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NEUROLOGIC EXAMINATION

Muhammad Iqbal Basri

Department of Neurology – Hasanuddin University


THE NEUROLOGIC EXAMINATION
After performing the Anamnesis, what you need to examine are:
1. Conscious Level
2. Higher cortical functions & mental status
3. Meningeal signs
4. Cranial Nerves
5. Motor function & Reflexes (physiologic & pathologic)
6. Sensory function
7. Coordination
8. Autonomic function
9. Etc., depends on chief complaint
Anamnesis
 Interviewing a patient (Pt)
 Taking the history of Pt’s illness/complaint
- Not easy – needs practice!
- Special art  need :
~ Interview skill
~ Knowledge on symptoms and signs of
diseases/specific diseases.
 directed anamnesis
 good anamnesis
Neurologic Examinations
 DON’T DO EVERYTHING!
 Screening tests vs detailed testing 
Problem orientated approach or Screen all
systems
 Concentrate on systems relevant to
complaint
 Formal cognitive testing may be skipped if
patient is cognitively intact during history and
problem seems unrelated, e.g. foot-drop.
http://www.medem.com/MedLB/article_detaillb.cfm?article_ID=ZZZ0ZFP46JC&sub_cat=75
http://www.apparelyzed.com/spinalcord.html
1 - Olfactory
2 - Optic
3 - Oculomotor
4 - Trochlear
5 - Trigeminal
6 - Abducens
7 - Facial
8 - Vestibulocochlear
9 - Glossopharyngeal
10 - Vagus
11 - Accessory
12 - Hypoglossal

http://library.thinkquest.org/11965/html/cyber-anatomy_ner692.html
http://www.alsa.org/images/cms/Research/Topics/disease_process.jpg
CONSCIOUS LEVEL
CONSCIOUS LEVEL
 Conscious  alert, self awareness &
attention to the surrounding
 Using the GLASGOW COMA SCALE
(GCS):
Eye response (E)
Motoric response (M)
Verbal response (V)
CONSCIOUS LEVEL
 Decrease of conscious level 
disturbance of the center of consious in
the brainstem and reticular formation,
could be caused by:
- lesion in the brain (stroke, brain tumor,
meningitis, etc)
- from systemic cause  effect to the
brain, e.g.: hyperglicemia, hyponatremia.
CONSCIOUS LEVEL
 GCS 15 = E4 M6 V5 ( Compos Mentis )
 GCS 3 = E1 M1 V1 ( Deep Coma )
 GCS =≤7 ( Coma )
 GCS = E4 M6 V- ( Motoric aphasia )
 GCS = E4 M1 V1 ( Coma Vigil )
Mental Status Exam /
Higher Cortical Function
Mental Status Exam
 Family story of memory loss
 Orientation

 General Information

 Spelling &/or numbers

 Recognition of objects

 Commonly use: MMSE (Mini Mental


State Examination)
 Higher cortical function  Integration between:
- nervous system
- movement
- five senses
- consciousness
 Manifestation:
speaking & comprehension
reading & comprehension
listening & comprehension
executing instructions
Mental Status Exam
Lesion in the brain  Disturbance of higher
cortical functions:
 Aphasia

 Memory disturbance

 Acalculia

 Agraphia

 Dementia

 etc
MENINGEAL SIGNS EXAMINATION
MENINGEAL SIGNS EXAMINATION

1. NUCHAL RIGIDITY

2. KERNIG’S SIGN

3. BRUDZINSKI I, II, III, IV

Meningeal signs can be found in:


 Meningitis
 Subarachnoidal Haemorrhage
NUCHAL RIGIDITY / NECK STIFFNESS

Patient in supine position


Passive flexion & extension of the neck.
Test result positive if:
Stiffness + / Rigidity +
KERNIG’S SIGN

Supine position, hip flexion 90°, extention


of knee joint.

< 1350

Positive: pain/stiffness of knee joint < 1350


BRUDZINSKI I

Rapid passive flexion of the neck


Response is positive when: involuntary flexion of
the hips and knees.

BRUDZINSKI II
Passive flexion of hip and knee
Response is positive: involuntary flexion of
kontralateral leg.
BRUDZINSKI III
Pressing the zygomaticus bone
Positive: involuntary flexion of the arms on
elbow joints.

BRUDZINSKI IV
Pressing the symphysis bone
Positive: involuntary flexion of the lower
extremities on knee joint.
Cranial Nerves
Olfactory Nerve (N. I)
 The sense of smell rarely identifies any
significant pathology.
 Use tobacco, soap, orange, coffee,
smelling salts, etc for some idea to get
some idea if they smell.
 Ammonia stimulates pain endings of N.
V (Trigeminal) rather than N. I.
• Not routinely examined in clinical
practice.
Result/Interpretation :
 Normosmia
 Hyposmia - Anosmia

Disturbance or smell (N. I disorder):


- Frontal lobe tumor
- Head trauma (e.g. skull-base fracture)
Optic Nerve (N. II)

• Assess visual acuity.


“Can you read my badge?” “Does my face
look whole to you, are any parts missing?”
Snellen chart would be ideal, but not
routinely done in clinical practice.
• Visual fields by confrontation.
• Funduscopy examination
• Color perception (using Ishihara card)
http://www.unmc.edu/Physiology/Mann/mann7.html
Visual field disturbance
 Narrowing of visual field.
 Hemianopia / hemianopsia
- Hemianopsia Heteronim  Bitemporal
 Binasal
- Hemianopsia homonim  left
 right
 Quadrianopsia
 Tubular vision
Oculomotor, Trochlear and
Abducens Nerves (N. III, IV, VI)

- Pupil (shape, diameter/size, position,


light reflex, acommodation reflex)
- Palpebral cleft  Ptosis
- Eye ball movement (extraocular
muscles)
PUPILS
 Constricted pupils may indicate pontine
injuries, narcotics i.e. Demerol,
Morphine.
 Argyll Robertson pupil (in tabes
dorsalis)  absence of light reflex, but
accomodation reflex is intact.
 Marcus Gunn syndrome  midriasis of
the pupil on light reflex examination.
Eye ball movement (extraocular
muscles)

• “Keeping you head perfectly still, follow


my finger with your eyes.”
• Make a H pattern with your finger.
• “Do you see double anywhere?”
• Look for nystagmus.
http://www.fotosearch.com/comp/LIF/LIF118/SA702031.jpg
Trigeminal Nerve (N. V)

• Two parts:
- Sensory to face
- Motor to muscles of mastication
- Plus: reflexes (corneal & jaw reflex)
• Assess sensation to face
• Determine if patient can open mouth.
• “Clench your teeth” - feel for muscle
bulk at Masseters
V1 – Ophthalmic

V2 – Maxillary

V3 - Mandibular
Facial Nerve (N. VII)

• Motoric  Must assess at least 3 muscle groups:


“Raise your eyebrows”
“Show me your teeth”
“Puff out your cheeks”
 Sensoric  taste on 2/3 anterior part of the
tongue
 Secretion  Salivatory Glands
Facial nerve paresis:
 N. VII paresis, central type:

 Supranuclear lesions: stroke, meningitis,


craniocerebral trauma.
 N. VII paresis, peripheral type:

 ear infection (otitis media), cerebellopontine


angle tumor, brainstem (pons) lesion, viral
(herpes simplex), idiopathic (Bell’s Palsy)
Vestibulocochlear / Acoustic
Nerve (N. VIII)
• 2 components:
- Vestibular nerve  equilibrium
- Cochlear nerve  hearing
• Grossly assess by rustling fingers at
one ear and whispering in opposite.
• Can confirm using Weber’s and
Rhine’s tests
Acoustic system disturbance:
 Deafness
 Tinnitus
 Hearing scotoma
 Sensoric aphasia  disturbance
association cortex & auditory cortex 
the patient can hear voices but no
comprehension.
Vestibular system disturbance
 Nistagmus 

horizontal nistagmus
vertical nistagmus
rotatoir nistagmus

 Vertigo
Glossopharyngeal and Vagus (N.
IX & N. X)

• Open your mouth.


• Say “arrgh”
• Look at palatal movement. Deviates
AWAY from affected side.
• Assess gag reflex - not routinely done
• Swallowing test
• Phonation/voice test
Accessory (N. XI)

• Motoric of: - M. Sternocleidomastoid


- M. trapezius
• Put hand on one cheek, “push me
away” (turning head), and feel
sternocleidomastoid bulk on opposite
side.
• ‘please lift your shoulder’
Hypoglossal (N. XII)

 Motoric : extrinsic & intrinsic muscles


of the tongue
• “Stick out your tongue”
• Look for deviation TOWARDS affected
side.
• Can assess power, but only if deficit
found on gross examination.
Symptoms of N. XII disorder:
 Dysarthria

 Tongue deviation

 Dysphagia (swallowing difficulties)

 Atrophy of the tongue

 Fasciculations of tongue
Motor System Examination
Motor System Examination

• Aim is to be systematic
• Ensure you have permission, adequate
exposure and tendon hammer to hand.
Same system for upper and lower limb
• Inspection
• Palpation of Tone (passive & active)
• Power / muscle strenght
• Physiologic Reflexes
• Pathologic Reflexes
• Coordination
Upper Motor Neuron lesions (UMN)

• Spastic paresis, e.g.: hemiparesis, paraparesis/


paraplegia
• Hypertonic
• Reduced power
• Hyper-reflexia & or clonus
• Impaired coordination
• Atrophy – (or disuse atrophy +)
• Pathologic reflex +
Lower Motor Neuron lesions (LMN)

 Flaccid Paresis/paralysis
 Atonic / hypotonia
 Reduced power
 Atrophy +
 Areflex / hyporeflex
 Pathologic reflex is absent
 Impaired coordination
Extrapyramidal disorder

 Muscle tone : rigid


 Abnormal & uncontrol movement
(involuntary movement), e.g.: tremor,
chorea, athetosis, ballismus.
 Disturbance of voluntary movement
Cerebellar disorder

• D ysdiadokinesis / dysmetria
• A taxia
• N ystagmus
• I ntension tremor
• S tacatto speech
• H ypotonia
• P endular reflexes
Common etiology: Trauma, alcohol, SOL, old age.
Inspection

• Look for muscle wasting, atrophy,


hypotrophy, hypertrophy,
pseudophypertrophy, scars, abnormal
movements (tremor, ballismus, etc),
fasciculations.
Tone

• Assess tone in upper limb by holding


hand and moving wrist, elbow joint,
etc.
• Tone in lower limb can be assessed by
rolling leg and looking at ankle
movement, or lifting up leg by knee
and dropping onto bed.
Power / Muscle Strength

• Best assessed by moving joint into neutral and moving


all power groups in turn against your resistance.
 Key tests:
- Drift of upper & lower extremity
- Hand grip & toe & foot dorsiflexion
- Testing of other muscles when their proper function is
in question

• Needs to be systematic and compare ‘like with like’.


• Remember old people are not as strong as you!
Muscle Strength Grading Scale (from 0 – 5)

 Normal strength 5
 Active movement against resistance but less 4
than normal strength
 Active movement against gravity but not 3
against resistance
 Movement occurs only in the plane of gravity 2
 A barely detectable flicker or trace of 1
contraction
 No muscle contraction detected 0
Reflexes

• Elicit biceps (BPR), triceps (TPR) and


supinator in upper limb.
• Elicit knee (KPR – patella reflex), ankle
(APR – achilles reflex).
• Elicit pathologic reflex
 Ifthe Reflex Arc is affected  Reflex is
absent/decrease (LMN lesion)
 If the connection to the brain is disturbed 
Reflex ↑ (UMN lesion, as a result of release
from normal descending inhibition)
TYPE OF REFLEXES
1. Deep tendon reflex
2. Superficial reflex
3. Pathological reflex
1. Deep tendon reflex

REFLEX SEGMENTS
Biceps Reflex (BPR) C5 – C6
Brachioradialis reflex C5 – C6
Triceps reflex (TPR) C7 – C8
Knee reflex (KPR) L2 – L4
Ankle reflex (APR) L5 – S2
Tendon Reflex Grading Scale
0 Absent
1 Diminished
2 Normal
3 Increased (may spread to adjacent
muscles)
4 Unsustained clonus (a few beats)
5 Sustained clonus
2. Superficial Reflex
REFLEX Reflex Arc
Corneal reflex Af:N.V, Ef:N.VII
Cremasteric reflex L1 – L2
Abdominal reflex involved supraseg-
mental neurons
Bulbocavernosus reflex S2 – S5
& anal wink
3. Pathological Reflexes
1. Upper Extremities
Hoffman-Tromner
2. Lower Extremities
BABINSKI (Plantar reflex), Chaddock,
Schaefer, Oppenheim, Gordon.
A positive test is when the lateral aspect
of the foot is scratched & the big toe
dorsiflexes & the other toes fan out.
Eliciting Reflexes:

1. Patient is fully relaxed


2. Muscles in optimum strain
3. Enough stimuli (hammer swinging, not
pecking!)
4. Reinforcement  Jendrassik maneuver
Coordination

Upper limb:
•“Touch the index finger of your right hand to
your nose (Finger to Nose test)  the
disturbance called: Dysmetria.
•Look for intention tremor.
•Repeat for left hand side.
•Can also assess coordination by looking for
dysdiadokinesis (pronation-supination test).
Coordination

Lower limb:
• “Place the heel of your right foot on left
knee and run foot down left shin and back
to knee as fast as possible.” heel-shin test)
 Dysmetria.
• Repeat for left hand side.

Balance test: Tandem gait or Romberg


test.
SENSORY EXAMINATION
Sensation
SENSORY EXAMINATION

- Very subjective, most difficult,


sometimes least reliable.
- Key to a successful & efficient
sensory examination is to know
what you are looking for.
SENSORY EXAMINATION

1. Primary sensory modalities


a. Spinothalamic tracts:
superficial pain & temperature, light touch.
 Pain Sensation: Use simultaneous stimulation (sharp,
dull, etc.)
b. Dorsal columns:
vibration, joint position, deep pain.
 Proprioception- Test big toe (position).

2. Cortical sensory modalities


Dysfunction of contralateral parietal lobe: double
simultaneous stimulation (face-hand test), graphesthesia,
stereognosis.
Patterns of Sensory Loss
Hemisensory loss Cortical lesions

Stocking-glove sensory loss Neuropathy

Spinal level & Brown-Sequard’s Spinal cord lesions


Syndrome

Dermatomal sensory loss Nerve root lesions

Peripheral nerve sensory loss Mononeuropathy

Saddle anesthesia Lesion in cauda equina or


conus medullaris
Summary

• Outlined basic neuroanatomy


• Highlighted key aspects of examination
• Described major pathology and
explained reasoning behind signs
THANK YOU

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