Neurological Examination

Indiana University Department of Neurology

OverviewLearn / do in organized sequence General

Vital signs: wt, pulse , BP, temp ( respirations) Skin for café au lait, meningococcal purpura, splinter

hemorrhages Measure OFC ( head size) in kids Listen for bruits in neck ( carotid or vertebral arteries)

Neurological exam Mental status Cranial nerves Motor exam Cerebellar Sensory Station & Gait

Mental StatusMental Status Level of consciousnessLevel of consciousness

Alert Sleepy but awakens to verbal prompting ( Lethargic) Unresponsive to painful stimuli ( Comatose)

OrientationOrientation To person, place, time, situation

Speech & LanguageSpeech & Language Normal Dysarthric (slurred, nasal) Use of language in symbolic sense Fluency, comprehension, repetition Aphasia: expressive (Broca)/ receptive (Wernicke)

Mental Status

Parietal Functions Spatial orientation

( R /L) Construction Calculation Stereognosis Gnosis (awareness)

agnosagnosia

CN I Olfactory nerve

Check each nostril individually with patient’s eyes closed

Use coffee, mint, vanilla, clove

Not ammonia (checks V2)

Anosmia in head trauma frontal lobe tumor Parkinson’s & Alzheimer’s

Optic System: Overview

Functions: Data acquisition &

transmission Camera control

Eye lids Eye movements Focus

CN II Optic nerve Visual acuity Visual fields Pupillary light reflex

CN 2 Afferent CN 3 Efferent

Funduscopic exam

Visual acuity

Visual acuity Corrected (with glasses)

OS left OD right

Ask patient to start at top read down the chart

VA is last line read correctly

Visual fields

Pt looks at your forehead Check each eye alone Keep equidistance

between you and patient Count fingers in the 4

visual field quadrants Bring in your finger

inward from beyond your periphery to define pts field

Pupillary light reflex Direct and consensual

Observe pupil size ( mm) Shine light into eye from off center Observe for pupillary constriction in stimulated &

opposite eye

Accomodation As pt looks at close target; eyes converge and pupils

constrict Relative afferent pupillary defect (RAPD)

Light in abnl eye after good eye shows pupil dilation rather than constriction

Present with optic nerve lesions

Relative afferent pupillary defect

Optic disk ( optic nerve head)

Retinal vessels Retina

Fundoscopy (ophthalmoscope)

CN II Optic Nerve

Normal Papilledema

CN III (oculomotor), IV (trochlear), VI (abducens) Are the eyes

conjugate Puplliary function Evaluate motility

Horizontal Vertical Oblique

Disorders Nerve ( nucleus) Intra-nuclear Supra-nuclear

Extraocular muscles and their actions•CN III (Oculomotor nerve)

•Superior rectus:

•elevation when the eye is aBducted

•Inferior rectus:

•depression when the eye is aBducted

•Medial rectus: aDduction

•Inferior oblique:

•elevation when the eye is aDducted

•CN IV (Trochlear nerve)

•Superior oblique:

•depression when the eye is aDducted

•CN VI (Abducens nerve)

•Lateral rectus: aBduction

CN III—lesion causes eye motility problems, ptosis and mydriasis (enlarged pupil)

Third nerve palsy Eye is “down and out”

Pupil abnormalCompression by uncal

herniation or

P-com aneurysm

Pupil normal Nerve infarction

Left IV nerve palsy

Left hypertropia

Right head tilt….What about the doll’s eyes?

INO (Internuclear ophthalmoplegia)

Medial Longitudinal Fasciculus ( MLF) Lesion

CN V Trigeminal

Sensory to face and anterior scalp

Blink reflex Motor to muscles of

mastication (masseter/temporalis)

Test 3 divisions with cotton & pin

Jaw jerk reflex

CN VII -Facial nerve

Squeeze eyelids closed (like soap in eyes)

Raise eyebrows Smile / pucker Sneer (platysma)

Taste

Facial Nerve VII relaxed

Facial Nerve VII contraction

Corneal reflex afferent 5; efferent 7

CN VIII Vestibulo-cochlearTwo divisions:

Vestibular: head motion sensing Vertigo / nystagmus / veering gait

Cochlear: Auditory acuity finger rustle / ticking watch Rinne test: use tuning fork & compare perception

of sound via bone and air. In a normal ear air conduction > than bone conduction.

Weber test: tuning fork on the patients forehead. Normal: patient hears sound equally in both ears. .

CN IX Glossopharyngeal& X Vagus Palatal elevation Gag reflex

(sensory

& motor) Laryngeal

function

CN XI -- Spinal Accessory SCM--Right SCM turns head to the left Trapezius

Raise shoulders

CN XII Hypoglossal

Inspect bulk of tongue Protrude tongue

midline vs deviation to one side

Ask to press tongue against inside of cheek

Tongue deviates to the weak side

Motor Exam Inspection

atrophy, hypertrophy, fasciculation Involuntary movements

tremor, chorea, dystonia, myoclonus, myotonia Muscle Tone (resistance to passive movement)

Hypotonia (floppy) Hypertonia

Spasticity Clasp-knife Rigidity (Lead pipe)

Strength (grade 0 to 5) 0/5 no contraction, 3/5 overcomes gravity, 5/5 normal

Muscle stretch reflexes (0-4+) r” Plantar response: flexor or extensor (Babinski)

Upper versus Lower motor neuron lesions

Sign UMN LMN

Atrophy +/- yes

Weakness yes yes

Fasciculations no yes

Muscle tone inc dec

Reflexes inc dec

Motor Exam

Atrophy of intrinsic hand muscles

Calf muscle hypertrophy

Check strength proximal to distal

shoulder abduction (deltoid) elbow flexion/extension wrist flexion/extension finger flexion/extension finger abduction/adduction

hip flexion, abduction/adduction knee extension/flexion ankle extension (dorsiflexion) / plantar flexion toe extensors / flexors/ abductors

Muscle stretch reflexes

Reflex Nerve rootBiceps C5 & 6Brachioradialis C5Triceps C7Knee ( quadriceps) L3 & 4Ankle ( gastroc/soleus) S1Masseter CN V

Muscle stretch reflexes (MSR)

Usually graded 0 to 4 +

0 no response

1+ present but slight in magnitude

2+ present, easily observable

3+ present, “don’t stand in front of pt”

4+ present, recurrent contractions (clonus)

Testing for ankle clonus (4+)

Plantar reflex

Toe flexion is normal. Toe extension is abnormal ( Babinski sign)

Superficial Abdominal Reflex

Stroke anterior abdominal skin toward umbilicus

Rectus muscles Contract in quadrantstimulated

Other superficial reflexes

Tremor types

Resting tremor : present when limb is relaxed or not in active use Parkinson’s & related disorders

Action / postural tremor :present when body part is in sustained posture ( holding phone, newspaper) Physiological, familial

Intention tremor: present when limb actively / quickly being moved (eating, pointing, applying makeup) Cerebellar lesions

Cerebellar Functions

Nystagmus (jerky eye movments) Dysarthria (scanning / ataxic speech) Finger-nose-finger Rapid alternating movements (hands) Heel -knee -shin Tandem gait ( heel to toe walking)

Cerebellar testing requires cooperative patient

Cerebellar: finger-nose finger

Patient extends finger out to your finger

Then moves finger back to nose

The back to your finger

Repeat with your finger in different position

Cerebellar: finger to nose

Pattern of dysfunction: Actions break into

jerky steps Target may be

missed (dysmetria)

Guy in movie Airplane with the “drinking problem”

Cerebellar: heel to shin testingCerebellar: heel to shin testing

Patient flexes hip to place heel to knee

Runs heel smoothly down the crest of tibial ( shin) to ankle

Abnormal: heel oscillates above knee & slips off shin

Sensory Examination

Sensory Modalities: Light touch* Vibration* (dorsal column) Pin* (spinothalamic) Temperature (spinothalamic) Position (dorsal column)

* = most commonly performed in routine examinations

Sensory Examination

Light touch Use cotton ball Patient closes eyes Present stimulus & ask for response Move from abnormal area to normal

Sensory Examination

Vibration Tuning fork ( 128 Hz preferred) Apply stimulus to toe or finger Yes / No response or have patient tell when vibration

stops If abnormal distally move proximally: ankle knee wrist

elbow

Significance of deficits which split the forehead or chest

Sensory Examination

Pin ( pain) sensation Use safety pin or broken cotton swap stick Ask patient to distinguish pin from opposite end

of safety pin ( or your finger tip) Identify abnormal areas and then find normal

ones: distal / proximal vs dermatomal

Sensory Examination

Position Sense Use toes & fingers Patient closes eyes Move part from straight (neutral) position

into either flexion (down) or extension ( up) Patient reports direction of movement

Sensory Examination

Temperature Sensation Hot vs Cold Cold used more often Tuning fork often used for this vs tube of cool

water Limb must be warm to properly test Start distally & move proximally

Good for finding “spinal level” in cord lesions

Gait & Station Testing

Causal walking & then heel to toe ( tandem)

Observe: Stride length Smoothness of movement Symmetry Steadiness during turning

Gait & Station

Standing (station) Normal foot spread vs wide vs narrow

normal width is feet directly under hips Steady vs unsteady Have patient move feet close together Have patient close eyes

Worsening with eye closure is Rhomberg’s sign (sensory deficit)

Common Patterns of Abnormality

Foot slap: peroneal palsy / L5 radiculopathy

Spastic/scissoring: corticospinal tract lesion

Waddling: hip girdle weakness muscle diseases / dystrophy

Broad based: sensory or cerebellar

Short stepped with reduced arm swing: basal ganglia (parkinsons)

Non-organic patterns