Download Neurological Exam Overview for Neurology Neurosurgery Clerkship

Neurological Examination
Indiana University
Department of Neurology
Overview
Learn / 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 Status

Level of consciousness




Orientation


Alert
Sleepy but awakens to verbal prompting ( Lethargic)
Unresponsive to painful stimuli ( Comatose)
To person, place, time, situation
Speech & 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
Fundoscopy (ophthalmoscope)



Optic disk ( optic
nerve head)
Retinal vessels
Retina
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
abnormal
Compression 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-cochlear
Two 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,

Involuntary movements


hypertrophy, fasciculation
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
Atrophy
Weakness
Fasciculations
Muscle tone
Reflexes
UMN
+/yes
no
inc
inc
LMN
yes
yes
yes
dec
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
Biceps
Brachioradialis
Triceps
Knee ( quadriceps)
Ankle ( gastroc/soleus)
Masseter
Nerve root
C5 & 6
C5
C7
L3 & 4
S1
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 quadrant
stimulated
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 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