NEUROSCIENCE

3.06 NEUROLOGIC EXAMINATION

VANESSA CALIMAG, MD | APRIL 3, 2022

OUTLINE → Often, patients want to discuss only other

I. Overview physicians' opinions about the illness and to
II. History Taking describe the many tests that were done.
III. Physical Examination • Make special inquiry about the following complaints:
A. Mental Status → Changes in memory or personality
B. Cranial Nerves → Disturbances of consciousness
C. Motor System → Convulsions
D. Sensory System
→ Headaches
E. Reflexes
→ Loss of vision
→ Diplopia (double vision)
→ Deafness
LEGENDS
Remember Lecturer Book Presentation → Tinnitus(ringing or roaring in the ears)
→ Vertigo(a sense of movement of the
environment or of the patient)
I. OVERVIEW → Nausea and vomiting
• Clinical Evaluation of Neurologic Disorders → Language disturbances (trouble with
→ History & Physical Examination comprehension or execution of language)
→ Differential Diagnosis → Weakness, stiffness, or paralysis of the limbs
→ Laboratory Evaluation → Gait imbalance and falls
→ Tremors or other involuntary movements
→ Pains and paresthesias
→ Loss or decrease of sensation
→ Disturbances in control of the bowel or
bladder
B. Past Medical History
• Major Illness
• Surgery
• Allergies
• Medications
• System Review
• Birth and Developmental milestone

II. HISTORY TAKING C. Family History

• Patient History • Inquire about their ages and state of health.
→ Neurologic History • If they are no longer living, obtain the age of death
→ Past Medical History and cause of death as well as any antecedent chronic
→ Family History illnesses, particularly neurologic disorders, in the
→ Social History mother and father.
• Make similar inquiries about siblings.
A. Neurologic History • Include inquiries about family members, immediate or
• Chief complaint remote, who had paralysis, gait or movement
→ Obtain the patient's name, age, gender, disorders, convulsions, or dementia.
occupation, and handedness. • If a first-degree relative (mother, father, or sibling) had
→ Record CC in the patient's own words an illness similar to that of the patient, obtain as full a
history of the illness as possible.
→ Duration of the complaint.
• Inquire about grandparents, aunts, uncles, and
→ If the patient cannot provide the chief complaint,
cousins who had similar illnesses as well.
attempt to obtain it from a family member, guardian,
or friend. • Inquire about the patient's children, including ages,
genders, and any illnesses.
• Present illness
• If the family history includes several members of
→ Chronologic sequence, beginning with the first
multiple generations with a similar illness, draw a full
symptom, and then describe how the symptoms
family tree.
have changed over time.

TRANS DANGARANG, IMPERIO 1 of

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3.06 Neurologic Examination
D. Social History effort, but is able to understand and to follow
• Education commands appropriately.
• Occupation o lesion in inferior frontal gyrus (sometimes
• Marriage called the Broca convolution) specifically
• Sexual Function involving pars opercularis and pars
• Habits triangularis.
• Living Situation ▪ FLUENT
− Fluent Aphasia / receptive or Wernicke
III. PHYSICAL EXAMINATION aphasia
• MATERIALS & EQUIPMENTS USED o patient has normal or even increased
→ Snellen card or chart Ophthalmoscope production of words, sometimes in long
sentences with normal prosody (rhythm of
→ tongue depressor
speech); well-articulated but frequent
→ Flashlight
neologisms (a series of meaningless words)
→ Reflex hammer, give these sentences no content or meaning
→ disposable safety pin o neither the patient nor the examiner is able
→ small pledget of cotton wool, to understand the meaning of the patient’s
→ 128 (Hz) and a 256-Hz tuning fork. speech.
→ Disorder of taste or smell - scented substance o A lesion of the lateral aspect of the dominant
such as coffee, mint, or cloves. hemisphere in the area of the supramarginal
→ higher cognitive functioning - pen, a blank sheet and angular gyri (and sometimes adjacent
of paper, and a paragraph of written material for portions of the superior temporal lobe)
testing reading. • NAMING
→ cortical sensory function - compass with two → Ask the patient to name various objects (e.g.,
blunt tips that can be separated for measurable pen, thumb, watch, face, belt buckle, and
distances of millimeters, several small coins, colors).
and several small common objects such as → Object agnosia
nails, screws, bolts, and nuts ▪ lesions in areas 18, 20, and 21 of the left
(dominant) hemisphere
A. Mental Status ▪ unable to recognize (i.e., identify or name)
• ORIENTATION real objects, although they are perceived.
• ATTENTION AND STATE OF CONSCIOUSNESS • REPETITION
→ Normal level of attention → Ask the patient to repeat a phrase such as "no ifs,
→ Confusional state ands, or buts" or “the lawyer's closing argument
→ Delirium convinced him."
→ Stupor • CONSTRUCTIONAL ABILITY
• MEMORY → Ask the patient to copy a cube or a complex figure
→ Remote memory or ask the patient to draw a house or a flower.
→ Intermediate memory → A disturbance of constructional ability in an
→ Recent Memory alert,non-aphasic patient suggests a lesion in the
→ Digit retention nondominant (usually right) parietal lobe,
• CALCULATION particularly when the left parts of the drawings
• GRASP OF GENERAL INFORMATION remain incomplete or have been ignored
• INTERPRETATION OF PROVERBS AND • PRAXIS
SIMILARITIES → This refers to the motor integration used in the
• INSIGHT AND JUDGEMENT execution of complex learned movements
→ Letter and Fire Test → Give the patient commands such as "Show me
• AFFECT how to blow out a match,” "Show me how to use
a toothbrush," "Show me how to wave goodbye."
• SPECIAL TESTS • COMPREHENSION
→ LANGUAGE → Determine the patient's ability to follow
▪ NONFLUENT commands such as “Close your eyes" or "Pick up
− Nonfluent aphasia / expressive or Broca the paper, fold it in half, and hand it to me."
aphasia; • READING
o patient has difficulty with verbal self- → Test the patient's ability to read aloud and
expression, producing words only with great comprehend a paragraph from a newspaper.

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3.06 Neurologic Examination
→ Disorder in comprehension of written material in
an alert patient often results from disease in the
posterior part of the dominant cerebral
hemisphere
• WRITING
→ Ask the patient to write an original sentence and
to copy a sentence.
→ Disturbance of writing in an alert patient usually
signifies a pathologic process in the posterior part
of the dominant cerebral hemisphere
B. Cranial Nerves
• Abnormalities found when examining the cranial
nerves may rise from the lesions at different levels
including:
→ The CNS pathways to and from the cortex,
diencephalon, cerebellum or other parts of the
brainstem
→ Lesions in the nucleus
→ Lesions to the nerve itself
→ Generalised problems of nerve, neuromuscular
junction or muscle
• CRANIAL NERVE I: OLFACTORY NERVE
→ Very simple: Ask the patient if they have noticed a
change in their sense of smell
Simple: Take a bedside object—a piece of fruit, an
orange, a juice bottle—and ask the patient if it
smells normal.
→ Testing agents commonly used: COFFEE and
MINT
→ Formal: A selection of substances with
identifiable smells in similar bottles is used.
Agents often used include peppermint, camphor
and rosewater. The subject is asked to identify
these smells. An agent such as ammonia is
usually included. Each nostril is tested
separately.
→ WHAT YOU FIND
▪ Normal
▪ Anosmia
▪ Unilateral anosmia.
▪ Consider that the loss may not be entirely
organic.
→ WHAT IT MEANS
▪ Anosmia in both nostrils: loss of sense of
smell.
▪ Common causes: blocked nasal passages
(e.g. common cold), trauma; a relative loss
occurs with ageing and Parkinson's disease
▪ Unilateral anosmia: blocked nostril, unilateral
frontal lesion (meningioma or glioma—
extremely rare)
• CRANIAL NERVE II: OPTIC NERVE
• Examination of the eye can provide many important
diagnostic clues for both general and medical
neurological diseases
→ General
▪ Look at the patient's eyes and note any
difference between the two sides.
▪ Look at the level of the eyelid; particularly
note asymmetry.
▪ If an eyelid is lower than normal, this is
referred to as ptosis; it can be partial or
complete (if eye is closed).
If an eyelid is higher than normal, usually
above the level of the top of the iris, this is
described as lid retraction.
▪ Look at the position of the eye. Is there
protrusion (exophthalmos) or does the eye
appear sunken (enophthalmos)? If you are
considering exophthalmos, it is confirmed if
the front of the orbital globe can be seen
when looking from above.
▪ Beware the false eye—usually obvious on
closer inspection.
→ Pupils
▪ Are they equal in size? Are they regular in
outline? Are there any holes in the iris or
foreign bodies (e.g. lens implants)
in the anterior chamber?
▪ Shine a bright light in one eye.
- Look at the reaction of that eye—the
direct reflex—and then repeat and look at the
reaction in the other eye—the consensual
reflex.
▪ Ensure that the patient is looking into the
distance and not at the light.
▪ Repeat for the other eye.
▪ Place your finger 10 cm in front of the
patient's nose. Ask the patient to look into the
distance and then at your finger.
▪ Look at the pupils for their reaction to
accommodation.
▪ Swinging light test - Shine a bright
light into one eye and then the other at about

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3.06 Neurologic Examination
1-second intervals. Swing the light
repeatedly between the two. Observe the
pupillary response as the light is shone into
the eye.
− The pupil constricts as the light is shone into it
repeatedly: normal.
− The pupil on one side constricts when the light
is shone into it and the pupil on the other side
dilates when the light is then shone into it: the
side that dilates has a relative afferent pupillary
defect (often abbreviated to RAPD). This is
also sometimes called the Marcus Gunn pupil
• Acuity
→ Using bedside materials (Newspaper)
→ Test as in (ii) and record the type size read (e.g.
headlines only, all print)
→ If unable to read largest letters, see if the patient
can:
▪ Count fingers
▪ See hand movements
▪ Perceive light
→ Ask the patient to look through a pinhole made in
a card. If acuity improves, the visual impairment
is refractive in origin and not from other optical or
neurological causes.
• Fields
→ It is best to test each eye separately and to ask
the patient to look straight at the examiner’s eye.
Bring the target object (eg, finger or pen) in from
the periphery of each quadrant of the eye.

• CRANIAL NERVES III, IV, VI: OCULOMOTOR,

TROCHLEAR, ABDUCENS
→ Look at the position of the head.
→ The head is tilted away from the side of a fourth
nerve lesion.
→ Look at the eyes.
→ Note ptosis
→ Note the resting position of the eyes and the
position of primary gaze.
→ Look at the position of the eyes in primary gaze.
→ Do they diverge or converge?
→ Does one appear to be looking up or down—skew
deviation?
→ Test CNs III, IV, and VI by having the patient follow
your finger or a light to the right, left, up, down, and
diagonally in both directions. Both eyes are tested
together, but if weakness is noted or the patient
complains of double vision, then each eye should be
tested separately.

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3.06 Neurologic Examination
→ Cover Test
▪ What you find:
− If one eye has to correct as it is uncovered,
this indicates that the patient has a latent
strabismus (squint), which can be classified
as divergent or convergent.
▪ What it means:
− Latent squint: congenital squint usually in
the weaker eye (and myopia in childhood)—
common.
Eye Movements
▪ Saccadic eye movements: the rapid movement from
one point of fixation to another. Site of Control:
Frontal Lobe
▪ Test Saccadic Eye movement
− Face the patient. Hold both your hands out in
front of you about 30cm apart from side to side
and about 30cm in front of the patient.
− Ask the patient to look from one hand to the other.
− Observe the eye movements: are they full, do
they move smoothly, do they move together?
− Look particularly at the speed of adduction.
− Then put your hands vertically one above the
other, about 30cm apart and ask the patient to
look from one to the other.
− Again observe the eye movements. Do the eyes
move at a normal speed and through the full
range?
▪ Pursuit Eye Movements
− Pursuit eye movements: the slow eye movement
used to maintain fixation on a moving object. Site
of control: Occipital Lobe
− Test the eye movement to pursuit
o Hold a pen vertically about 50cm away from
the patient in the centre of his gaze. Ask him
to follow it with his eyes without moving his
head and to tell you if he sees double. You can
hold the chin lightly to prevent head
movement.
o Move the pen slowly. Ask the patient to tell you
if he sees double: – from side to side
– up and down from the centre
– up and down at the extreme of lateral gaze.
NEUROSCIENCE
o Ensure the patient's nose does not prevent
the pen being seen at the extreme of lateral
gaze.
▪ Vestibular–positional (vestibulo-ocular reflex) eye
movements: the eye movements that compensate
for movement of the head to maintain fixation. Site
of control: Cerebral Vestibular nuclei
− Test:
o Ask the patient to look into the distance at a
fixed point; turn his head to the left then the
right, and flex the neck and extend the neck.
The eyes should move within the orbits,
maintaining forward gaze.
o Doll’s Eye Maneuver
= FINDINGS:
= The eyes are misaligned in primary gaze:
– The misalignment remains constant in
all directions for gaze = convergent or
divergent concomitant strabismus
(squint).
– One eye is deviated downwards and
out, with ptosis = third nerve lesion.
– Eyes aligned in different vertical planes
= skew deviation.
= The patient has double vision, try to
answer the following questions:
Is there a single nerve (VI, III or IV) deficit
– If there is a third nerve deficit, is it
medical (pupil-sparing) ormsurgical (with
pupillary dilatation)?
If not single nerve:
Is there a combination of single nerves?
Is it myasthenia or dysthyroid eye
disease?
= The patient does not have double vision:
Compare movements on
command, on pursuit and on vestibular
positional testing.
▪ Convergence: the movements that maintain
fixation as an object is brought close to the
face. These are rarely affected in clinical
practice. Site of control: Midbrain
− Ask the patient to look into the distance and
then look at your finger placed 50cm in front of
him. Gradually bring the eyes in, observing the
limit of convergence of the eyes
• CRANIAL NERVE V: TRIGEMINAL NERVE
→ There are three divisions:
▪ ophthalmic (V1)
▪ maxillary (V2)
▪ mandibular (V3).
→ What to do?
→ Motor: Test muscles of mastication
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3.06 Neurologic Examination
→ Test these muscles by having the patient clench the
jaw while you palpate the masseter and the temporal
muscles on each side and watch the jaw open.
→ Look at the side of the face and check if is there
wasting of the temporalis muscle.
→ Ask the patient to clench his teeth and feel the
masseter and temporalis muscles.
→ Ask the patient to push his mouth open against
your hand and resist his jaw opening with your
hand under his chin. Note if the jaw deviates to
one side.
→ Jaw jerk. Ask the patient to let his mouth hang
loosely open. Place your finger on his chin.
Percuss your finger with the patella hammer. Feel
and observe the jaw movement.
→ Sensory: Test facial sensation
→ Test light touch and pinprick in each division on
both sides:
▪ V1 : forehead
▪ V2 : cheek
▪ V3 : lower lip
→ Compare one side to the other.
▪ If abnormal, test temperature.
▪ If a sensory deficit is found, determine its
edges, moving from abnormal to normal.
→ What you find:
▪ Motor:
− Wasting of temporalis and masseter: rare.
Causes: myotonic dystrophy, motor neurone
disease.
▪ Weakness of jaw closure: very rare.
▪ Weakness of jaw opening: jaw deviates to
the side of the lesion. Cause: unilateral lesion
of motor V.
→ Sensory:
▪ Impairment or loss in one or more divisions
on one side of light touch or pinprick and
temperature or both.
▪ Unilateral facial loss: one or all modalities.
▪ Muzzle loss of pinprick and temperature.
▪ Unilateral area of sensory loss not in
distribution of whole division.
▪ Trigger zone that produces facial pain.
→ What it means:
▪ Loss of all modalities in one or more
divisions:
▪ Lesion in sensory ganglion: most commonly
herpes zoster.
▪ Lesion of division during intracranial course:
V 1 cavernous sinus (associated III, IV, VI) or
orbital fissure, V 2 trauma, V 3 basal tumours
(usually associated motor V).
→ b) Loss of sensation in all divisions in all
modalities:
▪ Lesion of the Gasserian ganglion, sensory
root or sensory nucleus: lesions of
NEUROSCIENCE
cerebellopontine angle (associated VII, VIII),
basal meningitis (e.g. sarcoid, carcinoma).
→ c) Loss of light touch only:
▪ With ipsilateral hemisensory loss of light
touch: contralateral parietal lobe lesion.
▪ With no other loss: sensory root lesion in
pons.
• CRANIAL NERVE VII: FACIAL NERVE
→ Peripheral function can be summarised as ‘face,
ear, taste, tear’
→ With lower motor neurone (LMN) facial weakness,
all muscles are affected.
→ With upper motor neurone (UMN) facial weakness,
the forehead is relatively preserved.
→ What to do:
▪ Look at the symmetry of the face and note
nasolabial folds and forehead wrinkles. Watch
spontaneous movements like smiling and
blinking.
▪ Ask the patient to show you his teeth, to whistle,
close his eyes tightly as if he had soap in them
and during this, watch eye movement and
assess the strength by trying to open his eyes
with your fingers.
→ Test the nerve by asking patients to “wrinkle your
forehead,” “close your eyes,” and “show me your
teeth.” Note the symmetry of these movements.
• Crainial Nerve VIII: Auditory Nerve
• There are two components: Auditory and Vestibular.
• Auditory
→ What to do:
→ Test the hearing.
▪ Test one ear at a time. Block the opposite
ear; either cover it with your hand or produce
a blocking white noise, e.g. crumpling paper.
▪ Hold your watch by the patient's ear.
Discover how far away from the ear it is still
heard. Alternative sounds are whispering or
6
3.06 Neurologic Examination
rubbing your fingers together. Increase in
volume to normal speech or loud speech until
your patient hears.
▪ If the hearing in one ear is reduced, perform
Rinne's and Weber's tests.
▪ For Rinne's test, hold a 256 or 512 Hz tuning
fork on the mastoid process for bone
conduction and then in the front of the ear for
air conduction. Then ask the patient in which
position the sound is louder.
▪ For Weber's test, hold the 256 or 512 Hz
tuning fork on the vertex of the head and ask
in which ear the sound is louder: the good ear
or the deaf ear.
▪ What you find:
• Vestibular system
• What to do:
→ Ask the patient to lie down with his head on a pillow
at 30 degrees so the lateral semicircular canal is
vertical.
→ Cool water (usually about 250 ml at 30°C) is
instilled into one ear over 40 seconds. The patient
is asked to look straight ahead and the eyes are
watched. This is repeated in the other ear, and then
in each ear with warm water (44°C).
• What you find:
→ For normal responses: cold water: nystagmus fast-
phase away from stimulated ear and warm water:
nystagmus fast-phase towards stimulated ear.
→ Reduced response to cold and warm stimuli in one
ear: canal paresis.Reduced nystagmus in one
direction after warm stimuli from one ear and cold
stimuli from the other: directional preponderance.
• CN IX, X, XII
• Glossopharyngeal nerve: IX
→ Sensory: posterior one-third of tongue, pharynx,
middle ear.
→ Motor: stylopharyngeus.
→ Autonomic: to salivary glands (parotid).
→ Gag reflex is used to test the glossopharyngeal
nerve (and the vagus nerve) clinically. A tongue
depressor applied to the posterior pharynx causes
the pharyngeal muscles to con- tract, with or
without gagging.
• Vagus nerve: X
→ Sensory: tympanic membrane, external auditory
canal and external ear.
NEUROSCIENCE
→ Motor: muscles of palate, pharynx, larynx (via
recurrent laryngeal).
→ Autonomic: afferents from carotid baroreceptors,
parasympathetic supply to and from thorax and
abdomen.
• Hypoglossal nerve: XII
→ Motor: intrinsic muscles of the tongue.
→ Test this nerve by asking the patient to stick out the
tongue and move it from side to side.
A. Mouth and tongue
• What to do:
• Ask the patient to open his mouth. Look at the gums
and check for any hypertrophy. Then look at the
tongue and check if it is normal in size and are there
rippling movements and also is it normal in colour and
texture.
• Ask the patient to put out his tongue and check if it
move straight out or deviate to one side.
b) Pharynx
• What to do:
• Look at the position of the uvula and see if it is central.
• Ask the patient to say ‘Ahh’ and look at the uvula and
check if it move up centrally or does it move over to
one side.
c)Gag reflex
• What to do:
• Touch the pharyngeal wall behind the pillars of the
fauces.
• Watch the uvula; it should lift following the stimulus.
• Ask the patient to compare the sensation between
two sides.
d) Larynx
• What to do:
• Ask the patient to cough and listen to the onset and
check if it is explosive or gradual.
• Check if the volume and quality are normal and does
the speech fatigue.
• CN XI: Accessory Nerve
• What to do:
→ Look at the neck and check:
→ Is the sternocleidomastoid wasted or fasciculating?
→ Is the sternocleidomastoid hypertrophied?
→ Is the head position normal?
→ Look at the shoulders and check:
→ Are they wasted or fasciculating?
• Sternocleidomastoid
→ Ask the patient to lift his head forward.
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3.06 Neurologic Examination
→ Push the head back with your hand on his
forehead. Look at both sternocleidomastoids.
→ Ask the patient to turn his head to one side.
→ Push against his forehead. Watch the opposite
sternocleidomastoid.
b) Trapezius
• Ask the patient to shrug his shoulders.
• Watch for symmetry.
• Push down the shoulders.
• What you find and what it means:
→ Weakness of sternocleidomastoid and trapezius on
the same side: peripheral accessory palsy. Look for
associated ipsilateral IX and X lesions: suggests a
jugular foramen lesion (glomus tumour or
neurofibroma).
→ Weakness of ipsilateral sternocleidomastoid and
contralateral trapezius: upper motor neuron
weakness on ipsilateral side.
→ Unilateral delayed shoulder shrug: suggests
contralateral upper motor neuron lesion.
→ Bilateral wasting and weakness of
sternocleidomastoid indicates myopathy or motor
neurone disease.
→ Unilateral sternocleidomastoid abnormalities:
indicate unilateral trauma or upper motor neuron
weakness.
→ Abnormal head position and hypertrophy of neck
muscles occur in cervical dystonia.
C. Motor System
There are five patterns of muscular weakness:
1. Upper motor neuron (UMN)
2. Lower motor neuron (LMN)
3. Muscle disease
4. Neuromuscular junction
5. Functional weakness
→ Evaluation of the motor system involves
assessing the symmetry of muscle strength,
bulk, and tone. Abnormal muscle movement
such as fasciculations should be noted.
→ The major tract of the motor system is the
corticospinal, or pyramidal tract which originates
in the precentral gyrus (primary motor cortex) of
the frontal lobe
→ The leg is represented on the medial surface
and the face, arm and hand on the lateral
surface. At the junction between the medulla
and spinal cord, the corticospinal tract crosses
the midline (pyramidal decussation). Because of
this decussation, the right cerebral hemisphere
controls the muscles on the left side of the body
and the left hemisphere controls those on the
right side
NEUROSCIENCE
→ The clinical features of an upper motor neuron
disorder include weakness, spasticity,
hyperreflexia, and extensor plantar reflex or
Babinski sign (“up-going toe”)
→ The lower motor neuron is also called the “final
common pathway”. Clinical features of a lower
motor neuron lesion include weakness,
decreased muscle stretch reflexes
(hyporeflexia), loss of muscle bulk or atrophy,
and fasciculations
The level of the nervous system affected can be
determined by the distribution and pattern of the
weakness and by associated findings(Table 1)
• Examples of brainstem signs
→ (all contralateral to the upper motor
neurone weakness): third, fourth and
sixth palsies, seventh lower motor
neurone loss, nystagmus and dysarthria
• Hemisphere signs:
→ aphasia, visual field defects, inattention
or neglect, higher function deficits.
• Mixed UMN and LMN lesions:
→ motor neurone disease (with normal
sensation), or combined cervical
myelopathy and radiculopathy and
lumbar radiculopathy (with sensory
abnormalities).
Functional weakness should be considered when:
→ the weakness is not in a distribution that can be
→ understood on an anatomical basis
→ the movements are very variable and power is
erratic
→ there is a difference between the apparent
power of moving a limb voluntarily and when
power is being tested
→ as long as there are no changes in tone or
reflexes
→ Proximal muscle weakness indicates myopathy,
whereas distal muscle weakness may indicate
peripheral neuropathy, especially if there are
associated sensory findings
→ Weakness of a specific muscle suggests a
problem with the nerve that innervates the
muscle
GRADING POWER
MUSCLE TONE
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3.06 Neurologic Examination
• BACKGROUND The three nerves of greatest clinical importance in the
→ Testing muscle tone is a very important arm are the radial, ulnar and median nerves.
indicator of the presence and site of • The radial nerve and its branches supply all
pathology. It can be surprisingly difficult to extensors in the arm.
evaluate. • The ulnar nerve supplies all intrinsic hand
• WHAT TO DO muscles except ‘LOAF’.
→ Ensure the patient is relaxed, or at least • The median nerve supplies:
distracted by conversation. Repeat each L lateral two lumbricals
movement at different speeds. O opponens pollicis
ARMS A abductor pollicis brevis
→ Take the hand as if to shake it and hold the F flexor pollicis brevis
forearm. First pronate and supinate the forearm.
Then roll the hand round at the wrist ( Fig. 16.1 ). • WHAT TO DO
Hold the forearm and the elbow and move the arm Look at the arms
through the full range of flexion and extension at → Note wasting and fasciculations, especially in the
the elbow. shoulder girdle, deltoid and small muscles of the
LEGS hands (the first dorsal interossei and abductor
→ Tone at the hip The patient is lying with straight pollicis brevis)
legs. Roll the knee from side to side ( Fig. 16.2 ).
→ Tone at the knee Put your hand behind the knee • PRONATOR TEST
and lift it rapidly. Watch the heel. Hold the knee and → Ask the patient to hold his arms out in front with
ankle. Flex and extend the knee. his palms facing upwards and to close his eyes
→ Tone at the ankle Hold the ankle and flex and tightly (demonstrate ). Watch the position of the
dorsiflex the foot. arms.
• WHAT YOU FIND → What you find and what it means:
→ Normal: slight resistance through whole range of – One arm pronates and drifts downwards:
movements. Heel will lift minimally off the bed. indicates weakness on that side.
→ Decreased tone: loss of resistance through – Both arms drift downwards: indicates
movement. Heel does not lift off the bed when the bilateral weakness.
knee is lifted quickly. Marked loss of tone=flaccid. – Arm rises: suggests cerebellar disease.
→ Increased tone: – Fingers continuously move up and down—
– Resistance increases suddenly (‘the catch’); the pseudoathetosis—indicates deficit of joint
heel easily leaves the bed when the knee is lifted position sense
quickly: spasticity.
– Increased through whole range, as if bending a BASIC SCREENING EXAMINATION
lead pipe: lead pipe rigidity. Regular intermittent Shoulder abduction
break in tone through whole range: cogwheel rigidity. 1. Ask the patient to lift both his elbows out to the side (
– Patient apparently opposes your attempts to move demonstrate ).
his limb: Gegenhalten or paratonia. 2. Ask him to push up
ARMS - Muscle : deltoid
→ Upper motor neurone or pyramidal weakness - Nerve : axillary nerve
predominantly affects finger extension, elbow - Root : C5.
extension and shoulder abduction. N.B. Elbow Elbow flexion
flexion and grip are relatively preserved 1. Hold the patient's elbow and wrist.
→ Muscles are usually innervated by more than one 2. Ask him to pull his hand towards his face. N.B. Ensure
nerve root. The exact distribution varies between the arm is supinated ( Fig. 17.2 ).
individuals - Muscle : biceps brachii
- Nerve : musculocutaneous nerve
- Root : C5, C6.
Elbow extension
1. Hold the patient's elbow and wrist.
2. Ask him to extend the elbow (Fig. 17.3).
- Muscle: triceps
- Nerve: radial nerve
- Root: (C6), C7, (C8)
Wrist extension
1. Hold the patient's forearm.

NEUROSCIENCE 9
3.06 Neurologic Examination
2. Ask him to make a fist and bend his wrist up (Fig.
17.4).
- Muscle: flexor carpi ulnaris and radialis
- Nerve: radial nerve
- Root: (C6), C7, (C8).
Finger extension
1. Fix the patient's hand.
2. Ask him to keep his fingers straight.
3. Press against the extended fingers (Fig. 17.5).
- Muscle: extensor digitorum
- Nerve: posterior interosseous nerve (a branch of
the radial nerve)
- Root: C7, C8
Finger flexion
1. Close your fingers on the patient's fingers palm to
palm so that both sets of fingertips are on the other's
metacarpal phalangeal joints.
2. Ask the patient to grip your fingers and then attempt
to open the patient's grip (Fig. 17.6).
- Muscles: flexor digitorum superficialis and
profundus
- Nerves: median and ulnar nerves
- Root: C8
Finger abduction
1. Ask the patient to spread his fingers out
(demonstrate).
2. Ensure the palm is in line with the fingers. Hold the
middle of the little fingers and attempt to overcome
the index finger (Fig. 17.7).
- Muscle: first dorsal interosseous
- Nerve: ulnar nerve
- Root: T1
Finger adduction
1. Ask the patient to bring his fingers together.
2. Make sure the fingers are straight.
3. Fix the middle, ring and little fingers.
4. Attempt to abduct the index finger (Fig. 17.8).
- Muscle: second palmar interosseous
- Nerve: ulnar nerve
- Root: T1.
Thumb abduction
1. Ask the patient to place his palm flat with a supinated
arm. Ask him then to bring his thumb towards his
nose.
2. Fix the palm and, pressing at the end of the proximal
phalanx joint, attempt to overcome the resistance
(Fig. 17.9).
- Muscle: abductor pollicis brevis
- Nerve: median
- Root: T1
LEGS
→ Upper motor neurone or pyramidal weakness
predominantly affects hip flexion, knee flexion and
foot dorsiflexion. Simplified root distribution in the
legs is shown in Table 18.1
NEUROSCIENCE
→ Femoral nerve supplies knee extension.
→ Sciatic nerve supplies knee flexion. Its branches
are:
o Posterior tibial branch—supplies foot
plantarflexion and inversion and the
small muscles of the foot.
o Common peroneal branch—supplies
dorsiflexion and eversion of the ankle.
• WHAT TO DO
→ Look at the legs for wasting and fasciculation.
→ Note especially the quadriceps, the anterior
compartment of the shin, the extensor digitorum
and brevis, and the peroneal muscles.
→ Look for the position and for contractures,
especially at the ankle; look at the shape of the
foot, a high arch or pes cavus.
→ Pes cavus is demonstrated by holding a hard,
flat surface against the sole of the foot; a gap
can be seen between the foot and the surface.
POWER TESTING SCREENING
Hip flexion
1. Ask the patient to lift his knee towards his chest.
When the knee is at 90 degrees, ask him to pull it up
as hard as he can; put your hand against his knee
and try to overcome this (Fig. 18.1).
- Muscle: iliopsoas
- Nerve: lumbar sacral plexus
- Root: L1, L2. Power testing screening
Hip extension
1.The patient is lying flat with his legs straight.
2. Put your hand under his heel and ask him to push
down to press your hand (Fig. 18.2).
- Muscle: gluteus maximus
- Nerve: inferior gluteal nerve
- Root: L5, S1.
Knee extension
1. Ask the patient to bend his knee.
2. When it is flexed at 90 degrees, support the knee with
one hand and place the other hand at his ankle and
ask him to straighten his leg (Fig. 18.3).
- Muscle: quadriceps femoris
- Nerve: femoral nerve
- Root: L3, L4
Foot dorsiflexion
1. Ask the patient to cock his ankle back and bring his
toes towards his head.
10
3.06 Neurologic Examination
2. When the ankle is past 90 degrees, try to overcome
this movement. Watch the anterior compartment of
the leg (Fig. 18.5).
- Muscle: tibialis anterior
- Nerve: deep peroneal nerve
- Root: L4, L5.
Plantar flexion of the foot
1. Ask the patient to point his toes with his leg straight.
2. Try to overcome this (Fig. 18.6).
- Muscle: gastrocnemius
- Nerve: posterior tibial nerve
- Root: S1.
• WHAT YOU FIND
1. Weakness in all four limbs
A. With increased reflexes and extensor plantar
responses
o Anatomical localisation: cervical cord
lesion or bilateral pyramidal lesions
B. With absent reflexes
o Polyradiculopathy, peripheral
neuropathy or a myopathy. Sensory
testing should be normal in a myopathy
C. Mixed upper motor neurone (in the legs) and
lower motor neurone weakness (in the arms)
o Suggests motor neurone disease (which
has no sensory loss) or mixed cervical
myelopathy and radiculopathy (with
sensory loss).
D. Normal reflexes
o Fatigable weakness, particularly with
associated cranial nerve abnormalities
(eye movements, ptosis, facial muscles):
myasthenia gravis.
o Variable weakness, normal tone:
consider functional non-organic
weakness.
2. Weakness in both legs
a. With increased reflexes and extensor plantar
responses
o Suggests a lesion in the spinal cord. The
lesion must be above the root level of the
highest motor abnormality. A level may
be ascertained with sensory signs.
b. With absent reflexes in the legs
o Polyradiculopathy, cauda equina lesions
or peripheral neuropathy.
3. Unilateral arm and leg weakness
→ Upper motor neuron lesion in the high cervical
cord, brainstem or above
o Contralateral sensory findings (pain and
temperature loss) indicate lesion of half
ipsilateral cervical cord lesion (Brown–
Séquard)
o Contralateral cranial nerve lesions or
brainstem signs indicate the level of
brainstem affected.
NEUROSCIENCE
o Ipsilateral facial or tongue weakness
indicate lesion above brainstem.
o Ipsilateral sensory loss indicate a lesion
above the medulla.
o Visual field or higher function deficits
indicate hemisphere lesion.
D. Sensory System
SENSORY EXAMINATION
→ Responses to sensory testing are subjective and
some patients provide misleading or exaggerated
responses that complicate the interpretation of the
findings
→ It is important to be familiar with the essential
anatomy of the sensory system and to correlate the
sensory findings with the more objective
information obtained from the motor and reflex
examinations
→ Purely subjective thus results obtained depend
heavily on the patient’s accuracy and cooperation
Sensory examination should be used:
- as a screening test
- to assess the symptomatic patient
- to test hypotheses generated by motor examination
2 major somatosensory pathways that are examined:
o Dorsal Column-Medial Lemniscus (DCML) System
• Vibratory Sensation
• Position Sense
• Discriminative Sensation
˗ Tactile Discrimination
˗ Two-point Discrimination
˗ Graphesthesia
˗ Stereognosis
˗ Double Simultaneous Stimulation
o Spinothalamic (ST) System
• Pain
• Temperature
• major types of somatic sensation are
exteroceptive sense, including pain and
temperature sensations, and proprioceptive
sense, including position sense and vibratory
sensation
• all sensory modalities are represented
together at the level of the thalamus. This
explains why the thalamic syndrome is
characterized by dense sensory loss of all
modalities over an entire half of the body and
face
• lesions of the postcentral gyrus, or primary
somesthetic cortex, are associated with the
loss of discriminative sensation: joint position
sense, two-point discrimination, stereognosis
and graphesthesia (ability to recognize figures
written on the skin)
• only a minimal deficit of touch, pain,
temperature, and vibratory sensation may be
noted with cortical lesions
11
3.06 Neurologic Examination
LIGHT TOUCH (THIGMESIA)
• Used as a screening test for touch
• Both the spinothalamic and DCML systems serve
this sensation so it is not specific for either one
• Demonstrate: With the patient's eyes open, show
her that you will be touching an area of skin. Ask
her to say ‘yes’ every time she is touched.
• Procedure:
o Use a cotton tip applicator or fine hair brush.
Then select areas from different dermatomes
and peripheral nerves.
o Instruct the patient to close his/her eyes then
touch the patient with a cotton tip.
o Ask the patient if he/she can feel anything.
Compare right and left if same or if there is any
difference.
• Abnormal findings:
o Paresthesia/ Dysesthesia- perception of the
stimulus is different over the other side and
described as different, uncomfortable or
burning
o Allodynia- light touch causing pain
PAIN
• Standard method for evaluation of pain perception
is to stimulate the skin with a pin and to ask the
patient if the stimulus is perceived as sharp.
• Procedure:
o The sharp end of a broken wooden cotton tip
applicator can be used.
o Ask the patient if any sharp sensation is felt and
then compare between dermatomes, distal
versus proximal and right versus left for the
upper and lower extremities.
TEMPERATURE
• Screening:
An easy and practical approach is to touch the
patient with a tuning fork as metal feels cold
Procedure:
o Use a tuning fork, which is normally
perceived as cool or cold to the touch
o Compare between dermatomes and
right versus left.
• Confirmatory:
Fill two Tubes with warm water and cold
water. Ideally these are controlled temperatures.
Dry both tubes.
Procedure:
o Apply hot or cold at random to hands,
feet or an affected area of interest.
o Ask the patient to distinguish between
warm and cool on different areas of the
skin with their eyes closed.
VIBRATORY SENSATION (PALLESTHESIA)
Procedure:
NEUROSCIENCE
o Patient is instructed to close his/her eyes and to
indicate whether a “buzzing” sensation is
experienced.
o Use a 128 Hz tuning fork and place the vibrating
instrument over a bone or bony prominence of
the terminal phalanges of the thumbs and great
toes.
o Compare distal versus proximal and right
versus left.
POSITION SENSE (PROPRIOCEPTION)
- Tested by holding the most distal joint of a digit
by its sides and moving it slightly up or down
Procedure:
o Demonstrate the test with the patient watching so
they understand what is wanted.
o Ask the patient to relax and with the eyes closed, to
indicate whether he or she feels the finger (or toe)
moving up or down. The patient should be able to
detect 1 degree of movement of a finger and 2-3
degrees of movement of a toe.
o If the patient can't accurately detect the distal
movement then progressively test a more proximal
joint until they can identify the movement correctly
ROMBERG TEST
- Evaluates the sense of position of the legs and
trunk when the visual information is blocked
- Assesses proprioceptive function
- A normal person may sway slightly, but marked
swaying or falling indicates a proprioceptive deficit
(Romberg sign)
- Patients with Romberg sign may report difficulty
walking to the bathroom in the dark or trouble
maintaining their balance in the shower (because
reduced visual input accentuates the sensory
deficit)
Procedure:
o Ask the patient to stand with feet together and the
eyes closed
o Look for the presence of any sway or imbalance
TACTILE MOVEMENT
- If the dorsal column pathways are intact, then this
is a sensitive test of parietal cortical function.
- Tactile movement tests the patient's ability to
detect the direction of a 2-3 cm cutaneous
stimulus.
TWO POINT DISCRIMINATION
– Tested by using calipers or a fashioned paper clip
– The patient should be able to recognize two-point
separation of 2-4 mm on the lips and finger pads,
8-15 mm on the palms and 3-4 cm on the shins.
12
3.06 Neurologic Examination
– Determine the minimal distance at which the
patient is able to discriminate one from two
points.
– Normal: Patients can discriminate two points at
2-4mm apart on the fingertips, 4-6mm on top of
the fingers and 8-12mm on the palm
GRAPHESTHESIA
- Ability of the patient to identify characters that are
written on the skin using a dull pointed object
Procedure
o Demonstrate the test by writing single
numbers on the palm of the hand while the
patient is watching.
o The patient then closes his/her eyes and
identifies numbers that are written by the
examiner.
STEREOGNOSIS
- Ability to identify objects that are placed in the hand
when the eyes are closed
Procedure:
o Place a common object in the patient's palm
(for example a key, coin, or safety pin) and
ask him to identify it without looking.
Astereognosis- inability to identify by touch an object
placed in the palm.
DOUBLE SIMULTANEOUS STIMULATION
– Tested by touching homologous parts of the body
on one side, the other side or both sides at once
with the patient identifying which side or if both
sides are touched with their eyes closed.
– Normal: Patient should be able to attend to and
identify a tactile stimulus that is applied to both
sides of the body at the same time.
E. Reflexes
→ Examination of reflexes provides the most objective
information obtained with neurologic testing
→ Reflexes can be reinforced or decreased, they are
involuntary motor responses to sensory stimuli and
do not depend on voluntary control
→ Reflex tests can be performed in a patient who is
confused or in coma
→ Reflex abnormalities may be the first indication of
neurologic disease
REFLEXES
MUSCLE STRETCH REFLEXES
Ankle Reflex Sacral 1 primarily
Knee Reflex Lumbar 2, 3, 4
Brachioradialis Reflex Cervical 5, 6
Biceps Reflex Cervical 5, 6
Triceps Reflex Cervical 6, 7
CUTANEOUS STIMULATION REFLXES
NEUROSCIENCE
Abdominal Reflex Thoracic 8, 9, 10
(Upper)
Abdominal Reflex Thoracic 10, 11, 12
(Lower)
Cremasteric Reflex Lumbar 1, 2
Plantar Reflex Lumbar 5, Sacral 1
Anal Reflex Sacral 2, 3, 4
Muscle Stretch Reflexes
• Obtained in response to percussion of the tendons
of major muscles
• Typically monosynaptic and mediated by lower
motor neurons Muscle Stretch Reflexes
• Requires special handling of the reflex hammer.
o Hold the reflex hammer loosely between your
thumb and index finger so that it swings freely in
an arc within the limits set by your palm and
other fingers.
o Strike the tendon briskly using a rapid wrist
movement. ○ Strike should be quick and direct
o All major muscle stretch reflexed can be tested
with the patient seated and the arms resting in
the lap. This position allows rapid comparison of
the right and left sides and limits patient
movement
BICEPS REFLEX (C5, C6)
- Patient position: elbow partially flexed and
forearm pronated with palm down.
- Examiner: place thumb or finger firmly on biceps
tendon and aim the strike with the reflex hammer
directly through your digit.
- Result: flexion at the elbow
TRICEPS REFLEX (C6, C7)
- Patient position: flex the patient’s arm at the
elbow, with palm toward the body, and pull it
slightly across the chest
- Examiner: strike the triceps tendon with a direct
blow directly behind and just above the elbow
- Result: contraction of triceps and extension at
elbow
BRACHIORADIALIS REFLEX (C5, C6)
- Patient position: hand should rest on the
abdomen or lap, with the forearm partly
pronated
- Examiner: strike your thumbnail that is on top of
the radius, about 1-2 inches above the wrist.
- Result: flexion and supination of forearm
FINGER FLEXION REFLEX (HOFFMAN’S METHOD)
- Examiner: depresses the distal phalanx and allows
it to flip up
- Result: the extension of the phalanx stretches the
flexor muscles, causing the fingers and thumb to
flex.
FINGER FLEXION REFLEX (TROMNER’S METHOD)
13
3.06 Neurologic Examination
- Examiner: supports the patient’s completely o A technique involving isometric contraction of
relaxed hand briskly flips the patient’s distal other muscles for up to 10 seconds that may
phalanx upward increase activity.
- Result: the patient’s fingers and thumb flex in
response to the stretch of the finger flexor muscles. • Jendrassik’s Maneuver
QUADRICEPS REFLEX (L2, L3, L4) o Ask the patient to lock the fingers
- Patient position: sitting or supine with knees flexed together and pull hard as you tap the
- Examiner: briskly tap the patellar tendon just below quadriceps tendon.
the patella CUTANEOUS STIMULATION REFLEXES
- Result: contraction of quadriceps with extension of o Polysynaptic reflexes that are elicited by gentle
the knee cutaneous stimulation
ACHILLES REFLEX (S1) o Mediated by upper motor neuron pathways
- Patient position: sitting: partially dorsiflex foot at
ankle; supine: flex one leg at both hip and knee and • ABDOMINAL REFLEXES
rotate it externally so that the lower leg rests across o Above Umbilicus: T8, T9, T10
the opposite shin then dorsiflex o Below Umbilicus: T10, T11, T12
- Examiner: strike achilles tendon - Examiner: lightly but briskly stroke each side
- Result: plantar flexion at the ankle of the abdomen above and below the
TOE FLEXION REFLEX (ROSSOLIMO’S SIGN) umbilicus in the direction illustrated using the
- Patient position: seated wooden end of a cotton tipped applicator or
- Examiner: percusses the ball of foot broken tongue blade.
- Result: normal response: slight jiggling of the toes; - Result: contraction of abdominal muscles
in the presence of corticospinal tract disease: and movement of the umbilicus toward the
flexion (toes) stimulus
SCALE FOR GGRADING REFLEXES - PLANTAR RESPONSE (L5, S1)
REFLEX GRADING SCALE - Examiner: stroke the lateral aspect of the
GRADE DESCRIPTION sole from the heel to the ball of the foot,
0 Absent curving medially across the ball
1+ or + Hypoactive - Result: Normal: flexion of toes; Babinski
2+ or ++ “normal” sign: Dorsiflexion of great toe and fanning of
3+ or +++ Hyperactive without clonus the rest of toes
4+ or Hyperactive with clonus • ANAL REFLEX (S2, S3, S4)
++++ - Examiner: using a broken applicator stick or
pinprick, lightly scratch the anus on both
o
HYPERREFLEXIA sides
o Seen in CNS lesions of the descending - Result: contraction of the external anal
corticospinal tract sphincter
o Look for associated UMN findings of
weakness, spasticity or a positive Babinski REFERENCES
sign Reporters’ ppt
o HYPOREFLEXIA
o Occur in lesions of the spinal nerve roots,
spinal nerves, plexuses, or peripheral
nerves.
o Look for associated findings of lower motor
unit disease (weakness, atrophy, and
fasciculations).
REINFORCEMENT
o Use if the patient’s reflexes are symmetrically
diminished or absent

APPENDIX

NEUROSCIENCE 14
3.06 Neurologic Examination

NEUROSCIENCE 15
3.06 Neurologic Examination

NEUROSCIENCE 16