NEUROLOGICALEXAMINATION

Liaoning Medical University Affiliated First Hospital

He Xin

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IMPORTANTCE!

---Despite recent advances in neuroscience and the continuing development of sensitive diagnostic procedures, the essential skill required for the diagnosis remains the clinical neurologic examination

---Most neurologic diagnosis can be made on the basis of the history alone

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SIX PARTS OF THE NEURO EXAM

一、 Mental State & Cognitive Function

二、 Cranial Nerves

三、 Motor System

四、 Sensory System

五、 Reflexes

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一、Mental State & Cognitive Function

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---Level of consciousness( Mental State)

--NORMAL

patient awake and alert, attentive to

surrounding and to the examiner

--DEPRESSED

Sleepy

Lethargic

Stuporous-arousing only briefly in response to

pain stimulation

Comatose-not arousable by verbal and pain

stimulation5

---Cognitive function check list

A. Orientation to person, place, and time.

B. Common knowledge such as “ who is the president”

C. Memory: Short term-name three common objects, then recall them again after 5 minutes; Long term-verifiable events from the past

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D. Calculations: Serial sevens: count backward from 100, taking away 7 each time. Real-life problem

E. Abstract thought: “ How is an apple different from –or the same as – an orange

F.Other: Insight and judgment, concentration, verbal fluency, patients mood, content of thought, appropriateness of behavior, and so on

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---Language functioning check-up

--Broca’s Aphasias

expressive aphasias

--Wernicke’s Aphasias

receptive aphasias

--Conductional Aphasias

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MMSE

二、 CRANIAL NERVES

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---Olfactory (I)

--Ask the patient to identify common scents

such as coffee,vanilla,etc, with eyes closed

--Do not use irritants. In testing olfactory

nerve function, it is less important to

determine whether the patient can correctly

identify a particular odor than whether the

presence or absence of the stimulus is

perceived

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---Optic (II)

--Visual Acuity-pocket card or wall chart or

any reading matter such as news paper

--Visual Field• Confrontation Testing-Patient and

examiner stand at eye level at about arm’s length. Have the patient cover his own eye

• Threat Testing- applied when the patient is less than fully alert or is uncooperative

--Fundus ( Ophthalmoscopic ) Examination13

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---Pupillary Reflexes (II, III)

A normal pupil will constrict

--in response to direct light

--as a consensual response to light in the

opposite eye

--to accommodation ( convergence to focus

on a close object)

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---Control of Extraocular Muscle Movements (III, IV, VI)

--Extraocular muscle movements are controlled by the oculomotor (III), trochlear ( IV), and abducens (V) nerves--Volitional Eye Movement-Follow my finger, just with your eyes. Tracing the Letter H--Ask about Diplopia--Nystagmus is rthythmic oscillation of the eyes

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--Unilateral ptosis occurs in Horner’s

syndrome, with a small pupil; or in a III

cranial nerve lesion, with a large pupil and

loss of adductive and vertical eye

movement

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---Trigeminal Nerve (V)--Facial Sensation--Corneal Reflex-Sweep a wisp of cotton lightly across the lateral surface of the eye ( out of the direct visual field) from sclera to cornea- V, VII--Motor V Testing- Observe the symmetry of opening and closing of the mouth. Ask the patient to clench the teeth and then attempt to force jaw opening--Jaw jerk-brisk indicates UNL

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---Facial Strength (VII)

--Facial Symmetry-observe the patient’s face for symmetry of the palpebral fissures and nasolabial folds at rest. Ask the patient to wrinkle the forehead, then to squeeze the eyes tightly shut, then to smile or snarl, saying show your teeth

• Supernuclear lesion

• Nucleus or peripheral lesion

--Bilateral Facial Weakness

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---Auditory (VIII)--Auditory acuity can be tested crudely by rubbing thumb and forefinger together about 5cm from each ear. If the patient cannot hear the rub, proceed to the follow tests--Rinne Test-hold the base of tuning folk on the mastoid process until the sound is no longer perceived, then bring the still vibrating fork up close to the ear.

• Sensorineural loss• Conductive loss

--Weber Test29

--Weber Test-lightly strike a tuning fork and place the handle on the midline of the forehead

-Conductive loss -Sensorineural loss--Vestibular Function- need to be tested only if there are complaints dizziness or vertigo or evidence of nystagmus

-Nylen-Barany( Dix-Hallpike) maneuver test for positional nystagmus

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---Glossopharyngeal(IX) & Vagus(X)

Test the function of the palate, pharynx, and larynx

--Palatal elevation- say “ah”

--Gag reflex ( afferent IX, efferent X)- gently touch

each side of the posterior pharyngeal wall with a

cotton swab

--Sensory function-lightly touch each side of the soft

palate with the tip of a cotton swab

--Voice quality-listen for hoarseness or

“breathiness”, suggesting laryngeal weakness

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---Accessory (XI)

--Sternocleidomastoid- press a hand against

the patient’s jaw and have the patient rotate

the head against resistance. Pressing against

the right jaw tests the left sternocleidomastoid

and vice versa

--Trapezius-have the patient shrug shoulders

against resistance and assess weakness

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---Hypoglossal (XII)Tests for hypoglossal nerve function include the

following--Atrophy or Fasciculations-with the patient’s

tongue resting in the floor of the mouth, first

inspect for atrophy or fasciculations. Then ask the

patient to protrude the tongue, and observe for

deviation to the weak side

--Subtle Weakness-have the patient push the tongue

into each cheek against external resistance

(opposite hypoglossal m.)

--Subtle Dysarthria- Ask the patient to repeat difficult phrases35

三、 MOTOR SYSTEM

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---Muscle Tone• Decreased( floppy, flaccid, hypotonic)• Normal• Increased( Spastic vs. Rigid)

---Muscle Bulk Atrophy ( or with fasciculation)

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---Muscle Strength -The classic grading system scores as follows 5--full strength 4--movement against gravity and & resistance 3--movement against gravity only 2--movement horizontally along the surface of the

bed 1--palpable contraction but little visible movement 0--no contraction

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---Motor Coordination & GaitCerebellar hemisphere are responsible for

coordinating and fine-tuning movements (ipsilateral )

1.Finger-to-Nose

2.Rapid Alternating Movements

3.Rebound

4.Heel-Knee-Shin

5.Romberg’s test is a quick and excellent screen for

loss of proprioceptive feedback neuropathy or spinal

cord disease

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四、 Sensory System

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---Large-fiber & Dorsal Column Function• Vibration Sense• Joint Position Sense• Romberg’s Test

---Small-fiber & Spinothalamic Function• Temperature Sensation• Superficial Pain Sensation• Light Touch Sensation

---In the lesion of the somatosensory cortex joint

position perception is loss but vibration

sensation is not

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五、 REFLEXES

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---Deep Tendon Reflexes• Bicep Reflex(C5-6)• Tricep Reflex ( C7-8)• Quadiceps ( Patellar, Knee Jerk) Reflex ( L3-4)• Achilles ( Ankle Jerk) Reflex (S1-2)

---Pathologic Reflexes Babinski Sign

---Frontal Release Sign• Grasp Sign• Suck Sign• Snout Sign• Glabellar Sign

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---Brisk tendon reflexes signify upper motor

lesions, absence reflexes occur in peripheral

nerve or nerve root lesions

---An extensor plantar or Babinski response is a

definite immediate sign of an upper motor

neuron lesion, presents well before clonus or

hyperreflexia

---Ankle clonus, when sustained or unsustained but

of more than six beats duration, provides definite

evidence for an upper motor neuron lesion

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THANK YOU !