INTRODUCTION TO CLINICAL NEUROLOGY

A MANUAL FOR STUDENTS IN PATIENT-DOCTOR II

HARVARD MEDICAL SCHOOL

Compiled by Thomas Glick, M.D.

The Cambridge Health Alliance

12th Edition, September 2007

 V. Approach to the Neurologic Patient

I. Data Base: Information gathering in Neurology

A. History

The history often provides the best access to the nature of the patient's problem. However, when the
history is lacking, vague, or of questionable reliability, relatively more emphasis must fall on
examination and laboratory tests. Do not confuse an absent or unreliable history with a negative one.
The nature of neurologic disease itself may condition the history obtained from the patient; the history
may be confounded by anosagnosia (lack of insight into or recognition of one's deficit), aphasia,
confusion, dementia, any one of several forms of psychomotor retardation, or actual coma. Hence,
independent verification of the history from a close observer is especially important. Always directly
elicit a chief complaint: what does the patient perceive the trouble to be in terms of actual function.
Subsequently the patient's perception of the problem can be compared with objectively established
deficits.

The history should include a detailed description of the patient's cardinal symptoms, their temporal
profile, influencing factors, including effect of therapy, and associated symptoms. A careful inquiry into
medication history is of great importance and not infrequently unlocks the door to a confusing problem.
Handedness should be determined. Note should be made of the expression of patient's symptoms in
terms of functional deficits (e.g. difficulty ascending stairs) and disabilities ensuing in the course of
activities of daily living. Questions should initially be as non-directive and non-suggestive as possible,
but must eventually become highly detailed and specific to pin down critical points.

Finally, the process of eliciting the history should be viewed as a significant part of the neurologic
examination itself. One learns of attentiveness, memory, the clarity and internal consistency of thought,
insight into events, affect associated with significant issues, degree of spontaneity of thought, emotion,
and casual motor activity and so on. Difficulty in establishing contact or rapport may provide significant
clues. One may find, for example, that one relates to the patient much better from one side of the bed or
the other, suggesting lateralized deficits in hearing, vision, or attention to space. Such areas will then be
earmarked for special attention in the examination proper. Also, as the psychiatrists frequently remind
us, how the patient makes the examiner feel is likewise a pertinent observation. In short, the period of
history-taking is a fertile one for data-gathering by observation; this can be accomplished in the context
of establishing a warm relationship, not an aloof inspection.

B. The Examination

"Systematic or Selective?"

The examination, like the history, is necessarily selective, especially regarding mental status and
behavioral exams; thus, the degree of detail applied should be tailored to the nature of the patient's
problem as perceived from the history and remainder of the exam. The examiner attempts to achieve a
balance between a compulsively systematic approach (which tends to minimize errors of omission) and
a directed selective approach (which, if "on target" arrives at the critical data in the least amount of
time). The order of the exam is not invariable; especially if the patient displays limited concentration
and attention, the anticipated "high yield" aspects of the exam often should be done first, particularly if
these are areas involving maximum patient cooperation, like sensory testing and formal mental status
exam. Repeated testing, if the time course of the patient's illness permits, may be helpful, especially if
the exam initially may have been affected by fatigue or other unfavorable circumstances. In an unstable
condition the information gained from sequential exams can be invaluable in documenting the temporal
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profile, i.e. whether progressive, fluctuating, intermittent, etc. To this end, careful quantitative or semi-
quantitative notation of findings (e.g. grading of peak strength) allows the most valid comparisons
between serial observations of one or more examiners.

The Mystique of Neurologic Testing

It is worth remembering that many of the actual forms of the neurological examination are quite
arbitrary (e.g. finger-nose test for upper limb coordination). One should keep in mind the purpose of the
test and be prepared to devise other ways of obtaining the same or similar information; this is often
necessary when the patient's activity or use of the body part is restricted. While there are useful
subtleties available in neurologic testing, the best approach in general is to adhere to common sense and
practical innovation in the discovery of neurologic findings. The examination can assume an added
dimension of reality by relating its form to a patient's complaints. One tries to reproduce the functional
disability.

Normal or Abnormal, and How Much?

We regularly confront the question of standards of normality -- does one count peak (or best)
performance in strength testing, or average performance for a task repeated several times? Does one
discount for fatigue or use the fatigued state as a "stress test" to indicate subtle deficits? Does one
discount for age or gender in motor testing, or for education or anxiety level in mental status testing? In
general, what standard is used is less crucial than taking the trouble to specify it. At times, comparing
performance under different conditions, such as strength when fresh versus strength after multiple
fatiguing repetitions, may give the clue to a particular pathophysiologic process (e.g. myasthenia).
Similarly, the ability to produce a normal peak power, in contrast to a picture of minimal spontaneous
activity, may be the clue to another pathophysiologic state, akinesia (as in Parkinson's disease). A limb
with profound sensory loss may show little spontaneous movement but if tested against resistance may
be found to produce surprisingly good power. As a rule, the best performance may be taken to indicate
the minimum level of structural integrity preserved. Excellent function means that a substantial degree
of structural integrity must be present; conversely, a poor performance only indicates dysfunction and
does not necessarily indicate a commensurate loss of structural integrity.

The technique of neurologic examination involves continual comparisons, either of performance to a

"normal standard" derived from other sources, or by using the patient as his/her own control. The latter
can be done in two ways" first, by comparison of a particular performance at two different times, either
with a prior performance or with a subsequent one which may reveal (in retrospect) whether the initial
observation was normal or abnormal for him at the time; secondly, at a given time, the examiner can
utilize the other side or different portions of the patient's body as a "normal" control. We customarily
compare right versus left, proximal versus distal, upper extremities versus lower extremities, etc. Having
done this, one may then have to discount for such features as handedness (in assessing strength) and
other non-equivalent factors. In emphasizing symmetry one should not overlook the possibility of
bilateral dysfunction. Subtle, symmetric abnormalities are notoriously difficult to perceive.

As already noted, quantitation or semi-quantitiation plays an important role in the neurologic exam.
Common examples are to be found in muscle testing (strength marked on a scale of 5 or 10, or absent
through excellent), reflex testing (deep tendon reflexes on a scale of absent through 4+) or sensory
testing (duration of perception of a decaying vibratory stimulus). Other functions can be quantitated by
mere observation, such as the number of eye blinks per minute as a measure of spontaneous motor
activity.

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Abnormalities, Positive and Negative

Just as in the history we look for positive and negative symptoms (vertigo being positive, and "low
energy" being negative), we are confronted with positive and negative signs on the examination. This is
emphasized here because the negative signs may be less dramatic, but often no less important. In
Parkinsonism, for example, the positive sign of tremor may be a giveaway, but in fact may not be nearly
as disabling as the negative sign of akinesia - relative lack of motor activity. Since inactivity may not be
thought of by family or even the general physician as a sign of disease, much less a significant
neurologic sign, such patients may not reach medical attention, or if they do, may present with vague or
seemingly minor complaints. Thus, in examination, the index of suspicion for negative signs should be
especially high.

The States of Low-Output and Inappropriate Output

The neurologic exam may be limited by paucity of "output," as in the "frontal" abulic (slow, lacking in
initiative and spontaneity), akinetic (retarded or absent motor movement in the presence of normal
strength), or depressed patient. However, even in the comatose patient useful observations can be made
with patience and persistence.

Nonetheless, where the examination is relatively "silent" due to low output, one again has to rely more
heavily on ancillary laboratory tests, especially if the patient's condition does not seem to permit a
course of observation. The "difficult" (hostile, aggressive) patient, who "cannot be examined," presents a
different problem of access, but usually supplies much material to the observer. It may not be possible to
examine the fundi, pupils, pulses or reflexes, but much can be said, for example, about the spontaneous
motor activity and language function, of many such patients. With an abundance of output, despite lack
of cooperation, one can vouch for the function of a surprising number of neurologic systems.

The Sensory Exam: A Few General Words

The sensory exam is a challenge that is a subject in itself. However, it is particularly worth remembering
that the subtle, detailed and reliable sensory exam requires the cooperation of the patient. Thus, the
patient should be made, if possible, an ally in the exam, not an adversary to be fooled. At the same time,
it is a truism that sensory complaints, without findings, should alert one to the possibility of a hyper-
suggestible state or even lack of "organic" disease; thus, the patient's responses in the exam should be
checked for accuracy and consistency where possible. Having noted this, it is doubly important to
remember that the patient's sensory perceptions are often much more sensitive than even the most
detailed sensory testing, so that symptoms without findings should never be rejected out of hand.

Getting It Down on Paper

Finally, a few words on recording the neurologic exam. The order is not important, but it is helpful to
stick to a particular pattern. Ideally, the account should begin with a "gestalt" characterization of the
patient neurologically - what is the patient doing when first seen, what is the level of responsiveness,
activity, and mental, emotional and social output. The aspects of the exam most often omitted are those
that do not fall neatly in one category, e.g. articulation of speech.

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II. Case Formulation: Putting It All Together

Neurologic case formulation should proceed from Data Base (symptoms, signs, laboratory results) to:

Anatomy (this can be a single locus or, interpreted more broadly

a type of anatomic structure widely represented like
the neuromuscular junction)
Pathology (the possible types of tissues reaction that could occur
in the postulated anatomic locus)
Pathogenesis (the general processes by which that tissue reaction
could arise)
Etiology (the basic cause)

ANATOMIC LOCALIZATION

In approaching anatomical localization, we attempt to achieve a precise "fix" on the lesion by means of
"coordinates": First, does a symptom or sign indicate involvement of a neural system that is generally
organized in a longitudinal fashion, for example, the "pyramidal" (corticospinal) motor system, the
spinothalmic sensory system, or the optic relay system? Second, are there segmental signs that would
indicate at what level this system is involved? For example, the combination of long-tract (supranuclear,
upper motor neuron, pyramidal) motor findings (e.g. neurogenic atrophy and fasciculations) and
segmental findings (lower motor neuron findings) that correspond to a lower cervical segment in the left
arm, would suggest a lesion in the motor system on the left at a lower cervical level. Associated
abnormalities in related tests might be confirmatory (for example, a decreased triceps reflex on that
side).

Upper and Lower Motor Neuron Lesions

Before turning to the characterization of findings at different anatomic "levels," let us summarize some
distinctions concerning lesions of the "upper motor neuron" versus "lower motor neuron." Lesions of
lower motor neurons may be manifest by weakness, decreased tone, neurogenic atrophy, and
fasciculations. Reflexes (segmental) may be depressed. Motor findings may be limited to the outflow
from a single spinal cord segment, and muscles involved together as a functional group are involved in
common only if the motor outflow happens to involve part of each of them. In contrast, lesions of upper
motor neurons produce weakness that is more topographically organized (such as "distal extremity"),
although in some cases an extensor group, for example, may be preferentially impaired over a flexor
group. Deep tendon reflexes in the involved parts are typically increased (often after an initial decrease).

It is harder to make analogous distinctions in the sensory system, other than those based on the
distribution of the sensory loss. However, as one useful though oversimplified rule, it can be said that
disorders of sensory discrimination (e.g. graphesthesia) are of cerebral, often cortical, localization, as
opposed to disorders of primary modalities from lesions at any "level." In order to test discriminative
functions, ordinarily a high degree of preservation of the primary modality or modalities must exist; if
there is any impairment in the primary modality (e.g. light touch) it can be hard to know whether
difficulty in a discriminative test (e.g. touch localization, graphesthesia, or 2-pt. discrimination) is really
a function of altered discrimination per se or of greater demand on the primary modality.

As a rough guide, the following broad categories of nervous system anatomy may be implicated by the
symptoms or signs listed:

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Muscle (or Neuromuscular Junction):

Weakness tends to be proximal, although exceptions exist. Severe atrophy occurs with muscle disease
only in a very late stage. Milder atrophy is often due only to disuse and lacks the "hollowed out" quality
of neurogenic atrophy. Fasciculations are not seen. Tenderness of a muscle belly may be helpful if
present, but its absence does not diminish the chance of the disease being primarily a muscular one.
Aside from atrophy, other changes in bulk (e.g. swelling) or texture may occur. Reflexes are often, but
not invariably diminished in proportion to weakness. Definite sensory abnormalities (aside from pain)
are incompatible with a solely muscular process.

Peripheral Nerve Lesions

Findings in peripheral nerve disorders may include sensory loss, diminished reflexes, and weakness, as
well as autonomic changes. The following patterns may be observed, in which the signs and symptoms
will depend on what nerve structures are affected and whether they are affected in toto or certain fibers
selectively:

1) Mononeuropathy (involvement of a single nerve). Sensory and/or motor and/or autonomic

involvement in the territory of distribution of a single peripheral nerve. A purely sensory nerve, of
course, will have only sensory findings referable to it. On the other hand, disease in a mixed peripheral
nerve need not be clinically manifest in all modalities, either because of selective involvement or
disproportionate involvement of particular fiber seizes or types. Sensory impairment is most commonly
clinically demonstrated for pin and touch, but all modalities may be affected, though sometimes less
readily tested. The existence of a zone of decreased sensation is characteristically definite and
reproducible. The sensory loss in an area innervated by a diseased peripheral nerve may be complete in
the so-called autonomous zone in which there is no overlap from other peripheral nerves. Such a finding
is rarely seen in disease of a single nerve root because of the considerable peripheral overlap of adjacent
roots. Sensory symptoms in peripheral nerve lesions less commonly consist of shooting, radiating pains
than in root disease. Weakness and atrophy are limited to the individual muscles or parts of muscles
innervated by that nerve. (By contrast motor root fibers are typically distributed to a number of muscles
that are also innervated by fibers from adjacent roots). If fibers in a nerve participate in a reflex arc, that
reflex will tend to be decreased disproportionately to the degree of weakness, because of involvement of
the efferent limb of the arc as well as the afferent limb.

2) Multiple Mononeuropathies (mononeuropathy multiplex). As described for an individual diseased

nerve, but involving more than one such nerve, in any location. In cases of mononeuropathy multiplex in
which a great many individual nerves, and especially multiple smaller branches are involved, the clinical
picture may in the late stages be very difficult to distinguish from that of polyneuropathy (see below).

3) Polyneuropathy. A diffuse affection of peripheral nerves that at times may involve exclusively or
predominantly certain fiber types. Therefore, the disease process may be clinically manifest in purely or
mainly sensory, motor, or autonomic symptoms and signs. Also, for this reason, disorder of one or more
of the sensory modalities may predominate. The more distal area of sensory impairment typically shades
off gradually into the normal, more proximal area: thus, the common characterization as a "stocking" or
"stocking-glove" distribution is a misnomer, as a sharp demarcation is thereby implied. Impairment is
usually relatively symmetrical. The most common neuropathies are clinically more profound distally
than proximally, and legs are usually involved earlier than and more than arms, with intercostals nerves
and cranial nerves rarely involved.

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Root Lesions

Like the symptoms of posterior root lesions, the signs of motor sensory, and reflex impairment are to be
found in a dermatomal or segmental distribution. For reason noted above (see Peripheral Nerve,
Mononeuropathy), findings will be less profound (if present at all) in a single root lesion, than in a lesion
of a major peripheral nerve, because of the mixing and overlap of roots from adjacent segments prior to
innervation of the end organs.
On the other hand, lesions of multiple adjacent roots can be present with profound objective deficits.
The best delineation of the sensory effect of a single root lesion usually stems from the precise
description of symptoms by the observant patient.

Spinal Cord Lesions

First, one should be reminded to distinguish between lesions of the spinal cord per se and lesions within
the spinal canal that may involve one or more spinal roots but not the cord itself. Secondly, in speaking
of spinal levels, it is necessary to specify carefully the spinal cord (segmental) level versus the vertebral
level. Thus, for example, since the spinal cord in the adult usually ends at about the L1 (vertebra),
reference to an "L3 cord level" would signify a lesion that is anatomically placed at T12-L1 vertebral
level. Conversely, if the lesion were at the L3 vertebral level, intraspinal involvement would affect the
cauda equina, and not the cord itself.

A spinal cord lesion is clearly indicated when there are a) segmental spinal signs with long tract signs
below that level; b) a definite sensory and/or motor level on the trunk; c) a unique combination of
findings, such as ipsilateral loss of vibratory-position sense and corticospinal motor loss plus
contralateral pain-temperature loss several segments below that spinal level. Note that the fibers
subserving pain-temperature cross sides in the cord, just above their entry level, while the "posterior
column" fibers ascend ipsilateral to their side of entry to the cord. While a clear-cut sensory level on the
trunk always signifies cord disease, it can be notoriously hard to determine whether partial and often
patchy or indistinct areas of sensory impairment in the limbs are due to peripheral nerve, root, or cord
disease. Spinal cord lesions in CNS disease are suggested, in a negative sense, by strict absence of
abnormalities referable to structures above the foramen magnum. Presence of bladder, bowel or sexual
dysfunction should raise the question of a spinal cord lesion.

Infratentorial Lesions

This refers to lesions in structures in the posterior cranial fossa, and is equivalent to the brain-stem,
cerebellum and their connections, as well as portions of the cranial nerves (III-XII) that lie within this
compartment.

Characteristically, one may find:

a. Involvement of one side of the face and the opposite side of the body. (Cranial functions on one side
and long tract functions on the other).

b. Lower motor neuron or other "peripheral" types of deficit in functions subserved by the cranial nerves
(III-XII). (Note that such segmental "cranial nerve" findings may implicate either the nuclear group or
the nerve itself. The cranial nerve may be affected within (intra-axial) or outside (extra-axial) the
brainstem and within or without the posterior fossa compartment or cranial cavity itself). A "peripheral"
type of nerve lesion is usually taken to mean any lesion that is not supranuclear, that is, a lesion which is
nuclear or infranuclear. A "cranial nerve" lesion can be ascribed to the extra-axial course if there is

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common involvement of more than one nerve known to travel closely together in the subarachnoid space
or especially if they exit through a common foramen.

c. Coordination difficulties of a "cerebellar type" -- distinguishing this from incoordination due to

weakness, sensory impairment, extrapyramidal abnormalities, etc. It is very difficult to localize focal
disease to the cerebellum itself as opposed to the cerebellar-brainstem connections.

Supratentorial Lesions

a. Cortical function deficits. Confusion, dementia, behavioral abnormalities, memory loss, aphasia, and
myriad other deficits at least partly localizable to one lobe or another are reliable signs of supratentorial
dysfunction.
However, an altered state of consciousness can occur with bilateral lesions of the midbrain tegmentum.
Thus, impaired mental performance on the basis of drowsiness or stupor should not be confused with
dementia or confusion, which imply impaired cognition or attention in the alert state. Also, difficulty
speaking or lack of speech may be due to dysarthria/anarthria or aphonia, which can occur on a
brainstem as well as a hemispheric basis.

b. Seizures. True seizures should be distinguished from myoclonic jerks and spasms of decorticate or
decerebrate posturing.

c. Confluence of motor and sensory finding. Sensory-motor impairment of face, arm and leg on the
same side virtually always denotes a lesion at the level of the internal capsule or above.

d. Homonymous visual field cut. An invariable sign of supratentorial involvement.

e. Release of so-called "primitive" reflexes. Grasp, suck, etc. usually suggest frontal involvement but
may occur with diffuse cortical dysfunction.

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20
 VI. Neurological Examination: Procedures, Interpretation, and Relevant Symptoms

EXAM FUNCTION TESTING INTERPRETATION RELEVANT

CN SYMPTOMS
I Olfaction Use any non-irritating Exact identification of Patient is often
scent, one nostril at a time, scent is not important. unaware of
occluding the other. Cloves Unilateral loss is most apt olfactory loss if
keep their scent better than to be significant unilateral and if
coffee, but you can neurologically, e.g. bilateral may
improvise with soap, subfrontal tumor, but may complain of loss of
lotion, or toothpaste at the be due to deviated septum taste. Olfactory
bedside. or blocked passage. hallucination
Bilateral loss common with suggest temporal
rhinitis, traumatic damage lobe lesion, while
to filaments at cribriform perversions of
plate. odors may indicate
nasal infection.
II Visual acuity Use pocket screener, each Visual acuity reflects Blurred or dim
eye separately, with macular function (more vision. Patient may
glasses, if available. Can specifically, the foveola) & be unaware of
use newspaper headlines macular representation in insidious loss of
and text; an illiterate the optic relay system, acuity of one eye
patient can identify small providing there are no until there is a
objects or describe a opacities of the cornea or "sudden onset"
detailed picture. If glasses of the media (e.g. when the other eye
unavailable, can try central cataracts). is blocked. Ask for
acuity through a pinhole. history of a weak or
lazy eye from
childhood.
Visual fields Test each eye separately for Findings may be affected Difficulty reading
maximum information. Use by poor attention and (trouble tracking to
confrontation method with fixation, prominent nose or the right versus
fingers, pinheads. orbital rims if eyes are trouble with picking
deep-set (can turn the eye up the next line on
to shift the field). the left); bumping
Distinguish monocular into things on the
from binocular deficits. right or left or
below. Patient often
unaware of slowly
evolving field cuts,
especially quadrant
cuts and if
associated left
inattention.
Pupillary size See III below
and reactions
(afferent
limb)
III, IV, Extra-ocular Test full range of motion, Incomplete movement can Double vision;
VI movements up, down (and optionally be due to mis-alignment of blurring which
(EOM) diagonal movement) and the eyes (non-paralytic clears when either
21
 diagonal upon command or strabismus), paralysis of a eye is covered may
following a stimulus. specific function, or represent the least
(Doll's head maneuver or mechanical impediment of degree of double
ice water calorics in the the globe. With a vision. If
comatose patient). strabismus, which eye strabismus is
appears affected may unaccompanied by
depend upon which eye double vision, it is
fixes, usually a function of possibly chronic.
acuity.
III, IV, Lid elevation Observe width of palpebral Ptosis or lid droop, can be In mild cases,
VI (III and fissure (aperture between considered definite if the patient will only be
(cont.) sympathetic) upper and lower lids in lid covers part or all of a aware from a mirror
mid-pupillary line). See normal-sized pupil. If one or from others
also VII. fissure is merely different noticing, so time of
from the other side, is there onset may be hard
ptosis on one side or to document.
gaping (usually due to Request old photos
facial paresis) on the other? to see if asymmetry
is old or new.
Pupillary size Test direct and consensual Determine from the An acutely dilated
& reaction III light reaction and "near" responses directly and pupil may cause
(parasympath response with consensually in each eye light sensitivity
etic) & accommodation upon whether the afferent (II) or (photophobia).
sympathetic convergence. Quantitate efferent (III,
size (diameter) in mm. parasympathetic) arc is
Note irregularities of shape. responsible, and in which
You may need to use a very eye, for an impaired
bright light or even reaction. Obtain history of
magnifying glass to detect use of eye drops, diabetes,
a slight reaction. syphilis, ocular trauma or
surgery.
V Motor Palpate masseters when Weakness of the muscles Inquire for
jaws are clenched. Does of mastication is rare, difficulty with
jaw deviate to side on consider dystonic chewing, especially
opening against resistance? reactions, as to fatigue of
Try moving the jaw medications, mastication when
passively. temporomandibular joint eating meat.
dysfunction, and parotid
inflammations.
Corneal Observe direct and There is a very wide range Patients may be
Reflexes consensual response to of normal responses, but unaware of
cotton wisp stimulation of there should be no impaired corneal
the cornea. (The scleral consistent asymmetry. sensation, which
conjunctiva is much less Bilaterally "absent" corneal creates
sensitive). Avoid excessive responses are rarely vulnerability to
visual threat by significant in an alert damage from
approaching from the side. patient with normal pin dryness and foreign
Patients may react sensation on the face. bodies.
excessively to the first
stimulus (one side) or
second stimulus (other eye)
22
 in which case repeat,
reversing the order
V Sensory Test pin, temperature, and Inflammation and swelling Patients may
(cont) light touch (with a cotton of a part of the face may complain of
wisp) over forehead, impair sensory perceptions paresthesias (pins
cheeks, upper and lower Distinguish symptoms or and needles,
lip, and jaw. With pin signs of altered sensation novocaine feeling)
testing, especially near the in the mouth from altered or other numbness,
eyes, the patient should be taste on the tongue but are generally
reassured that you will be (anterior two-thirds). Also, aware of pain-
very careful and gentle. It note the separation of temperature
is often best to start side-to- trigeminal from cervical deficits. They may
side comparison with the dermatomes on the scalp, notice lack of hot or
side of suspected and at the ear and neck. cold sensation, as
impairment. Marching when washing.
from the impaired to the Teeth or gums may
normal side may elicit a feel numb during
grimace reaction that is brushing or the
helpful in the aphasic or tongue or cheeks
stuporous patient. For bitten unwittingly.
temperature testing, see
SENSORY, below.
Occasionally you may need
to test sensation on the
tongue, gums, lips or inside
cheeks.
VII Taste, anterior Apply a slurry of salt or Taste is usually not worth Patient is often
2/3 of tongue sugar or solution of other testing, unless one is: unaware of
primary, non-aromatic assessing a "peripheral- unilateral taste
flavors to each side of the type" of facial weakness; deficit. Complaint
tongue with a swab. Patient testing for a complaint of of general decrease
should not masticate. decreased taste; or in taste may be
Apply first to side comprehensively surveying referable to
suspected of having deficit. segmental brainstem and decreased smell,
CN functions. which should be
queried and tested;
ask about nutrition
and symptoms or
endocrine,
metabolic, renal
disease.
Motor
Muscles of Symmetry of expression, Asymmetries, such as Face may feel
Facial both spontaneous and crooked smile, are twisted (but
Expression forced, such as smile, common and should be abnormality often
showing teeth, forced eye regarded as soft signs. attributed to the
closure, wrinkling up Protruding or missing teeth good side to which
forehead; look for or partial dentures may mouth is pulled);
asymmetry (widening) of lend an appearance of may notice
palpebral fissure or asymmetry at the mouth. asymmetry in
(flattening) of nasolabial Inequality of palpebral mirror, drooling
23
 fold. On forced eye closure fissures may be due not from one side of
look for symmetry of only to gaping of the lids mouth, apparent
burying the eyelashes; if on the side of facial tearing from one
necessary, test resistance to weakness, but also to eye (overflow from
opening. Observe ptosis on the other side. gaping lid); speech
symmetry of blinking Distinguish: 1) lower may seem clumsy
spontaneously and with motor neuron type of or thick (but more
direct and consensual weakness ("peripheral- than slight
corneal reflex (efferent type" facial) (lesion is dysarthria is usually
limb). If dysarthria is ipsilateral to weakness of not due to the facial
present, check labial whole side of the face); 2) muscle weakness,
articulation ("me, me, me") upper motor neuron per se.
to distinguish from ("central-type") weakness
problems with lingual or with lesion in contralateral It is interesting to
guttural articulation. supranuclear pathway; note that there may
weakness spares upper face be dissociation of
(especially forehead), due the degrees of facial
to bilateral corticobulbar movement with
control of nucleus of VII). spontaneous
(emotional) and
voluntary ("forced")
expression.

Some General Comments:

Since we call these "cranial nerve" tests, it is easy to assume mistakenly that abnormalities indicate a
lesion of a cranial nerve in the brainstem or in its peripheral course. What we can actually test are
functions mediated by a series of neural and/or muscular mechanisms. Certain so-called "cranial nerve"
signs may, therefore, be due to cerebral, brainstem, peripheral cranial nerve, or end-organ malfunction.
For example, decreased eye closure ("VIIth nerve") might be due to primary muscular weakness of the
obicularis oculi, lesion of the VIIth nerve itself, the VIIth nerve nucleus in the pons, or the descending
corticobulbar fibers to that nucleus, anywhere in their path from frontal cortex to pons. A diminished
corneal reflex does not necessarily imply a Vth or VIIth nerve lesion, but may also be due to a decrease
in superficial reflexes contralateral to an acute cerebral lesion.

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EXAM FUNCTION TESTING INTERPRETATION RELEVANT
SYMPTOMS
VIII Auditory Use tuning fork, Assess whether Patient is often not
preferably high hearing is truly, not aware of decreased
frequency (512), for just "grossly" normal hearing, especially
screening or use by bedside techniques, if mild or on one
finger rubbing, watch realizing that an side; it may be
tick. Mask the audiogram provides noticed sooner if in
contralateral ear. much more telephone ear; other
Compare sides and information. persons are often
vs. independent Sometimes pure tones aware of problem
standard (such as will be appreciated but sooner. Inquire also
your hearing, if there will be trouble for plugged feeling
normal). You can hearing the spoken in ear, ringing
check perception of a word, such as a phrase (tinnitus), pulsatile
very low amplitude whispered in the ear. sounds such as
stimulus or check This indicates a "whooshing,"
when patient no discriminative deficit placement of
longer hears a or even, if bilateral, a foreign bodies in
decaying stimulus problem with cerebral ear, swimming
(then check auditory or language history, medication
immediately against reception. history including
other ear and/or your salicylates and
own). antibiotics. Is there
a past history of ear
Rinne test compares If air conduction is infections, draining
hearing with tuning less good, be sure to ear, head trauma? Is
fork on bone check for external or there earache, head
(mastoid) near middle ear disease. or neck ache, dental
external auditory problems, vestibular
canal vs. tuning fork or other neurologic
in air, close to ear. symptoms? Has
Ask response to patient become
sound, not felt more withdrawn or
vibration. A suggestible patient socially isolated? In
may lateralize the students, are there
Weber test assesses sound if the fork is felt learning problems?
lateralization of to be slightly off
sound perception center; try with fork
when base of slightly off center to
(strongly) vibrating the other side. If there
fork is placed in is a true conduction
center of forehead. deficit, the sound will
lateralize to that side
regardless of the exact
placement of the fork.
VIII (cont) Vestibular Test for nystagmus, Balance, ataxia, Patient's complaint
limb dysmetria, gait nystagmus, etc. are may be dizziness,
ataxia. Positional complex functions poor balance,
testing can be done involving one or more falling, etc. Ask if
25
 when there is vertigo, neurologic systems, there is a sense of
especially if altered such as the peripheral motion in the head
by position or or central vestibular (or of the
movement of head. system, cerebellar environment),
connection, especially if
proprioception, oculo- spinning (vertigo).
motor system, etc. Try Is "dizziness"
to dissect out each experienced as
component as much as "wooziness",
possible by doing blurred vision,
separate tests for each pressure? Is balance
system before trying impaired only when
to assess an even more the head is dizzy?
complex function such Does dizziness
as gait. occur when sitting
or lying? Does it
come on with head
turning, rolling
over, sitting up or
back, standing up
suddenly? Does it
increase with eyes
open or closed? Are
there associated
auditory symptoms,
nausea or vomiting,
headache?
IX, X Swallowing, Assess phonation Quality of phonation Complaints include
Phonation (?nasality) and may be hard to change or voice,
Gutteral & articulation, interpret without a thick or slurred
palatal especially palatal baseline, but speech, coughing on
articulation ("ka") and gutteral hoarseness requires food, difficulty
Gag reflex ("go"). Check palatal visualization of vocal swallowing, getting
Elevation of elevation ("ah") and cords, as do "loss" of fluids up the nose.
palate gag reflex by stroking voice to whisper and Occasionally pain in
Taste, posterior soft palate or stridor. Low and throat or neck will
1/3 of tongue pharynx, right and monotonous voice be neuropathic, but
(IX) left. Palate and uvula may be due to take care to rule out
Variety of may be asymmetric at extrapyramidal or local disease such
autonomic rest especially after frontal dysfunction, as nodes, abscess,
functions, etc. tonsillectomy, but but other behavioral neoplasm, foreign
palate should be and physical signs body.
sensitive and move should be associated.
well bilaterally. If Hypoactive gag
poor movement, ask bilaterally is not apt to
if patient feels be significant in the
stimulus well alert patient if normal
(afferent limb). Test swallowing of fluids is
swallowing with a maintained.
little water, also Neurologically-
cautiously with impaired swallowing
26
 bland, thick fluids or is worst for clear
soft solids. Taste fluids but may be
(post. 1/3) is quite adequate for thick
impractical to test. fluids or soft solids.
Dysphagia for chunky
foods only is usually
non-neurologic.
XI Shrug Observe quickness of Shoulder shrug is Patient or others
(trapezius) shoulder shrug, as typically decreased on may be aware of
Turning head well as strength the side of a unusual neck
(Contralateral- against resistance, hemiparasis, as there posture; there may
sternocleidoma comparing sides. is less bilateral be complaint of
stoid Check that full supranuclear painful or wry neck.
Flexion of passive range of innervation involved If head tilted,
head (Both motion of the neck is in this shoulder inquire for double
sternomastoids present, as well as girdle/appendicular vision when head is
) determining any soft function than in the in other positions; if
tissue or spinal more axial neck head or neck are
tenderness that might turning and flexion contorted,
affect effort. movements. determine
Compare head Suboptimal effort on chronicity, pain,
flexion with head head flexion is not ability to correct
extension (posterior uncommon, but if and maintain the
neck, paraspinal weakness if present posture voluntarily,
muscles) symmetrically, the medication history
pathology is often (especially major
myopathic, though tranquilizers). Is
occasionally cervical there a history of
cord or roots are acute or old trauma,
implicated, especially arthritic complaints,
if pain and/or neck or throat
tenderness are present. infection, systemic
Abnormal posture (tilt, infections? If
torsion) of the head strength is impaired,
may suggest cervical is there fatiguing?
inflammation, Are shoulder and
radiculopathy, hip girdle, chewing
segmental cord and ocular functions
disease, IVth nerve- all right?
superior oblique
lesion, posterior fossa
mass, or
extrapyramidal
dysfunction.
XII Tongue Does tongue protrude Minimal degrees Acute weakness of
(motor) well and in the (several mm.) of the tongue may
midline; is the tongue deviation on present
steady when protrusion, especially symptomatically as
protruded? Can it if only the tip, are difficulty with
wag and outpouch the often insignificant. speech or
cheeks well? Observe some restlessness and swallowing. Patient
27
 for atrophy on one or undulation, (but not may notice obvious
both sides. Are there "darting") of the atrophy or
fasciculations? protruded tongue are fasciculations in the
usually normal, mirror, or a dentist
especially if the may bring them to
tongue is quieter when patient's attention.
resting in the bottom
of the mouth. Be wary
of over-interpreting
questionable
fasciculations in the
absence of atrophy.

MOTOR TESTING INTERPRETATION HISTORY

Muscle bulk Inspect Handedness and type of Patient may note
Palpate muscle at rest hand and arm use will wasting ("melting
and when contracting affect bulk, as well as away") of a muscle but
Measure circumference strength of certain groups. may not be a good
for difference between Atrophy may be due to witness as to its time
comparable sites on right chronic malnutrition, course. Ask about old
and left, if atrophy is disuse, myopathies in late injuries and illnesses, as
suspected. Palpation for stages, or neurogenic. The well as family history.
the consistency (or latter is the most common
"tone") of the muscle cause of marked
mass is to be "hollowing out" which is
differentiated from the first visible at 14-21 days
more common use of and maximum at 3-6
tone as below. months after denervation.

Muscle tone The examiner assesses Increased tone (rigidity) in Patients are not aware of
the degree of resistance the relaxed patient may be altered tone as we view
to passive movement of conceived of as spastic it, but may complain of
a joint, one joint at a (clasp-knife character), stiffness, tightness,
time. Patient may need cog-wheeling (ratchet- aching, "curling-up" of
encouragement to relax, like), as in Parkinsonian limb parts. Such
"let go." If there is a extra-pyramidal disorders, complaints raise
question of slightly or paratonic (Gegenhalten) question of arthritis or
increased tone, in which the more disorders of other
especially if an movement or tension, the systems which need to
extrapyramidal disorder more resistance, as if there be pursued with
is suspected, try is difficulty relaxing or appropriate questioning.
"activation" which even willful resistance.
consists of the patient Often, increased tone is
engaging in motor acts, hard to characterize as
like drawing circles in above, and may be called
the air, with the plastic, lead-pipe, etc.
contralateral hand. Interpretation as to
normality may be difficult
in the very anxious patient.
Adventitious Inspect for any In assessing adventitious Patients and families
Movements involuntary activity, motor activity, concentrate may overlook or
28
 such as fasciculations, first on the descriptive minimize some
jerks, tremors, posturing, characteristics, i.e. movements as being due
etc. amplitude, frequency, to nervousness or to
rhythmicity, degree of clumsiness especially if
stereotypy, influence of there are volitional
attempted voluntary compensatory
intervention, compensatory movements.
movements, and effect of
environmental stimuli.
Don't label prematurely!
Strength Methods of testing In assessing resistive Patient may recognize
include observation power, in particular, the and designate weakness
(character of examiner should take into as such, but may
spontaneous movement), account the "energy state" describe the effects or
function (a complex of the patient, that is the feeling of weakness in
purposeful act such as psycho-physical output. If other terms: A weak
arising from a chair), little effort is expended in limb may feel heavy,
and resistance testing. any action, power is hard "numb," or may ache
Power should be semi- to assess, but if there is due to excessive effort
quantitated such as on a good effort anywhere, then or awkward
resistance scale or by general low output is not compensatory actions.
duration of a sustained an explanation for poor Weakness may be
posture. For screening, performance. Also, functionally reported in
test principal proximal consider effort limited by terms of clumsiness,
and distal limb group (as pain, and decremental dropping things,
well as cranial/cervical performance through the tripping, scuffing shoes,
musculature); one tests exam due to tiring, etc. buckling, falling, or
action at a joint, which Grading needs to be simply loss of ability to
usually involves two or adjusted for general perform some act.
more agonist muscles as development of Inquire for such
well as synergist. Thus, musculature, although operational markers, as
we usually rate "flexion small or wiry muscles, when a patient stopped
of the forearm" (at the even in old people, can be writing longhand or
elbow) rather than surprisingly strong. The switched the hand used
biceps strength. usual error is to discount for shaving.
Individual muscles can too much. Consider
be tested, however. dimensions other than peak
Testing strength in strength, e.g. fatiguing.
action is additionally Peak strength (best
helpful; look for drift or performance) defines the
pronation of outstretched minimum of structural
arms or difficulty integrity of the neuro-
walking on heels or toes. muscular system that must
Tests of everyday motor be present. In correlating
functions, such as muscle bulk with strength,
climbing stairs, are often the latter tends to be
better yet. relatively well preserved in
the presence of nutritional
or disuse atrophy, whereas
with atrophy due to
myopathic or neurogenic
29
 causes, power is usually
markedly and
disproportionately reduced.

SENSORY TESTING INTERPRETATION HISTORY

Pain Test with a safety pin Avoid calloused areas; Patients usually do not
but not so as to hurt the different skin surfaces have spontaneous feeling
patient; distinguish the and even individuals of altered pain (or
transition from dullness normally have different temperature) sensation.
to pointedness or thresholds to pin. They may notice not
compare degrees of "Average out" a experiencing pain from a
sharpness. Proceed from number of responses to noxious stimulus or
distal to proximal, right avoid examiner errors finding unexplained
versus left. Distal of varying stimuli; scars, burns, or
screening is usually avoid effects of ulcerations. ("Pins and
adequate in the absence temporal or spatial needles" are not
of symptoms or other summation of rapid or characteristic symptoms
signs; always define the close stimuli. of lesions in pain-
proximal extent of any temperature pathways!)
abnormality (including a
sensory level on the
trunk). If strong stimuli
are necessary, pinches
are less injurious.
Temperature Screen by comparing Abnormalities of Patient may be aware of
coldness of a tuning fork temperature sensation a difference between
(briefly but equally generally coincide with sides when testing wash
applied to skin) or pin and tend to be water, shaving, etc. Also,
tuning fork vs. rubber of confirmatory, but differences of fluid
reflex hammer. sometimes one is temperature on the two
(Quantitation is possible affected earlier or sides of the mouth or
with water flasks of more. A cold or warm throat may be noted.
measured temperature). stimulus may be more Feelings of being "cold,"
evenly applied than especially in distal limbs,
pin. A consistent may have no identifiable
though slight difference counterpart on testing.
reported by a good
observer should be
carefully heeded.
Joint Position Sense Test the ability of the JPS is only one aspect With decreased
(JPS) patient to specify the of proprioception. proprioception, patient
direction of movement Compare with ability to may complain of
at a joint. Look for locate part of patient's difficulty walking in the
subtle impairments, as own limb in space, with dark. Foot slapping may
normal people can eyes closed, or with be noted. There may be
perceive very small result of Romberg test. clumsiness not accounted
degrees of movement. JPS has a for by weakness or
discriminative "cerebellar" deficits.
(parietal) component
and hence may be
impaired despite
30
 normal primary
sensation.
Romberg Have patient stand with Anxious patients may
the narrowest base sway or even panic;
(distance between feet) they should be warned
with which balance can that slight swaying is
be maintained with eyes normal and encouraged
open; then eyes should to balance themselves.
be closed. Examiner The Romberg sign is
observes for swaying inability to maintain
but stand by to prevent this balance with eyes
actual falling. Testing is closed. It is listed as a
usually done with sensory test because of
station and gait. (see the stress on
COORDINATION). proprioception when
visual stimuli are
removed.
Vibration Use 128 (or 256) tuning Be sure that patient
fork on a bony appreciates vibration as
prominence. Compare opposed to pressure of
with what a normal fork; check with a
should be able to feel or sham vibration. Mild
what the examiner can decrease in vibratory
feel, as a standard, sense in old age is not
Quantitate by measuring necessarily significant
decay time of a clinically.
maximum stimulus.
Light touch Test threshold and An observant and not Symptomatic
compare sides or distal overly suggestible counterparts
vs. proximal with dabs patient can also of abnormal light touch
of cotton wool wisp. describe differences in or posterior column (JPS,
feeling when the skin is vibration) signs may be
stroked by the paresthesias, "pins and
examiner's hand or needles", constrictive or
when patient lightly tight feelings, leathery or
rubs fingers together. distant-feeling skin. Ask
The patient may be patient to distinguish
able to demarcate between spontaneous
abnormal areas with "internal" symptoms and
his/her own examining ones induced by
finger. cutaneous stimuli.
"Cortical"
Discriminative
sensory testing
(Examples):
Stereognosis Identify an object by To test stereognosis Occasionally, patients
shape, e.g. coin there must be adequate will volunteer that they
motor ability to palpate can't identify coins or
the object, as well as keys in their pockets, and
sufficient primary need to look at the; also,
touch sensation. patients may complain of
31
 a vague impairment of
facility, as in sewing or
other tasks that demand
fine perception of
textures and shapes, etc.
Graphesthesia Ability to identify letters Does not require motor
or numbers written with participation. Difficulty
examiner's finger or of test can be altered by
blunt rod on digit, palm, the way the letters or
sole, etc. numbers are printed in
space relative to the
patient.
Two-point (How close together can Look primarily for
discrimination two dull points be asymmetry of
distinguished as two performance between
rather than one?) sides.
Touch localization (Ability to localize a Good contralateral
stimulus, e.g. light motor function is
touch, by pointing to the required if testing the
same spot) arms, although patient
can describe
approximate areas.
Double This tests an ability to Extinction on one side
simultaneous perceive stimuli when (whereas a single
stimulation applied simultaneously stimulus is perceived
on the right and left on that side) indicates a
sides. relative inattention to
that side.

If discriminative
capacities are impaired,
out of proportion to
other sensory deficits,
then parietal cortex or
connections are
probably involved;
look for supporting
evidence from testing
of other parietal
functions.
COORDINATION TESTING INTERPRETATION HISTORY
Truncal Stance is tested first at Impairment of station Patients may complain
any comfortable base or gait may have of, or should be asked
(distance between two multiple possible about, dizziness (and
feet), then with feet causal deficits; associated auditory
together; Romberg is weakness, an symptoms such as
customarily tested at this extrapyramidal motor, hearing loss or tinnitus),
time (see Sensory). cerebellar, visual problems, fatigue
other tests that further proprioceptive, or or buckling of legs,
stress the balance vestibular dysfunction, difficulty starting or
system include standing as well as other sensory stopping walking, special
32
 on one foot, or ball of aspects such as visual difficulties in the dark or
foot, with eyes open and impairment, pain, on rough ground, pain in
closed. With severe arthritic stiffness, joints, thighs or calves,
balance problems even contractures, etc. Thus, need to use aids or walk
the ability to sit on a ataxia requires careful near walls or furniture.
firm surface with legs analysis and should not "Drunken" walking may
together may be be presumed to be be noted. Medication and
affected; this test is a cerebellar. alcohol or drug abuse
good preliminary to history is essential, as is
standing. Gait is family history.
observed with attention
to posture, length of
stride, width of base,
ease of starting, etc.
Tandem gait (walking
heel to toe), is more
demanding yet. Unless
contraindicated, always
insist on observing
station and gait (with
precaution against
falling.
Appendicular Tests require smooth Limb ataxia may also Symptoms include being
integration of motion, be complex. The most unable to control an arm
ability to produce and common problem is to or leg, failing in
sustain rhythms and distinguish whether everyday motor tasks,
rapid repetitions in both awkward motor shakiness, dropping
arms and legs, for performance is out of things. Patients may
example: Finger-nose, proportion to a degree interpret an intention
heel-shin, heel tapping of weakness in muscles tremor as "nervousness"
on shin, foot tapping on acting to produce the even when problem is on
floor, finger tapping on coordinated movement. one side only. There will
thumb, rapid supination Intention tremor is a be no symptoms at rest,
and pronation of hand, coarse tremor unlike Parkinsonian
rhythmic beating of perpendicular to the tremor or focal seizure
hand, etc. line of action and activity that might also
Ability to "check" a increasing as the target be reported as shakiness.
rapid movement, or is approached.
avoid excessive
rebound, tests cerebellar
function and may relate
to hypotonia seen with
some cerebellar lesions
(also manifest in
increased extensibility
of joints and pendular
reflexes). One example
is the capacity to regain
a fixed posture of
outstretched arms
without excess
33
 overshoot, when
suddenly displaced by
examiner.
Speech Listen for the rhythm of Dysarthria of speech is Tripping over words,
speech and the usually due to slurring, having a "thick
modulation of voice, as pyramidal and/or tongue" or "people can't
well as the distinctness extrapyramidal motor understand me" are
of articulation (see also impairment, rather than common symptomatic
CN VII, IX, X, XII). from incoordination of reports of incoordinated
speech per se. speech. Be careful to
Cerebellar speech is distinguish language
characterized by poor disorders, in which
rhythm and wrong words or parts of
modulation, giving a words are uttered
"scanning" quality (as (paraphasias).
in the lilt of poetry) or
a halting and explosive
quality,
Ocular Movements Test for ocular This is a particularly Rarely, patients may note
dysmetria: overshoot useful test when limbs visual blurring when
with quick changes of are inaccessible for moving eyes or some
fixation. Have the testing. Also, abnormal even vaguer visual
patient quickly shift results indicate that the complaint; such
gaze from examiner's lesion involves symptoms might also be
nose to finger held 20 to cerebellum and/or caused by minimal ocular
30 degrees to the side, brainstem connections. imbalance (short of
and also back to nose. producing double vision)
Check movements to or by nystagmus.
both right and left.

REFLEXES TESTING INTERPRETATION

"DEEP TENDON"
REFLEXES (DTRs)
Biceps (C5, 6) Limbs should be relaxed and well Deep tendon reflexes are
Triceps (C6, 7, 8) supported. Observe for amplitude conventionally graded on a 0-4
Brachioradialis (C5, 6) and quickness of the jerk, the plus scale of briskness with 1
(not strictly a tendon reflex) relaxation phase, any plus (+) being a slight but visible
Knee jerk (patellar) (L2, 3, 4) reduplication ("after-jerk") or or palpable response; 2 plus (++)
Ankle jerk (Achilles) (S1, 2) even clonus triggered by the tap. is average, a moderately brisk
Also look for "spread" i.e., jerks and full excursion; 3 plus (+++)
in more distant muscle groups, is very brisk and can be called
such as in the contralateral thigh hyperactive but is not pathologic
adductor group when the knee per se: 4 plus (++++) is
jerk is elicited. If reflexes appear extremely hyperactive,
"absent" or difficult to elicit, use associated with clonus, and
the "reinforcement" technique. usually but not necessarily
pathologic. Don't be fooled by
the direct myogenic response if a
muscle belly is tapped directly,
or by the passive movement due
to the mechanical deformation of
34
 the tendon by the tap. If reflexes
Test these reflexes when the more are absent or very hypo- or
Other tendon reflexes are also usual ones are inaccessible or for hyperactive, ask the patient
testable, e.g. Pectorals further documentation of whether an examiner had ever
asymmetries previously noted such responses.
SUPERFICIAL
REFLEXES
Corneal (Afferent V, Efferent See Cranial Nerve exam. Use See section on Cranial Nerves.
VII) cotton wisp
All superficial reflexes on a
given side may be decreased in
the presence of an acute
supranuclear lesion
contralaterally.
Abdominal With stick end of swab or other Abnormalities of abdominal
Upper (T7, 8,9) blunt object, stroke outward reflexes may help to establish
Lower (T11, T12) diagonally from the umbilicus thoracic spinal segmental lesions
into each periumbilical quadrant or a spinal level. Abdominals are
or, alternatively, stroke often affected by operative scars,
diagonally across each quadrant. obesity, or striae following
childbirth,
Cremasteric (T12, L1) A light stroke on the inside of the Cremasteric and abdominal
upper male thigh will result in a reflexes may be hard to elicit and
retraction of the testicle on that tend to fatigue quickly.
side.
OTHER REFLEXES
"PATHOLOGICAL"
Plantar response Stroke the lateral aspect of the The Babinski Sign is the
("Babinski") sole. In a given patient this may extensor plantar response:
take some "experimentation" to Dorsiflexion of great toes which
get the clearest, most may be associated with fanning
reproducible response: How far of the other toes and, at times, a
laterally, how firmly, whether to triple flexion response a t the
curve across the ball of the foot ankle (dorsiflexion), knee and
after coming up the side, whether hip (contraction of tensor fascias
to use a key, thumbnail, handle of latae). It is very important to
reflex hammer, etc. distinguish triple flexion, which
is stereotyped, from more
complex non-stereotyped,
Other means of eliciting the At times it is helpful to use other evasive, "voluntary' withdrawal.
extensor plantar response techniques to elicit or confirm The flexor plantar response is
(variety of techniques and pyramidal dysfunction if the the normal downcurling of the
eponyms) "receptive field" is broad enough. great toes, although in some
For example, stroke the lateral normals there may be little
ankle beneath the malleolus, movement. An equivocal
down the shin, squeeze the calf, response on one side may take
apply pin on the dorsum of the on more significance if the other
great toe, etc. side is clearly up (extensor), or
down (flexor). Rarely, there will
be a pseudo-flexor response due
to a marked plantar grasp reflex
35
 (analogous to palmar grasp).
Hoffman Flex the distal phalanx of the The Hoffman and finger jerks
middle finger by flicking it: A are merely examples of a
positive sign is a flexion number of additional reflexes
movement of the distal phalanx of that can be elicited to
the thumb. demonstrate or confirm subtle
pyramidal dysfunction or
asymmetries; as such they tend
to be confirmatory of
asymmetries of the DTRs and
pathological reflexes. Normal
hyperreflexic patients may have
slight Hoffman's or moderately
brisk finger jerks, but they will
be symmetrical.
Finger jerks Support the patient's fingers with
your own, then tap up on your
fingers so as to extend the
patient's: The reflex response will
be a jerk of the long fingers.
Clonus Sudden stretching of a tendon Clonus is a reflexive response
such as the Achilles, patellar, etc. that may occasionally occur with
may result in clonus, an apparent spontaneity (actually as
oscillatory tremor-like movement a result of some small stretch or
of the part moved by that tendon. other stimulus). Clonus is
another manifestation of upper
motor neuron hyperactivity and
is pathological if sustained or
asymmetrical. A few beats of
symmetrical unsustained clonus
are not necessarily pathological
in an n otherwise normal,
hyperreflexic person.
Bilateral Cortico-bulbar
reflexes
Jaw jerk Rest finger on the chin and tap For both the jaw jerk and
lightly downward. Reflex "snout", a mild response may be
response is an upward jerk of the normal in a hyperreflexic person,
chin (mandible). but a marked response suggests
dysfunction of the corticobulbar
tracts bilaterally. In the case of
the jaw jerk, these are the
supranuclear tracts to motor V
and with the snout, the tracts to
VII. Although these tracts
originate in the frontal lobe,
these are not "frontal release"
signs. These reflexes are
sometimes helpful in
distinguishing spinal from
intracranial lesions, as in the
36
 former there should be no
abnormality of jaw jerk or snout.
Pathological jaw jerk and snout
reflexes are typically part of the
syndrome of pseudobulbar palsy.
"Frontal Reflexes"
Grasp Gently stroking with fingers Grasping, as well as exploratory
across the patient's palm (or sole) behavior of the hands, is
elicits an involuntary grasping. generally taken to be associated
with contralateral (?also
ipsilateral) frontal, especially
pre-frontal lesions.
Suck Light stimulation of the central Sucking and rooting are said to
areas of the lips elicits a pursing be frontal "release" signs, that is,
or sucking response. release of primitive responses in
the presence of frontal
(especially pre-frontal, pre-
motorstrip) lesions.
Root Stimulation at the corner of the
mouth elicits a turning or groping
of the lips in that direction, like a
baby's lips searching for a nipple
Palmomental A blunt scratch or stroke across This is often characterized as a
the thenar eminence elicits an frontal sign, but there is no well-
ipsilateral contraction of the defined localization, and it may
mentalis muscle of the chin. be seen with widespread cortical
dysfunction which generally
includes a frontal component.
"Extrapyramidal"
Glabellar Tap repetitively with finger The normal person will blink a
between the eyebrows. few times and then suppress
blinking in response to
subsequent taps. Parkinsonian
patients will fail to suppress to
some degree.
"Spinal"
Cilio-spinal A pinch to the lateral neck elicits This appears to be mediated by
a slight papillary dilatation. the ascending sympathetic
system and thus is used as a
measure of the function of that
mechanism, especially in the
comatose patient.
Anal (S3, 4,5) A light scratch to the perianal The principal use is in patients
skin elicits anal contraction. with rectal and/or urinary
incontinence or other cause to
suspect lower spinal lesions; the
test assesses the function of the
lower sacral afferent and efferent
segments.

37
Other
Startle Myoclonus Create a sudden noise, light or A myoclonic startle response is
tactile stimulus. merely an exaggeration of the
normal startle response to an
unexpected stimulus. The
pathological response is
excessive and tends not to be
suppressed with repetitive
stimuli. Responses to different
types of stimuli may be
dissociated, but signify hyper-
excitability, as sometimes seen
in withdrawal syndromes and
certain metabolic derangements,
epileptic conditions and neuronal
diseases.

MENTAL STATUS
See subsequent guide in this manual.

Quantitation of Resistive Muscle Testing

As indicated in "Approach to the Neurologic Patient," an attempt to quantitate neurologic performance is

important. The effort to do so elicits from the examiner a more disciplined assessment and also
establishes a more precise baseline for future comparison. For resistive muscle testing several grading
systems are in use.
They can be defined and compared as follows:

Observation "Absent to "0-5" "0-10"

Excellent"
No Contraction Absent 0 0
Flicker or Trace Contraction Trace 1 1

Active Movement with Gravity Eliminated Poor 2 2

Active Movement Against Gravity Fair 3 3
4

5
4-
6
Active Movement Against Resistance Good 4 7
8
4+
9
Full Strength Excellent 5 10

Comment: Which Grading system is used is not very important, only that the scale be specified and the
definitions understood. Most physicians use the 0-5 scale, but note that subdivisions of 4 out
of 5 are needed because resistance covers such a wide range.
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 VII. Mental Status

Outline of the mental status examination

The mental status examination should be appropriate to the patient's complaint or the doctor's concerns.
The minimum mental status examination for a person in whom no brain disease is suspected, and who
has no complaint referable to the brain, depends on age and risk factors but relies largely on close
observation.

The following should be noted:

Spontaneous behavior and appearance

Level of consciousness:
What stimulus yields what response? Is the patient alert, awake, lethargic, stuporous, comatose?

Attention:

Tests of attention and concentration. Inattention is the major ingredient of "confusion", as formally used,
although the connotations of confusion are broader.

Digit span
Serial Subtractions
Ability to select a prearranged item from a recital list (e.g. letter from the alphabet)

Memory:

Remote (for events that can be independently established): short term (a story or a collection of objects
to be recalled more than five minutes later, after distraction).

Orientation:

Orientation to time, place, and person are so fundamental, that save for profound memory loss, in which
knowledge of time and place may not be available for recall, failure in these respects usually correlate
with a confusional state. A patient with good attention, but poor memory, should be able to pick up
some orientating information from the immediate environment, but this kind of orienting may have to be
continual, for lack of recall.

Intellectual Performance: (level of education?) (decline in abilities?)

General information - sports figures, public figures, news events, question about job, capitals, Presidents

Calculation - mental arithmetic; change to dollar for the modestly educated; long division or interest
calculation for the college educated

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Abstractions - observe the degree of thought productivity, coherence, continuity, internal consistency,
and adherence to the subject at hand.

a. open-ended questions - "why do we pay taxes?" "why are there traffic laws?"

b. judgment - "what would you do with a stamped envelope found on the ground?"

c. proverbs - "people in glass houses" "a rolling stone"

d. similarities - "egg-seed", "axe-saw", "apple banana", "eye-ear"

e. differences - "ice-glass", "wall-fence"

f. mistake recognition - (in a picture, in a statement)

Language:

Comprehension (assessed by yes-no questions, or performance); naming, repetition, spontaneous speech,

reading and writing (writing of full sentences, without coaching or dictation).

Construction:

Draw a clock; copy a cube, pyramid, etc.

Mood and Affect:

Inquire about mood, including depressive thoughts, suicide, hallucinations, ideas of reference, paranoid
feelings, strong fears; affect is the emotional content or component of the patient's feelings, that may not
be outwardly exhibited as affect.

The psychiatric mental status questions can occasionally be omitted, but never in any patient whose
presenting complaint is pain or mental symptom. If depressive ideation or paranoid feelings are
uncovered, one must evaluate whether the patient is suicidal or potentially dangerous to others and must
make an appropriate referral.

Mental status evaluation is a powerful diagnostic tool. It becomes most useful if one knows the wide
variations in mental status seen in people without neurological disease. Accordingly, students and intern
rotators on neurology should do a full mental status examination on all patients. In addition, dominance
and educational level must be noted, as the examination is not fully interpretable without that
information.

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