Neurological

Examination
Sofiati Dian
Disease is of antiquity and nothing about it changes. It is we who change as
we learn to recognize what was formerly imperceptible.

Jean Martin Charcot (1825-1893)

Overall principles
• Do an organized NE

• Ensure the Pt comfort and safety during each test

• Understand each test and each definition operationally

• Consider whether any unusual finding is a normal variation that simply

reflects the genetic

• Consider whether any finding pre-existed

Introduction
• Diseases that affect the nervous system manifest by cognitive, motor, or
sensory and signs and by abnormal body contours
Neurologic symptoms and signs
• Mental
 Alterations of level of consciousness
 Cognitive dysfunctions
 Affective dysfunction

• Motor
 Somatomotor
 Visceromotor

• Sensory
 Deficits of sensation
 Excessive sensation
The steps use four types of operations
• Inspections
 disclose the patient’s bodily contours and spontaneous and elicited behaviours

• Questions
 determine the patient’s mental status and sensory response

• Requests
 test the patient’s volitional responses

• Manoeuvres
 impose stimuli to elicit sensations and reflexes
Inspections
You can see an awful lot just by looking…

Yogi Berra--
Standing and gait
• Watching the Pt rise, stand, and walk.
 Walk on toes, heels, and in tandem, deep knee bend

• Steadiness of the vertical posture

• Walk freely back and forth

• Pay attention to Pt contours, dysmorphism, atrophy or hypertrophy.

Questions
I think; therefore I am

Rene Descartes—(1596-1650)
Sensorium
• The ancients recognized that every person who is sound of mind has a
sensorium commune, a sense in common of:
 Who, where, when, what, how’

• Casual conversation
Request
Between stimulus and response there is a space. In that space is our
power to choose our response.

Viktor Frankl
Sensory assessment
• The special senses consist of sight, taste, hearing, and equilibrium

• The general senses tested in the standard neurological examination (NE)

consist of touch, temperature, position, vibration, and stereognosis.

• Recognize that the Pt’s mental state, legal issues, or somatization from the
illness may drastically alter sensory results.
 “Let us see how light a touch you can feel..”
 Forced-choise testing (yes/no answer or ‘is stimulus one different from stimulus
two?’
 Have the pt close the eye to avoid visual cues
For the examiner
• Compare homologous areas of the right and left sides and compare
normal areas to any suspected abnormal areas.

• The skin areas differ greatly in sensitivity. Cold skin loses sensitivity,
ensure a warm skin before testing the Pt.

• Follow-up examinations to recheck any doubtful results

• Determine whether sensory deficits match a central pathway, segmental

(dermatomal), plexus, or peripheral nerve pattern or match a non-
anatomical distribution.
• Abnormal sensations may arise in two ways:
 Stimulation of the receptors
 Intrinsic disease of the nerves or central pathways

• Deficit phenomena
 Lack of sensation
 Hypesthesia, anesthesia, hypalgesia, analgesia

• Positive phenomena
 Excessive sensation
 Pain
 Tingling
Maneuvers
To every action there is always opposed an equal reaction

–Sir Isaac Newton

Strength testing
• Rostocaudal sequence

• Test for range of motion

• Abduction of arms, wrist dorsiflexion, grip, hip flexion, and foot dorsiflexion.
Eye movement
Examination of muscle stretch
• Evolution has perfected muscle fibers
as contractile engines. Whatever the
stimulus—a nerve impulse, chemical
agent, electricity, or mechanical
deformation, such as by percussion—
the fibers responds by contracting.

• Physiologic and pathological reflex

Minimum allowable 6 minutes neurologic
examination
• Appraisal during the history
• Visual system: visual acquity, peripheral fields, ophthalmoscopy, pupillary reflex
• 45 second of motor examination of CN III, IV, VI, VII, IX, X, XI, XII
• Hearing: test by conversational voice and by finger rustling
• Somatic motor examination:
 Inspection of muscle, tremors, fasciculations, involuntary movements, stigmata
 Gait test free walking, toe, heel, tandem walking, and deep knee bend
 Strength of abduction of arms, wrist dorsoflexion, grip, hip flexion, foot dorsiflexion
 Cerebellar function: finger-to-nose and heel-to-knee tests
 Muscle stretch reflexes of biceps, quadriceps femoris, and triceps surae
 Elicit plantar reflexes

• Somatosensory examination
 Test superficial sensation by light touch and temperature discrimination on the face, hand, and
feet
 Test deep sensation by directional scratch test
 Astereognosis with coins or paper clips
The concept of closure (cloture)
 Is there a lesion or disease?
 If so, where is the lesion or the disease?
 What is the lesion or the disease (the provisional diagnosis)
 What is the optimum diagnosis management? What clinical or
laboratory test, if any, will confirm or reject the provisional
diagnosis?
 What is the optimum therapeutic management?
 What is the optimum preventative management?
Thank you