Neurological Exam

Muscle Strength

• Pair the testing of each muscle group immediately with testing of its contralateral counterpart to enhance detection of any asymmetries.

• Have them flex, then extend, the chosen joint. First the right, then the left.

• Have them flex and extend that joint again, but this time, examiner pushes against the movement, creating resistance.

• Proceed to the next joint.

Muscle Strength

• Upper Extremity– Shoulder– Elbow– Wrist

• Lower Extremity– Hip– Knee– Foot

0/5: no contraction1/5: muscle flicker, but no movement2/5: movement possible, but not against gravity (test the joint in its horizontal plane) 3/5: movement possible against gravity, but not against resistance by the examiner 4/5: movement possible against some resistance by the examiner 5/5: normal strength

Upper Extremity Strength VideoLower Extremity Strength Video

Reflexes

• Biceps (C5-6)• Triceps (C7)• Patellar (L4)• Ankle (S1)• Plantar– Babinski sign

0: absent reflex 1+: trace2+: normal3+: brisk4+: nonsustained clonus (i.e., repetitive vibratory movements)5+: sustained clonus

http://www.neuroexam.com/content.php?p=2http://meded.ucsd.edu/clinicalmed/neuro3.htm

Deep tendon reflexes are normal if they are 1+, 2+, or 3+ unless they are asymmetric or there is a dramatic difference between the arms and the legs.

Reflexes Exam• The limbs should be in a relaxed and symmetric position.• The muscle group to be tested must be in a neutral position

(i.e. neither stretched nor contracted).• Compare each reflex immediately with its contralateral

counterpart so that any asymmetries can be detected.• If you cannot elicit a reflex, you can sometimes bring it out

by certain reinforcement procedures. For example, have them forcefully contract a different muscle group when the reflex is tested.

• Upper Extremity reflexes video• Lower Extremity reflexes video• Plantar Reflexes video

Biceps Reflex

• Place your thumb over the tendon and tap the pointed side of the reflex hammer onto your thumb and observe the reflex in their biceps.

• Have the patient’s elbow resting in your arm at a 90 degree angle.

• Place your thumb over the antecubital fossa (inside of elbow) of the patient.

• Ask the patient to flex their forearm (i.e. contract their Biceps muscle) while you simultaneously palpate the fossa. The Biceps tendon should become taut and thus readily apparent.

Triceps Reflex• Have the patient’s elbow resting in your arm at a

90 degree angle.• Ask the patient to extend their forearm (i.e.

contract their Triceps muscle) while you simultaneously palpate the tendon behind the elbow.

• Place your thumb over the tendon and tap the pointed side of the reflex hammer onto your thumb and observe the reflex in their triceps.

Patellar Reflex

• Make sure the leg is relaxed.

• Use the wide side of the hammer.

• If no reaction, have patient clasp fingers together and pull while the test is performed.

Achilles Tendon Reflex

• This is most easily done with the patient seated, feet dangling over the edge of the exam table.

•Use one hand to hold the foot at a 90 degree angle, and strike the tendon with the wide side of the hammer in the other hand. Feel for

the foot plantarflexion.

Plantar Reflex• Scrape an object across the sole of the foot

beginning from the heel, moving forward toward the small toe, and then arcing medially toward the big toe.

• The normal response is downward contraction of the toes.

• The abnormal response, called a positive Babinski's sign, is characterized by a dorsiflexed big toe and fanning outward of the other toes. This is normal in children under 1 year of age, but abnormal in adults.

Cerebellar Function• Finger to Nose

– Patient is asked to alternately touch their nose and the examiner's finger as quickly as possible, while the examiner's finger is held at the extreme of the patient's reach, and the examiner's finger is moved after each attempt.

• Heel to Shin– Touch the heel of one foot to the opposite knee and then to

drag their heel in a straight line all the way down the front of their shin and back up again. Do not touch the shin with the toes.

• Rapid Alternating Movements– Touch the thumb to each finger quickly.– Can also wipe one palm alternately with the palm and dorsum

of the other hand

Station and GaitStation = how far apart the feet are when standing. Normal is same width as shoulders. Observe if they have a wide, narrow, or normal station.Gait = walking

•Tandem gait– walk a straight line while touching the heel of one foot to the toe of

the other with each step. Tests cerebellar function.•Hopping on one foot (not for feeble patients)•Romberg

– Ask the patient to stand with their feet together (touching each other). Then ask the patient to close their eyes. Remain close in case the patient begins to sway or fall.

– With the eyes open, visual input helps to maintain stability. Closing the eyes and having difficulty with the task suggests a mild lesion in the vestibular system.

Cranial Nerves Exam

• CN I• Smell test

Patient closes eyes and plugs one nostril. Hold an alcohol swab a few inches away and have them sniff. Repeat with the other nostril. Is the strength of the smell the same?

CN III, IV, and VI• Instruct the patient to hold his head still and follow the

examiner’s finger with his eyes as the examiner circumscribes a large "H" in front of the patient. Then move the finger towards the patient’s nose. Weakness in an eye muscle indicates cranial nerve damage.

• CN III also controls the pupillary reflex. Have the patient look straight ahead, then shine a light into the left eye once to see if the left pupil constricts. Remove the light and shine it again at the left eye, but look at the right eye to see if the right pupil constricts.

• Repeat this, shining the light twice in the right eye to see if the right and left pupil constrict.

Extraocular Movements: CN III (except as listed)

CN VI

CN IV

Look for Nystagmus

• Nystagmus is involuntary eye movement.• http://en.wikipedia.org/wiki/Physiologic_nystagmus• It is characterized by the eye flicking right to left when

the examiner pulls a nystagmus flag quickly through his fingers. Nystagmus is normal.

• Pathological nystagmus (flicking without the flag) is the result of damage to one or more components of the vestibular system, including the semicircular canals, otoliths, and the vestibulocerebellum.

• Many blind people have pathological nystagmus, which is one reason that some wear dark glasses.

CN V

• Check sensation on the upper, middle, and lower part of the face.

CN VII

• Voluntary facial movements, such as wrinkling the brow, showing teeth, frowning, closing the eyes tightly, pursing the lips and puffing out the cheeks, all test the facial nerve. There should be no noticeable asymmetry.

• Check for ability to open and close mouth in a chewing fashion.

• CN VII also supplies taste to the anterior 1/3 of tongue.

CN VIII - XII

• Vestibulocochlear (VIII) hearing/balance• Glossopharyngeal (IX) taste on posterior 1/3 of

tongue, and swallowing. Open mouth and say “ah”, see if uvula moves to one side instead of straight backwards.

• Vagus (X) larynx moves with speech• Accessory (XI) shrug shoulders, w/resistance• Hypoglossal (XII) stick out tongue (does it

deviate to one side?)

Cranial Nerves• Olfactory (I) smell• Optic (II) Visual Acuity• Extraocular Movement (III)

– Pupil Reactions to light– Nystagmus

• Superior oblique (Trochlear IV)• Lateral Rectus (Abducens VI) • Trigeminal (V) sensory of face• Facial Motor (VII) blink and smile• Vestibulocochlear (VIII) hearing/balance• Glossopharyngeal (IX) swallowing, say “ah”, and taste anterior tongue• Vagus (X) larynx moves with speech• Accessory (XI) shrug shoulders• Hypoglossus (XII) stick out tongue, and taste posterior tongue

Sensation

• Hot, Cold• Pain (pointy wheel)• Light Touch (cotton swab)• Vibration (tuning fork)• Proprioception (thumb up or down)• Two-point discrimination (pointy caliper)

Perform each of these tests throughout the dermatome map.

Map of Dermatomes

Test from the sides of the neck , to the shoulder

For pain, use the pointy wheel and circumscribe the upper and lower arms

Test down the front of the chest or back

Test the lateral sides of the thigh

Circumscribe the leg

Sensation

• Temperature sensation can be tested with a cool piece of metal such as a tuning fork or stethoscope diaphragm. Warms can be tested with warm hands or warmed cloth.

• Light touch is best tested with a cotton-tipped swab

• Pain is tested by poking gently with a sharp object, such as a broken wooden stick from a Q-Tip

Sensation

• Vibration– Have patient close their eyes. Place the stem of a

vibrating tuning fork on the fleshy portion of the patient's toe or finger and ask him to report when you stop the vibration by grasping the top of the fork with your hand.

– Take care not to place the tuning fork on a bone, since bones conduct the vibration to much more proximal sites, where they can be detected by nerves far from the location being tested.

Sensation

• Proprioception (joint position)– Patient closes eyes. Move the patient's thumb up

and down and then stop, asking the patient to report if it is up or down right now.

– Hold the digit lightly by the sides while doing this so that tactile inputs don't provide significant clues to the direction of movement.

Sensation• Two-point discrimination– Use a caliper or bent paper

clip, touch the patient with one or both points, alternating randomly.

– Ask them each time: can you feel one prong or two? If you use two and they say “one”, spread the clip points wider and try again.

– The minimal separation (in millimeters) at which the patient can distinguish these stimuli should be recorded in each extremity.

Eye Exam

Visual Acuity•Stand 20 feet from eye chart, read line 8. If no errors, you have 20/20 vision.

Colorblind test•Read the numbers from the color patterns in the book in the front of the room.

Retinal Exam

• Have the patient stare at a the corner of the room where the ceiling meets the wall.

• Approach the right eye from the right side of the patient. Place one hand on their forehead so you have depth perception and don’t run into their face. Put the knuckle of your third digit on their cheek.

• Direct the light onto their pupil, then look into the pupil. Examine the fundus (interior of the eye) for abnormalities.

Normal Fundus

Diabetic Retinopathy

Diabetic Retinopathy

Middle Ear Exam

• Make sure the light is OFF, then switch to the ear piece.

• Make sure a disposable specula is on the otoscope!

• Approach the patient from the side.• Grasp the pinna (external ear) and gently pull it superiorly

and posteriorly to straighten out the ear canal.• Place the specula of the otoscope into the ear first, before

looking into the otoscope. Otherwise, you might drive the specula in too deep and hurt the patient.

• Then look into the otoscope. Examine the canal for redness, look for perforation or scars on the tympanum (ear drum).

Normal Ear

Inflamed Ear

Hearing Loss

• Conductive hearing loss happens when there is a problem conducting sound waves through the outer ear, tympanic membrane (eardrum) or middle ear (ossicles).

• Sensorineural hearing loss is a problem in the vestibulocochlear nerve (Cranial nerve VIII), the inner ear, or central processing centers of the brain.

• Weber Test: only tests unilateral problems. A tuning fork is touched to the middle of the forehead:– Sensorineural hearing loss: sound is heard louder

in the normal ear because the damage is to the nerve, so bone conduction of the sound is ineffective.

– Conductive hearing loss: sound is heard louder in the problem ear (earwax, etc) because reflected soundwaves cannot escape the ear canal, so they penetrate deeper into the inner ear.

Weber Test

Rinne Test

• Performed by placing a vibrating tuning fork on the mastoid process (from the ear lobe, go 2” down and 2” back) until sound is no longer heard, the fork is then immediately placed just outside the ear. Normally, the sound is audible at the ear, indicating a positive Rinne test.

• If they cannot hear the sound at the ear, it is a negative Rinne test, and indicates Sensorineural hearing loss