The Neurological examination

General frame

Reduced your neurological differential diagnosis

• How the symptoms started?• How they progressed over time?• What is the localization?

• Mental status, cognition & language• Signs of meningeal irritation.• Cranial nerves• Motor system• Sensory system • Cerebellar functions• Gait and balance

• Remember that normal range of findings dynamically changes with age.

• We all have some soft neurological signs – be symptoms oriented and try to look at the entire picture and not on a soft abnormal finding.

The technique and expected

findings

Mental status, cognition & language

• Define the patient mental status - alert? Confused? Lethargic? comatose?

• Be sure your patient is oriented to time and place.

• If during conversation you suspect any language abnormality test spontaneous conversation (fluency, paraphasia), understanding commands, low and high frequency naming, repetition, reading, writing. Distinguished and define dysarthria.

Look for nuchal rigidity (meningial irritation)

Cranial Nerves

•(I), II-XII

CN II - OphthalmicTest each eye separately

Visual Acuity

Optic discs

Visual fields(confrontation)

Pupils(also CN III)

Use printed text, your fingers or

hand-palm, light. Do not remove glasses

Don't ask and we won't tell

Light from asideClose your eye and Move your finger fromOutside in (4 quarters)

CN II - OphthalmicVisual Acuity

Optic discs

Visual fields(confrontation)

Pupils(also CN III)

No difference frombaseline

Equal and responsiveVisual fields as good as yours

Sharp borders

CN III(Oculomotor) , IV(Trochlear) & VI (Abducens)

Distant large movements in 6 directions plus convergence

Full coordinated movements, no pathological nystagmus

CN V - TrigeminalPinprick to compare sides in the distribution of the 3 branches

CN VII - FacialLower face Upper face

Smile or blow chicks Forcefully close eyes or lift eye browses

CN VIII - Vestibulocochlear

Rub fingers, hair or paper near each hear separately

CN IX & X – Glossopharyngeal and vagus

Look for deviation of the uvula, lowering of palatal arch or a coarse voice

CN XI - Accessory

Sternocleidomastoid – ask patient to turn head against resistance (contralateral to turning direction)

Trapezius - press shoulderagainst patient resistance

CN XII - HypoglossalLook for atrophy or fasciculationswhile mouth slightly open andtongue rests on the floor of the mouth

Ask patient to stick tongue out

MotorSystem• Observe• Passive tone• Muscle force• Reflexes• Babinski

No asymmetry, atrophy (hypertrophy) or fasciculations. No involuntary movements,

or abnormal posture.

Observe exposed limb / trunk

Test passive tone by asking the patient to relax andmoving his upper and lower limbs.

Look for mild weakness by asking patient to close his eyes, stretch his arms with his palms up.

Biceps Triceps

Gastrocnemius Tibialis anteriorIliopsoas Quadriceps femoris

Deltoid Grip (many muscles)

Compare muscle force on both sides:

Hamstrings (opposite)

Deep Stretch reflexes

Muscle Nerve Root

Biceps Musculocutaneous C 5-6

Triceps Radial C 6-8

Brachioradialis Radial C 5-6

Quadriceps femoris Femoral L 2-4

Gastrocnemius Tibial S 1-2

Use reflex hammer as a pendulum: Biceps Triceps Brachioradialis

Quadriceps femoris Gastrocnemius

Test for pathological pyramidal release sign (Babinski):

Plantar-flexion of toe

Equivalent signs:

SensoryExam

Pinprick to compare sides and proximal vs. distal sensation. Ignore uncertain differences.

Ask patient to stand, close eyes and stretch arms (Romberg test)

Remember you are testing proprioception (large diameter fibers, posterior spinal columns) and the integrative function of the vestibular system rather then cerebellar functions.

Cerebellar functions

Smooth and regular movements(no dysdiadochokinesia)

Finger on target without significantcorrections (dysmetria) or tremor at the end of the movement (intentiontremor)

Alternating palm movements: Finger to nose test (slow):

Gait & Balance

Steps are regular and in normal length, base in narrow and postureis errect.

Patients younger than 65 years are expected to succeed

Natural walking: Tandem walking (heel to toe):

While patient is bared-foot (if possible):

Abnormalfindings

Cranial Nerves

•(I), II-XII

Visual Acuity

Optic discs

Visual fields(confrontation)

Pupils(also CN III)

CN II - Ophthalmic

Finger counting?Hand movements?Light perception?

CN III(Oculomotor) , IV(Trochlear) & VI (Abducens)

CN VII - Facial

CN IX & X – Glossopharyngeal and vagus

CN XII - Hypoglossal

MotorSystem

Decreased passive tone

ParatoniaRigiditySpasticity

Uniform throughout movement, not speed dependent, feels like ‘cogwheel’ or lead-pipe’, increases with movements of other limb

Not uniform throughout the range of movement , varied with speed of movement, ‘clasp knife’ phenomenon, more severe in upper limb pronators and knee extensors.

Increased passive tone

Patients does not relax, he increases his resistance proportionally with the force you apply. Patient continues repetitive movements after you stop

Lower motor neuron, acute upperMotor neuron or (cerebellar)

Upper motor neuron (corticospinal , pyramidel)

Basal ganglia (parkinsonian sign) Frontal release sign

Exam tone

Pronator drift

What is the origin of muscle weakness?

Upper motor neuron Lower motor neuron

Atrophy (in chronic disease) Severe with fasiculations None or mild due to disuse

Tone Decreased Spastic in chronic stage, spastic or decreased in acute stage

Deep tendon reflexes Decreased Increased

Babinski sign Negative Positive

Remember – motor system is not just about weakness but also deals with abnormal involuntary movements, fine movements etc and possible localization is not just upper vs. lower motor neurons but also frontal lobes, basal ganglia and cerebellum.

SensoryExam

Cerebellar functions

Gait & Balance

Few more tests you should apply

when relevant

Mental status, cognition & language

• Glasgow coma scale• Mini-mental test• Drawing clock• Many others.

Cranial Nerves

CN I - OlfactoryApply a pleasant smell to each nostril separately when suspecting frontal space occupying lesion (or certain neurodegenerative disease)

CN II - OphthalmicIn case you suspect optic nerve injury:

Test relative afferent papillary defect (RAPD) using light swing test

Use red object to test for red saturation

CN V - TrigeminalSuspect weakness of jaw muscles? Test jaw muscle Force.

Suspect pyramidal involvement above the foramen magnum? Check jaw jerk reflex.

MotorSystem

Suspect pathological increased reflexes or wish to better localize lesion?

Pectoral reflex

Supra-patellar reflexCross-adductors reflex

Hoffman Tromner

Ankle clonus:Abruptly dorso-flexed ankle.

Suspect frontal lesion? Neurodegenerative disease? Check frontal release signs.

Palmo-mental Grasp

Snout Glabellar tap

SensoryExam

Suspect peripheral neuropathy, spinal posterior columns involvement or hemi-spinal syndrome? Use you tuning fork.

Test for extinction when you suspect non-dominant parietal involvement. You can apply the test while checking visual fields

Visual extinction Tactile extinction

Cerebellar functions

Heel-to-shin test is the equivalent to finger-to-nose test

Gait & Balance

Use pull test when patients gait is impaired or when falls are reported. Stand with a wall on your back!

Thanks,