NEUROLOGIC EXAMINATION

Dr. Getahun Mengistu, Internist, Neurologist , headache

medicine specialist
Associate professor

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NEUROLOGIC EXAMINATION

• Mental Status Examination

• Cranial Nerves

• Motor System

• Sensory System

• Meningeal Signs

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MENTAL STATE EXAMINATION
 Level of Consciousness
 Orientation
 Memory
 Attention
 Calculations
 Constructional Tasks
 Speech & Language
 Insight & Judgement
 Emotional State (Mood)
 Hallucinations
 Delusion 3
 LEVEL OF CONSCIOUSNESS

 Conscious = fully alert having a clear sensorium

 Drowsy = light sleep, easily arousable & alert for a brief period
 Stupor = only a brief & incomplete arousal even by vigorous stimuli
 Comatose = pt cannot be aroused
 the Glasgow’s scale

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ORIENTATION

 to time = time, day, date, week, month, year

 to place = where now, address, town / city, zone, region….
 to person = his name, name of relatives, friends, known persons

MEMORY

 Immediate memory = to repeat a list of 3 items e.g. pencil, car, bird

 Recent memory = ask to recall the 3 items 5, 15min later
 Remote Memory = ask schools, jobs held, known past events ……

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ATTENTION

 Digits span = to repeat series of numbers

- Usually 5 digit, if performed, 6, 7. If 7 digits
Ok, stop testing.

 Spelling Backward = a five letter word e.g. W-O-

M-E-N

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 Arithmetic calculations

 from 100, subtract 7 & keep subtracting 7...

 multiply 5 by 13
 divide 58 by 2

Constructional Tasks

• Draw the face of the clock showing 11:15

• Copy a three dimensional cube

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 SPEECH & LANGUAGE
Examination includes:

Spontaneous speech
Test: Note speech during the interview
Assess: Rate, rhythm, articulation, effort required, pressure of speech,
phrase length, paraphasia, substantive content

Comprehension:
Test: Spoken directions: point to… Do ….
Written directions

Word finding (naming):

Test: Visual: objects, body parts, colors

Auditory: coins, paper, keys, etc. 8
Tactile: object placed in right or left hand
Repetition
Test: Repeat spoken language : words, phrases, then sentence
“ If he were not here, I would go away”

Series speech
Test: Alphabet, days of week, months, count to 20

Writing:

Test: Address, description of objects in room , a letter to his family

Write dictating

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INSIGHT & JUDGEMENT

 Insight = perception or understanding of a situation

- Does the pt understand that he/she is sick?

 Judgment- abstract reasoning: ability to assess situations accurately

and form valuable opinion /decision /conclusions.

- What would you do if you found a wallet on the sidewalk?

- interpreting proverbs e.g. “A bird in the hand…..”

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EMOTIONAL STATE (MOOD)

 Contentment / joy / euphoria / elation

 Sadness / depressions
 Anger / rage
 Anxiety / worry
 Detachment / Indifference

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HALLUCINATIONS

= without external stimuli

 Auditory hallucinations =hear voices e.g. ‘you are horrible’, ‘go kill yourself’
 Visual hallucinations = sees people or animals, insects, rats, tiny people.
 Olfactory hallucinations = smells foul odor from external environment, his own
 Tactile / somatic hallucinations e.g. insects are crawling over them

DELUSION
 a false belief e.g. controlled by psychic or physical forces

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CRANIAL NERVES (CN)

Nerve Name Superficial Exit Level

CN I Olfactory Olfactory bulb [superior to brainstem]
CN II Optic Optic chiasm [superior to brainstem]
CN III Oculomotor Medial midbrain
CN IV Trochlear Dorsal midbrain
CN V Trigeminal Pons
CN VI Abducent Pons
CN VII Facial Pons
CN VIII Vestibulocochlear Rostral medulla
CN IX Glossopharyngeal Rostral medulla
CN X Vagus Rostral medulla
CN XI Accessory Spinal C1-C6
CN XII Hypoglossal Rostral Medulla

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 CN I: (Olfactory
nerve)
Smelling
Test each nostril: soap, coffee, lemon, etc.
 Abolished sense = anosmia.
 Perversion of sense = parosmia

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CN II: (Optic nerve):

Visual acuity:

 Rough test
 reading book

 Formal test:
 Snellen’s chart = normally pt is at 6 meter e.g. 6 / 60
- if <6/60, nearer distance, 5, 4, 3, 2, 1meters
 If <1/ 60, test with:
 Counting fingers (CF)
 Hand movements (HM)
 Perception of light (PL)

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Visual field
 Confrontation method
 Using Perimeter

Color vision
 Ishihara chart - Color blindness – red/green, blue/yellow

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Visual loss

Right hemifield
Left hemifield

Visual field lost

Meyer’s Loop
3
Optic nerve

Optic tract
4

5
LGN

Optic radiations 6

Occipital lobes

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CN III: (Oculomotor), IV: (Trochlear), & VI: (Abducent)

CN IV:
 Superior oblique muscle

CN VI:
 Lateral rectus muscle

CN III
 Medial rectus
 Inferior rectus
 Superior rectus
 Inferior oblique
 Levator palpebrae
 Parasymapathetic suppply
- Ciliary muscles
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- Iris
Testing CN: III, IV &VI:

1. Eyelids for ptosis

• Upper eyelid elevation - by third nerve & sympathetic supply

2. Examination of ocular Movements

 Observe the eyes (by elevating the lids) and note
- the resting position
- spontaneous and conjugate movements of the eyes.

 Ask the pt to look in all directions & observe for:

- Any direction of impaired movement
- Presence of squint (strabismus), nystagmus, diplopia)

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Eye movement abnormalities:

A. Infranuclear (lower motor) lesions:

Sixth nerve palsy:

• Inability to move laterally
• Diplopia on attempt to aterally
• convergent squint

Fourth nerve palsy:

• Impaired downward mov’t
• Diplopia on trying to look in down ward

Third nerve palsy:

• Downward and lateral displacement of the eyes

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B. Supranuclear (upper motor) lesions

 palsies of gaze movements

Gaze preference:
 In damaging lesions:
- the eyes look  toward a hemispherical lesion
 away from a brainstem lesion (pons)
- In thalamic hemorrhage  eyes look towards the tip of the nose

 In irritative lesions:
- cortical lesion  eye deviate towards the healthy side
- lesion in the pons  deviation towards the same side of the lesion

Skewed deviation of the eyes  (one eye upwards & the other downwards)

–in lesions of labyrinth & cerebellar disease.

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 Internuclear opthalmoplegia: lesion in one MLF in mid-brain or upper pons.

Attempted lateral gaze to left

R L

Weak adduction Nystagmus

Aqueduct
MLF Descending fibers for
Oculomotor conjugate lateral gaze
(a) Trochlear
Mid-brain
Abducent

Pons

PPRF PPRF

(b)
 A lesion (a) in the right MLF, during attempted lateral gaze to the left.
 impaired adduction of R eye and
 nystagmus on the abduction of L eye

 A lesion (b) in one PPRF  impaired conjugate lateral gaze to the side of the lesion (right)

 The ‘one-and-a-half syndrome’ = lesion at both (a) and (b) = lesions in both PPRF & MLF on the
same side – results in:
 failure of lateral conjugate gaze to the side of the lesion (right) + impaired adduction of
the (right) eye + the opposite eye (left) move only in abduction (with nystagmus)
= paralysis of one-and-a-half lateral movements.
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 Vertical gaze movements and the pupillary reactions are normal.
3. Examination of pupils

a. Size of pupils
 controlled by balance b/n parasympathetic and sympathetic nerves

III

• Normal pupillary size = midsize (2.5 to 5mm)

• Damage to parasympathetic fibers  pupillary dilatation
e.g. Midbrain lesion, third nerve palsy
• Lesions that damage sympathetic fibers  pupillary constriction
- post.hypothalamus  brainstem (pons)  cervical cord  upper chest  internal
carotid artery  ophthalmic artery eye (Horner’s syndrome) 23
 R L

a. Bilateral pinpoint pupils (pontine Hge) ptosis

b. Left third nerve palsy

c. Left Horner’s syndrome

d. Brain stem death

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b. Shape
 one or both have circular (normal) or irregular shape.

Causes of irregular pupils:

 adhesions of iris to lens as a result of an old iritis.
 Argyll Robertson pupil –neurosyphilis

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c. The pupillary light reflex: (direct or consensual)

• Optic nerve (sensory) + parasympathetic nerve via CN III (motor)

Geniculate
Lateral
Pretectum
ganglia
Ciliary

colliculus
Superior
III

Cortex
III

II
Cortex
colliculus
Superior
Pretectum
ganglia
Ciliary

Geniculate
Lateral

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Thus,
- In lesions in mid brain  pupil unreactive to light (fixed) & dilated
- In lesions damaging CN III  pupil unreactive to light (fixed) & dilated

But,
- In lesions affecting sympathetic nerve  pupil reactive to light &
constricted

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 c. Accommodation Reflex

- Hold a finger close to p’ts nose. pt to look at a distant  at your finger.

- Normally as eyes look at your finger, eyes converge & pupils smaller.

Geniculate
Lateral
ganglia
Ciliary

Pretectum

colliculus
Superior
III
Cortex
III

Cortex

colliculus
Pretectum

Superior
ganglia
Ciliary

Geniculate
Lateral

Accommodation reflex pathways

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 CN.V: (Trigeminal
nerve)
Sensory + motor

 Corneal reflex
- CN V (afferent) & both CN VII (efferent), their connection in pons.
- Absent reflex in damages to CN V, or CN VII, or connection in pons.
 Sensation over the face
 Contraction of Temporalis & masseter muscles (mandibular division)

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 CN.VII: (Facial nerve)

• All muscles of the face & scalp except the levator palpebrae superioris
• Anterior two-third of the tongue for taste

Test:
 Inspect the face both at rest and during conservation .
 Note any asymmetry
- affected side droop & pulled towards stronger side.
 Look for flattening of creases of forehead & naso-labial angle

 Note any weakness & facial asymmetry asking the pt to:

- Raise both eyebrows
- Frowning
- Show both upper and lower teeth
- Smile
- Close both eyes tightly while you are trying to open it.
- Puff out both cheeks
- Blowing the cheek against resistance of your hand
.
Test taste on the anterior 2/3 of tongue 30
- for sweat, salt, sour, and bitter
Upper (supranuclear) facial palsy  forehead is spared
Lower (infranuclear) facial palsy  all of one-half of face affected

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 CN VIII: (Vestibulo-cochlear nerve)

I. Testing for hearing

1. By the use of sounds of : - fingers rubbed together,
- ticking of a watch or
- human voice

2. By the use of tuning fork

a. Rinne test:- air vs bone conduction

- In normal ear = air > bone conduction = Rinne positive.

- Also, in sensori-neural deafness = Rinne is positive.
- In conductive deafness = bone > air conduction =Rinne is negative
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b. Weber test - lateralization

- Normally –sound is heard equally in each ear.

- In conductive deafness – deafer ear perceives it more.
- In sensori-neural loss – better hearing ear hears it more =Weber test is lateralized

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II. Caloric test: test for vestibular function (balance)
 pt head raised 300 – 20-30 ml cold water (or 1-3 ml ice water) & hot water (370c +7)
into external canal

Result in normal person

Stimuli
Slow drift (tonic deviation) of eyes Compensatory (fast phase)
nystagmus
Cold water To the side of the irrigated ear Away from the side of the irrigated ear
Warm water To the opposite side of irrigated ear To the side of the irrigated ear


COWS represents this fast phase

Abnormal:
 no response implies severe dysfunction of the brain stem.
 In unilateral brainstem lesion, the eye on that side will not move
 Peripheral lesion tends to cause a diminished response on one side
 damaged cerebral hemispheres –conjugate deviation of eyes, but no nystagmus
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 CN IX: (glossopharyngeal nerve) and X: (Vagus nerve)

 Test for:
- the taste of posterior third of tongue
- sensation of mucous membrane of pharynx
- gag reflex (often absent in normal individuals)
 Look the position of the uvula
 Watch movement of soft palate & uvula during pt says ‘ah’

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 CN XI: (Spinal Acessory
nerve)

 Shrugging the shoulder ----- Trapezius muscle:

 Turning the head ------ Sternocleidomastoid muscle (the opposite side)

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 CN XII: (Hypoglossal nerve)

• look the tongue for - asymmetry, atrophy, fasciculation, tremor

• symmetry of movement – on moving from side to side
• Check for strength –of pushing the tongue against the inside of the
each cheek as you palpate it externally.

The tongue is pushed over to the paralyzed side in hypoglossal paralysis.

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MOTOR EXAMINATION

 Muscle bulk
 Muscle Tone
 Power of muscles
 Reflxes
 Fasciculation of muscles
 Involuntary movements
 Coordinations
 Gait 38
Muscle Bulk

 Inspection - compare on both sides

- normal & symmetrical, or
- hypertrophy or
- atrophy (flat or concave)

Palpation
- wasted muscles - softer & flabby than normal.

Measuring

- with a tape meter - on the two sides

Atrophy  LMNL or disuse atrophy in UMNL

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Muscles Tone
= the resistance of a relaxed limb to passive movement at a joints

 Normal tone
 Hypotonia  LMNL

 Hypertonia  UMNL
- Spasticity (clasp knife type) =  tone with rapidly flexed or extended limb
 cortico-spinal tract lesions
- Cog wheel rigidity =  resistance throughout passive mov’t with jerky
interruptions  parkinsonism.
- Lead pipe (plastic) type =  tone with uniform resistance throughout
passive mov’t  extrapyramidal tract lesion

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 Power of
muscles
 Pronator drift
 Muscle Strength Testing
- pt flex, extend, adduct, & abduct at each joint actively against your resistance
Grading of power:

Grade 0 = no movement
Grade 1 = a visible or palpable flicker of contraction only but no associated movement at a joint
Grade 2 = movement detectable only when gravity is eliminated
Grade 3 = Movement against the force of gravity but not against resistance of the examiner
Grade 4- = Movement against mild resistance
Grade 4 = Movement against moderate resistance
Grade 4+ = Movement against strong resistance
Grade 5 = Full (normal) power/ strength

• UMNL  Proximal + distal weakness

• Proximal weakness alone  myopathy (NMJ or muscle) e.g. Myasthenia gravis
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• Distal weakness alone  peripheral neuropathy
 REFLEXES

Deep tendon reflexes (DTR)

Reinforcement (Jendrassik maneuver):

• Upper limb reflexes - by voluntary teeth clenching
• Lower limb reflexes - by hooking the flexed fingers of the two hands together and
attempting to pull them apart.

 Biceps reflex (C5, C6 nerves)

 Triceps reflex (C6, C7, C8 nerves)
 Brachioradialis reflex (C5, C6 nerves)
 Knee (patellar or quadriceps) reflex (L2,L3, L4 nerves)
 Ankle (Achilles, gastrocnemuis–soleus ) reflex (S1, S2 nerves)
 Hoffmann’s reflex (C7,8 ,T1)
Clonus (ankle, patellar)
2- 3 clonus = unsustained (physiological) 42
> 3 clonus =sustained  UMNL
 Reflex contd
• Hypothyroidism –hang-up reflex: both the
contraction and the relaxation phase are
delayed

• Cerebellar ataxia-pendular reflex:

oscilatory limb movement after the initial
reflex

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 Grading reflexes
Grade 0 Absent
Grade 1 + Diminished (hypoactive)

Grade 2 ++ Brisk, averagely normal (normoactive)

Grade 3 +++ Exaggerated, very brisk (hyperactive)

(possibly but not necessary indicative
of disease)
Grade 4 ++++ Clonus (often indicative of disease)

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Cutaneous (Superficial) reflexes

 Corneal reflex (CN V, VII)

 Pharyngeal reflex (gagging) reflex (CN IX, X)

 Abdominal reflex =epigastric (T6-9), midabdomen (T9-10),

hypogastrium (T11-L1)

 Cremasteric reflex (L1,2)

 Anal reflex (S2,3,4)

 Plantar reflex (L5, S1,2)

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  Extensor plantar response may also be elicited by:
1. Pressure applied to the tibia, stroking towards the ankle =Oppenheim sign
2. Pressure applied to the calf or pinching the calcaneus tendon= Gordon sign
3. Stroking along the lateral aspect of the foot below the external malleolus =
Chaddock’s sign / reflex
4. Pressure applied to ankle = Schaefer sign
5. Pricking the dorsum of the toe = Bing sign
6. Abduction of little toe slowly but maximally and after the maximal abduction for 1-
2 sec, it is suddenly released = Stransky’s sign
7. Traction and simultaneous flexion of the third or fourth toe for a few seconds and
then released suddenly = Gonda reflex

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Primitive Reflexes

Suck response: - touching of the center of the lip  suck

Root response: - touching the corner of lips  opens
mouth + turns head toward it
Grasp reflex: - touching the palm b/n thumb &index finger
 grasp
Palmomental reflex-

 damage to the frontal

lobes
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Fasciculation of muscles

 flicker of mov’ts under skin – sponataneously / induced by light percussion

 LMNL

signs of LMNL: signs of UMNL:

 Weakness  Weakness
 Fasciculation  Spasticity
 Muscle wasting   DTR
 Loss of DTR and  Extensor plantar responses
 Hypotonia (flaccidity)

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Involuntary movements
a. Abnormal movements provoked by an uncontrollable urge
e.g. - Tics
- Restless legs syndrome

b. Abnormal movements initiated outside conscious awareness

- Tremor = a rhytmic (periodic) mov’t of a body part
- Dystonia = abn. Psture of one or more of the body & involves contraction of both
agonst & antagonst muscles
- chorea = rapid and flowing mov’t of one or more body parts as a random event
- Ballismus =subtype of chorea = wild flailing, sometimes violent mov’t
- Myoclonus = involuntary lightening-like jerk of an area of the body
- Asterixis = with wrist fully extended
- Spasms = hypercontractile state of muscle + no mov’t at involvede jts
- cramps = painful spasms
- Tetany = neuromuscula hyperexitability & repetitive motor neuro firing 2 0 49
hypocalcemia
CO-ORDINATION EXAMINATION (Cerebellar Function Test)

In the upper limbs:

 Finger to nose test
 Rapid movements of fingers
 Rapid alternating supination and pronation movements of forearm

In the lower limbs:

 Rapid taping with foot
 Toe to finger test
Heel-knee-shin test
Draw a large circle in the air

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 Clinical signs of cerebellar lesion

• Crebellar ataxia
• Intention tremor
• Nystagmus titubation
• Past-pointing
• Rebound
• Impaired alternating rhythmic movement

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 Stance and GAIT

Spastic gait = narrow base, difficulty in bending knee & drags foot along
as if it was glued to the floor. Foot & leg swung forward making an arc
Parkinsonian (festinate) gait = Pt bends forwards; rapid, short,
shuffling steps; arms don’t swing.
 Cerebellar gait (ataxia) = like drunken – walks on a broad base, feet
being planted widely apart & placed irregularly; inability to walk on a narrow
base,
 Sensory ataxia = While walking pt raises feet very suddenly, abnormally
high & then jerks them forward, brings them to ground with a stamp, and often
heel first.  posterior column or peripheral nerve lesion

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Gait cnt

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 SENSORY SYSTEM

Sensory dermatomes (A) Anterior, B) Posterior 54

Sensory Exam

• Light touch = wisp of cotton or examiner’s finger.

• Pain = blunt & sharp end of new pin
• Temperature
• Position sense
• Deep pressure
• Vibration sense
• Two point discrimination
- on finger tips = normally 2mm separation can be recognized
- on pulps of toes = ~1cm separation recognized normally
• Recognition of size, shape, weight & form (Stereognosis)
• Identification of number or letter written on palm (Graphesthesia)
• Romberg’s sign = test for loss of position sense (sensory ataxia) in legs.
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SIGNS OF MENINGEAL IRRITATIONS (meningism)

 Nucheal rigidity (neck stiffness) = the

pathognomonic sign
 Kernig’s sign = classic sign
 Brudzinki’s sign = also a classic sign

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Neurologic Examination in Comatose pt

1. State of consciousness
2. Respiratory pattern
3. Pupils & Fundi
4. Brainstem Reflexes
5. Motor Examin
6. Meningism

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1. State of consciousness

Activity Best Response Score

Spontaneous 4
Eye Opening To verbal stimuli 3
To pain 2
None 1
Oriented 5
Verbal Responsse Confused 4
Inappropriate words 3
Incomprehensible sounds 2
None 1
Follows commands 6
Best motor response Localize pain 5
Withdrawal to pain 4
Flexion response to pain 3
Extension response to pain 2
None 1
Total 3-15 58
2. Respiratory pattern
• Different levels of CNS inv’t in coma induce different respiratory patterns

• Respiratory center are in pons & medulla.

• Influence from higher area (forebrain) activate normal breathing in

situations where CO2 is reduced.

 Deep lesion in the hemispheres, in region of

diencephalon

 in lower pontine lesion

 lesion in midbrain

 medullary lesion (gasping,  & then stop

 lesion in pons

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. Pupils & Fundi

Fundi – papilledema

Pupillary abnormalities:

• Lesion in Hypothalamus ==> small pupil

R L
• Midbrain damage ==> mid-positioned, no light reflex

• Lesion of third nerve ==> Fixed dilated pupil

a. Bilateral pinpoint pupils (pontine Hge)
ptosis
• Pontine lesion ==> pipoint pupil, reactive

b. Left third nerve palsy

c. Left Horner’s syndrome

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d. Brain stem death
4. Brainstem Reflexes

A. Oculocephalic Reflex (Doll's eyes movement):

- move head from side to side or vertically

 Preservation of the reflex in comatose pt => cerebral diencephalic structural lesion

 Absence of the reflex on one side => ipsilateral pontine lesion
 Complete absence the reflex => extensive structural lesions in brainstem and in deep
metabolic coma.
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b. Oculovestibular (caloric) Reflexes

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c. Corneal, gag, cough, and blink reflexes

d. Ciliospinal reflex

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 5. Motor Function examin
• In same line as in conscious pt.

Abnormal posturing - Inspection

• Head & eyes may be turned:
- to the side of the lesion in a hemispherical lesion
- away from a brainstem lesion
• If one leg is everted compared with the other hemiparesis
• Decorticate posture – severe bilateral damage rostral to midbrain (isolating
brinstem & spinal cord from cortical influence)
• Decerebrate posture – midbrain lesion (isolating only lower brainstem & spinal cord from
cortical influence)

A. Decorticate posture

B. Decerebrate posture 64
Tone
Power
Reflexes (DTR, Plantar, premitive reflexes)
Sensory testing – response to pinprick and deep pain

6. Meningeal irritation signs – mentioned above

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