Neurological Examination-Lab

Dr. Anas Alashram

Neurological Examination

1. Patient Hx
2. Mental status
3. Cranial nerves
4. Sensory functions
5. Perceptual functions
6. Motor functions
7. CNS infection or meningeal irritation
8. Increase ICP secondary to brain edema and brain herniation
2-Mental status

´ Level of Consciousness (LOC)

´ Orientation (A&O*3)
´ Memory (Immediate recall, recent, and remote)
´ Language (dysartheria, aphasia, verbal apraxia)
3-Cranial Nerves
I. Olfactory nerve
II. Optic nerve
III. Oculomotor nerve
IV. Trochlear nerve
V. Trigemenal nerve
VI. Abducense nerve
VII. Facial nerve
VIII.Vestibulocochlear nerve
IX. Glossopharyngeal nerve
X. Vagus nerve
XI. Spinal accessory nerve
XII. Hypooglossal Nerve
 I- Olfactory nerve

• Type: Sensory.
• Function: Smell.
• Assessment: The patient is asked to identify
odors (eg, soap, coffee, cloves) presented to
each nostril while the other nostril is occluded.
• Normal response: to perceive the scent with
either nostril.
• Abnormal response: unilateral loss may due
to stractural brain damage affecting the
olfactory bulb or tract, deviation of septum,
blocked nasal passage. Bilateral loss occurs
with cribriform plate.
II- Optic nerve-Visual acuity

• Type: Sensory.
• Function: Visual acuity, visual field, papillary reflex.

• Assessment: each eye is tested separately. The patient instructed to read

progressively smaller lines of letters until they can go no further.
• Normal response: the patient reads a line that a normal eye sees at 20 feet.
• Abnormal response: the patient unable to see clearly.
II- Optic nerve-Visual fields

• Assessment:
• Peripheral visual field: wiggling fingers, counting fingers, white pin.
• Central visual field: red pin.
• Normal response: 100 degrees laterally, 60 degrees medially, 60 degrees
superiorly, 75 degrees inferiorly.
II- Optic nerve-Pupillary light reflex

• Assessment:
• Observe the pupils for size and equality.
• Dim the lights, ask the patient to look into the distance, shine a bright light obliquely
(approaching laterally) into the pupil.
• Observe for the direct response (same eye) and consensual response (opposite eye).
• Normal response: constriction of both pupils.
Cont...

• Abnormal response:
• i.e., RT light
• No constriction in both pupils------ both oculomotor and Rt optic lesions.
• Constriction in Rt pupil only------- Lt oculomotor lesion.
• Constriction in Lt pupil only------- Rt oculomotor lesion.

• Ptosis: III nerve

 III- Oculomotor, IV-Trochlear, and VI-Abducens

•III: Medial & Inferior rectus &

Inferior oblique
•IV: Superior rectus & Superior
oblique
•VI: Lateral rectus
III- Oculomotor, IV-Trochlear, and VI-Abducens

• Type: Motor
• Function: eye movement
• Assessment:
• Stand approximately 1 meter in front of the patient.
• Ask the patient to look to each side, up and down following ‘H’ pattern.
• Repeated the previous step, pause at ends o each direction of gaze to observe for
nystagmus.
 V- Trigemental nerve

• Type: Mixed.
• Function: pain, light touch, temperature
over whole face, temporalis and masseter
muscles.
• Assessment:
• Corneal reflex: opthalmic V afferent, facial
VII efferent
• Jaw jerk: place finger on the chin and tap
with hammer
ü Normal response: slight jerk
ü Abnormal response: increased bilateral
 VII-Facial nerve

• Type: Mixed.
• Function: taste of the anterior 2/3 of the
tongue, facial expression.

• Assessment:
• Taste: a small sample of solution is applied to
one side of the anterior 2/3 of the tongue using
a cotton, the patient should be asked to point to
sign displaying one of the four possible tastes.
• Motor: observe for asymmetry
ü Ask the patient to wrinks their forhead, close
their eyes tightly, show their teeth, puff out their
cheecks.
VIII- Vestibulocochlear nerve

• Type: Sensory
• Function: hearing and balance
• Assessment:
• 1. Hearing
Rinne test:
• Apply the vibration fork against the mastoid process.
• Ask the patient when he can can no longer hear it, then place it in front of the air
• Normal response: air conduction > bone conduction
• Abnormal response:
• Conduction hearing loss: bone conduction > air conduction
• Sensorineural deafness: air conduction > bone conduction (non affected side > affected side)
Cont...

• Weber test:
• Apply tje vibrating tuning fork to the center of forehead and ask the patient where they
hear it
• Normal response: patient will either hear it equally from both ears or respond that he is
not sure
• Abnormal response:
• Conduction hearing loss: patient laterlization the sound to the affected ear.
• Sensorineural deafness: sound is the best heard by the non affected ear.

• 2. Vestibular function:
• Observe for nystagmus when extraocular ms are assessed.
 IX- Glossopharyngeal and X-Vagus nerves
• Type: Mixed.
• Function: Swallowing and phonation.

• Assessment:
ü Check palatial elevation by having the patient sustain an ‘ah’
ü Assess the gag reflex by gentling stroking the soft palate on
each side.
ü Swallowing
ü Listen to patient voice

• Normal response: the palate should elevate symmetrical,

absent gag response can be normal if it is absent bilaterally
• Abnormal response: with unilateral palatal weakness, the
palate fails to elevate on the weak side and the gag reflex
will be absent on that side.
XI- Spinal accessory nerve

• Type: Motor.
• Function: SCM and trapizius.

• Assessment:
ü Resist ipsilateral sidebending and contralateral rotation.
ü Resist shoulder elevation.
XII- Hypoglossal nerve

• Type: Motor.
• Function: tongue movement.

• Assessment:
• Ask the patient to move his tongue to each side.
• Deviation towards weakness side.
Sensory exam
Components of the sensory examination

• Superfical sensations:
ü Pain, temperature, touch.
• Deep sensations:
ü Joint position, Vibration
• Cortical sensations:
ü Sterognosia, barognosia, graphesthesia
Examination technique

• Begin distally and move proximally

• Compare right and left
• When necessary, assess for sensory level, peripheral nerves or dermatomal
sensory impairments
Dermatomes
Motor exam
Muscle bulk and power
Muscle tone
• Drop arm test
ü Suddenly dropping a limb that has been held
ü Normal limb falls momentarily, catches
ü Hypotonic limb: falls abruptly.
ü Hypertonic limb: displays resistance to falling.

• Pendulum test
ü Patient seated or with knees flexed over the end of table
ü Patient knee is fully extended
ü Allow limb to drop and swing like pendulum
ü Normal/hypotonic limb: swing freely
ü Hypertonic limb: limited arc of movement
Reflexes
Deep tendon reflexes
• Supperficial reflexes:
ü Abdominal
ü Lingunal

• Pathological reflexes:
ü Babiniski
ü Clonus
Coordination

ü Forward/Backward walking
ü Finger to nose
ü Finger to finger
ü Foot taping
ü RAM
ü Heel to shin
Balance

• Static balance:
ü Sitting
ü Standing
ü Romberg test
ü Tendem romberg test
Dynamic balance:
ü Functional movement tasks
ü Dual tasks
ü BOS challenges
Gait

• Walk a cross the room, turn and come back

• Walk heel to toe in a straight line
• Walk on their toes in a straight line
• Walk on their heels in a straight line
• Hop in place on each foot
• Rise from sitting position
Thank you!