The Neurological Examination
Neuro Exam Tools
128-Hz
7 categories of the neurological exam Mental status
Cranial nerves
Motor system
Reflexes
Sensory system
Coordination
Station and gait
7 components of the mental status exam
Level of consciousness Attention Orientation Language fluency, comprehension, repetition,
naming, reading, writing Memory immediate recall, recent, remote
Higher intellectual functiongeneral knowledge,
abstraction, judgment, insight, reasoning
Mood and affect
CNI: Olfactory nerve
Cannot evaluate if nasal passages obstructed by rhinitis, polyps, etc. Eyes closed Occlude one nostril and test other Compare 2 sides Use nonirritating substances Avoid those that stimulate trigeminal nerve endings or taste buds (e.g., peppermint, menthol, ammonia)
CNII: Optic nerve
Visual acuity
Visual fields
Fundoscopy
Afferent limb of pupillary function
CNII: Visual acuity
Hold card at comfortable reading distance Cover 1 eye Glasses on (looking for optic nerve lesion, not refractive error)
CNII: Visual fields
60
75
100 60
Greenberg Clinical Neurology, 1993
CNII: Fundoscopic exam
CNII & III: Pupillary function
Normal pupils are equal in size and shape and are situated in center of iris Pupillary size varies with intensity of ambient light, but at average intensity is 3-4 mm Miosis < 2 mm Mydriasis > 5 mm Anisocoria = pupillary asymmetry
CNII & III: Light reflex
Dim lights
Fix gaze on opposite wall to eliminate effects of accommodation Shine bright light obliquely into each pupil
Look for both direct (same eye) and consensual (opposite eye) reaction Record pupil size and shape
CNII & III: Accommodation
Hold finger 10 cm from patients nose Alternate looking into distance and at finger Observe pupillary response
CNIII, IV, VI: Ocular nerves
CNIII Oculomotor nerve CNIV Trochlear nerve CNVI Abducens nerve
Visual inspection: ocular alignment, lids Convergence Smooth pursuits Saccades Nystagmus 6 cardinal directions of gaze
Smooth Pursuits
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Saccades
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Optokinetic Nystagmus
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Extraocular movements
III inferior oblique III superior rectus
Nasal
medial rectus III superior oblique inferior rectus III lateral rectus
Temporal
VI
IV
CNV: Trigeminal nerve
C2
C3
CNV: Trigeminal nerve
Corneal reflex
(CN V-afferent limb CN VII-efferent limb)
Masseter strength Jaw jerk
Corneal Reflex
CNVII Facial nerve
Loyola University Medical Education Network
CNVIII: Auditory nerve
Hearing (cochlear nerve)
Test with finger rubbing at arms length If cant hear strong rubbingimpaired If can hear faint rubbingnormal
Tuning fork tests (Weber, Rinne) have extremely poor sensitivity
CNIX & X: Glossopharyngeal & vagus nerves
Testing centers on motor function
Palate elevation
Swallowing
Voice
Cough
Gag reflex
Examination of the palate
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CNXI: Spinal accessory nerve
Trapezius
Push head back against resistance
Shrug shoulders
Sternocleidomastoid Place hand on lower face and have patient rotate head toward that side Observe contraction of opposite SCM
CNXII: Hypoglossal nerve
Note tongue position at rest and on protrusion
Does tongue deviate in either position?
Note strength and rapidity of movements
Have patient push tongue into each cheek
Motor exam
Compare left to right, proximal to distal, arms to legs Bulk (muscle mass)
Tone (muscle tension at rest)
Test with passive manipulation
Strength
Speed of movement; extraneous movement
Endurance
Muscle strength testing
Direct muscle strength testing more sensitive to lower (alpha) motor neuron dysfunction, while tests of dexterity/coordination more sensitive to upper motor neuron (corticospinal tract) dysfunction
Isolate muscle
Fix proximal joint when testing distally Always give yourself the advantage Increase sensitivity in lower extremities with heel/toe walking and deep knee bend
Normal variabilityage, sex, muscle, handedness
Giveway weakness
Grading muscle strength
(Medical Research Council scale)
0 1 2 3
No muscular contraction Visible muscle contraction, but no movement at joint
Movement at the joint, but not against gravity Movement against gravity, but not against resistance Movement against some resistance, but < full Movement against full resistance; normal strength
4
5
Upper extremity muscles you should know how to test
Deltoidabduction (elevation) of upper arm Bicepsflexion of forearm at elbow Tricepsextension of forearm at elbow Extensor carpi radialisdorsiflexion of hand at wrist Abductor pollicus brevispalmar abduction of thumb (C8-T1, median nerve) w/ thumb at right angle to palm Interroseifinger abduction (dorsal) & adduction (palmar)
(C8-T1, ulnar nerve) (C5-6, radial nerve) (C6-8, radial nerve) (C5-6, musculocutaneous nerve) (C5-6, axillary nerve)
Lower extremity muscles you should know how to test
Iliopsoaship flexion (L1-3, femoral nerve) Quadricepsknee extension
Hamstringsknee flexion Tibialis anteriorankle dorsiflexion Gastrocnemius/soleusankle plantar flexion
(S1-2, tibial nerve) (L4-5, deep peroneal nerve) (L2-4, femoral nerve)
(L5-S2, sciatic nerve)
Muscle stretch reflexes
Biceps (C5, C6; musculocutaneous)
Triceps (C6, C7; radial)
Patellar (L2-L4; femoral)
Ankle (S1-S2; tibial)
Reflex grading
0 1 2 3 4 absent hypoactive normal brisk/hyperactive markedly hyperactive with clonus
Biceps reflex
Triceps reflex
Knee Jerk
Ankle Jerk
Reflexes: Reinforcement
Isometric contraction
of other muscles (Jendrassik maneuver, teeth clenching)
Distraction Slight tension in muscle
group being tested
Haerer DeJongs The Neurologic Exam, 1992
Superficial reflexes
Plantar (L4-S2, esp S1; tibial nerve)
Babinski, etc.
Normal response = flexion (toes go down)
Abnormal response = extension (dorsiflexion of great toe as the extensor hallucis longus is recruited)
Sign of hyperexcitability associated with corticospinal dysfunction
Plantar reflex
Plantar reflex
Sensory Exam: General Points
Explain each test before you do it
Patients eyes should be closed during testing
Test all 4 extremities
Avoid leading questions like Is this sharp?
Compare side-to-side and distal-to-proximal asking if they are about the same When you detect an area of sensory loss, map out its boundaries in detail
Sensory exam
Primary sensation Pain and temperature Light touch/pressure Vibration Proprioception
Characterize as normal, absent, reduced, exaggerated, or perverted (dysesthesias)
Integrative sensation Graphesthesia Stereognosis Double simultaneous stimulation
Vibration sense
128-Hz tuning fork
Test toe & finger
What do you feel?
Count seconds til stops
Compare side to side
If impaired, move proximally
Joint position sense
Test toes and fingers Move digit only a few degrees If impaired, move digit greater distance -> test more proximally
Patten Neurologic Differential Diagnosis
Pain sensation
Test for distal gradient of sensory loss in the leg Test for sensory loss in most commonly affected nerve and nerve root distributions Palmar aspect of index finger (median nerve). Palmar aspect of 5th finger (ulnar nerve) Web space between thumb and index finger on dorsal surface of hand (radial nerve). Lateral surface of foot (L5). Posterior aspect of leg (S1). Ask patient if the sensation is about the same
Light Touch & Double Simultaneous Stimulation
Lightly touch face and extremities in random order, asking patient to respond whenever a touch is felt
Touch both sides of face or body simultaneously, asking patient to indicate whether touch is felt on left, right, or both sides
Stereognosis & Graphesthesia
Romberg sign
Ability to maintain upright position with feet together and eyes open Sway/fall when eyes closed Indicates impaired proprioception or vestibular dysfunction
Coordination
Control, precision, rhythm, synergy of movement Test at rest and with action in trunk and limbs Finger-nose-finger Rapid alternating movements Heel-knee-shin Finger or toe tapping
Gait
Posture of body and limbs
Length, speed, and rhythm of steps
Symmetry and base of gait
Steadiness Arm swing Turns Test with normal gait, toe walking, heel walking, tandem walking
Meningeal signs
Neck mobilitylook for nuchal rigidity (neck stiffness)
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Movies marked as from NeuroLogic Exam and PediNeuroLogic Exam movies are used by permission of Paul D. Larsen, M.D., University of Nebraska Medical Center and Suzanne S. Stensaas, Ph.D., University of Utah School of Medicine. Additional materials were drawn from resources provided by Alejandro Stern, Stern Foundation, Buenos Aires, Argentina; Kathleen Digre, M.D., University of Utah; and Daniel Jacobson, M.D., Marshfield Clinic, Wisconsin. Subsequent re-use of any materials outside of this program, presentation, or website requires permission from the original producers. Contact SLICE@media.utah.edu.
