Neurological System

Examination

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 Objectives

• Identify the basic techniques used to assess the

neurological system
• Assess level of consciousness
• Assess cranial nerve
• Assess the motor system of the body
• Assess the sensory system of the body
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 Objectives …

• Assess the reflexes

• Relate assessment finding of the neurological
system with finding of other system
• Differentiate “normal” from “abnormal”
findings on neurological examination

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 Components of Complete Neurological
Examination

1. Mental status exam

2. Cranial nerves assessment
3. Motor system assessment
4. Sensory system assessment
5. Reflex testing
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 1. Mental status examination

• Mental status assessment include assessment

of appearance (A), behavior (B), cognition
(C)and thought process (T).

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 1.1 Appearance
• Look for posture. Normally it is erect and
position is relaxed.
• Normal body movements are voluntary,
deliberate, coordinated, smooth and even.
• Dress should be appropriate for setting,
season, age, gender and social group.
• Note grooming & hygiene. Normally it should
be clean well-groomed, and hair should be neat
and clean.
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 1.2 Behavior
1. Level of consciousness: look, is the person
awake, alert and aware of stimuli from the
environment and responds appropriately?
2. Facial expression: look, is facial expression
appropriate to the situation and changes
appropriately with the topic?
3. Speech: Pace of conversation should be
moderate and stream of talking should be
fluent. Articulation should be clear and
understandable.

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 Behavior …

4. Mood (affect): judge the mood of the patient.

You can do this in two ways:
1. Focus on body language and facial
expression
2. Ask directly “how do you feel today?”

 The mood should be appropriate to the

person’s place & and should change
appropriately with topic.
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 Level of consciousness

1. Normal/alert/awake-aware: spontaneous
eye opening and responding to command
 The patient is awake verbally and
motorally responsive.

2. Drowsy/lethargy:
Drowsy/lethargy awake in response to
stimuli (loud noise or deep pain stimuli),
answering to simple questions, falling asleep
if not stimulated
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 Level of consciousness …

3. Stuporous: eye opening in response to deep

pain, answering simple questions with yes or
no.
 The patient becomes unconscious
spontaneously and is very hard to
awaken.
4. Comatose: no eye-opening in response to
pain. The patient is completely unresponsive

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 The Glasgow coma scale (GCS)

• The GCS evaluates consciousness by scoring

a response in three areas: eye opening,
motor response and verbal performance.

• The application of the GCS requires skill to

achieve consistency in scoring.

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 Assess grades of best motor response

6= Carrying out request ('obeying command')

5= Localizing response to pain.
4= Withdrawal to pain - pulls limb away from
painful stimulus.
3= Flexor response to pain - pressure on nail
bed causes abnormal flexion of limbs
2= Extensor posturing to pain - stimulus causes
limb extension
1= No response to pain
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 Assess grades of best verbal response

5= Oriented - patient knows who & where they

are, and why, and the year, season & month.
4= Confused conversation - patient responds in
conversational manner, with some
disorientation and confusion.
3= Inappropriate speech - no conversational
exchange.
2= Incomprehensible speech - no words uttered,
only moaning but no words.
1= No verbal response.
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 Eye opening

4= Spontaneous eye opening.

3= Eye opening in response to speech - that is,
any speech or shout.
2= Eye opening in response to pain.
1= No eye opening.

• TOTAL SCORE ...... 15

• Score of 4-7 is coma
• Score of ≤ 3 is deep coma
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 1.3 Cognitive functions
Orientation: assess the following:
1. Time: by asking day of week, date or year
2. Place: ask present location or name of city
3. Person: ask own name, age, or name of well-
known person.
• Disorientation can occur with organic brain
disorders.
• Orientation is usually lost first to time, then to
place, and finally to person.
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 1.4 Thought Process & Perceptions
1. Thought process: to check this ask your self
“does this person make sense? Can I follow
what the person is saying?”
• The way a person thinks should be logical, goal
directed, coherent and relevant.
• The person should complete a thought.
• As abnormalities with thought process there
may be illogical, unrealistic thought process &
evidence of blocking.
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 Thought Process & Perceptions …

2. Thought content: what the persons says

should be coherent and consistent as well as
logical.

3. Perceptions: the person should consistently

be aware of reality and his perceptions
should be congruent with your own (the
examiner’s).

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 Thought Process & Perceptions …

• Ask questions like “how do people treat

you? Do other people talk about you? Do
you feel you are being watched or
followed?” just to check the perceptions of
your patient.

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 Thought Process & Perceptions …

• Obsessions and compulsions are

abnormalities of thought content.
• Illusion and hallucinations are abnormalities
of perception.
• Auditory and visual hallucination occur with
psychiatric and organic brain disorders.
• Tactile hallucination occur with alcohol
withdrawal.
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 2. Motor System Examination
2.1 Balance tests

• In this part cerebellar function is assessed.

1.Gait
• Observe the person while walks, turns and
returns.

• Normally the gait is smooth, rhythmic and

effortless.
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 Balance tests …

 As the person to walk straight line in a heel-to-

toe fashion (tandem walking).

 Normally the person can walk straight and stay

balanced.

 Abnormalities such as staggering or loss of

balance can be detected

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 Balance tests …

2. Romberg Test
• Ask the person to stand up with feet together
and hands at sides.
• Once in a stable position, ask the person to
close his eyes and hold the position.
• Wait about 20 seconds.
• Normally posture and balance are
maintained.
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 Balance tests …

• Positive Romberg’s sign is loss of balance with

closing of eyes that occur with cerebellar
ataxia and loss of vestibular function.

• Ask the person to hop first on one leg, and

then on the other.

• This demonstrates muscle strength and

cerebellar function.

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 Romberg Test

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 2.2 Coordination & Skilled Mov’t

1. Rapid alternating movement (RAM)

• Ask the person to pat knees with both hands,
lift up, turn hands over and pat the knees with
backs of hands.

• Then ask the person to do this faster.

• Normally, this is done with equal turning and

a quick rhythmic pace.
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 Coordination & Skilled Mov’t …

• Alternatively, ask the person to touch the

thumb to each finger on the same hands,
starting with index finger, then reverse the
direction.

• Normally, this can be done quickly and

accurately.

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 Coordination & Skilled Mov’t …

• Abnormally, lack of coordination can be

detected with cerebellar disease.

• Failure to do this rapid movement is known

as Dysdiadochokinesia.

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 Coordination & Skilled Mov’t …

2. Finger-to-finger test
• With the persons eyes open, ask the person to
touch your index finger with his index finger,
and then his own nose with the same index
finger.
• After some time move your finger to a
different spot.
• Normally, the person’s mov’t should be
smooth and accurate. Abnormally, the person
misses.
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 Coordination & Skilled Mov’t …

3. Finger-to-nose test
• Ask the person to close his eyes and to stretch
out his arms.
• Ask the person to touch the tip of his/her nose
with each index finger, alternating hands and
increasing speed.
• Normally, it is done with accurate and smooth
movement. Abnormally, the person misses
nose.
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 Coordination & Skilled Mov’t …
4. Heel-to-shin test
• Test the coordination of lower extremity by
asking the person, who is in a supine position,
to place the heel on the opposite knee and run
it down the shin from the knee to ankle.
• Normally, moves the heel in straight line
down the shin.
• Abnormally, lack of coordination or heel falls
off shin.
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 Heel-to-shin test

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 3. Sensory System Assessment
Pattern of testing

• Pay special attention to those areas:

1.Where there are symptoms such as numbness

or pain

2. Where there are motor or reflex abnormalities

that suggest a lesion of spinal cord or
peripheral nervous system

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 Pattern of testing …

3. Where there are tropic changes such as absent

or excessive sweating
The following pattern of testing help you to
identify sensory deficit accurately and
efficiently

1. Compare symmetrical areas on two side of the

body including leg, arm, and trunk
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 Pattern of testing …

2. When testing pain, temperature and touch

sensation and compare the distal with the
proximal area of the extremities.

3. Before each test, show the pts what you plan to

do and what respond you want. Unless
otherwise specified the pts eyes should be
closed during actual testing

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 3.1. Pain

• Pain is tested by the person’s ability to

perceive a pin prick.
• Using a sterile needle, lightly apply the sharp
point or the dull to the person’s body in a
random and ask the person to say “sharp” or
“dull” depending on the sensation felt.
• Abnormalities are hypoalgesia (decreased pain
sensation), analgesia, hyperalgesia (increased
pain sensation)
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 3.2. Temperature

• This is often omitted if pain sensation is

normal, but include it if there is any question

• Use 2 test tubes filled with hot and cold water

or a tuning fork heated or cooled by water,
touch the skin and ask pt to identify “hot” or
“cold”.

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 3.3. Light touch

• Apply a wisp of cotton to the skin randomly

including arms, forearms, face, chest and legs.

• Ask the person to say “now” or “yes” when

touch is felt.

• Compare symmetric points.

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 3.4. Vibration
• Test the person’s ability to feel vibration of a
tuning fork over bony prominences.
• Strike on the heel of your hand, and hold the
base on the bony surface of fingers and great
toe.
• Ask the person to indicate when the vibration
starts and stops.
• Loss of vibration sensation occurs with
peripheral neuropathy. E.g. DM, alcohol
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 3.5. Stereognosis

• Test the person’s ability to recognize objects by

feeling their forms, size and weights.
• With eyes closed, place a familiar object (paper,
clip, key, coin, cotton ball or pencil) in the
person’s hand and ask the person to identify it.
• Normally, will be explored and identified.
• Astereognosis: unable to identify object which
occurs with sensory cortex lesion
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4. Cranial Nerves Assessment

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 CN I: Olfactory Nerve

• Test the sense of smell by presenting the

patient with familiar and nonirritating odors.

• First, assess patency by occluding one nostril at

a time and asking the person to sniff.

• Then with the person’s eyes closed, occlude

one nostril and then present an aromatic
substance such as coffee, orange, soap.
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 Olfactory Nerve …
• Function: special sensory ie sense of testing
• Testing:
• Use 2-3 vials of familiar odors eg lemon,
coffee…
• Test one nostril at a time with patient’s eyes
closed
• Use least irritating scent first and allow the
patient to rest in between vials
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 Olfactory Nerve …

• Assessment - identify familiar testing

• Signs of Dysfunction: anosmia

• Loss of smell has many causes, including

nasal disease, head trauma, smoking, aging,
and the use of cocaine.

• It may be congenital

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 CN II: Optic Nerve

• Function: special sensory-Test visual acuity

• Name & Location: retina
• Testing: Snellen eye chart, visual fields via
confrontation and pupillary light reflex.
• Signs of Dysfunction
• Blindness
• Loss of pupillary constriction (sensory)

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 CN III: Occulomotor Nerve

• Function:
– Muscles that move the eye, lid, papillary
constriction, lens accommodation
• Testing:
• Six Cardinal Fields of Gaze
• Pupillary Light reflex: (motor)
• Accommodation

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 Occulomotor Nerve …

• Assessment
– Test for ocular rotation, nystagmus,
Papillary reflexes, check for ptosis

• Signs of Dysfunction:
• Eye turned down & out w/ ptosis
• Mydriasis, Loss of accommodation,
Diplopia

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 CN IV: Trochlear Nerve

• Motor
• Function
– Muscles that move the eye, lid, papillary
constriction, lens accommodation

• Assessment
– Test for ocular rotation, nystagmus,
Papillary reflexes, check for ptosis

– Signs of Dysfunction: Vertical diplopia.

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 CN V: Trigeminal Nerve
1. Motor function: Assess the muscles of
mastication by palpating the temporal and
masseter muscles as the person clenches
his/her teeth.
• Muscles should equally feel strong on both
sides.
• Try to separate jaw by pushing down on the
chin. Normally you can not.
• Decreased strength on one or both sides,
asymmetry in jaw, or pain are abnormal
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 Trigeminal Nerve …

2. Sensory function: with the persons eyes

closed, test light touch sensation by touching
with a cotton wisp on forehead, chicks and
chin.
• Ask the person to say “now” whenever the
touch is felt.
• This tests all the three divisions of the nerve:
1, ophthalmic 2, maxillary and 3, Mandibular.
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 Trigeminal Nerve …

3. Corneal reflex: with the person looking

forward, bring a wisp of cotton and touch
gently the cornea on the outer aspect of the
each eye.
• Normally, the person will blink bilaterally.
• No blinking indicates cranial nerve V
lesion/paralysis.

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 CN VI: Abducens Nerve

• Motor
• Function
– Muscles that move the eye, lid, papillary
constriction, lens accommodation
• Assessment
– Test for ocular rotation, nystagmus,
Papillary reflexes, check for ptosis

• Signs of Dysfunction: Horizontal diplopia and

medial deviation of the eye
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 CN VII: Facial Nerve

1. Motor function
• Note mobility and facial symmetry as the
person smiles, frowns, closes eyes tightly, lifts
eye brows, shows teeth and puffs cheeks.

• Press the puffed cheeks. Air should escape

equally from both sides.

• Abnormality: muscle weakness

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 Facial Nerve …

2. Sensory function: not routinely tested.

• If indicated test sense of test by applying to

the tongue a cotton applicator covered with a
small amount of sugar, salt or lemon juice.

• Ask the person to identify the test.

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 CN VIII: Acoustic Nerve
(Vestibulocochlear)
Vestibulocochlear

• Special sensory
• Function - hearing & equilibrium
• Testing: hearing tests: Rinne, Weber,
• Signs of Dysfunction:Vertigo, nystagmus,
disequilibrium and sensorineural deafness

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 CN IX (glossopharyngeal) & X (vagus)
Nerves

1. Motor function
• Depress the tongue with a tongue blade and
note pharyngeal movement as a person says
“ahh…”
• Normally, uvula and soft palate rises in
midline.
• Abnormally, uvula deviates to one side.
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 CN XI: Spinal Accessory Nerve

• Function: somatic motor

• Testing: Resisted shoulder elevation & head

rotation

• Signs of Dysfunction: Atrophy & Weakness,

fasciculations and neck or shoulder deviation

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 CN XII: Hypoglossal Nerve

• Function: somatic motor

• Testing:
– Stick out tongue
– Press tongue against check while palpating
to test muscle strength
– Articulation of hard consonants: ‘L’, ‘T’, ‘D’,
& ‘N’.
• Signs of Dysfunction: Atrophy & weakness,
deviation and dysarthria-imperfect
articulation of speech
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 5. Reflexes assessment

• Reflexes are movements produced in body

parts when hammering a tendon in a body.

• Ask the patient to relax, position the limbs

properly and symmetrically, and strike the
tendon briskly, using a rapid wrist movement.

• Your strike should be quick and direct, not

glancing.
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 Reflexes …

• Hold the reflex hammer between your thumb

and index finger so that it swings freely within
the limits set by your palm and other fingers.

• Note the speed, force, and amplitude of the

reflex response.

• Always compare one side with the other.

• Reflexes are usually graded on a 0 to 4+ scale:

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 Reflexes …
• 4+ Very brisk, hyperactive, with clonus
(rhythmic oscillations between flexion and
extension)
• 3+ Brisker than average; possibly but not
necessarily indicative of disease
• 2+ Average; normal
• 1+ Somewhat diminished; low normal
• 0 No response
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 Reflexes …

• Hyperactive reflexes suggest central nervous

system disease. Sustained clonus confirms it.

• Reflexes may be diminished or absent when

sensation is lost, when the relevant spinal
segments are damaged, or when the peripheral
nerves are damaged.

• Diseases of muscles and neuromuscular

junctions may also decrease reflexes.
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 The Biceps Reflex (C5, C6)

• The patient’s arm should be partially flexed at

the elbow with palm down.
• Place your thumb or finger firmly on the biceps
tendon.
• Strike with the reflex hammer so that the blow
is aimed directly through your digit toward the
biceps tendon.
• Observe flexion at the elbow, and watch for and
feel the contraction of the biceps muscle.
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 The Triceps Reflex (C6, C7)

• Flex the patient’s arm at the elbow, with palm

toward the body, and pull it slightly across the
chest.
• Strike the triceps tendon above the elbow.
• Use a direct blow from directly behind it.
• Watch for contraction of the triceps muscle and
extension at the elbow.
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 The Triceps Reflex (C6, C7)

• If you have difficulty getting the patient to

relax, try supporting the upper arm as
illustrated on the right.

• Ask the patient to let the arm go limp, as if it

were “hung up to dry.”

• Then strike the triceps tendon.

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 The Supinator or Brachioradialis Reflex
(C5, C6)

• The patient’s hand should rest on the

abdomen or the lap, with the forearm partly
pronated.

• Strike the radius about 1 to 2 inches above the

wrist.

• Watch for flexion and supination of the

forearm.
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 The Abdominal Reflexes

• Test the abdominal reflexes by lightly but

briskly stroking each side of the abdomen,
above (T8, T9, T10) and below (T10, T11, T12)
the umbilicus, in the directions illustrated.

• Use a key, the wooden end of a cotton tipped

applicator, or a tongue blade twisted and split
longitudinally.

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 The Abdominal Reflexes …

• Note the contraction of the abdominal

muscles and deviation of the umbilicus toward
the stimulus.
• Obesity may mask an abdominal reflex.
• In this situation, use your finger to retract the
patient’s umbilicus away from the side to be
stimulated.
• Feel with your retracting finger for the
muscular contraction.
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 The Abdominal Reflexes …

• Abdominal reflexes may be absent in both

central and peripheral nervous system
disorders.

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 The Knee Reflex (L2, L3, L4)

• The patient may be either sitting or lying

down as long as the knee is flexed.
• Briskly tap the patellar tendon just below the
patella.
• Note contraction of the quadriceps with
extension at the knee.
• A hand on the patient’s anterior thigh lets you
feel this reflex.
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 The Knee (Pattelar) Reflex (L2, L3, L4)

• When examining the supine patient, rest your

supporting arm under the patient’s leg.

• Some patients find it easier to relax with this

method.

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 The Ankle (Achilles)
Achilles Reflex
(primarily S1)

• If the patient is sitting, dorsiflex the foot at the

ankle.
• Persuade the patient to relax.
• Strike the Achilles tendon.
• Watch and feel for plantar flexion at the ankle.
• Note also the speed of relaxation after
muscular contraction.
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 The Ankle Reflex …

• When the patient is lying down, flex one leg at

both hip and knee and rotate it externally so
that the lower leg rests across the opposite
shin.

• Then dorsiflex the foot at the ankle and strike

the Achilles tendon.

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 The Plantar Response (L5, S1)

• With an object such as a key or the wooden

end of an applicator stick, stroke the lateral
aspect of the sole from the heel to the ball of
the foot, curving medially across the ball.

• Use the lightest stimulus that will provoke a

response, but be increasingly firm if necessary.

• Note movement of the toes, normally flexion.

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 The Plantar Response (L5, S1)

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 The Plantar Response (L5, S1)

• Dorsiflexion of the big toe, often accompanied

by fanning of the other toes, constitutes a
Babinski response.
• It often indicates a central nervous system
lesion in the corticospinal tract.
• A Babinski response may also be seen in
unconscious states due to drug or alcohol
intoxication or in the postictal period
following a seizure.
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 Meningeal Signs

• Testing for these signs is important if you

suspect meningeal inflammation from
infection or subarachnoid hemorrhage.

Neck Mobility
• First make sure there is no injury to the
cervical vertebrae or cervical cord.
• (In settings of trauma, this may require
evaluation by x-ray.)
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 Meningeal Signs …

• Then, with the patient supine, place your

hands behind the patient’s head and flex the
neck forward, until the chin touches the chest
if possible.
• Normally the neck is supple and the patient
can easily bend the head and neck forward.
• Pain in the neck and resistance to flexion can
arise from meningeal inflammation, arthritis,
or neck injury.
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 Meningeal Signs …

• As you flex the neck, watch the hips and knees

in reaction to your maneuver. Normally they
should remain relaxed and motionless.

• Flexion of the hips and knees is a positive

Brudzinski’s sign and suggests meningeal
inflammation.

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 Meningeal Signs …

• Flex the patient’s leg at both the hip and the knee,
and then straighten the knee.
• Discomfort behind the knee during full extension
occurs in many normal people, but this maneuver
should not produce pain.
• Pain and increased resistance to extending the
knee are a positive Kernig’s sign.
• When bilateral, it suggests meningeal irritation.
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