Neurologic Exam

„ Where is the lesion „ What is the lesion

… Cerebral hemisphere … Congenital
… Cerebellum … Traumatic
… Basal ganglia … Infectious
… Brain stem … Metabolic
… Spinal cord … Toxic
… Peripheral nerve … Vascular
… Neuromuscular … Neoplastic
junction … Degenerative
… Skeletal muscle … Idiopathic

History
„ Date of onset
„ Character and severity
„ Location and extension
„ Time relationship
„ Associated complaints
„ Aggravating/alleviating factors
„ Previous treatments and their effect
„ Progress, remissions, exacerbations

Neurologic Exam Equipment

„ Bed
„ Stethoscope
„ Penlight
„ Tuning fork
„ Safety pin
„ Tissue paper
„ Hot and cold water
„ Coffee, lemon juice, etc for smell
„ 2-point discriminator
„ Percussion hammer
„ Ophthalmoscope
„ Visual acuity card
„ Tongue blades
„ Measuring tape

1
 Cortical Function
„ Level of consciousness
… Alert/oriented, hyperalert, sleepy, lethargic,
comatose
Cortical Function
„ Higher cortical function
… General knowledge: who is
the president, what is the
capital, current events
… Oriented:
„ Time: day, month, year
„ Place
„ Person
… Memory
„ Birth/wedding date, names
and ages of children, etc
… Language
„ Read, write, speak,
comprehend
Cranial Nerves
„ I – smell – coffee/lemon
„ II – visual acuity – Snellen
chart
„ II – visual field –
confrontation test
„ II/III – pupillary response to
light/accommodation
… Light response
… Look at near object
„ II/IV/VI – extraocular
movements – H test
„ V (sensory) – facial
sensations – pin/cotton
… Calculation
„ 1-20 forward/backward,
serial sevens [100,
backwards by 7],
multiplication, division
… Retention
„ Give digits [i.e. a phone
number], remember in
forward/backward order
… Judgment
„ Define proverbs/meaning
of a story
… A penny saved is a
penny earned
… Mood
… Sensory interpretation
„ Spatial orientation
„ V/VII – corneal reflex –
cotton
„ V (motor) – forceful jaw
deviation to one side
„ V (motor) – teeth clenching
„ VII – facial symmetry – smile,
whistle, pucker lips, show
teeth, close eyes, wrinkle
forehead
„ VII/IX/X – taste – sugar,
vinegar, saline, quinine
„ VIII – hearing – tuning fork
(ear & bone)
2
 Cranial Nerves
„ IX/X – palatal elevation – say
‘Ah’
„ IX/X – gag reflex – touch
pharynx with tongue blade
„ XI – shoulder shrug against
resistance
„ XI – head and neck turning
against resistance
„ XII – tongue mass and
movement

Cranial Nerve
Summary Table

Motor Function
„ Gait & stance
… Posture, balance, arm swing, leg movement
„ Muscle tone
… Resistance to passive movement
„ Muscle bulk
„ Muscle strength
… Hopping, squatting, walking on heels/tiptoes,
individual muscle groups
„ Scale: 0-5,
… 5 = normal
… 4 = movement against gravity/resistance
… 3 = movement against gravity/no resistance
… 2 = movement only with gravity eliminated
… 1 = flicker or trace of contraction
… 0 = no contraction

3
Motor Coordination
„ Cerebellar/basal ganglia function
„ Gait/posture
„ Tandem gait: heel/toe down a line
„ Rapid alternate movement
„ Finger to nose to finger test
„ Heel to knee to shin
„ Finger tapping

Sensory Function
„ Vibration sense: upper/lower limbs
„ Joint position sense
„ Pain – pin
„ Temperature – hot/cold water
„ Light touch – cotton
„ 2 point discrimination

Reflexes
„ Deep tendon reflexes –
hammer
… Biceps
… Triceps
… Brachioradialis
… Quadriceps
… Achilles
„ Superficial reflexes
… Plantar – stroke outer
border of sole – toes curl
… Abdominal – stroke each
quadrant, belly button
moves that way
… Cremasteric (male) –
stroke inner thigh,
ipsilateral testis retracts
„ Pathological reflexes
… Babinski – dorsiflexion of
toe & fanning of others
… Clonus – repetitive,
rhythmic, involuntary
contraction of muscles
… Frontal release – stroke
palm of hand, fingers curl
… Crossed adductor reflex -
Both thighs adduct when
strike the tendon of one
thigh
… Finger flexor reflex - Snap
nail of middle finger, thumb
and fingers flex
… Jaw jerk – tap relaxed chin,
jaw jerks shut

4
 Site
„ Cortex – seizures, aphasia,
hemianopia, hemiplegia,
dementia, headache,
delirium
„ Brain stem – cranial nerve
palsies
… Ocular signs, involuntary
movements, crossed
syndromes (cranial nerve palsy
on one side, hemiparesis on
the other)
„ Cerebellum – ataxia,
volitional tremor, nystagmus
„ Basal ganglia
… Dyskinesia – hyperkinetic
(Huntington’s), hypokinetic
(Parkinson’s)
„ Wednesday’s class is Question and
Answer
… Bring the slide/book page you are asking a
question about
„ Monday Dec. 4th, no class
„ Final Exam
… Monday Dec. 11, 9-Noon
„ Spinal Cord
… Spastic gait, bladder/bowel
symptoms, sensory level
„ Peripheral nerves –
neuropathies
… Distal – glove and sock
sensory deficit & distal
weakness over proximal
weakness
„ Neuromuscular junction
… Motor disorders, fluctuate
during the day, triggered by
use, relieved with rest
„ Usually face/ocular
muscles
„ Muscle – myopathies
… Purely motor, proximal
muscles, no sensory
deficits