Neurologic Examination

Stephen Jo T. Bonilla, RN, MD

Department of Surgery
St. Luke’s Medical Center
 Neurologic Examination
 Mental Status Examination
 Cranial Nerves
 Motor System
 Sensory System
 Cerebellar System
 Reflexes
 Mental Status Examination
 Appearance and behavior
 Speech and language
 Mood
 Thoughts and perceptions
 Cognitive functions
- Memory
- Attention
- Information & vocabulary
- Calculations
- Abstract thinking
- Constructional ability
 Appearance and Behavior
 Level of Consciousness
 Posture and Motor Behavior
 Dress, Grooming, and Personal Hygiene
 Facial Expression
 Manner, Affect, and Relationship to
Persons and Things
 Level of Consciousness
 Alert
- speak to px in a normal tone of voice
- opens eyes, looks at you, responds fully &
appropriately
 Lethargy
- speak in a loud voice (“How are you?”)
- drowsy, opens eyes, looks at you,
responds to questions and falls asleep
 Level of Consciousness
 Obtundation
- shake the px gently as if awakening a sleeper
- opens eyes, looks at you, responds slowly, & is
somewhat confused
 Stupor
- apply a painful stimulus (rub the sternum)
 Coma
- apply repeated painful stimuli
- remains unarousable w/ eyes closed
 Posture and Motor Behavior
 Does the px lie in bed or walks around?
 Note body posture and ability to relax
 Observe pace, range & character of
movements
 Voluntary control?
 Are certain parts immobile?
 Dress, Grooming, and
Personal Hygiene
 Grooming & personal hygiene may
deteriorate in depression, schizophrenia, &
dementia
 Excessive fastidiousness may be seen in an
obsessive-compulsive disorder
 One-sided neglect may result from a lesion
in the opposite parietal cortex, usually the
non-dominant side
 Facial Expression
 Observe the face, both at rest & when
interacting with others
 Are they appropriate?
 Anxiety, depression, apathy, anger, elation
 Facial immobility of parkinsonism
 Manner, Affect, and
Relationship to Persons and
Things
 Assess the patient’s affect & its appropriateness
 Blunt
 Flat
 Does the patient seem to hear or see things that
you do not?
 Does the patient seem to be conversing with
someone who is not there?
 Speech and Language
 Quantity
 Rate
 Loudness
 Articulation of words
- Dysarthria – defect in the muscular control of speech
apparatus (lips, tongue, palate or pharynx) (nasal, slurred,
or indistinct)
- Aphasia – disorder in producing or understanding
language
- Aphonia – loss of voice accompanying disease affecting
the larynx or its nerve supply
- Dysphonia – less severe impairment in volume, quality or
pith of voice
 Aphasia
Wernicke’s (receptive)
- fluent, rapid, effortless
- articulation are good but
sentences lack meaning
- impaired word/reading
comprehension, repetition,
naming, writing
- posterior superior
temporal lobe
Broca’s (expressive)
- nonfluent, slow, laborious
- articulation are impaired but
words are meaningful
- impaired repetition & writing
- fair word/reading
comprehension
- posterior inferior frontal lobe
 Testing for Aphasia
 Word comprehension
- “point to your nose”
- “point to your eye, then knee”
 Repetition
- “ask px to repeat a phrase (“no ifs, ands, or buts”)
 Naming
- parts of a watch
 Reading comprehension
- read a paragraph aloud
 Writing
- write a sentence
 Speech and Language
 Fluency
- rate, flow, melody of speech, content & use of
words
- hesitancy & gaps
- monotonous
- circumlocutions (phrases or sentences are
substituted for a word the person can not think of)
- paraphasia – words are malformed (“I write w/ a
den”); wrong (“I write w/ a beer”); or invented (“I
write w/ a zar”)
 Mood
 Sadness
 Contentment
 Joy
 Euphoria
 Anger
 Anxiety
 Attachment
 Thought and Perceptions
 Thought Processes
- logic, relevance, organization, & coherence
 Circumstantiality
 Derailment (Loosening of Associations)
 Flight of Ideas
 Neologisms
 Blocking
 Confabulation
 Perseveration
 Echolalia
 Clanging
 Thought Content
 Compulsions
 Obsessions
 Phobias
 Anxieties
 Feelings of Unreality
 Feelings of Depersonalization
 Thought Content
 Delusions

- persecution
- grandiosity
- jealousy
- reference
- being controlled
- somatic
 Perceptions
 Illusions
 Hallucinations
 Insight and Judgment
 Insight

- “what seems to be the problem?”

 Judgment

- process of forming an opinion or

evaluation about something
- “how do you plan to get the help you’ll
need after leaving the hospital?”
 Cognitive Functions
 Orientation

- time
- place
- person
 Attention

- digit span
- serial 7s
- spelling backward
 Cognitive Functions
 Memory (ability to register, store, &
retrieve information)
- immediate
- recent (short-term)
- remote (long term)
- retrograde, antegrade, psychogenic
amnesia)
 New Learning Ability
 Higher Cognitive Functions
 Information and Vocabulary
 Calculating ability
 Abstract thinking

- proverbs
- similarities
 Constructional ability

- ability to reproduce figures or draw a figure on

command
 Cranial Nerve
Examination
I Olfactory Se Smell
II Optic Se Vision
III Oculomotor Mo EOM except lateral rectus & sup oblique; pupil & ciliary muscle of lens
IV Trochlear Mo Sup oblique muscle
V Trigeminal Mi
Ophthalmic (S) Cornea, nasal mucous membrane, skin of face & scalp
Maxillary (S) Skin of face, mucous membrane of mouth & nose, teeth
Mandibular (M) Muscles of mastication; (S) skin of face, mouth, teeth
VI Abducens Mo Lateral rectus muscle
VII Facial Mi (M) Muscles of facial expression; (S) taste (ant 2/3 of tongue);
lacrimal, submandibular & sublingual glands
VIII Vestibulo- Se Equilibrium
cochlear Hearing
IX Glossopharyngeal Mi (M) Stylopharyngeus muscle; (S) taste (post 1/3 of tongue); pharynx;
parotid gland
X Vagus Mi (S) External meatus, pharynx, larynx, aortic sinus, thoracic &
abdominal viscera; (M) pharynx & larynx
XI Accessory Mo Trapezius, SCM, muscles of pharynx & larynx
XII Hypoglossal Mo Muscles of tongue
 Cranial Nerves
 I: Olfactory
- present patient w/
familiar & non-
irritating odors (coffee,
soap, vanilla)
- with eyes closed, test
each nostril one at a
time & ask px to
identify
 Cranial Nerves
 II: Optic
- inspect both optic fundus (optic disc) w/
ophthalmoscope
- check visual fields by confrontation test
 Cranial Nerves
 III:Oculomotor
- pupillary
reactions to light
 Cranial Nerves
 III:Oculomotor
 IV: Trochlear
 V: Abducens
 Cranial Nerves
 V: Trigeminal
- Motor (palpate
temporal &
masseter muscles
while patient
clenches teeth)
- Sensory (light
touch & corneal
reflex)
 Cranial Nerves
 VII: Facial
- raise both eyebrows
- frown
- close both eyes
tightly & try opening
- show both upper &
lower teeth
- smile
- puff out both cheeks
 Cranial Nerves
 VIII: Vestibulo-
Cochlear
- Hearing (Weber’s &
Rinne’s test)
- specific tests of
vestibular function are
seldom included in the
usual neuro exam
 Cranial Nerves
 IX:
Glossopharyngeal
 X: Vagus
- voice
- swallowing
- movements of soft
palate & pharynx
- gag reflex
 Cranial Nerves
 XI: Spinal
Accessory
- shoulder shrug
- turn head side-to-
side
 Cranial Nerves
 XII: Hypoglossal
- move tongue from
side to side
 Motor System
 Body Position
- during movement & at rest
 Involuntary Movements

- tremors, tics, or fasciculations

 Muscle Bulk

- compare size & contour of muscles

- check for atrophy
 Motor System
 Muscle Tone
- feel the muscle’s resistance to passive stretch
- spasticity (increased muscle tone)
- rigidity (increased resistance)
 Muscle strength
- ask px to move actively against your resistance
or to resist your movements
*muscle is strongest when shortest & weakest
when longest
 Muscle Strength Grading
5 Active movement against
gravity & full resistance;
normal muscle strength
4 Active movement against
gravity & some resistance;
examiner can overcome
resistance
3 Active movement against
gravity
2 Active movement of the body
part when gravity is eliminated
1 Very weak muscle contraction;
no active movement
0 No muscle contraction is
detectable
 Muscle Strength (Upper
Extremities)
 Flexion (C5, C6—biceps)
 Extension (C6, C7, C8—triceps)
 Grip (C7, C8, T1)
 Finger abduction (C8, T1, ulnar nerve)
 Thumb opposition (C8, T1, median nerve)
 Muscle Strength (Trunk &
Lower Extremities)
 Flexion, extension & lateral bending of the spine
 Thoracic expansion & diaphragmatic excursion during
respiration
 Hip flexion (L2, L3, L4—iliopsoas)
 Adduction at the hips (L2, L3, L4—adductors)
 Abduction at the hips (L4, L5, S1—gluteus medius &
minimus)
 Hip extension (S1—gluteus maximus)
 Knee extension (L2, L3, L4—quadriceps)
 Knee flexion (L4, L5, S1, S2—hamstring)
 Dorsiflexion (L4, L5)
 Plantarflexion (S1)
 Motor System
 Coordination
- rapid alternating movements
- point-to-point movements
- gait
- standing & balance
- walk heel-to-toe
- walk on toes & heels
- hop in place
- rising from sitting position
 Sensory System
Superficial
 Pain and temperature
(spinothalamic test)
 Light touch (both
pathways)
Deep
 Position and vibration
(posterior columns)
 Two-point
discrimination
 Stereognosis
 Cerebellar System
 Finger-to-nose test
 Dysmetria –
inability to control
accurately the
range of movement
in muscle action
with resultant
overshooting the
mark (past-point)
 Reflexes
 4+ Very brisk, hyperactive,with clonus
 3+ Brisker than average; possibly but not
necessarily indicative of disease
 2+ Average; normal
 1+ Somewhat diminished; low normal
 0 No response
 Reflexes
 Biceps (C5, C6)
- pxs arm is partially
flexed at the elbow w/
palm down
- place thumb or finger
firmly on biceps tendon
- strike w/ reflex hammer
- observe flexion at the
elbow, & watch for &
feel contraction of biceps
muscle
 Reflex
 Triceps (C6, C7)
- flex px’s arm at the
elbow, w/ palm toward
the body, pull it
slightly across the
chest
- strike the triceps
tendon above the
elbow
- watch for contraction
of the triceps muscle &
elbow extension
 Reflex
 Brachioradialis or
Supinator (C5, C6)
- px’s hand should rest
on the abdomen or lap,
w/ the forearm partly
pronated
- strike the radius about
1-2 inches above the
wrist
- watch for flexion &
supination of forearm
 Reflex
 Abdominal reflexes
- briskly stoke each side of abdomen above
the umbilicus (T8, T9, T10), and below
umbilicus (T10, T11, T12)
- use a key, wooden end of cotton
applicator, or tongue blade
- note contraction of abdominal muscles &
deviation of umbilicus toward the stimulus
 Reflex
 Knee (L2, L3, L4)
- sitting or lying down
as long as the knee is
flexed
- briskly tap the
patellar tendon just
below the patella
- note contraction of
quadriceps with
extension at the knee
 Reflex
 Ankle (S1)
- if px is sitting, dorsiflex the foot at the
ankle
- persuade the px to relax
- strike the Achilles tendon
- watch & feel for plantar flexion at the
ankle
- if px is lying down, flex one leg at both
hip and knee & rotate it externally so that
the lower leg rests across the opposite shin
- dorsiflex the foot at the ankle & strike the
Achilles tendon
 Reflex
 Plantar (L5, S1)
- with an object such as key or
wooden end of applicator stick,
stroke the lateral aspect of the
sole from the heel to the ball of
the foot, curving medially across
the ball
- use lightest stimulus that will
provoke a response
- note movement of toes,
normally flexion
Thank You.