Download The Neurological Exam

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