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The Neurological Exam Vikram Bhise, MD A lesion of the facial nerve will NOT affect: 1. Lacrimation (eye tearing) 2. Hearing 3. Speech 4. Taste 5. Eye closure A motor score of 3 means: 1. Full strength 2. Movement laterally along a surface 3. Partial resistance but otherwise able to move freely 4. No resistance but movement against gravity 5. No movement or a twitch Steppage gait refers to: 1. Pain-limited gait 2. Short steps with poor foot elevation 3. Staggering walk with a broad base 4. Extended stiff leg that circumabducts 5. Foot slapping and high step Components 1. 2. 3. 4. 5. 6. 7. Mental status Cranial Nerves Motor Sensory Coordination Reflexes Gait Mental status Awake and alert Agitated Lethargic – Arousable with Voice Gentle stimulation Painful/vigorous stimulation Comatose Attention Digit span Spelling forwards and backwards Months forwards and backwards Serial 7 subtraction Orientation Person Place Time Language Fluency Naming Repetition Reading Writing Comprehension Memory Immediate – 3 or 4 words Remote – Historical events – Personal events: School, summer Other Calculation Abstraction – Proverb – Similarities & Differences Judgment and insight Affect, mood, and behavior Praxis Visuospatial – L/R, clock drawing Cranial nerves I Olfactory nerve – Head trauma II Optic nerve – Visual acuity (corrected) – Visual fields – Fundoscopic exam Margins Color SVP III Oculomotor – SR, IR, MR, IO IV Trochlear – superior oblique V Abducens – lateral rectus Pupil – II in, III out Eyelid – III and sympathetic open – VII close Cover/uncover test – phoria Maddox rod Color vision – Ishihara plates Saccades V Facial – V1 sensory – V2 sensory – V3 sensory and motor (muscles of mastication) Corneal – V in, VII out VII facial – Facial asymmetry, smile – Forehead – Lacrimation (greater petrosal nerve) – Whistle, pucker, close eyes, cheeks – Hearing for hyperacusis (stapedius) – Taste anterior 2/3 tongue (chorda tympani) VIII Vestibulocochlear – Hearing – Rinne & Weber IX Glossopharyngeal – Taste posterior 1/3 – Sensory tonsils, middle ear, posterior 1/3 tongue X Vagus – Voice quality, pitch – Gag reflex IX in, X out XI Spinal Acessory – Sternocleidomastoid muscle and bulk – Trapezius muscle XII Hypoglossal – Strength – Right genioglossus muscle thrusts forward and to left Motor Exam 1. 2. 3. 4. Strength Tone Bulk Adventitious movements Strength –5 –4 –3 –2 –1 –0 full strength resistance but not full can lift against gravity can move laterally flicker no movement Upper versus lower extremities Proximal versus distal Upper motor neuron distribution Subtle signs – Drift – Arm roll (orbiting) Shoulder abduction – deltoid Shoulder adduction – latissimus Arm flexion – biceps Arm extension – triceps Wrist flexion – FCU, FCR Wrist extension – ECU, ECR Hip extension – gluteus maximus Hip flexion – iliopsoas Hip abduction – gluteus medius and minimus Hip adduction – gracilis, adductor L/M/B Knee extension – quadriceps Knee flexion – hamstrings Ankle dorsiflexion – tibialis anterior Ankle plantarflexion – gastrocnemius Foot inversion – tibialis anterior and posterior Foot eversion – peroneus longus and brevis Tone – proximal and distal Spasticity Adventitious movements – Fasciculations – Myoclonic jerks – Choreoathetosis – Tremor – Dystonia Bulk – atrophy, hypertrophy Sensory Light touch Spinothalamics – Pinprick – Temperature Dorsal columns – Vibration – Joint position sense Higher cortical sensory Graphesthesia Stereognosis Double simultaneous stimulation 2-point discrimination Barognosis Topognosia Romberg Coordination (Cerebellar) Rhythm – Finger counting and tapping – Foot tapping – Rapid alternating movements Meter – Finger-nose-finger – Heel-knee-shin – Foot-to-finger Rebound (check) Reflexes Strength –0 –1 –2 –3 –4 absent reduced normal brisk associated clonus DTRs Biceps [C5/C6] Brachioradialis [C5/C6] Triceps [C7-T1] Knees [L3/L4] Ankles [S1/S2] Primitive reflexes Jaw jerk Frontal release – snout, suck, grasp, palmomental, glabellar Pectorals Hoffman’s Finger flexors Cross-adductors Babinski/Chaddock/Oppenheim Moro (28 wks GA to 3 m) Propping (5-7m) – anterior then lateral Parachute (5 m, by 11 m) Fencing (asymmetric tonic neck reflex) (34 wks GA to 4m, max 2 m) Stepping (34 wks GA to 4 m) Crawling (to 2m) Blink (5 m) Grasp palmar/plantar (28 wks GA to 6m) Rooting (28 wks GA to 4m) Suck (28 wks GA to 2m) Gallant (to 4m) Righting reflex – clears head and nose Withdrawal to pain Protective – clears cloth Babkin – hand to mouth Swim/diving Gait Baseline – Base – Armswing Toe Heel Tandem and reverse tandem Rise from squatting Rise from seated position Step up Balance or hop on one leg Pull test Types hemiparetic ataxic antalgic hysterical steppage shuffling/festination magnetic A lesion of the facial nerve will NOT affect: 1. Lacrimation (eye tearing) 2. Hearing 3. Speech 4. Taste 5. Eye closure A motor score of 3 means: 1. Full strength 2. Movement laterally along a surface 3. Partial resistance but otherwise able to move freely 4. No resistance but movement against gravity 5. No movement or a twitch Steppage gait refers to: 1. Pain-limited gait 2. Short steps with poor foot elevation 3. Staggering walk with a broad base 4. Extended stiff leg that circumabducts 5. Foot slapping and high step Answers Question Question gravity Question 1: 3 speech 2: 4 movement against 3: 5 foot slap