Neurologic Exam
Neurologic Exam
Neurologic Exam
Dr Yacoub Bahou
Professor in neurology
at the University of Jordan
I) Introduction
II) Principles
III) Elements of the examination
1. Mental status
2. Cranial nerves
3. Motor examination
4. Reflexes
5. Sensory examination
6.Coordination
7.Gait
I) Introduction
The care of the patients in all specialties has been enhanced by the use
of an increasingly sophisticated array of biomarkers, genetic tests, and
imaging modalities.
The resultant picture can narrow the list of possible diagnoses and
guide further investigation.
II) PRINCIPLES
1. It is useful to conduct a complete examination at least once for
every Neurology patient.
The Neurological examination may be unique in its length, but it is
worthwhile to complete a thorough assessment at least once with each
Neurology patient for several reasons:
The central nervous system includes the brain and spinal cord.
The 1st step is to assess level of consciousness , which can range from awake
and alert to unarousable even with noxious stimulation.
Rather than using medical terms such as stuporous or obtunded in the latter
setting, it is more helpful to describe what external stimuli are required to
arouse a patient or to maintain wakefulness.
Patients with dense neglect may fail to describe items on one side of a
picture or of their surroundings or fail to bisect a line properly .
One way to test cranial nerves is to start at eye level and move down
the face in approximate numerical order (table).
- visual fields are tested by having the patient cover one eye and focus on
the examiner’s nose; they are then asked to signal when they can appreciate
a small red object enter the field of view from each of 4 quadrants when the
object is held halfway between the patient’s eye and the examiner’s ( the
limits of the patient’s visual field should correspond to those of the
examiner’s).
- The afferent limb of the pupillary light reflex is mediated by the optic
nerve; the efferent limb is subtended by cranial nerve III.
Extraocular movements ( III, IV and VI) are tested in 3 main ways:
- by having the patient pursue a moving target ( e.g., an examiner’s
finger drawing of the letter “ H” in front of the face i.e pursuit) ;
- and by having the patient fixate on an object while the head is turned
passively ( vestibulo-ocular movements).
Facial sensation can be tested to all modalities over the forehead ( V1) ,
cheek ( V2) and jaw ( V3) regions.
Though uncommonly tested, taste over the anterior 2/3 of the tongue
is mediated by this nerve and can be evaluated with sugar or other
non-noxious stimulus.
Hearing ( VIII) may be evaluated in each ear simply by whispering or
rubbing fingers; more detailed assessment of hearing loss may be
accomplished with the Weber and Rinne tuning fork ( 512 Hz) tests.
Tone is one of the most important parts of the motor exam.In the arms,
tone is checked by moving the patient’s arm, flexing and extending at
the elbow, moving the wrist in a circular fashion, and pronating and
supinating the forearm rapidly using a handshake grip.
Abnormalities of tone are spasticity and rigidity.
Tone in the legs can be tested well only with the patient supine.The
examiner lifts the leg up suddenly under the knee;in the presence of
increased tone, the heel comes off the bed.
The patient may be asked to rise from a chair without using the arms or
to walk on the heels and toes.
In the arms, the biceps, brachioradialis, and triceps reflexes are most
commonly tested.
The adductor reflex can also be tested by striking the medial thigh and
looking for thigh adduction.
The Babinski sign is sought by stroking the lateral sole of the foot while
observing for extension of the great toe.
In some cases, an exaggerated jaw jerk can localize a problem above the
level of the cervical spine.
5. SENSORY EXAM
The sensory examination assesses small fiber ( pinprick, temperature)
and large fiber ( vibration, proprioception) function.
Pinprick: Using a sterile instrument ( e.g. , special pins designed for the
neurologic exam), the examiner starts to prick the toes and gradually
moves up the leg to assess if there is a gradient to sensation.
The process can be repeated starting in the fingers , and moving up the
arm.
If there is concern for a spinal cord lesion, it is important to perform
pinprick along the length of the torso to identify a “ level” where
sensation transitions from abnormal to normal .
If the patient reports facial symptoms, the pin should be used to assess
sensation in areas representing each branch of the trigeminal nerve.
Temperature: Using a similar approach, a cold tuning fork can be used
to assess temperature sensation.
Vibration: After striking the 128 Hz tuning fork, the stem is placed
against a joint, and the duration for which the stimulus is appreciated is
recorded.In general, the great toe is tested first, with the examiner
testing increasingly proximal joints if the distal findings are abnormal.
Proprioception: Proprioception, or joint position sense, is tested in an
order similar to that used for vibration assessment.
Usually, the examiner starts by holding the sides of the great toe and
asking the patient to report when it is moved upward and downward
by a few millimeters.
To test axial abnormalities, the patient can be asked to sit upright and
unsupported, with the eyes closed.
Rapid alternating movements , rhythmic finger tapping, and heel
tapping are particularly sensitive to coordination problems.
Patients may also have trouble with the timing, or cadence , of these
movements.
The patient with a normal base, or stance, maintains the feet at about
hip-width apart.
Stride length should be full, with clearance of the feet from the floor.
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