerve –normosmia
• Hyposmia/anosmia=tumor, Parkinson disease
• Hyperosmia=stress, pregnancy
- Olfaction is often not tested, unless a specific pathology is suspected
like a subfrontal brain tumor
Optic nerve
• Visual acuity: covering each eye alternately and using an eye chart
• Visual field: by asking the patient to fixate straight ahead and report
when a finger can be seen moving in each quadrant
• Simmetry of pupils
• Light pupil reflex: direct when de illuminated pupil constricts and
consensual (indirect pupil) constricts
• Afferent pupilary defect NII swinging a flashlight test-instead of
constriction the pupil is dilated
 2. -the patient is asked which hand/finger is moved
1. Monocular visual field testing-the patient is asked simultaneously
when the finger can be seen
Ocular motility+conjugate gaze exam
• Oculomotor nerve (III)
• Trohlear nerve IV
• Abducens nerve VI

Abnormalities:
a. Diplopia
b. Dysconjugate gaze
c. Nystagmus?
Trigeminal nerve
• is divided into 3 branches: ophtalmic V1, maxillary branch V2 and
mandibular V3=provoides the sensory extinction of the face
• Test the tactile extinction using double simultanously stimulation
(altered in brainstem lesion, peripheric nerve lesions, but also parietal
opposite brain lesions)
• The corneal reflex by stimulating the corneea with a cotton wisp on
both sides =it is a polisynaptic reflex with the afference represented
by nerve V and closure of the eyelid on the same side through N VII
Facial nerve
• Inspection: asymmetry of the facials fold for ex the nasolabial fold is
not seen anymore; absence of the wrinkles of the forehead
• Active movements: ask the patient to smile, to puff out their cheeks
or to clench their eyes tight, to whistle, to frown, to raise the
eyebrowns, to wrinkle the forehead
• Can be central vs peripheral
Vestibulocohlear nerv (transmits sound and
balance from the inner ear to the brain)
• Rubble the fingers together for testing the auditory function
• Looking for nystagmus
• Pendular walking
• Romberg maneuver is testing the balance is performed by asking the
patient to stand straight to the exminator with leg tight togehter with
eyer opened andthen with eyes opened: is positive if there is an
increased lossed of balance after closing the eyes (proprioception is
affected)
IX, X and XI
• dysartria= altered pronunciation of speech (slurred speech)
Vs aphasia which means an abnormality in language production and
comprehension
• Dysphagia
• Dyphonia
-examine the elevation of the palate, if it is symmetrically, if the velum
is displaced, gag relfex with a spatula
- Test the function of the accesor of XI- raise the shoulder, turn the
head against the examinator resistance to both sides (innervates the
sternocleidomastoid and trapezius)
NXII-hypoglossal
• Inspection-observe when the tongue is resting in the mothe any
fasciculation or athrophy (are signs of lower motor neuron lesions-
ex.:lateral amyothrophic sclerosis=motor neuron disease)
• In unilateral lesions=when resting the tongue is deviated to the healty
side, ask the patient to stick out the toungue and move form side to
side; outside the tongue is deviated to the affected side through the
action of the genioglossus muscle
 Stance and gait
• Watch how the patients stand and walk!
• Tandem walking, posture,
standing on one foot, balance, hopping
etc.
• Possible with or without aid
Gait (and stance)
- How far apart the feet are
- Posture
- Stability
- How far feet are raised
- Circumduction
- Arm swing
- The tendency to fall or sway in any direction
 Coordonation and gait
- finger-nose-finger test
- heel-shin test
- Rapid alternaiting movements
(drum beating)

- Romberg test: to stand with their

feet together; eyes closed; stay near
to the patient in case the patient falls
or sways
Motor exam
• Inspection: muscle hyperthrophy/atrophy
• Examination: the patients holds up both arms simultanously with eyes closed.
Check if the arm drifts
• Grades of motor deficite:
• Grade 0 = no contraction
• Grade 1= only muscle contraction
• Grade 2 =active movement posibile with gravity eliminated (in plane of the bed,
can move slightly on the bed)
• Grade 3=active movement posibile-can be sustained against gravity but less than 5
seconds
• Grade 4= same and against resistance (a slightly weak muscle)
• Grade 5= normal
Patterns of weakness can help to localize the
lesion
• Cortex:disproportionat deficite; predominantly faciobrahial or curual
associated with cortical signs
• White matter: without cortical signs as aphasia, apraxia, agnosia
• Caspular infarcts: proportionated motor deficite
• Brainstem: alternating hemiplegia (cranial nerve palsy is on the same
side and hemiplegia is contralateral
• Spinal cord –cervical-hemiplegia only toracal and lumbar spinal cord-
crural weakness
• peripheral nerve (neuropathy-with distal weakness), nerv-muscle joint
(MG) or muscle (myopathis-with proximal weakness)
Patterns of weakness can help to localize the
lesion Indicates together with other symptoms the
Neurological Syndrom:
- Pyramidal syndrome
- Alternanting syndrom (brainstem)
- Spinal cord syndrome
- Myopathy (proximal m. weakness+DTR
normal or mild decreased, proximal
m.atrophy)
- Polyneuropathy (distal m.weakness+DTR
decreased/absent+sensory abnormalities,
distal m.atrophy)
DTR=deep tendon reflexes
Tone
• Hypotonia=often present in the first weeks (4-6 weeks) after upper
motor neuros lesion and than followed by hypertonia
• Hypertonia is typical for UMN lesions
• Hypotonia is typical for LMN
Testing through passive movements of each limb simultanously
If you can touch with the hand wrist the shoulder it is a sign for
hypotonia
If you can touch with the heel the buttock –hypotonia
Hypertonia can be of two types: spasticity (pyramidal) and rigidity
(extrapyramidal)
Deep tendon reflexes

• Hyporeflexia/arflexia= characteristical for LMN syndrome

• Hyperreflexia=characteristical for UMN syndrome
• Hyporeflexia can be present in the period of diaschisis for example in
stroke (few weeks)

• Plantar response
Phisiologically:in flexion bilateral
Pathologically: in extension bilateral=Babinski
 Senzory exam
- Touch sense- touching the patients simultanously on both sides of the body
- Pain sense – stimuli with sharp pin or broken wood stab (use for each patient
another)

- Temperature sensation can be tested with a cool piece of metal like the reflex
hammer

- Vibration sense is tested by placing a tuning fork on the ball of the large toe or
finger and asking the patient when vibration stops

- Joint position sense by moving the patients toe and finger upward and
downward and asking the patient with closed eyes to report which way it moves

Cortical sensation including extinction: graphestesia, stereognosis, tactile extinction

(on double stimulation)
 Language
• Dominant hemisphere lesions: Aphasia = is an impairment of the language, affecting the
production and comprehension of speech and the ability to write and/or to read

• Nondominant-hemisphere lesions: Dysarthria (slurred speech)= difficulties in

articulation and pronouncement of different words
 Types of aphasia (Two major types)
I. Non-fluent aphasia (motor aphasia): production is affected and comprehension
is preserved
• Most representative is Broca’s aphasia (lesion in the frontal lobe, 44 and 45
Brodmann area)
+ contralateral hemiparesis/-plegia
+ contralateral homonymous hemianopsia/contralateral quadrantic anopsia
+ ipsilateral gaze and head deviation (towards the lesion)
II. Fluent aphasia (sensory aphasia): production is preserved and comprehension
is affected
• Most representative is Wernicke’s aphasia (lesion in the superior temporal
gyrus, 22 Bodmann area)
+ contralateral upper quadrantanopia
+amnesia
+ behavior and personality disturbances
+/- mild contralateral hemiparesis and hemihypesthesia (hemi-hyposthesia)
Other types of language disturbances
• bradylalia= unusual slowness and hesitation in speech ( ex.: Parkinson
Disease)
• tahylalia= the opposite of bradylalia (patient with mania or
psychomotor agitation)
• Echolalia=non-voluntary repetition of phrases and/or word of another
individual (dementia, tics, ADHD, within aphasia)
• Coprolalia= involuntary swearing or use of inadequate words and
remarks (Tourette syndrome)
 Apraxia
• Inability to perform certain movements and tasks, in the absence of apparent
neurological insult to the motor, sensor or comprehension
General:
1. Ideational apraxia: failure to conceive the use of tools/ series of acts (for example
when writing a letter the patient may seal the envelope before inserting the letter)
2. Ideomotor apraxia: the patient may remember the planned action but cannot
execute it with either hand (ex.: cutting a piece of paper with scissor)
3. Conceptual apraxia= do not knows the meaning of objects/tools (mistakes the use of a screwdriver with a hammer)
4. Disassociation apraxia=cannot gesture normal to command but can use well with imitation tools and objects
5. Conduction apraxia= imitation is more impaired than others

Task-specific apraxia:
1. Gait apraxia (frontal lobe lesions) 2. Speech 3.Constructional (draw, construct, copy)
4. Apraxia agnosia
Apraxia-how to exam
• Simple command: ,,Close your eyes!?” (comprehension/motor-function
must be unimpaired)-not performing= ideational apraxia
• Complicated commands: ,,Put your right hand to the left ear!” or ,,Fold this
paper in thirds and put it on your right side!’’-not performing= ideomotor
apraxia
• Imitation of different movements more impaired than gesture to command=
conduction apraxia
• Imitation preserved but patient have difficulties with spontaneous response
to different commands=disassociation apraxia

Disease: left parietal stroke, neurodegenerative diseases (often in

dementia), traumatic brain injuries (TBI), brain tumors
 Information (for better understanding
apraxia)
Performing a gesture involves 3 stages:
1. Conception stage (area 40). Knowledge
and representations of objects and actions
are stored in parietal lobe (area 39 or
angular gyrus and area 40 or
supramarginal gyrus)
2. The stage of choosing the appropiate
kinetic formulas (premotor area or are 6)
3. The stage of the execution of the motor
act (primary motor area or 4 area)

Therefore lesions in dominant parietal and frontal

lobe can lead to apraxia!
 Continence of the sphincters
• Urinary incontinence (involuntary leakage of urine)
a. Stress incontinence= a small spurt of urinary leakage, caused by the incompetence of
urinary sphincter and/or weak pelvic floor muscle weakness
b. Urge/urgency incontinence=uncontrollable urgent desire to pass urine (overactive
bladder-AE of drugs/pshychogenic)
c. Complete acute incontinence=conus medullaris syndrome/cauda equine syndrome
(can be a red flag)
• Retention
a. Acute retention (frequently stroke patients habe bladder globe)-requires emercency
catetherization
b. Chronic (overflow incontinence)- prostate adenoma, myelopathies (cord transection
syndrome-spastic phase)
• Faecal incontinence (can be a red flag for acute, severe spinal cord injury)/constipation
Cognition

MMSE-interpretation:
20-25 points-mild cognitive
impairment
10-19 points-moderate
cognitive impairment
9 or lesser-severe cognitive
impairment
Notes:
MMSE is more popular but
MOCA is more confident