Neurological Examination

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Neurological Examination

• Sherif Elwatidy MSc, FRCS(SN), MD
• Professor of Neurosurgery,
• College of Medicine - KSU

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Neurologic History

• Like history in Medicine Surgery
• Personal history
• History of the present complaints
• Social History
• Past medical History

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• From the history we should be able to answer 2
  important questions
• Where is the problem ? (brain, spine Cx.,
  Thoracic, lumbar)
• What is the nature of the problem ? (Congenital,
  inflammatory, neoplastic, degenerative, .)

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The objective of a neurological exam is
threefold. 1. To identify an abnormality in
the nervous system. 2. To differentiated
peripheral from central nervous system
lesions.
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Neurologic examination includes 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
Rhomberg's Test Examining the comatose patient
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General appearance

• Level of consciousness
• Personal hygiene and dress
• Posture and motor activity
• Height build and weight
• Vital signs

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• POSTURE
• Chorea refers to sudden, ballistic movements,
• Athetosis refers to writhing, repetitive
  movements.
• Fasciculations are fine twitching of individual
  muscle bundles, most easily noted on the tongue.
• Dystonia refers to sudden tonic contractions of
  the muscles of the tongue, neck (torticollis),
  back (opisthotonos), mouth, or eyes (oculogyric
  crisis).
• Early signs of tardive dyskinesia are lip
  smacking, chewing, or teeth grinding.
• Damage to the substantia nigra may produce a
  resting tremor.
• This tremor is prominent at rest and
  characteristically abates during volitional
  movement and sleep.
• Damage to the cerebellum may produce a
  volitional or action tremor that usually worsens
  with movement of the affected limb.
• Spinal cord damage may also produce a tremor,
  but these tremors do not follow a typical pattern
  and are not useful in localizing lesions to the
  spinal cord.

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Higher mental functions

• Consciousness (GCS)
• Intelligence
• Nominate week days forward backward
• Nominate months Forward backward
• Digit span (6 forward 4 backward)
• Spelling short word forward backward e.g
  W-O-R-L-D
• and D-L-R-O-W
• -
• Memory
• Short term
• Long term
• Language
• Spoken
• written

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Language
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Cranial nerve examination

• I Olfactory
• II Optic
• III-IV-VI extraoculars
• V Trigeminal
• VII Facial
• VIII Vestibulocochlear
• IX-X Glossopharyngeal, Vagus
• XI Accessory
• XII Hypoglossal

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CN I Olfactory

• Usually not tested.
• Observe for rash, deformity of nose or discharge
  (CSF).
• Test each nostril with essence bottles of coffee,
  vanilla, peppermint.

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CN II Optic

• With patient wearing glasses.
• Test each eye separately on eye chart/ card using
  an eye cover.
• Examine visual fields by confrontation , keep
  examiner's head level with patient's head.
• If poor visual acuity, map fields using fingers
  and a quadrant-covering card.
• Look into fundi.

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papilloedema
Normal
papilloedema
Optic atrophy
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Light Reflex
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Fudoscopy

• Papilledema
• Optic atrophy

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CN III, IV, VI Oculomotor, Trochlear, Abducens

• Look at pupils shape, relative size, ptosis.
• Shine light in from the side to gauge pupil's
  light reaction. Assess both direct and
  consensual responses. Assess afferent pupillary
  defect by moving light in arc from pupil to
  pupil. unne). Optionally as do arc test, have pt
  place a flat hand extending vertically from his
  face, between his eyes, to act as a blinder so
  light can only go into one eye at a time.
• "Follow finger with eyes without moving head"
  test the 6 cardinal points in an H pattern.
• Look for failure of movement, nystagmus pause to
  check it during upward/ lateral gaze.
• Convergence by moving finger towards bridge of
  pt's nose.
• Test accommodation by pt looking into distance,
  then a hat pin 30cm from nose.
• If MG suspected pt. gazes upward at Dr's finger
  to show worsening ptosis.

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CN V Trigeminal

• Corneal reflex patient looks up and away.
  Touch cotton wool to other side. Look for blink
  in both eyes, ask if can sense it. Repeat other
  side tests V sensory, VII motor.
• Facial sensation sterile sharp item on forehead,
  cheek, jaw. Repeat with dull object. Ask to
  report sharp or dull. If abnormal, then
  temperature (heated/ water-cooled tuning fork),
  light touch (cotton).
• Motor pt opens mouth, clenches teeth
  (pterygoids). Palpate temporal, masseter
  muscles as they clench.
• Test jaw jerk (pseudobulbar palsy).

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CN VII Facial

• Inspect facial droop or asymmetry.
• Facial expression muscles pt looks up and
  wrinkles forehead. Examine wrinkling loss.
  Feel muscle strength by pushing down on each side
  UMNL preserved because of bilateral
  innervation.
• Pt shuts eyes tightly compare each side.
• Pt grins compare nasolabial grooves.
• Also frown, show teeth, puff out cheeks.
• Corneal reflex already done. See CN V.

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CN VIII Vestibulocochlear

• Dr's hands arms length by each ear of pt. Rub
  one hand's fingers with noise on one side, other
  hand noiselessly. Ask pt. which ear they hear
  you rubbing. Repeat with louder intensity,
  watching for abnormality.
• Weber's test Lateralization 512/ 1024 Hz 256
  if deaf vibrating fork on top of patients head/
  forehead. "Where do you hear sound coming
  from?" Normal reply is midline.
• Rinne's test Air vs. Bone Conduction 512/ 1024
  Hz 256 if deaf vibrating fork on mastoid behind
  ear. Ask when stop hearing it. When stop
  hearing it, move to the patients ear so can hear
  it. Normal air conduction ear better than
  bone conduction mastoid.
• If indicated, look at external auditory canals,
  eardrums.

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CN IX, X Glossopharyngeal, Vagus

• Voice hoarse or nasal.
• Pt. swallows, coughs (bovine cough recurrent
  laryngeal).
• Examine palate for uvular displacement.
  (unilateral lesion uvula drawn to normal side).
• Pt says "Ah" symmetrical soft palate movement.
• Gag reflex sensory IX, motor X Stimulate
  back of throat each side. Normal to gag each
  time.

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CN XI Accessory

• From behind, examine for trapezius atrophy,
  asymmetry.
• Pt. shrugs shoulders (trapezius).
• Pt. turns head against resistance watch, palpate
  SCM on opposite side.

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CN XII Hypoglossal

• Listen to articulation.
• Inspect tongue in mouth for wasting,
  fasciculations.
• Protrude tongue unilateral deviates to affected
  side.

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Coordination

• Gait
• Tandem walking
• Limb coordination
• Rapid alternating movement
• Finger - nose
• Finger finger
• Heel - shin

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Motor examination

• Muscle status
• Muscle tone
• Muscle power
• Tendon reflexes
• Gait coordination

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Deep tendon Jerks
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Sensory system

• Cortical sensation
• Superficial sensation (pain, temp, light touch)
• Deep sensation (joint movement, position
  vibration sensation)

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