Clinical skills I

Module I

Neurological Exam
Prepared by Dr Nelly Kleimeh
The neurological examination
Introduction
The goals of the Neurological
Examination
The health history
Techniques of examination
Introduction
The NE one of the least popular, poorly
performed aspects of the complete PE.
It is hard to remember what to do.
It is not easy to know what we are
looking for.
It is not easy to know how to describe
what we find.
The goals of the NE
1. Screening tool.
2. Investigative tool.
The aim of the NE is to determine
-if the dysfunction really exist
-if the findings can be explained by a
precise anatomical location.
-generate possible etiologies
Anatomy & Physiology review
The nervous system is divided in :
-Central (CNS)
-Peripheral (PNS)
The CNS consists of the brain and the
spinal cord.
The PNS consists of the cranial nerves
(12 pairs) and the spinal and peripheral
nerves.
The spinal cord
Encased within the bony vertebral
column.
From the medulla till L1,L2 .
Contains important sensory motor nerve
pathways.
Mediates reflex activity of the DTR .
The peripheral nervous system

The CN 12 pairs of special nerves

(IXII).
Arise from the diencephalon and the
brainstem.
They are motor, sensory or mixte .
The motor pathways
The nerve cell bodies of the UMN lie in the
cerebral cortex and in several brainstem
nuclei.
Their axons synapse with the motor nuclei in
the brainstem(CN) in the spinal cord(PN)
A damage to the UMN above crossover
give controlateral effect , below
crossover ipsilateral effect.
It will result in weakness / paralysis with
increased muscle tone and DTRs.
The motor pathway
LMN have their cell bodies in the spinal
cord (anterior horn cell), their axons
transmit impulses through the anterior
roots and the spinal nerves into
peripheral nerves terminating at the
neuromuscular junction.
A damage to the LMN result in
ipsilateral weakness /paralysis with
decreased muscle tone and DTRs
THE SENSORY PATHWAY
Sensory impulses participate in reflex
activity.
Give rise to conscious sensation,
calibrate body position in space.
Help regulate internal autonomic
functions like BP , heart rate and
respiration.
DERMATOMES
A dermatome is the band of skin
innervated by the sensory root of a
single spinal nerve.
Dermatomes overlap each other
it is useful to remember the locations of
some:(C2, T4, T10, L4, L5 )
I-THE HEALTH HISTORY
Common symptoms:
1-Headache.
2-Dizziness
3-Generalized ,proximal or distal weakness.
4-Numbness,abnormal or loss of sensation.
5-Loss of consciousness,Syncope.
6-Seizure.
7-Tremor,or involuntary movements.
The neurological exam
I- General Appearance, including posture, motor activity, vital signs and
perhaps meningeal signs if indicated.
II- Mini Mental Status Exam, including speech observation.
III- Cranial Nerves, I through XII.
IV- Motor System, including muscle atrophy, tone and power.
V- Sensory System, including vibration, position, pin prick,
temperature, light touch and higher sensory functions.

VI- Reflexes, including deep tendon reflexes, clonus, Hoffman's response

and plantar reflex.
VII- Coordination, gait and Romberg's Test

Examining the comatose patient

I-General appearance
Have the patient sit facing you on the
examining table. Take a few seconds to
actively observe the patient. Continue to
actively observe the patient during the exam:
1. Level of consciousness
2. Personal Hygiene and Dress.
3. Posture and Motor Activity.
4. Height, Build and Weight
5. Vital Signs.
II- Mental status
Level of Consciousness
1. Awake and alert
2. Agitated
3. Lethargic
1. Arousable with
1. Voice
2. Gentle stimulation
3. Painful/vigorous stimulation
4. Comatose
II- Mental status
LANGUAGE
FLUENCY

NAMING

REPETITION

READING

WRITING

COMPREHENSION

Aphasia vs. dysarthria

II- Mental status
MEMORY
IMMEDIATE
REALLY A MEASURE OF ATTENTION
RATHER THAN MEMORY
REMOTE
3 OBJECTS AT 0/3/5 MINUTES
HISTORICAL EVENTS
PERSONAL EVENTS
II- Mental status
ORIENTATION
PERSON
NOT WHO THEY ARE BUT WHO YOU
ARE
PLACE
TIME
II- Mental status
OTHER COGNITIVE FUNCTIONS
CALCULATION
ABSTRACTION
SIMILARITIES/DIFFERENCES
JUDGEMENT
PERSONALITY/BEHAVIOR
 III- CRANIAL NERVES
I - Smell
II - Visual acuity, visual fields and ocular
fundi
II,III - Pupillary reactions
III,IV,VI - Extra-ocular movements, including
opening of the eyes
V - Facial sensation, movements of the jaw,
and corneal reflexes
VII - Facial movements and gustation
III-CRANIAL NERVES
VIII - Hearing and balance
IX,X - Swallowing, elevation of the
palate, gag reflex and gustation
V,VII,X,XII - Voice and speech
XI - Shrugging the shoulders and
turning the head
XII - Movement and protrusion of
tongue
III-CRANIAL NERVES
Olfactory nerve CN I :
test the sense of smell .
Use non irritating familiar odors.
Make sure each nasal passage is open.
You can use coffee, soap, vanilla or
cloves.
III-CRANIAL NERVES
Optic nerve - CN II .
Test visual acuity, optic fundi and visual
acuity.
Visual acuity : Snellen chart well lighted
patient stands 20 feet from the chart.
There is the Snellen cards that looks
like the chart , but the patient is at 14
inches, used for convevience.
III-CRANIAL NERVES
Optic fundi using your ophtalmoscope .

Visual field by confrontation.

III-CRANIAL NERVES
Oculomotor nerve - CN III.
Inspect the size and shape of the pupils
(II,III).
Test pupil reaction to light.
CN III is responsible of most of the eyeball s
mobility.
Also the muscle which raises the upper eye
lid.
CNIII is assessed in concert with CN IV and
VI.
III-CRANIAL NERVES
Trochlear nerve CN IV controls the
Superior Oblique muscle : allows the
eye to look down and medially.
Abducens nerve CN VI controls the
Lateral Rectus muscle : allows the eye
to move laterally.
S O 4 L R 6 All the Rest 3
III-CRANIAL NERVES
Ask the patient to keep their head in one
place , and to follow your finger while moving
only their EYES.
Move your finger out laterally, up and down,
then across the patients face to the other
side of their head.
Also move it again up and down .
So roughly you will trace out the letter H
I-CRANIAL NERVES.
FIG 9.2 PAGE 75

FIG9.4 PAGE 79.

III-CRNIAL NERVES.
Trigeminal- CN V:
The motor limb of CN V innervates the
Temporalis and Masseter muscles important
for closing the jaw, muscles of mastication.
Palpate temporal and masseter muscles.
Ask pt to clench his teeth.
Note the strength of muscle contraction.
III-CRANIAL NERVES
Sensory: three divisions V1,V2,V3.
Test facial sensation:Light touch, pinprick in 3

divisions
Use a safety pin and ask the patient to report

whether it is sharp or dull and compare sides

if you find abnormality check for temperature
sensation
Test corneal reflex (V,VII):

Lightly touch the cornea with a fine wisp of cotton

avoid eyelashes, look for blinking of the eyes.
Fig page 614
III-CRANIAL NERVES
Facial nerve CN VII.
Inspect for asymmetry at rest and during contraction,
note any abnormal movement.
Ask the patient to:
1-raise eyebrows
2-frown
3-close both eyes tighty so you cannot open them. Test for
muscular strength by trying to open them.
4-show upper and lower teeth
5-smile
6-puff out both cheeks.
III-CRANIAL NERVES.
Acoustic nerve CN VIII:
Assess hearing : Stand behind patient (eyes
closed) , whisper a few words from just
behind one ear.
He should be able to repeat the words
accurately .
Perform the same for the other ear.
if hearing losss is present test for
lateralization and compare air and bone
conduction.
 III-CRANIAL NERVES.

Glossopharyngeal and Vagus nerve CN IX & X: These

nerves are responsible for raising the soft palate and
the gag reflex:
Listen to the patient s voice : hoarse ? Nasal quality?
Ask him to say ah and watch the movement of
the soft palate (the uvula should rise up straight and
in the midline.)
Is there any difficulty swallowing.
Gag Reflexe :stimulate the back of the throat
lightly on each side.
III-CRANIAL NERVES.
Spinal acessory nerve CN XI :
From behind look for any atrophy or
fasciculations in the Trapezius.
Shoulder shrug upward against your
hands.
Lateral rotation of neck against
resistance.
III-CRANIAL NERVES
Hypoglossal nerve CN XII:
Listen to word s articulation.
Ask him to protrude his tongue and look
for asymmetry, atrophy or deviation
from midline.
Ask him to move his tongue from side
to side and note the symmetry of the
movement,
IV-MOTOR SYSTEM
When you assess the motor system find if the
abnormality is central or peripheral, identify
which muscle (s) are involved.
Things that you will look for:
1-Patient body s position.
2-Involuntary movement.
3-Muscle bulk.
4-Muscle tone.
5-Muscle strength.
IV-THE MOTOR SYSTEM

1-Body position: position at rest

and during movement. Look specially
for a hemiplegic positioning (flexion
of elbow and wrist with extension of
knee and ankle).
2-Involuntary movement: look for
fasciculation: fine subcutaneous
movements that represent
contractions of a motor unit;
tremors, tics..
IV-THE MOTOR SYSTEM
3-Muscle bulk: compare the size
contours of muscles. Look for wasting
atrophy.
This assessment is subjective
dependent on the age, sex and the
activity/ fitness of the patient.
Atrophy is specifically checked over the
hands, shoulders and thighs.
 IV-MOTOR POWER
4-Muscle tone : even voluntary
relaxed a normal muscle with intact
nerve supply maintains a slight residual
tension: muscle tone .
The patient should be relaxed or at
least distracted by conversation.
Marked floppiness: hypotonic muscle
Increased resistance: spasticity, rigidity.
IV-MOTOR POWER
5-Muscle strength.
Take into account age, sex and level of
activity.
Motor power is graded to a scale from 0
to 5.
Test muscle strength by asking the patient to
move actively against your resistance .
Test major muscles groups.
 Scale for grading Muscle Strength

Muscle strength is graded on a 0 to 5:

0- No muscular contraction detected.
1- A barely detectable flicker or trace of contraction.
2- Active movement of the body part with gravity
eliminated.
3- Active movement against gravity.
4- Active movement against gravity and some
resistance.
5- Active movement against full resistance without
evident fatigue. This is normal muscle strength.
 IV-MOTOR POWER
5-Muscle strength: grossly test groups of
muscles bilaterally at the same time.
Any abnormality, do more refined testing.
For upper and lower limbs at each major joint
test
- Flexion / extension
- Abduction / adduction
- Test grip finger abduction
- Test thumb opposition.
IV-MOTOR SYSTEM
A coordinated combination of a series
of motor actions is needed to produce a
smooth and accurate movement.
This requires integration of sensory
feedback with motor output.
This integration occurs mainly in the
cerebellum.
IV-MOTOR POWER.
To assess Coordination observe :
1-Rapid alternating movements.
2-Point-to- point movements.
3-Gait and other related body
movements.
4-Standing in specific ways.
IV-MOTOR POWER
Rapid alternating movements: Ask the
patient to place their hands on their thighs
and then rapidly turn their hands over and lift
them off their thighs .
Tell them to repeat it rapidly for 10 seconds .
Normally this is possible without difficulty.
This is considered a rapidly alternating
movement.
Dysdiadochokinesis is the clinical term for
an inability to perform rapidly alternating
movements .
IV-MOTOR POWER
Point to point movements:
1-finger-nose
2-heel-shin
IV-Motor power (finger-nose)
Ask the patient to extend their index finger
and touch their nose, and then touch your
outstretched finger with the same finger.
Ask the patient to go back and forth
between touching their nose and your finger.
Once this is done correctly a few times at a
moderate cadence, ask the patient to
continue with their eyes closed.
IV-MOTOR POWER
Normally this movement remains
accurate when the eyes are closed.
Repeat and compare to the other hand.
Dysmetria is the clinical term for the
inability to perform point-to-point
movements due to over or under
projecting ones fingers
IV-MOTOR POWER (heel-shin)
With the patient lying supine, instruct him or
her to place their right heel on their left shin
just below the knee and then slide it down
their shin to the top of their foot.
Have them repeat this motion as quickly as
possible without making mistakes.
Have the patient repeat this movement with
the other foot. An inability to perform this
motion in a relatively rapid cadence is
abnormal.
IV-MOTOR POWER (heel-shin)
The heel to shin test is a measure of
coordination and may be abnormal if
there is loss of motor strength,
proprioception or a cerebellar lesion.
If motor and sensory systems are
intact, an abnormal, asymmetric heel to
shin test is highly suggestive of an
ipsilateral cerebellar lesion.
IV-MOTOR POWER
Gait: ask the patient to walk , observe posture,
balance, swinging of the arms and movements of the
legs .
A slight decrease in arm swinging is a highly sensitive
indicator of upper extremity weakness.
Walk heel-to toe (tandem walking).
Walk on the toes (walking on toes is the best way to
test early foot plantar flexion weakness).
Walk on the heels (the most sensitive way to test
for foot dorsiflexion weakness )
Hop in place.
Do a shallow knee bend.
III-MOTOR POWER
FIG4-1 PAGE 39
IV-MOTOR POWER (Romberg
test)
The patient stand still with heels together.
Ask him to remain still and close his eyes.
If the patient loses balance, the test is
positive.
Therefore, if a patient loses his balance after
standing still with his eyes closed, and is able
to maintain balance with his eyes open, then
this is indicative of pathology in the
proprioceptive pathway.
This is a positive Romberg.
IV-MOTOR POWER (Romberg
test)
To achieve balance, a person requires
2 out of the following 3 inputs to the
cortex:
1. Visual confirmation of position.
2. Non-visual confirmation of position
(including proprioceptive and
vestibular input)
3. A normally functioning cerebellum.
V-SENSORY SYSTEM
There is five basic modalities of
sensation:
1- Vibration sense
2- Joint position sense
3- Light touch
4- Pin prick
5- Temperature.
First teach the patient about the test,than
perform the test.
V -SENSORY SYSTEM
1-Pain : use a sharp safety pin ,ask the
patient is it sharp or dull ?
Apply the lightest pressure , try not to
draw blood.
2-Temperature : omitted if pain
sensation is normal.
Use 2 tests tubes filled with cold and
hot water.
V-SENSORY SYSTEM
3- Light touch :touch skin lightly no
pressure ,compare one area to another.
Anesthesia is absence of touch
sensation.
4- Vibration : the first to be lost in
peripheral neuropathy (diabetic) .
V-SENSORY SYSTEM
5-Position: grasp the patient big toe and
hold it by its side between your thumb and
finger .
Pull it away from the other toes and ask the
patient about its position up or down .
Holding the top or bottom provides the
patient with pressure cues which make this
test invalid.
V -SENSORY SYSTEM
The corresponding nerve root for each area tested is indicated
in parenthesis.
1. posterior aspect of the shoulders (C4)
2. lateral aspect of the upper arms (C5)
3. medial aspect of the lower arms (T1)
4. tip of the thumb (C6)
5. tip of the middle finger (C7)
6. tip of the pinky finger (C8)
7. thorax, nipple level (T5)
8. thorax, umbilical level (T10)
9. upper part of the upper leg (L2)
10. lower-medial part of the upper leg (L3)
11. medial lower leg (L4)
12. lateral lower leg (L5)
13. sole of foot (S1)
V-SENSORY SYSTEM
- Discriminative sensation: It test the ability of the
sensory cortex to correlate analyse and interpret
sensations. They are useful only when touch and
position sense are intact.
- Stereognosis : asking the patient to close their
eyes and identify the object you place in their
hand
- Number identification : Graphesthesia asking the
patient to close their eyes and identify the number or
letter you will write with the back of a pen on their
palm.
V-SENSORY SYSTEM
Extinction.
Have the patient sit on the edge of the
examining table and close his eyes.
Touch the patient on the trunk or legs in one
place and then tell the patient to open their
eyes and point to the location where they
noted sensation.
Repeat this maneuver a second time,
touching the patient in two places on
opposite sides of their body, simultaneously.
V-SENSORY SYSTEM
Then ask the patient to point to where
they felt sensation.
Normally they will point to both areas.
With lesions of the sensory cortex only
one stimulus may be recognized,the
stimulus on the side opposite the
damaged cortex is extinguished.
VI-DEEP TENDON REFLEXES
(DTR)
Using a reflex hammer DTR are ellicited in all
extremities.
Ensure patient is relaxed (avoid telling him to
relax this will guarantee to produce tension).
Place your thumb on the tendon and strike
your thumb with the reflex hammer and
observing the muscle movement.
Repeat and compare with the other arm
You may strike the tendon directly
VI-DEEP TENDON REFLEXE
Reinforcement : done by asking the
patient to clench their teeth, or in lower
extremity reflexes, have the patient
hook together their flexed fingers and
pull apart.
This is known as the Jendrassik
maneuver.
Grading DTRs
VI- D T R
Grading DTRs
.Grade 0 no response
.Grade 1 minimal response
.Grade 2 mild range normal response.
.Grade 3 slightly hyperactive response
.Grade 4 hyperactive response with
clonus
VI- D T R
DTR to test:
Biceps
Triceps
Brachioradialis
Patellar
Achilles.
Babinski.
Page 136 fig 19.1

fig 19.2

fig 19.3-

fig 19-4

fig 19-5

fig 19.6

19.9 babinski
VI- D T R (Babinski)
The Plantar reflex (Babinski) is tested by
coarsely running a key or the end of the
reflex hammer up the lateral aspect of the
foot from heel to big toe.
The normal reflex is toe flexion.
If the toes extend and separate, this is an
abnormal finding called a positive Babinski's
sign.
A positive Babinski's sign is indicative of an
upper motor neuron lesion affecting the lower
extremity in question.
VI- D T R ( clonus)
Finally, test clonus if any of the reflexes
appeared hyperactive.
Hold the relaxed lower leg in your
hand, and sharply dorsiflex the foot and
hold it dorsiflexed.
Feel for oscillations between flexion and
extension of the foot indicating clonus.
Normally nothing is felt.
SPECIAL TECHNIQUES OF
EXAMINATION
ASTERIXIS
WINGING OF THE SCAPULA
MENINGEAL SIGNS
ANAL WINK
ASTERIXIS
Asterixis:help identify metabolic
encephalopathy.
Ask pt to stop trafic, by extending
both arms, hands cocked up fingers
spread.
Watch 1, 2 mn for any sudden brief non
rythmic flexion of the hands.
Meningeal Signs
Neck mobility
Brudzinski s sign: as you flex the neck watch
hips and knees ,normally stay relaxed
motionless.
Kernig s sign: flex the patient s leg at both
the hip and the knee and then straighten the
knee. This maneuver should not produce
pain. Pain and resistance to extend the knee
is a positive sign.
SPECIAL TECHNIQUES OF
EXAMINATION
Anal reflex :using a cotton swab stroke
outward in the four quadrants from the
anus . Watch for the reflex contraction
of the anal musculature.
Winging of the scapula:when muscle of
shoulders are weak or atrophic the
scapula juts backward when the
patient extend both arms and push
against the wall or our hands.
The comatose patient
I. Motor Response
6 - Obeys commands fully
5 - Localizes to noxious stimuli
4 - Withdraws from noxious stimuli
3 - Abnormal flexion, i.e. decorticate posturing
2 - Extensor response, i.e. decerebrate posturing
1 - No response

II. Verbal Response

5 - Alert and Oriented
4 - Confused, yet coherent, speech
3 - Inappropriate words, and jarbled phrases consisting of words
2 - Incomprehensible sounds
1 - No sounds

III. Eye Opening

4 - Spontaneous eye opening
3 - Eyes open to speech
2 - Eyes open to pain
1 - No eye opening

Glascow Coma Scale = I + II + III.

A lower score indicates a deeper coma and a poorer prognosis.
Patients with a Glascow Coma Scale of 3-8 are considered comatose. Patients with an initial score of 3-
4 have a >95% incidence of death or persistent vegetative state.
 PRATICAL SUGGESTIONS

In general ,the NE is not applied in its

entirety to asymptomatic , otherwise
healthy people
Its is sometimes appropriate to perform
only certains parts of the NE .
Take advantage when a more
experienced clinician examines one of
your patients .