Neurology Exam

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Neurology Exam

• Farzad Fatehi, M.D.
• Assistant Professor of Neurology,
• Shariati Hospital,
• Tehran University of Medical Sciences

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Some points

• Be systematized.
• Always use a similar algorithm for taking
  history.
• Do not forget the general exam.
• Do not forget to auscultate bruits on eye and
  carotid.

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Sample
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• Cranial Nerves

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Cranial Nerve I

• This CN is tested one nostril at a time by using
  a nonirritating smell such as tobacco, orange,
  vanilla, coffee, etc.

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Cranial Nerve I
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Cranial Nerve II

• Visual Acuity
• Visual Field
• Funduscopy
• Pupil Reflex

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Cranial Nerve II

• Cranial Nerve 2- Visual acuityThe first step in
  assessing the optic nerve is testing visual
  acuity.
• This can be done with a standard Snellen chart or
  with a pocket chart (Rosenbaum).
• Have the patient use their glasses if needed to
  obtain best-corrected vision.

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Cranial Nerve II

• Cranial Nerve II- Visual fieldsThere are several
  different screening tests that can be used to
  assess visual fields at the bedside.
• First hold up both hands superiorly and
  inferiorly and ask the patient if they can see
  both hands and do they look symmetric.
• Then test each eye individually using your
  fingers in the four quadrants of the visual field
  and ask the patient to count fingers held up or
  point to the hand when a finger wiggles using
  yourself as a control.

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Cranial Nerve II

• Cranial Nerve II- Visual fieldsA second
  screening test is to use a grid card.
• A third method is to use a cotton tip applicator.
  Testing one eye at a time ask the patient to say
  "now" as soon as they see the applicator come
  into their side vision as they focus on the
  examiner's nose.
• All of these tests are screening tests. Formal
  perimetry is the most accurate way of assessing
  visual fields

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Grid Card
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Cranial Nerve II

• Cranial Nerve II- FunduscopyDirect visualization
  of the optic nerve head is an important and
  valuable part of assessing CN 2.
• Systematically look at the
• optic disc
• Vessels
• Retinal background and fovea.

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Cranial Nerve II III

• Cranial Nerves 2 3- Pupillary Light ReflexThe
  afferent or sensory limb of the pupillary light
  reflex is CN2 while the efferent or motor limb is
  the parasympathetics of CN3.
• Shine a flashlight into each eye noting the
  direct as well as the consensual constriction of
  the pupils.
• The swinging flashlight test is used to test for
  a relative afferent pupillary defect or a Marcus
  Gunn pupil. Swinging the flashlight back and
  forth between the two eyes identifies if one
  pupil has less light perception than the other.

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Cranial Nerve III, IV, VI

• Cranial Nerves 3, 4 6- Inspection and Ocular
  AlignmentBefore checking ocular movements it is
  important to inspect the eyes.
• Look for ptosis.
• Note the appearance of the eyes and check for
  ocular alignment ? (the reflection of your light
  source should fall on the same location of each
  eyeball).

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Eye movements

• Version
• Moving both eyes coordinately
• Vergence
• Moving both eyes toward the midline or far from
  the midline
• Duction
• Movement of one eye

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Cranial Nerve III, IV, VI

• Cranial Nerves 3, 4 6- VersionsTesting
  extraocular range of motion with both eyes open
  and following the target (conjugate gaze) is
  called versions.

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Cranial Nerve III, IV, VI (supranuclear)

• SaccadesSaccades are tested by holding up your
  two hands about three feet apart and instructing
  the patient to look at the finger that is
  wiggling without moving their head. The patient's
  eyes should be able to quickly, smoothly and
  accurately jump from target to target.

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Saccade
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Cranial Nerve III, IV, VI (supranuclear)

• Smooth PursuitTo test Smooth Pursuit ask the
  patient to keep watching the target without
  moving their head. Then move the target slowly
  from side to side and up and down. The eyes
  should be able to follow the target smoothly
  without lagging behind or jerking to catch up
  with the target.

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Pursuit
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Cranial Nerve III, IV, VI (supranuclear)

• Optokinetic NystagmusOptokinetic Nystagmus is a
  test of smooth pursuit with quick resetting
  saccades.
• Use a tape with repeating shapes on it and ask
  the patient to look at each new object as it
  appears as you run the tape between your fingers
  to the right, left, up, and down.
• The patient will have brief pursuit eye movements
  in the direction of the tape movement with quick
  saccades or jerks in the opposite direction.

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OKN
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Cranial Nerve III, IV, VI (supranuclear)

• VergenceVergence eye movements occur when the
  eyes move simultaneously inward (convergence) or
  outward (divergence) in order to maintain the
  image on the fovea that is close up or far away.
• Most often convergence is tested as part of the
  near triad (convergence, pupil constriction,
  accommodation).
• When a patient is asked to follow an object that
  is brought from a distance to the tip of their
  nose the eyes should converge, the pupil will
  constrict and the lens will round up
  (accommodation).

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Vergence
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Cranial Nerve V

• Cranial Nerve 5- SensoryTest for both light
  touch (cotton tip applicator) and pain (sharp
  object) in the 3 sensory divisions (forehead,
  cheek, and jaw) of CN 5.

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Cranial Nerve V, VII

• Cranial Nerves 5 7 - Corneal reflexThe
  ophthalmic division (V1) of the 5th nerve is the
  sensory or afferent limb and a branch of the 7th
  nerve to the orbicularis oculi muscle is the
  motor or efferent limb of the corneal reflex.
• The limbal junction of the cornea is lightly
  touched with a strand of cotton.
• The patient is asked if they feel the touch as
  well as the examiner observing the reflex blink.

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Cranial Nerve V

• Cranial Nerve 5- MotorThe motor division of CN 5
  supplies the muscles of mastication (temporalis,
  masseters, and pterygoids). Palpate the
  temporalis and masseter muscles as the patient
  bites down hard.
• Then have the patient open their mouth and resist
  the examiner's attempt to close the mouth.
• If there is weakness of the pterygoids the jaw
  will deviate towards the side of the weakness.
• Have the patient slightly open their mouth then
  place your finger on their chin and strike your
  finger with a reflex hammer.
• Normally there is no movement.
• If there is a jaw jerk it is said to be positive
  and this indicates an upper motor neuron lesion.

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Cranial Nerve VII

• Cranial Nerve 7- MotorThe motor division of CN 7
  supplies the muscles of facial expression.
• Start from the top and work down.
• Have the patient
• wrinkle forehead (frontalis muscle)
• close eyes tight (orbicularis oculi)
• show their teeth (buccinator)
• purse lips (orbicularis oris)

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Cranial Nerve VII

• Cranial Nerve 7- Sensory, TasteTaste is the
  sensory modality tested for the sensory division
  of CN 7.
• The examiner can use a cotton tip applicator
  dipped in a solution that is sweet, salty, sour,
  or bitter.
• Apply to one side then the other side of the
  extended tongue and have the patient decide on
  the taste before they pull their tongue back in
  to tell you their answer.

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Cranial Nerve VIII

• Cranial Nerve 8- Auditory Acuity, Weber Rinne
  TestsThis can be done by the examiner lightly
  rubbing their fingers by each ear or by using a
  ticking watch. Compare right versus left
• Weber test
• Rinne test

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Cranial Nerve VIII

• Cranial Nerve 8- VestibularThe vestibular
  division of CN 8 can be tested for by using the
  vestibulo-ocular reflex as already demonstrated
  or by using ice water calorics to test vestibular
  function.

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Cranial Nerve IX, X

• Cranial Nerves 9 10- MotorThe motor division
  of CN 9 10 is tested by having the patient say
  ah.
• The palate should rise symmetrically and there
  should be little nasal air escape.
• With unilateral weakness the uvula will deviate
  toward the normal side because that side of the
  palate is pulled up higher.

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Cranial Nerve IX, X

• Cranial Nerves 9 10- Sensory and Motor Gag
  ReflexThe gag reflex tests both the sensory and
  motor components of CN 9 10.
• This involuntary reflex is obtained by touching
  the back of the pharynx with the tongue depressor
  and watching the elevation of the palate.

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Cranial Nerve XI

• Cranial Nerve 11- MotorCN 11 is tested by asking
  the patient to shrug their shoulders (trapezius
  muscles) and turn their head (sternocleidomastoid
  muscles) against resistance.

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Cranial Nerve XI

• Cranial Nerve 12- MotorThe 12th CN is tested by
  having the patient stick out their tongue and
  move it side to side.
• Inspect the tongue for atrophy and
  fasciculations.
• If there is unilateral weakness, the protruded
  tongue will deviate towards the weak side.

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• Motor Exam

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Motor Exam

• Upper extremities Inspection and Palpation The
  muscles are inspected for
• bulk and fasciculations
• palpated for tenderness, consistency and
  contractures.

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Motor Exam

• Tone - Upper extremity Muscle tone is assessed
  by putting selected muscle groups through passive
  range of motion.
• The most commonly used maneuvers for the upper
  extremities are flexion and extension at the
  elbow and wrist.

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Motor Exam
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Motor Exam

• Tone - Lower extremity Muscle tone is assessed
  by putting selected muscle groups through passive
  range of motion.
• The most commonly used maneuvers for the lower
  extremities are flexion and extension at the knee
  and ankle.

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Motor Exam

• Strength testingMuscle strength is tested from
  the proximal to the distal part of the extremity
  so that all segmental levels for the extremity
  are tested (for the upper extremity that is C5 to
  T1).
• Muscle power is graded on a scale of 0-5.

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Motor Exam

• Strength Testing upper limbs
• C5 Shoulder extension
• C6 Arm flexion
• C7 Arm extension
• C8 Wrist extensors
• T1 Hand grasp

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Flexion
Abduction
Extension
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Motor Exam

• Strength Testing lower limbs
• L2 Hip flexionL3 Knee extensionL4 Knee
  flexionL5 Ankle dorsiflexonS1 Ankle plantar
  flexion

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Motor Exam

• Muscle Strength Grading
• 0 No contraction1 Slight contraction, no
  movement2 Full range of motion without
  gravity3 Full range of motion with gravity4
  Full range of motion , some resistance5 Full
  range of motion, full resistance

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Motor Exam

• Testing for pronator drift The patient extends
  their arms in front of them with the palms up and
  eyes closed.
• The examiner watches for any pronation and
  downward drift of either arm.
• If there is pronator drift this indicates
  corticospinal tract disease.

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• Coordination Tests

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Coordination Tests

• TremorPatient's arms are held outstretched and
  fingers extended.
• Watch for postural or essential tremor.

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Coordination Tests

• ReboundTap outstretched arms. Patient's arms
  should recoil to original position.

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Coordination Tests

• Check ReflexExaminer pulls on actively flexed
  arm then suddenly releases.
• The patient should be able to check or stop the
  arm's movement when released.

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Coordination Tests

• Hand Rapid Alternating MovementsFinger tapping,
  wrist rotation and front-to-back hand patting.
  Watch for the rapidity and rhythmical performance
  of the movements noting any right-left disparity.

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Coordination Tests

• Finger-to-noseThe patient moves her pointer
  finger from her nose to the examiner's finger as
  the examiner moves his finger to new positions
  and tests accuracy at the furtherest outreach of
  the arm.

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Coordination Tests

• Foot Rapid Alternating MovementsPatient taps
  her/his foot on the examiner's hand or on the
  floor.

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Coordination Tests

• Heel-to-shinThe patient places her heel on the
  opposite knee then runs the heel down the shin to
  the ankle and back to the knee in a smooth
  coordinated fashion.

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Coordination Tests

• Tandem gaitThe patient is asked to walk
  heel-to-toe. Note steadiness.
• Tandem gait requires the patient to narrow the
  station and maintain balance over a 4-5 inch
  width.
• Patients with midline ataxias have difficulty
  with tandem gait.

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• Deep Tendon Reflexes

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Deep Tendon Reflexes

• Stretch or Deep Tendon Reflexes A brisk tap to
  the muscle tendon using a reflex hammer produces
  a stretch to the muscle that results in a reflex
  contraction of the muscle.
• Levels for DTR's
• Biceps C5-6Brachioradialis C5-6Triceps
  C7Finger Flexors C8

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Deep Tendon Reflexes

• Levels for DTR's
• Patellar or Knee L2-4Ankle S1-2

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Deep Tendon Reflexes

• Grading DTR's
• 0 Absent1 Decreased but present2 Normal3
  Brisk and excessive4 With clonus

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Plantar Reflex

• Plantar Reflex The plantar reflex is a
  superficial reflex obtained by stroking the skin
  on the lateral edge of the sole of the foot,
  starting at the heel advancing to the ball of the
  foot then continuing medially to the base of the
  great toe.
• The normal response is flexion of all the toes.
• The abnormal response is called a Babinski sign
  and consists of extension of the great toe and
  fanning of the rest of the toes.

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• Joseph Jules François Félix Babinski (1857 1932)
  was a French neurologist of Polish decent.
• This reflex was described in 1896.

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• Sensory Exam

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Sensory Exam

• Light TouchLight touch (thigmesthesia) is used
  as a screening test for touch.
• A cotton tip applicator or fine hair brush is
  used.
• Select areas from different dermatomes and
  peripheral nerves and compare right versus left.

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Sensory Exam

• PainPain is one of the principle sensory
  modalities of the spinothalamic system.
• The sharp end of a broken wooden cotton tip
  applicator can be used then discarded.
• It is important for the patient to be able to
  identify the sensation as sharp and then compare
  between dermatomes, distal versus proximal and
  right versus left for the upper extremities.

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Sensory Exam

• TemperatureTubes or vials of hot and cold water
  can be used but this is usually impractical.
• Using a tuning fork, which is normally perceived
  as cool or cold to the touch, compare between
  dermatomes and right versus left.

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Sensory Exam

• VibratoryVibratory sensation (pallesthesia) is
  one of the sensory modalities of the DCML system.
  It is tested by using a 128 Hz tuning fork and
  placing the vibrating instrument over a bone or
  boney prominence.

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Sensory Exam

• Position SenseFirst, demonstrate the test with
  the patient watching so they understand what is
  wanted then perform the test with their eyes
  closed. The patient should be able to detect 1
  degree of movement of a finger and 2-3 degrees of
  movement of a toe.
• If the patient can't accurately detect the distal
  movement then progressively test a more proximal
  joint until they can identify the movement
  correctly.

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Sensory Exam

• Tactile MovementTactile movement as well as the
  remaining sensory tests are discriminatory
  sensory tests that examine cortical somatosensory
  (parietal lobe) function and require an intact
  dorsal column system.
• Tactile movement tests the patient's ability to
  detect the direction of a 2-3 cm cutaneous
  stimulus.

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Sensory Exam

• Two-Point DiscriminationTwo-point discrimination
  is tested by using calipers or a fashioned paper
  clip.
• The patient should be able to recognize two-point
  separation of 2-4 mm on the lips and finger pads,
  8-15 mm on the palms and 3-4 cm on the shins.

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Sensory Exam

• GraphesthesiaThe examiner demonstrates the test
  by writing single numbers on the palm of the hand
  while the patient is watching.
• The patient then closes their eyes and identifies
  numbers that are written by the examiner.

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Sensory Exam

• Double Simultaneous StimulationDouble
  simultaneous stimulation (DSS) is tested by
  touching homologous parts of the body on one
  side, the other side or both sides at once with
  the patient identifying which side or if both
  sides are touched with their eyes closed.
• If the patient neglects one side on DSS
  (extinction or simultanagnosia) this indicates
  dysfunction of the contralateral posterior
  parietal lobe.

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Sensory Exam

• Romberg TestThe Romberg test is a test of
  proprioception. This test is performed by asking
  the patient to stand, feet together with eyes
  open, then with eyes closed.
• The patient with significant proprioceptive loss
  will be able to stand still with eyes open
  because vision will compensate for the loss of
  position sense but will sway or fall with their
  eyes closed because they are unable to keep their
  balance.

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