NEUROLOGICAL
EXAMINATION
Dr,Lu Qinchi
Dept,Neurology,Ren Ji Hospital
Shanghai Second Medical University
Tel,63260930-2217
Email,qinchilu@hotmail.com
IMPORTANTCE!
?Despite recent advances in
neuroscience and the continuing
development of sensitive diagnostic
procedures,the essential skill required
for the diagnosis remains the clinical
neurologic examination
?Most neurologic diagnosis can be
made on the basis of the history alone
SIX PARTS OF THE NEURO
EXAM
? Mental State & Cognitive Function
? Cranial Nerves
? Motor System
? Sensory System
? Reflexes
?MENTAL STATE&
COGNITIVE
FUNCTION
Mental State & Cognitive
Function
-Level of consciousness( Mental State)
? NORMAL,
– patient awake and alert,attentive to surrounding and
to the examiner
? DEPRESSED,
– Sleepy
– Lethargic
– Stuporous-arrousing only briefly in response to pain
stimulation
– Comatose-not arousable by pain stimulation
Mental State & Cognitive
Function
-Cognitive function check list
? A,Orientation to person,place,and time,
? B,Commom knowledge such as, who is
the president”
? C,Memory,Short term-name three
common objects,then name them again
after 5 minutes; Long term-verifiable events
from the past
Mental State & Cognitive
Function
-Cognitive function check list
? D,Calculations,Serial sevens,count backward
from 100,taking away 7 each time,Real-life
problem
? E,Abstract though:, How is an apple different
from –or the same as – an orange
? F.Other,Insight and judgment,concentration,
verbal fluency,patients mood,content of
though,appropriateness of behavior,and so on,
Mental State & Cognitive
Function
-Language functioning check-up
? Broca’s Aphasias
? Wernicke’s Aphasias
? Conductional Aphasias
?CRANIAL NERVES
CRANIAL NERVES
-Olfactory (I)
? Ask the patient to identify common scents
such as coffee,vanilla,etc,with eyes closed,
? Do not use irritants,In testing olfactory
nerve function,it is less important to
determine whether the patient can correctly
identify a particular odor than whether the
presence or absence of the stimulus is
perceived
CRANIAL NERVES
-Optic (II)
? Visual Acuity-pocket card or wall chart or any
reading matter such as news paper
? Visual Field
– Confrontation Testing-Patient and examiner stand at
eye level at about arm’s length,Have the patient cover
his own eye
– Threat Testing- applied when the patient is less than
fully alert or is uncooperative
? Fundus ( Ophthalmoscopic ) Examination
CRANIAL NERVES
-Pupillary Reflexes (II,III)
? A normal pupil will constrict (1) in response
to direct light,(2) as a consensual response
to light in the opposite eye,and (3) to
accommodation ( convergence to focus on a
close object)
CRANIAL NERVES
-Control of Extraocular Muscle Movements
(III,IV,VI)
? Extraocular muscle movements are
controlled by the oculomotor (III),trochlear
( IV),and abducens (V) nerves
? Volitional Eye Movement-Follow my finger,
just with your eyes,Tracing the Letter H
? Ask about Diplopia
? Nystagmus is rthythmic oscillation of the
eyes
?Unilateral ptosis occurs in
Horner’s syndrome,with a small
pupil; or in a III cranial nerve
lesion,with a large pupil and loss
of adductive and vertical eye
movement
CRANIAL NERVES
-Trigeminal Nerve (V)
? Facial Sensation
? Corneal Reflex-Sweep a wisp of cotton lightly
across the lateral surface of the eye ( out of the
direct visual field) from sclera to cornea- V,VII
? Motor V Testing- Observe the symmetry of
opening and closing of the mouth,Ask the patient
to clench the teeth and then attempt to force jaw
opening
? Jaw jerk-brisk indicates UNL
CRANIAL NERVE
-Facial Strength (VII)
? Facial Symmetry-observe the patient’s face for
symmetry of the palpebral fissures and nasolabial
folds at rest,Ask the patient to wrinkle the
forehead,then to squeeze the eyes tightly shut,
then to smile or snarl,saying show your teeth
– Supernuclear lesion
– Nucleus or peripheral lesion
? Bilateral Facial Weakness
CRANIAL NERVE
-Auditory (VIII)
? Auditory acuity can be tested crudely by rubbing
thumb and forefinger together about 5cm from
each ear,If the patient cannot hear the rub,
proceed to the follow tests
? Rinne Test-hold the base of tuning folk on the
mastoid process until the sound is no longer
perceived,then bring the still vibrating fork up
close to the ear,
– Sensorineural loss
– Conductive loss
? Weber Test
CRANIAL NERVE
-Auditory (VIII)
? Weber Test-lightly strike a tuning fork and place
the handle on the midline of the forehead
– Conductive loss
– Sensorineural loss
? Vestibular Function- need to be tested only if there
are complaints dizziness or vertigo or evidence of
nystagmus
– Nylen-Barany( Dix-Hallpike) maneuver test for
positional nystagmus
CRANIAL NERVE
-Glossopharyngeal(IX) & Vagus(X)
? Test the function of the palate,pharynx,and
larynx
? 1.Palatal elevation- say,ah”
? 2.Gag reflex ( afferent IX,efferent X)- gently
touch each side of the posterior pharygneal wall
with a cotton swab
? 3.Sensory function-lightly touch each side of the
soft palate with the tip of a cotton swab
? 4,Voice quality-listen for hoarseness or
“breathiness”,suggesting laryngeal weakness
CRANIAL NERVE
-Accessory (XI)
? Sternocleidomastoid- press a hand against
the patient’s jaw and have the patient rotate
the head against resistance,Pressing against
the right jaw tests the left
sternocleidomastoid and vice versa
? Trapezius-have the patient shrug shoulders
against resistance and assess weakness
CRANIAL NERVE
-Hypoglossal (XII)
? Tests for hypoglossal nerve function include the following
? 1.Atrophy or Fasciculations-with the patient’s tongue
resting in the floor of the mouth,first inspect for atrophy or
fasciculations,Then ask the patient to protrude the tongue,
and observe for deviation to the weak side
? 2,Subtle Weakness-have the patient push the tongue into
each cheek against external resistance(opposite
hypoglossal m.)
? 3,Subtle Dysarthria- Ask the patient to repeat difficult
phrases
?MOTOR SYSTEM
Motor Function
? Muscle Tone
– Decreased( floppy,flaccid,hypotonic)
– Normal
– Increased( Spastic vs,Rigid)
? Muscle Bulk
– Atrophy ( or with fasciculation)
? Muscle Strength-The classic grading system scores as
follows,5,full strength; 4,movement against gravity and
& resistance; 3,movement against gravity only;2,
movement horizontally along the surface of the
bed;1,palpable contraction but little visible movement; 0,
no contraction
? Motor Coordination & Gait
?Tibialis anterior will be weak in
upper motor neuron lesions,in
polyneropathy,in common
peroneal never lesions,and in
L5/S1 root lesions due to
prolapsed intervertebral disc
Motor Coordination & Gait
? Cerebellar hemisphere are responsible for
coordinating and fine-tuning movements
(ipsilateral )
? 1.Finger-to-Nose
? 2,Rapid Alternating Movements
? 3.Rebound
? 4,Heel-Knee-Shin
?Romberg’s test is a quick and
excellent screen for loss of
proprioceptive feedback
neuropathy or spinal cord
disease
?SENSORY SYSTEM
Sensory Function
? Large-fiber & Dorsal Column Function
– Vibration Sense
– Joint Position Sense
– Romberg’s Test
? Small-fiber & Spinothalamic Function
– Temperature Sensation
– Superficial Pain Sensation
– Light Touch Sensation
?In the lesion of the
somatosensory cortex joint
position perception is loss but
vibration sensation is not
? REFLEXS
Reflexes
? Deep Tendon Reflexes
– Bicep Reflex(C5-6)
– Tricep Reflex ( C7-8)
– Quadiceps ( Patellar,Knee Jerk) Reflex ( L3-4)
– Achilles ( Ankle Jerk) Reflex (S1-2)
? Pathologic Reflexes
– Babinski Sign
? Frontal Release Sign
– Grasp Sign
– Suck Sign
– Snout Sign
– Glabellar Sign
?Brisk tendon reflexes signify
upper motor lesions,absence
reflexes occur in peripheral
nerve or nerve root lesions
?An extensor plantar or Babinski
response is a definite immediate
sign of an upper motor neuron
lesion,presents well before
clonus or hyperreflexia
?Ankle clonus,when sustained
or unsustained but of more than
six beats duration,provides
definite evidence for an upper
motor neuron lesion