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Erman Fandialan M.D.

Department of Clinical
Neurosciences
UERMMMC

To review the different parts of the


neurologic examination.
To review techniques of eliciting the
abnormalities.

Facilitates communication
Provides baseline
Directs testing
Localizes the lesion

The customary sequence of information


collection in the neurological interview is
outlined below:

Chief Complaint
History of Present Illness
Past Medical History
Review of Systems or Functional Inquiry
Family History
Social History

Accurate history often suggest correct


diagnosis
Chronological order and systematic
manner
Symptoms characterized in terms of:
severity, location, temporal profile,
aggravating and ameliorating factors

Includes complete general physical


examination + neurologic examination
Emphasis on:

Vital Signs
Head: Evidence of Trauma
Neck: Bruits
Heart: Murmurs, rhythm
Abdomen: Masses / Distention
Skin / Scalp: Lesions / Tenderness

MUST HAVES:

Neurological
hammer
Pen light
Pin / cotton
Tongue depressor
Stethoscope
BP apparatus

NICE TO HAVE:

Ophthalmoscope
Tuning Fork
Pocket Snellen

1.
2.
3.
4.
5.
6.
7.

Mental Status Exam


Cranial Nerves
Motor Exam
Sensory Exam
Reflexes
Cerebellar Exam
Meninges

Do the neurological examination in an


orderly fashion.
Finish the examination for one system
before starting another.
Always examine the left and the right
side of the body and compare.
Compare proximal against distal
findings.

1. Level of Alertness, Attention


and Cooperation
Awake, drowsy, stuporous, comatose
Best response
Spelling a short word forward and
backward (W-O-R-L-D / D-L-R-O-W is a
standard or naming the 12 months forward
and backward )

2. Orientation
Person
Place
Time

3. Memory
Immediate
recall
Recent Memory
Remote
Memory

4. Language
Spontaneous speech
Comprehension
Naming
Repetition
Reading
Apahasia

Brocas
Transcortical
Wernickes
Global
Conduction

5. Calculations, RightLeft Confusion, Finger


Agnosia, Agraphia*
Addition, subtraction,
multiplication, division
exercises
Identify right and left body
parts
Name and identify each
digit
Write the name and a
sentence

* Gerstmann's syndrome
dominant parietal lobe

6. Apraxia
Inability to follow a
motor command that
is not due to a primary
motor deficit or a
language impairment
Ideomotor apraxia
left inferior parietal
lobe lesion
Constructional Apraxia
non-dominant
parietal lobe lesion
Dressing Apraxia

7. Neglect and
Constructions
Hemineglect
Extinction on double
simultaneous
stimulation
Construction tasks
involving drawing
complex figures or
manipulating blocks
Anosognosia inability
to recognize ones body
part (non-dominant
parietal lobe lesion)

8. Sequencing
Tasks and Frontal
Release Signs
Continue drawing a
silhouette pattern of
alternating triangles
and squares
Frontal release signs:
the grasp, root, and
suck reflexes
Abulia

9. Logic and
Abstract thinking
Simple problem
solving
Proverb
interpretation
Similarity
comprehension
e.g. how are a car
and an airplane
alike?

FRONTAL LOBE:
Abstract thinking and
logic
Speech - Brocas area
Sequencing Tasks and
Frontal Release Signs
Concentration
Emotional expression
(abulia, apathy)

TEMPORAL LOBE:
DOMINANT:
Wernickes area
Memory,learning, orientation,
hearing
NON-DOMINANT:
Prosopagnosia (recognizes
persons by pictures)
Music, hearing

PARIETAL LOBE
DOMINANT :
Calculations, Right-Left Confusion,
Finger Agnosia, Agraphia
Naming,reading,stereognosis,
graphesthesia, somatognosia
NON-DOMINANT :
Apraxia, neglect, constructions
Stereognosis, graphesthesia

OCCIPITAL
LOBE:
Identify
objects and
colors

Use at least 3 substances


Do not use alcohol or
perfume
Cover one nostril
Ask the px to close his/her
eyes
While occluding each nostril,
patient is asked to sniff and
identify various odorants
Unilateral anosmia
hippocampus problem

A. Visual Acuity

Snellens or Jaeger
chart
Pinhole

B. Visual Fields

Confrontation test

C. Funduscopy

Red orange reflex


Media clear, hazy
Disc borders distinct, blurred
Cup disc ratio = 0.4 0.5
Arteriole/Venule ratio (AVR) =
2:3

Hemorrhages, Exudates

Papilledema

D. Pupillary Reflex

Afferent arm :optic nerve


Efferent arm: oculomotor
nerve
effector organ: pupillary
constrictor muscle
direct & consensual

CN III: MR, SR, IR, IO, levator palpebrae


CN IV: Superior oblique
CN VI: Lateral rectus

Mixed nerve
Sensory: corneal reflexes

Stimulate the corneoscleral junction


Afferent arm CN V
Efferent CN VII
Effector ms orbicularis oculi

Sensory V1, V2, V3


Test pain, temperature, vibration,
light touch
Compare areas
Report in %

Motor: jaw strength and muscle


bulk (masseter, temporalis)

Mixed nerve, predominantly


motor
Sensory: Taste anterior 2/3 of
tongue
Motor

Smile
Bury eyelashes
Nasolabial fold
Forehead has bihemispheric
innervation centrally

Central Vs Peripheral facial palsy

CENTRAL FACIAL PALSY

PERIPHERAL FACIAL PALSY

Gross hearing
Weber
No lateralization

Rinne
Compare air conduction
and bone conduction length
AC>BC
Normal
Sensorineural hearing loss
both are decreased

BC>AC
Conductive hearing loss

Taste / sensation
posterior pharynx
Swallow
Gag reflex
Without gag but
can swallow
normal CN IX & X

Sternocleidomas
toid - chin to the
opposite side

Trapezius raise
shoulder

Tongue
Stick out tongue
Tongue receives
bilateral innervation
from R and L CN XII
Tongue deviated
towards R - problem
on R CN XII
Check for atrophy and
fasciculations

Inspection: bulk, fasciculations


Palpation: tenderness
Tone
Hypertonia: subacute or chronic corticospinal lesion
Hypotonia: LMN lesion or acute UMN
Rigidity: basal ganglia disease

Muscle testing
Primary concern: can patient breathe
Key test: drift of extremity
Check both distal and proximal muscles

Grading:

0 - No muscle contraction is detected


1 - A trace contraction is noted in the muscle by
palpating the muscle while the patient attempts to
contract it.
2 - The patient is able to actively move the muscle when
gravity is eliminated.
3 - The patient may move the muscle against gravity but
not against resistance from the examiner.
4 - The patient may move the muscle group against
some resistance from the examiner.
5 - The patient moves the muscle group and overcomes
the resistance of the examiner. This is normal muscle
strength

Deltoid

Biceps

Wrist flexors

Finger flexors

Triceps

Thumb add.

Finger abd.

Dorsiflexors

Hip flexors
Hip abductors

Plantarflexors

Hip extensors

Hip adductors

Knee flexors

Toe extensor

Pain, Temperature: Lateral spinothalamic tract


Light touch, Pressure: Anterior spinothalamic tract
Vibration, joint position sense: Dorsal column
Medial lemniscal system

Cortical sensation

Graphesthesia

2 point Discrimination:
2-4 mm fingertips
4-6 mm dorsum of fingers
8-12 mm palm
20-30 mm dorsum of hand

Stereognosis

Tactile Extinction

REFLEXES GRADING
4+ Very brisk, hyperreflexive, with clonus
3+ Brisker or more reflexive than normally.
2+ Normal
1+ Low normal, diminished
0
No response

Biceps
brachii
tendon
reflex

C5-6

Triceps
tendon
reflex

C6-8

Brachioradia
lis tendon
reflex

C5-7

Patellar
tendon
reflex

L2-4

Corneal CN V, CN VII
Pharyngeal CN IX, X
Abdominal - T6-9, T10-12
Beevors sign

Anal S2-4
Cremasteric L1-2
Bulbocavernosus S3-4

Babinski
Chaddock
Oppenheim
Gordon
Schaefer
Hoffman
Myersons sign

Requires integration of cerebellar, motor, and


sensory functions
1. Appendicular Coordination
Rapid alternate pronation & supination

Dysdiadochokinesia

Ask patient to tap distal joint of thumb with tip of index


finger
Ask patient to tap your hand quickly with the ball of each
foot in turn

2. Point-to-point movements
Finger-to-nose pointing
Dysmetria

Heel-to-shin movement

3. Stance
With feet apart, then closed together
With eyes open, then eyes closed

4. Gait
Ask patient to walk across the room then turn and come
back
Ataxia when gait lacks coordination and unstable

Tandem Walking
Walk Heel-to-toe in a straight line
Walk on toes, then on heels

5. Nystagmus
Refers to involuntary rhythmic movements of
the eyes
Reflects an imbalance in one or more of the systems
that maintain stability of gaze:
Cerebellum and vestibular system

Supple or rigid neck


Kernigs
Brundzinskis

Not getting a complete history utilizing


family or observers
Not performing a systematic exam
Jumping to conclusions before gathering all
the data
Misinterpreting old lesions for new
Misinterpreting limitations from pain as
neurologic deficits

Lesions of the cerebral cortex and internal capsule


(supratentorial) sensory and motor defects confined to the
contralateral side of the body

Brain stem and spinal cord lesions ipsilateral as well as


contralateral defects due to varying patterns of crossover

Unilateral pain syndromes without motor deficits thalamic


pathology

A careful exam of CN II, III, IV and V is indicated in patients with


headache or suspected processes that cause increased ICP

Testing for pronator drift is the best screen for muscle weakness
of central origin