The Neurological Examination

Dante P. Bornales, MD, MHPEd

Fellow of the Philippine Neurological Association
 The Neurological Examination

In doing the Neuro. Exam., always bear the following in mind:

5. The purpose of the detailed neurological evaluation is to isolate

the “deficits” so that one could make a neurological localization ,
reserve the determination of “what is the lesion” after one has correlated
the findings with the “temporal profile” of the case;

2. The complexity of the procedures relates to the extensiveness of the

functions of the nervous system, it is necessary for a clinician to
master the procedure with constant and regular practice so that one
can vary and even short cut the procedures depending on the
neurological complaint of the patient;
 The Neurological Examination

In doing the Neuro. Exam., always bear the following in mind:

3. It is necessary to integrate parts of the neurological exam with the

other parts of the history and general physical examination
eg.: assess MSE and speech during the interview
evaluate some of the CN exam as one go through the
history and PE

4. During the conduct and in the documentation of the findings, make

sure that one’s thinking is organized in the following categories:

I. Cerebral Examination / Mental Status Examination

II. Cranial Nerve Examination
III. Motor System Examination, including Coordination
IV. Sensory System Examination
V. Muscle Stretch Reflexes
VI. Other Significant Neurological Findings
 The Neurological Examination

In doing the Neuro. Exam., always bear the following in mind:

5. In each of the categories, make sure that one compares “symmetry” of

the findings;

8. What you will document are the findings, and not conclusions! Avoid
using “normal” blatantly, rather describe objectively what you
observe from the patient;

7. It is better to commit rather than to omit the seemingly insignificant

neurological findings; and,

8. “If one doesn’t write anything, one did not do anything” , a thorough
and detailed documentation of the neurological findings is better
than a lacking neurological evaluation.
The neurological history and the neurological exam findings
should closely be correlated in order for one to determine
the nature of the lesion, as follows:

Major Neurological Disease Categories:

(Adams and Victor’s: Principles of Neurology)

1. Cerebrovascular Diseases (Vascular Diseases)

2. Infections of the Nervous System
3. Neoplasms of the Nervous System
4. Traumatic Injury
5. Neurodegenerative Diseases
6. Demyelinating Diseases
7. Inflammatory Diseases / Autoimmune Diseases
8. Congenital / Developmental Diseases
9. Metabolic Diseases affecting the Nervous System
The Components of the Neurological Examination

Cerebral Examination / Mental Status Examination

Speech, Level of consciousness, Attention and Orientation,
Memory processing, Calculation, Abstract thinking, Fund of
information
Cranial Nerve Examination
CN I to XII
Motor System Examination, including Cerebellar tests
Inspection of body position, Involuntary movements, muscle bulk,
Muscle Tone, Manual Motor Testing, Coordination and Gait
Sensory System Examination
Light touch, pain and temperature, position and vibration senses,
Descrimination modalities
Muscle Stretch Reflexes
Deep tendon reflexes
Other Significant Findings
Signs of meningeal irritation, primitive reflexes, superficial reflexes
Things needed for the neurological examination

Don’t forget: the ophthalmoscope for fundoscopy

Mental Status Examination

1. Speech
Phonation
Articulation
Language Production
2. Level of consciousness
3. Attention and Orientation
4. Memory processing
Immediate recall
Recent Memory
Remote Memory
5. Calculation
6. Abstract thinking
7. Fund of information
 Mental Status Examination

Speech

Phonation
- is the production of sounds as the air passes through the
vocal cords
Disorder: dysphonia

Articulation
- is the manipulation of sounds as it passes through the upper
airways by the palate, tongue, and the lips to produce phonemes
Disorder: dysarthria

Language production
- the organization of phonemes into words and sentences, and
is controlled by the speech centers in the dominant hemisphere
Disorder: dysphasia or aphasia
Phonation

Assessment:
- could have been observed during the history-taking
- if not, simply ask questions and get him to talk

- in dysphonia:
the speech volume is reduced
the voice sounds husky

- dysphonia is usually due to

lesion of the recurrent laryngeal nerves
respiratory muscle weakness (eg. GBS)
Articulation

Assessment:

- ask patient to recite tongue-twisting words

“Baby hippopotamus”
“kapakipakinabang”

- causes of dysarthria:
1. Cerebellar dysarthria - speech is slurred (“drunk”)
with scanning quality

2. Extrapyramidal dysarthria - speech is soft and monotonous

3. Pseudobulbar dysarthria - high pitch with a strangulated

quality; sounds like “Donald Duck”

4. Bulbar dysarthria - nasal quality that may worsen as

patient continues to talk
Language production

Assessment:

• establish patient’s handedness (dominant hemisphere dysfunction)

• listen to the patient’s spontaneous speech, assess the fluency
and content
• assess comprehension by observing his or her response to simple
questions

“open your mouth”; “look up to the ceiling”; “protrude your

tongue”

• assess the patient’s ability to name objects

eg: show your wristwatch

• assess the patient’s ability to repeat sentences

“no ifs, ands, or buts”

• if any of these features is abnormal, consider aphasia/dysphasia

 Classification of Aphasia

TYPE OF LESION SPEECH SPEECH COMPRE- REPE-

APHASIA FLUENCY CONTENT HENSION TITION

Expressive Broca’s Non-fluent normal normal Variable

area

Anomic Angular Fluent normal normal normal

gyrus
Receptive Wernicke’s Fluent Impaired Impaired Variable
area
Conductive Arcuate Fluent normal normal Impaired
fasciculus

Global parietal Non-fluent Impaired impaired Impaired

Your task: determine the clinical differences of the different types

of aphasia
Level of Consciousness

components: level of arousal (wakefulness)

content of consciousness (awareness)

Level of arousal:

Alert
Obtunded
Stupor
Coma

Your task: define the different levels of consciousness

Level of Consciousness

level of arousal (wakefulness)

• alternatively, can be assessed clinically using the

“Glasgow Coma Scale”

content of consciousness (awareness)

• alternatively, can be assessed using the “Mini-Mental

State Scale”
Appearance and behaviour

- assessment begins as soon as one meet the patient

- look for evidences of self-neglect
- observe the patient’s responses to questions during
the history-taking
- assess the level of comprehension and insights into
his or her problem

Remember: these questions can be incorporated or are already

Implied during the “history-taking”!!!
Attention and Orientation

Attention:

First! Assess that the pt’s comprehension is normal

Formal assessment is done using serial reversals:

• spell “WORLD” backwards for me, please

• can you name the months of the year backwards
• can you count backwards from 10
Attention and Orientation

Orientation:

assess the patient’s orientation to time, place, and person

ask:
• What day of the week is it today?
• How long have you been in the hospital?
• Can you tell me where are you now?
• What city are we in now?
• Who is this person? (point to a family member, or nurse)

Remember: these questions can be incorporated or are already

Implied during the “history-taking”!!!
Memory Processing

assess: immediate memory recall

recent memory recall
remote memory recall

Immediate memory recall

• establish patient’s comprehension and attention

• test for digit span:

“can you repeat these numbers after me (eg. 293, 9785)

please”

- start with 2 or 3 figures

- avoid recognizable numbers
- a normal person can repeat a five- to seven-digit
sequence
Memory Processing

assess: immediate memory recall

recent memory recall
remote memory recall

Recent memory recall

• ask to recall about politics, social events, sporting events,

taking into account his previous premorbid condition
and socioeconomic status

• ask to memorize a short address (ask the patient back to be

assured that it has been registered); distract pt. for about
10 min. by continuing with the other parameters of the MSE,
then ask him to repeat the statement

Pearl: most individuals can recall all data in 10 min

 Memory Processing

assess: immediate memory recall

recent memory recall
remote memory recall

Remote memory recall

• ask about childhood, schooling, work history, or marriage/s

(you need a third party to confirm/verify information!!!)

Remember: - the questions in the remote memory processing are already

implied during the interview
- immediate and recent memory are usually affected early in
dementing diseases, eg. Alzheimer’s disease
- remote memory is relatively sparred in pts. With minor
degrees of brain damage, however always affected
in advanced dementia
 Calculation

- should be done in the light of pt’s education

Assessment:
• give simple addition and subtraction
• do – serial of sevens or threes ( subtracting sevens or
threes serially from 100)

• give simple daily-living-problem solving scenarios,

eg. “If a kilo of mangoes cost 75 pesos, how much
will 5 kilos cost?”

Pearl: dyscalculia is a prominent fetaure of Gerstmann’s syndrome

(dyscalculia, R-L disorientation and finger agnosia) caused by
a dominant hemisphere lesions like stroke
Abstract thinking

- this is tested by asking the patient to interpret common

proverbs:

“ A bird in the hand is worth two in the bush”

“ Ang lumakad ng matulin, kung matinik ay malalim”
“ Ang hindi lumingon sa pinanggalingan ay di makararating
sa paroroonan”

- this can also be tested by assessing the patient’s ability

to identify similarities between pairs of objects,
eg. “cow and dog”, “air and water”

Your tasks: Define and differentiate the following

1. apraxia from agnosia
2. cortical and subcortical dementia
Cranial Nerve I – Olfactory Nerve

Assessment:

• Ask patients about any recent

change in their sense of smell
(eg. Anosmia, parosmia)

• Check for the patency of the nostrils

• Examine each nostril in turn, using tobacco, coffee, or cinnamon

(use colored vials so that patient will not be able to identify the
test agents even before the procedure)

Tip: avoid using irritating substances (ammonia, alcohol) for these

substances could stimulate the trigeminal nerve endings, even
in anosmic patients!
Cranial Nerve I – Olfactory Nerve

Checking for the patency of each nostrils

Cranial Nerve I – Olfactory Nerve

Examine each nostril with the test agent, preferably with the examiner
closing each of the patient’s nostrils
Cranial Nerve I – Olfactory Nerve

• Unilateral loss of smell is usually asymptomatic

• Bilateral loss of smell is always associated with an altered

sense of taste

• Always examine the CN I in all patients with persosnality changes,

disinhibition, or dementia (frontal lobe involvement), and in
all cases of head trauma
Cranial Nerve I – Olfactory Nerve

Causes of olfactory symptoms:

Anosmia
congenital
nasal sinuses infections/tumors
head injury/cranial injury
frontal lobe tumors
subfrontal meningiomas

Parosmias (persistent unpleasant smells)

nasal infections
head injury
depression

Olfactory hallucinations
temporal lobe epileptic seizures

Paroxysmal unpleasant smell (burning rubber, gas)

psychosis
Cranial Nerve II – Optic Nerve

Examine:

• Visual acuity using the Snellen chart

or a near chart

6. Peripheral field of vision by doing the Gross

Confrontational Test

9. Do the fundoscopy using the ophthalmoscope

11. Check for reaction of pupils (for CN II and III)

Cranial Nerve II – Optic Nerve

Assessment using the Snellen chart:

• Position the patient 20 ft away from the chart

2. Ask the patient to read the smallest line of print possible,

coaxing him to read the next line may improve
performance

Ask the patient to cover one eye during the tests for each
eye

12. Determine the smallest line of print from which the

patient can identify more than half the letters

4. For those with refractive errors, use a pinhole to correct

the patient’s vision, and record the findings
Cranial Nerve II – Optic Nerve

Assessment using the near chart:

If the Snellen chart is not available, use the near chart. Hold the hand held chart 14
inches away, and do much the same procedure as using a Snellen chart
Cranial Nerve II – Optic Nerve

If the patient is unable to read the largest character, assess his ability to count
your fingers at 1 m (report as VA:CF)

If the patient cannot see your fingers, ask him to identify your moving hands (report
as VA:HM)

If the patient cannot see hand movements, flash light in front of his eyes (report as
VA:LP). If patient is unable to perceive light (VA:NLP), then the patient is
medically blind!
Cranial Nerve II – Optic Nerve

The Gross Confrontational Test

1. Sit or stand about 1 m from the patient with your eyes at the same horizontal
level

2. Ask the patient to look directly into your eyes and hold your hands halfway
between you and the patient
• Ask the patient to point at your moving finger/s for you to assess his visual
fields (Make sure that the examiner’s visual field is normal before the
procedure!)

4. The patient’s visual field will match the examiner’s if the head positions are
exactly halfway between the examiner and the patient (this is seldom the case)
If a visual defect is detected, test one eye at a time.

In a right temporal field defect, ask the patient to cover the left eye, and with the
right eye, to look into your eye directly opposite. Then slowly move a
wriggling / moving finger from the defective area toward the better vision,
noting where the patient first responds.

Repeat this at several levels to determine the borders.

Your task: review the visual pathway and the visual field defects
that can be assessed using the Gross Confrontational test
The Fundoscopic examination using the ophthalmoscope

Your task: practice the procedure after the demonstration; make

sure that you know how to handle the instrument
before the session ends
This is the area that you will be able to see using
your ophthalmoscope
Cranial Nerve II, III – Optic and Oculomotor Nerves

Pupillary Light Reflexes

Ask the patient to fixate on a distant target and shine the light in each eye in turn
from the lateral side. Observe for the direct and consensual light reflexes
Accomodation Reflex
Accomodation Reflex
Cranial Nerve III, IV, VI – Oculomotor Nerve
Trochlear Nerve, Abducens Nerve

Inspect the eyes and note for the

position of the eyelids and the
presence of any strabismus and ptosis

Strabismus is concomitant if it remains

constant all throughout the range of eye
movement. It is inconcomitant
(paralytic) if it varies

Do pursuit and saccadic movements to

assess whether the eye movements are
conjugate, and to detect diplopia and
nystagmus
Pursuit eye movements

Steady the pt’s. head and hold an

object (eg. pen) 4-5 cm in front of the
eye

Ask the pt. to follow the moving

object throughout the range of the
binocular vision in the horizontal and
vertical planes in an “H” pattern

Assess the smoothness, speed and

magnitude of the movements

Saccadic eye movements

Steady the pt’s. head and to look in all directions as quickly as possible. Assess the
velocity and the accuracy of the movements
Describe this patient’s EOM paralysis. (The patient was instructed to
look downwards!)
Describe this patient’s EOM paralysis. (The patient was instructed to
look to the left!)
Describe this patient’s EOM paralysis. (The patient was instructed to
look to the right!)
Describe each of the images and discuss the EOM findings
Cranial Nerve V – Trigeminal Nerve
Motor functions of the CN V

Inspect for wasting of temporalis muscle,

which produces hollowing above the
zygoma

Ask the patient to clench his teeth together

and palpate the temporalis and masseter
muscles

The pterygoids are assessed by resisting

the pt’s. attempts to open his mouth

In unilateral trigeminal lesions, the lower

jaw deviates to the paralytic side as the
mouth is opened
Sensory functions of the trigeminal nerve

Using light touch, test for the presence and

symmetry of the facial sensation

Test for pain sensation using a pin (with

blunt end) in the same fashion as you have
tested for fine touch

Reserve the tests for temperature and

proprioception if there’s an abnormal
finding with pain sensation
Sensory testing of the face

Always:

• instruct the patient on what to do

before proceeding with test
• show the test objects to be used
• ask the patient to close his eyes
throughout the procedure
Sensory testing of the face – fine touch

Note for symmetry of the sensation by comparing symmetrical dermatomal

segments on the face
Sensory testing of the face – pain sensation

Note for symmetry of the sensation by comparing symmetrical dermatomal segments

on the face
Sensory testing of the face – temperature sensation

Note for symmetry of the sensation by comparing symmetrical dermatomal segments

on the face
Corneal Reflex (CN V and VII)

Reserve this procedure if one

cannot test for the separate
functions of the V and VII cranial
nerves!
Cranial Nerve VII – Facial Nerve

Sensory testing for the taste (anterior 2/3 of the tongue has
less clinical benefit, thus, it is reserved for special cases
Motor functions of the CN VII

Always check for symmetry!!!

Your task: review the facial muscle innervation and differentiate
peripheral from central facial paralysis
Describe the facial paralysis of
this patient.

Does he has peripheral or central

facial palsy?
Cranial Nerve VIII – Vestibulocochlear Nerve

Clinical bedside assessment of hearing is not sensitive, and can

detect only gross hearing loss!

Reserve the oculovestibular reflex (Doll’s eye) in unresponsive

patients!
Grossly assess hearing in each ear while masking the hearing in the
other ear by occluding the external meatus with your index finger

Test the pt’s. sensitivity by whispering numbers into his ears and
asking him to repeat it
Weber test
Check for lateralization of sounds conducted through the bones
Rinne test

Compare air conduction and

bone conduction
Cranial Nerve IX, X - Glossopharyngeal Nerve, Vagus Nerve
This is the normal palatal arches as the patient opens his
mouth and when he says “ahhhhh”
Note for gag reflex by touching the soft palate or the
pharyngeal walls separately
sensory: IX
motor: X

Observe for the patient’s voluntary swallowing

Describe the direction of the uvula
Cranial Nerve XI – Spinal Accesory Nerve
The function of the trapezius is
assessed by asking the pt. to
elevate his shoulders, first
without, then with resistance

The function of the sternocleidomastoids is assessed by

asking the patient to turn his head and applying resistance,
note for the bulk and strength of the muscles
Always check for symmetry of the bulk and strength
Cranial Nerve XII – Hypoglossal Nerve
Describe the findings in this patient when you ask
him to protrude his tongue
End of segment