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Neurological Examination

Neurological Examination

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John W. Engstrom, M.D.October 5, 2007
The Neurological Exam
 
Mental Status Examination
Before beginning the mental status examination, assess education level and native language of the patient. The results of the exam must be interpreted in the context of these factors.1.
 
Orientation – Ask for the patient's name, the date (as day, month, year), and where thepatient is located now. You will have an excellent index of orientation simply byinterviewing the patient. “Learning effect” – a patient repeatedly asked the sameorientation question on successive days will “learn” the answers. Ask about other items(i.e. – seasons, holidays close to the current date).2.
 
Attention span – One simple test of attention span is the instantaneous recall of aparticular order of numbers, such as a telephone number. Normally a patient should beable to recall 7-8 digits forward and 4 - 5 digits backward. An alternative is to ask thepatient to spell “world” forward and backward. The likelihood of normal recent recall at5 minutes is low if attention span is impaired.3.
 
Recent recall – Ask the patient to remember 3 items and repeat them back to you after 5minutes. This test is best performed if the objects to be remembered are familiar to thepatient. For example, one might ask a carpenter to remember a hammer, a board, and ahouse. In addition, you should always ask the patient to repeat all 3 items immediatelyback to you to make sure the patient understands each item.4.
 
Aphasia – Aphasia can be detected by the ability of the patient to repeat, to name, and tocomprehend. A sentence can be repeated such as, “Today is a sunny day”. Naming canbe performed with common objects such as a pencil, tie, shoe, or belt. Objects should beeasily identifiable and appropriate to the cultural background and educational level of thepatient. Comprehension is tested throughout the examination history and by the ability of the patient to follow directions and answer questions.5.
 
Calculations (optional) – Calculations can be difficult to assess depending on theeducational level of the patient and cultural background, but can be useful under certaincircumstances. For example, it would be abnormal for an accountant to be unable toperform simple subtraction (i.e. – serial 7s).6.
 
Abstractions – Abstractions are complex, difficult tasks for a cognitively impaired patientto perform. Examples of testing simple abstractions are, “What is the difference betweena cat and a dog?” “How would you distinguish between a lake and a river?” or “How area lake and river alike?” The answers will be abnormal in patients with either delerium ordementia.7.
 
Speech – One can easily argue that the evaluation of 
language
is a part of the mentalstatus examination (i.e. – the aphasia screen). Speech is often placed under the mentalstatus examination as well. Abnormalities of speech (dysarthria) can be related to cranial
 
 
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nerve abnormalities including VII (labial dysarthria), X (palatal dysarthria), or XII(lingual dysarthria). For simplicity, one can include speech under the mental statusexamination when a specific etiology for the speech difficulty is not clear.8.
 
The above guidelines are for a screening mental status examination only. There are manydifferent forms of the mental status examination that can be adapted to specificcircumstances.
Cranial Nerve Examination
If in doubt about whether or not a cranial nerve finding is abnormal,
check for symmetrybetween the two sides.I
– Smell (optional) – Testing smell is not part of a routine screening examination. Coffee, floralscents, or cloves are all adequate. Avoid using noxious odors (i.e. – ammonia, alcohol). Smelltesting is particularly useful when a subjective lack of taste or smell is a primary symptom. Twomost common causes – prior head trauma and smoking.
II
– Vision – Screen corrected (i.e.- with glasses) visual acuity with a vision card. Allow thepatient to hold the card. Screen for major visual field deficits by having the patient cover oneeye and identify an object (often a finger) in the center of each visual quadrant of each eye.
II, III
– Pupillary examination – Normal size in moderate light for adults is 3-4 mm. Larger inchildren and smaller in the elderly (senile miosis). Acceptable asymmetry is
1 mm. Check both direct and consensual reactions. For patients with a dark pigmented iris, try using a secondflashlight held from below or above the face to illuminate the pupils without causingconstriction.
III, IV, VI
– Extraocular movements. Check horizontal, vertical, and inferonasal (down and in)eye movements. Can the patient move the eyes from side-to-side fully so as to eliminate thesclera from view? Nystagmus is a rapid, beating movement of the eyes – (usually in a horizontalplane) that is triggered by eye movement. Remember that VI controls abduction and IV controlsinferonasal movement. III controls the other eye movements. Ask the patient to follow yourfinger with his/her eyes as you elicit the eye movements.
V
– Corneal response, facial sensation, and pterygoid power. Use a wisp of cotton and lightlytouch the cotton to the surface of each cornea. Note if both the direct and consensual cornealresponses are present. Check pin and light touch sensation on each cheek. Check pterygoidmuscle power by having the patient keep the jaw open against resistance provided by theexaminer’s hand. If the pterygoid muscles are weak, then the jaw will deviate toward the side of the weakness.
VII
– Facial expression – Test the muscles of facial expression by having the patient raise theeyebrows, close the eyes tightly, and smile. Note any asymmetry in the extent of facialmovement and speed of movement on the two sides of the face.
VIII
– Hearing – Rub the fingers together by each ear so that the fingers can normally be heard,but no movement of the fingers or arms seen by the patient. Vestibular function is screened
 
 
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during testing of the extraocular movements by noting the presence or absence of nystagmus. Afew beats of nystagmus at the extremes of horizontal eye movement is normal. The direction of the nystagmus (by convention) is named for the fast component of the beating eye movements.
IX, X
– Soft palate function – Gag reflex, nasal voice, elevation of the palate. Elevation of thepalate is the best screening test. The uvula will normally elevate in the midline when the patientsays 'Ahhhhhhhl" A nasal voice is an indication of soft palate dysfunction. The gag reflex ishelpful when asymmetric, but it is uncomfortable for patients and may be bilaterally absent innormal patients.
XI
– Sternomastoid (SM) – Many muscles turn the head from side-to-side. The SM turns thehead toward the opposite side. As a practical matter, compare the bulk of the SM muscles on thetwo sides. It is very difficult to convincingly demonstrate weakness limited to this muscle.
XII
– Tongue – Note the bulk of the two sides of the tongue when protruded. If the tongue isweak from a XIIth nerve lesion, it will protrude toward the side of the lesion. Strength can betested by having the patient push the tongue against the inside of each cheek. In the presence of facial weakness, one can be misled into thinking the tongue protrudes to one side. Be careful toline up the position of the tongue with the tip of the nose and the middle of the chin to determineif the tongue has protruded to one side or another.
The Motor Examination
1. If in doubt about whether or not a finding (bulk, power, reflexes) is abnormal, check forsymmetry between the two limbs.2. A screening examination will include sampling of the proximal and distal muscles of thearms and legs. In otherwise healthy patients, the ability to perform a deep-knee bend is agood screen of proximal leg power.3. You cannot perform an adequate muscle examination unless you can see the muscles! Thepatient must be positioned and dressed appropriately.4. You will not remember the innervation and action of all the muscles. You may want to geta portable book with diagrams that can serve as an instant resource (i.e.-Aids to theExamination of the Peripheral Nervous System).Bulk – Check the bulk of the deltoid, abductor pollicis brevis (APB), quadriceps, and theextensor digitorum brevis (EDB) muscles. Visually compare the same muscles on the right withthe left arm. Repeat inspection in the legs.Tone – Move the limbs slowly and quickly through their range of motion with the patient relaxedand supine. Increased tone consists of resistance to passive movement of the limbs, despiteadequate relaxation and the absence of pain during the movement. Spasticity is a velocity-dependant increase in resistance that is greatest in the flexors of the arms and extensors of thelegs.

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