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THE NEUROLOGIC EXAMINATION

NEUROLOGIC EXAMINATION

A proper neurologic examination begins with a careful clinical history.

Reasons for Neurologic Exam

Tools of the trade

Neurological Examination

Mental Status Exam

I. Mental Status Examination


Level of Consciousness Attention Language Memory Constructional ability Higher Cognitive Functions Related Cognitive Functions

Mental Status Examination


I. LEVELS OF CONSCIOUSNESS

Level
Alert Lethargic Obtunded

Response
Responds fully and appropriately to stimuli Drowsy, sluggish, responds to question then falls asleep Opens eyes, responds slowly, confused, decreased interest in the environment

Stuporous
Comatose

Arouses from sleep only after painful stimuli


Unarousable with eyes closed, unconscious and unresponsive
DeMyer. Technique of the Neurologic Examination. 5th ed. 9

Mental Status Examination


II. ATTENTION

Patients ability to attend to a specific stimulus without being distracted by extraneous internal or environmental stimuli

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Mental Status Examination


III. LANGUAGE

Handedness
Should be determined before beginning formal language testing

Speech
Quantity Is the patient talkative or silent? Are comments spontaneous or only responsive to direct questions? Rate Loudness
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Mental Status Examination


III. LANGUAGE

Speech
Articulation of words
Dysarthria specific disorder of articulation in which basic language is intact

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Mental Status Examination


III. LANGUAGE

Verbal fluency
Refers to the ability to produce spontaneous speech fluently without undue word-finding pauses or failures in word searching Involves the rate, flow and melody of speech and the content and use of words
Hesitances and gaps in the flow & rhythm of words Disturbed inflections, such as monotone Circumlocutions
what you write with for pen

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Mental Status Examination


III. LANGUAGE

Verbal fluency
Paraphasias
Semantic Paraphasia I drove home in my pen Literal Paraphasia I drove home in my lar

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Mental Status Examination


III. LANGUAGE Non-fluent output
Sparse and effortful, contains primarily nouns, agrammatic, and contains frequent word-finding pauses ah, ah, cold.snowfreezing

Fluent output
Normal or excessive rate of word production, often with distinct press of speech Content words (nouns & verbs) are lacking
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Mental Status Examination


Testing Aphasia
Word comprehension Ask the patient to follow a one-stage command, such as point to your nose. Try a two-stage command: Point to your mouth, then to your knee. Ask the patient to repeat a phrase of one-syllable words: No ifs, ands or buts. Ask the patient to name a watch. Ask the patient to read a paragraph aloud.

Repetition Naming Reading comprehension

Writing

Ask the patient to write a sentence

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Mental Status Examination


LANGUAGE

Repetition
A complex process that can be affected by impaired auditory processing, disturbed speech production, or disconnection between receptive and expressive language functions

Ascending order of difficulty from monosyllabic words and proceeding to complex sentences
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Aphasia
Inability to understand or express words as symbols for communication, even though the primary sensorimotor pathways to receive and express language and the mental status are relatively intact
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Classification of Aphasias
Types of Aphasia Fluency Comprehension Repetition Naming Lesion location

Brocas
Wernickes Conduction Transcortical motor Transcortical sensory Anomic Global

Good Good Good

Good
Good Good

Good Good

Maybe normal Usually normal

Frontoparietal operculum
Inferoposterior perisylvian Posterior perisylvian Frontal, striatum Parietal, temporal, thalamus Depends on type of anomia Perisylvian

Good

Good

Good

Brazis. Localization in Clinical Neurology. 5th ed. 19

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Mental Status Examination


IV. MEMORY

Orientation Immediate recall (short-term memory)


Recall a memory trace after a few seconds

Recent memory
Patients capacity to remember current, day-to-day events Ability to learn new material and to retrieve that material after an interval of minutes, hours or days
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Mental Status Examination


IV. MEMORY

Remote memory
Recall of events or facts that occurred years previously

New learning ability


Give the patient 3 or 4 words and ask the patient to repeat them After about 3-5 minutes, ask the patient to repeat the words
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Mental Status Examination


V. CONSTRUCTIONAL ABILITY

Ability to draw or construct two- or threedimensional figures


Reproduction drawings Clock drawing test Block design

Grade the drawings as poor, fair, good and excellent


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Mental Status Examination


VI. HIGHER COGNITIVE FUNCTIONS

tests of intelligence and higher order reasoning


1. 2. 3. 4. Fund of information or store of knowledge Manipulation of old knowledge (Calculations) Abstract thinking (Proverb interpretation) Insight and judgement

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Mental Status Examination


VI. RELATED COGNITIVE FUNCTIONS

Apraxia
acquired disorder of learned, skilled, sequential motor movements that cannot be accounted for by elementary disturbances of strength, coordination, sensation, or lack of comprehension or attention
1. Ideomotor apraxia fail to perform previously learned motor acts accurately 2. Ideational apraxia breakdown in performance of a task that involves a series of related, but separate steps

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Mental Status Examination


VI. RELATED COGNITIVE FUNCTIONS

R-L disorientation
Capacity for spatial orientation

Finger agnosia
Inability to recognize, name and point to individual fingers on oneself and on others

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Cranial Nerves

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Cranial Nerve I (Olfactory Nerve)

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Cranial Nerve I (Olfactory Nerve)


Technique for testing olfaction
1. Successful sensory testing depends on communication between the patient and examiner.
Say to the patient Close your eyes, sniff and try to identify this odor.

2.

Compress one of the patients nostrils. Hold the vial in front of the open nostril and ask the patient to sniff. Wait a moment for the patient to perceive the odor and then identify it.
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Cranial Nerve I (Olfactory Nerve)


3. For the second trial, compress the opposite nostril and this time DO NOT present the stimulus. Withholding the stimulus tests the patients suggestibility and attentiveness.

4. The third time, present the stimulus to the untested nostril.

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Cranial Nerve II (Optic Nerve)

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Cranial Nerve II (Optic Nerve)


Testing for central vision
Tests of visual acuity Screening central vision with an Amsler grid Tangent screen testing of central vision

Testing for peripheral visual fields


Confrontation testing

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Cranial Nerve II (Optic Nerve)


Tests of visual acuity
For crude screening of VA, have the patient read newsprint held at arms length. Test each eye separately. The patient keeps eye glasses on.
If the history or screening suggest a visual complaint, use a Snellen or Jaeger chart or a Rosenbaum Pocket Vision Screener for a numerical evaluation of acuity
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Cranial Nerve II (Optic Nerve)

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Cranial Nerve II (Optic Nerve)


Tests of visual acuity
For a small child or mentally defective patient, use a large E printed on a card and have the patient point in the direction that the cross bars point after you direct E up, down, right and left.
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Cranial Nerve II (Optic Nerve)


Tests of visual acuity
Tests the acuity of partially blind patients by having them count the number of fingers held up at various distances. If the patient cannot count fingers, try hand movement. If the patient cannot identify hand movement, try light perception

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Cranial Nerve II (Optic Nerve)


Tests of the peripheral visual fields
Station yourself directly in front of the patient. Start with your left eye directly in line with the patients right eye, at a distance of about 50cm eye to eye. The patient covers the left eye with the left hand.

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Cranial Nerve II (Optic Nerve)


Tests of the peripheral visual fields
Hold up your left index finger just outside your own peripheral field, in the inferior temporal quadrant. Hold the finger about equidistant between your eye and the patients.

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Cranial Nerve II (Optic Nerve)


Tests of the peripheral visual fields
Ideally, the finger should extend beyond the perimeter of the field. Wiggle the finger slowly and move it very slowly toward the central field. Request the patient to say now as soon as the wiggling finger is seen. Try to match the perimeter of the patients visual field against your own. Test all quadrants of each eye separately, each time starting at the limit of the field.
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Cranial Nerve II (Optic Nerve)


Tests of the peripheral visual fields
Test the midpoint of the quadrants about 45, 135, 225 and 315 degrees rather than 0, 90, 180 and 270 degrees.

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Optic Nerve Pathway


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Cranial Nerve II (Optic Nerve)


Funduscopy
Red orange reflex Clear media Cup to disc ratio AV ratio Papilledema Retinal hemorrhages

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Normal Fundus

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Cranial Nerve II, III


(Optic & Oculomotor nerves)

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Cranial Nerve II, III


(Optic & Oculomotor nerves)

Pupillary Responses Pupil size and shape at rest Direct response to light; consensual response

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Extraocular Muscles

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Cranial Nerve III, IV, VI


(Oculomotor, Trochlear & Abducens Nerves)

Check eye movements in all directions Check smooth pursuit in horizontal and vertical directions Test convergence by moving object slowly toward nose
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Cranial Nerve V (Trigeminal)

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Cranial Nerve V (Trigeminal)


Sensory Component
ask the patient to close his/her eyes, a tissue or pin is touched alternately to each side of the forehead, cheeks and chin and the patient is asked to compare sensations

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Cranial Nerve V (Trigeminal)


Corneal reflex
Tested by touching each cornea gently with a cotton wisp

Observe any asymmetries in the blink response

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Cranial Nerve V (Trigeminal)


Tests for motor function Inspection
Inspect the temples and cheeks for atrophy of the temporalis and masseter muscles

Palpation
To test for masseter atrophy, ask the patient to clench the teeth together strongly and unclench several times, while you simultaneously palpate the muscles of the two sides as they mound up and relax under your fingertips
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Cranial Nerve V (Trigeminal)

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Cranial Nerve V (Trigeminal)

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Cranial Nerve V (Trigeminal)


Testing for weakness of jaw closure
Ask the patient to clench the teeth strongly Place the heel of one palm on the tip of the patients mandible and the other hand on the patients forehead. Press hard on the tip of the mandible. You must brace the patients head with your opposite hand because jaw closure is a very strong movement.

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Cranial Nerve V (Trigeminal)


Testing for weakness of the lateral pterygoid muscles
Ask the patient to forcefully open the jaw. Note whether its tip aligns with the crevice between the upper, medial incisor teeth. Weakness of one pterygoid muscle would cause the jaw to deviate to the ipsilateral side.

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Cranial Nerve V (Trigeminal)


Testing for weakness of the lateral pterygoid muscles
Ask the patient to move the jaw side to side

Ask the patient to hold the jaw forcefully to the side as you try to push it back to the center with the heel of your palm. Brace the patients head by pressing your other hand against the opposite cheekbone.
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Cranial Nerve V (Trigeminal)

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Cranial Nerve VII (Facial)


Testing for motor function
Examiners Command Wrinkle up your forehead or Look up at the ceiling Close your eyes tight and dont let me open them Observation Inspect for asymmetry Muscle tested Frontalis

Inspect for asymmetry of wrinkles; try to pull eyelids apart

Orbicularis oculi

Pull back the corners of your mouth, as in smiling


Wrinkle up the skin on your neck or Pull down hard on the corners of your mouth

Inspect for asymmetry of nasolabial fold


Inspect for symmetry

Buccinator

Platysma

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Facial Innervation

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Cranial Nerve VII (Facial)


Testing for loss of taste (ageusia) Stimulus
Salty, sweet, sour or bitter substance Conceal the salt or sugar

Communication with the patient


Tell the patient, I want to place something on your tongue for you to taste. Stick out your tongue and keep it out. When you recognize the taste, hold up your hand.
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Cranial Nerve VII (Facial)


Testing for loss of taste (ageusia)
Place a few crystals of your test material on the right or left half of the tongue and massage these around with the well-moistened cotton tip of an applicator stick Allow 15-20sec for the substance to dissolve and for the patient to respond. After the patient rinses his mouth, test the opposite side of the tongue with the same or different substance
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Cranial Nerve VIII (Vestibulocochlear)


Technique for screening hearing Ask the patient about hearing deficits Do otoscopy Rub your fingers together beside one of the patients ear and then the other Present a vibrating tuning fork to each ear and ask the patient to compare the loudness
Hold the prongs perpendicular to the patients ear
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Cranial Nerve VIII (Vestibulocochlear)


Forks with a frequency of 512-2000cps match the frequencies most important for speech perception, but they do not vibrate very long Neurologist use a fork of 126 or 256 cps To semi-quantitate the test, move the fork from one ear to the other and ask the patient to compare the loudness of the sound in the two ears

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Cranial Nerve VIII (Vestibulocochlear)


Sound lateralizing test of Weber
Examiner places a vibrating tuning fork on the middle of the patients forehead or vertex of the skull Normal: sound is heard in the center

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Weber test

Conductive Hearing Loss

Sensorineural Hearing Loss


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Cranial Nerve VIII (Vestibulocochlear)


Rinne test

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Rinne test

Conductive Hearing Loss

Sensorineural Hearing Loss


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Cranial Nerves IX, X


(Glossopharyngeal and Vagus Nerves)
Testing the motor functions Speech
During the history, the examiner appraises the patients speech almost automatically. Perfect normal articulation requires no formal testing. Test the articulation by the soft tissues, the soft palate, tongue and lips with the KLM test
Let the patient say Kuh, Kuh, Kuh La, La, La Mi, Mi, Mi Structures being tested Soft palate (velopharyngeal valve) Tongue (linguals) Lips (labials)

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Cranial Nerves IX, X


(Glossopharyngeal and Vagus Nerves)
Neurologic examination of the palate and larynx
Let the patient say "ahh" or kah, inspect the tonsillar pillars for asymmetry as they arch upward and medially to form the palate The palate and uvula should rise symmetrically in the back of the oral cavity Paralysis of the ninth nerve causes a pulling of the uvula to the unaffected side

Normal

Affected: L

Affected: 71 R

Cranial Nerves IX, X


(Glossopharyngeal and Vagus Nerves)
Testing the motor functions Gag reflex
Test for palatal elevation Touch one tonsillar pillar and then the other with a tongue blade The afferent arc of the gag reflex is primarily CrN IX. The efferent arc is CrN X.

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Cranial Nerve XI
(Spinal Accessory nerve)
Test for the motor function
Command to patient Turn your head to the left. Do not let me push it back. Examiners maneuver Place your right hand on the left cheek of the patient, your left hand on his right shoulder to brace him, and try to force his head to the midline. Place one hand on the patients forehead and push backward. Place your hands on both of the patients shoulders and press down. Observe from the front and back and watch for scapular winging that may occur with trapezius or serratus anterior weakness.
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Push your head forward as hard as possible. Try to touch your ears with the tips of your shoulders. Hold them there and dont let me push them down.

Cranial Nerve XI
(Spinal Accessory nerve)

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Cranial Nerve XII


(Hypoglossal Nerve)
Inspection of the tongue at rest Testing tongue motility and deviation
Say to the patient, Stick your tongue straight out as far as possible and hold it there. Check for alignment of the median raphe of the tongue with the crevice between the medial incisor teeth. Ask the patient to move the tongue alternately to the right and to the left.

Tongue strength
Have the patient press the tongue against the cheek while you press your finger against the cheek

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Cranial Nerve XII


(Hypoglossal Nerve)
Involuntary movements of the tongue
Ask the patient to hold the tongue protruded and still for 30 seconds. Patient with involuntary movements such as chorea or athetosis cannot keep a protruded tongue still.

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Hypoglossal Nerve
Lower motor neuron lesion of CN XII
Ipsilateral atrophy Ipsilateral deviation of the tongue on attempted midline protrusion

Upper motor neuron lesion of CN XII


One hemisphere sends crossed and uncrossed axons to the hypoglossal nucleus Contralateral deviation of the tongue on attempted midline protrusion
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Motor Exam

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Motor cortex

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Motor Homunculus
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Corticospinal Tract
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Extrapyramidal system
Cerebral cortex Basal ganglia Brainstem Spinal cord

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Muscle Strength

Muscle Tone

Muscle Bulk Involuntary Movements

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Individual Muscle Testing


Testing for weakness of shoulder girdle muscles

Method of Testing Shoulder Girdle Strength


Action Arm elevation Commands and Maneuvers Request the patient to hold the arms straight to the sides. Press down on both arms at a point where you expect your strength to approximate the patients.

Arm adduction downward With the arms extended to the sides, the patient resists your efforts to elevate them. Arm adduction across the With the arms, extended straight in front, the patient crosses the chest (pectoralis muscle) wrist. You try to pull them apart. Scapular adduction With the hands on the hips, the patient forces the elbows backward as hard as possible. Standing behind the patient, the examiner tries to push them forward. Have the patient try a push-up or lean forward against a wall, supporting the body with outstretched arms.
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Scapular winging

Individual Muscle testing

Deltoid (C5, C6) Axillary Nerve

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Individual Muscle testing


Testing for weakness of upper arm muscles 1. Elbow flexors

Biceps (C5, C6) Musculocutaneous nerve


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Individual Muscle testing


Testing for weakness of upper arm muscles 2. Elbow extensors

Triceps (C6, C7, C8) Radial Nerve


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Individual Muscle testing


Testing for weakness of forearm muscles 1. Wrist flexors
Patient makes a fist and holds the wrist flexed against your efforts to extend it

2. Wrist extensors

Extensor Carpi Ulnaris (C7, C8) Posterior interosseous nerve


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Individual Muscle testing


Testing for weakness of finger muscles
Inspect and palpate the thenar and hypothenar eminences for size and asymmetry

1. Abduction-adduction of the fingers

Dorsal Interosseous (C8, T1) Ulnar Nerve


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Individual Muscle testing


Testing for weakness of finger muscles 2. Finger extension
Patient holds out the hands with palms down and fingers hyperextended Turn your hand over so that the dorsum of your fingernails presses against the dorsum of the patients.

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Individual Muscle testing


Testing for weakness of finger muscles 3. Finger flexion

Flexor Digitorum (C7, C8) Median Nerve


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Individual Muscle Testing


Testing for abdominal muscle weakness Position: with the patient supine, ask for a sit-up or for the patient to elevate the legs or the head Watch the umbilicus as the muscles contract
Normal -- umbilicus at the center Weakness of lower abdominal muscles -- umbilicus migrates upward (Beevors sign)
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Individual Muscle Testing


Testing for weakness of the hip girdle 1. Hip flexion
With the patient sitting, ask the patient to lift the knee off the table surface and to hold the thigh in a flexed position With the butt of your palm, try to push the knee back down

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Individual Muscle Testing


Testing for weakness of the hip girdle 2. Thigh abduction and adduction 3. Hip extension
With the patient prone, have the patient lift the knee from the table surface and hold it up Place your hand on the popliteal surface and try to press the knee back down
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Individual Muscle testing

Iliopsoas (L1, L2, L3) Femoral Nerve

Gluteus Maximus (L5, S1, S2) Inferior gluteal nerve 95

Individual Muscle testing

Adductors (L2, L3, L4) Obturator nerve

Gluteus medius and minimus, tensor fascia latae (L4, L5, S1) Superior gluteal nerve

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Individual Muscle Testing


Testing for weakness of the thigh muscles 1. Knee extensors

Quadriceps (L2, L3, L4) Femoral nerve

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Individual Muscle testing


Testing for weakness of the thigh muscles 2. Knee flexors

Hamstrings (L5, S1, S2) Sciatic nerve


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Individual Muscle testing


Testing for weakness of ankle and toe movements 1. Dorsiflexion

Tibialis anterior (L4, L5) Deep peroneal nerve


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Individual Muscle testing


Testing for weakness of ankle and toe movements 2. Plantar flexion

Gastrocsoleus (S1, S2) Tibial nerve


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Individual Muscle testing

Extensor hallucis longus (L5, S1) Deep peroneal nerve

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Individual Muscle testing


Ask the patient to extend and raise both arms in front of them and keep their arms in place while they close their eyes and count to 10 Note for pronator drift

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Numerical Scale to Record Muscle Strength


Scale 5 Active movement against full resistance without evident fatigue 4 Active movement against gravity and resistance 3 Active movement against gravity

2 Active movement of the body part with gravity eliminated


1 A barely detectable flicker or trace of movement 0 No muscular contraction detected
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Muscle Tone
Hypotonia - decreased resistance the examiner feels when manipulating a patients resting joint Hypertonia
Spasticity is an initial catch or resistance and then a yielding when the examiner briskly manipulates the patients resting extremity Rigidity increased muscular resistance felt throughout the entire range of movement when the examiner slowly manipulates a patients resting joint
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Muscle Bulk
Compare the size and contours of muscle When looking for atrophy, pay particular attention to the hands , shoulders and thigh Thenar and hypothenar eminences Spaces between the metacarpals

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Involuntary movements
Tremors Fasciculations Tics

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Sensory Exam

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Sensory cortex

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Somatosensory Homunculus
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Sensory pathways

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Sensory Examination
Primary Sensation
Pain and Temperature Vibration and joint position sense Light touch and two-point discrimination

Cortical sensation
Graphesthesia Stereognosis

Extinction
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Patterns of testing
Compare symmetrical areas of the body, including the arms, legs and trunk When testing pain, temperature and touch sensation, compare the distal with the proximal areas of the extremities When testing position and vibration sensation, tests first the fingers and toes Vary the pace of your testing so that the patient does not merely respond to your repetitive rhythm
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Light touch
With a fine wisp of cotton, touch the skin lightly, avoiding pressure Ask the patient to respond whenever a touch is felt Compare one with the other

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Pain sensation

Instruct the patient to say yes" when they feel the stimuli With the patient's eyes closed, alternate touching the patient with the needle on each side of the body Instruct the patient to report if they notice a difference in the strength of sensation on each side of their body

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Joint Position Sense

Ask patient to close his eyes Report if their large toe is "up" or "down" when the examiner manually moves the patient's toe in the respective direction Repeat on the opposite foot and compare
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Vibration Sense
Place a vibrating tuning fork (usually 128 c/s) on a bony prominence Ask the patient to indicate when the vibration, if felt, ceases If impaired, move more proximally and repeat Of value in the early detection of demyelinating disease and peripheral neuropathy

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2-point discrimination

Tested with a special type of caliper or 2 pins/paper clips Ask patient to close his eyes then touch him alternately with one or both points randomly Ask patient if he feels one or two stimuli Normal 2 point discrimination: 4-5 mm
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Graphesthesia

Ask the patient to close their eyes and identify the number or letter you will write with the back of a pen on their palm Repeat on the other hand with a different letter or number

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Stereognosis

Ask the patient to close their eyes and identify the object you place in their hand Use common objects like a coin or pen Repeat this with the other hand
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Extinction

Touch the patient in two places on opposite sides of their body, simultaneously Ask the patient to point to where they felt sensation Extinction is present if they only report feeling the sensation on one side of the body
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Rombergs Test
Ask the patient to remain still and close her eyes (+) Romberg test
if a patient loses balance after standing still with their eyes closed

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dermatomes

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Nomenclature
Esthesia Hypesthesia Anesthesia Therm Thermhyperesthesia Thermanesthesia Algesia Hypalgesia Analgesia Touch or feeling Partial loss of touch Total loss Heat Partial loss of temperature sensation Total loss Pain Partial loss of pain sensation Total loss

Hyperesthesia
Hyperalgesia Hyperthermesthesia Paresthesia s Dysesthesias Hyperpathia

Increased sensitivity to touch


Increased sensitivity to pain Increased sensitivity to temperature Describe such sensations when they accompany a normal external stimulus to the skin Describes their spontaneous occurrence without any obvious external stimulus Extreme over-response to pain

Neuralgia

Multiple, severe, electric shock like pains that radiate into a specific root or nerve distribution

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Muscle Stretch Reflex

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Muscle stretch reflex


Percussion hammer

Tromner hammer Babinski hammer

Taylor or tomahawk hammer

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Muscle Stretch Reflex


Technique for striking a blow with w reflex hammer
Dangle the hammer handle loosely between the thumb and forefinger, allowing it swing like a pendulum

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Biceps reflex C5, C6

Patient lying supine

Patient sitting

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Triceps reflex C6, C7

Patient sitting

Patient lying supine 129

Brachioradialis reflex C5, C6

Patient sitting
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Abdominal reflexes

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Knee reflex L2, L3, L4

Patient sitting

Patient lying supine


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Ankle reflex S1, S2

Patient sitting

Patient lying supine133

Muscle Stretch Reflex


Scale 4+ 3+ Description Very brisk, hyperactive, with clonus Brisker than average

2+ 1+ 0

Average, normal Somewhat diminished, low normal No response

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When eliciting MSR fails


Strike a crisper blow Change the mechanical tension on the muscle
Flex or extend the joint somewhat to alter the tension on the tendon Compress the tendon slightly more or slightly less

Try reinforcement
Jendrassik maneuver
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Absent MSR
In infants or girls, the lack of prominent tendons may make it difficult to elicit MSR Lack of patellar development in infants During neural shock, such as after acute spinal cord transection, the MSRs maybe inactive

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Babinski Reflex

Positive Babinski 137

Clonus
To and fro, 5-8 cycles per second, rhythmic oscillation of a body part, elicited by a quick stretch

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Clonus

A sustained ankle clonus indicate a central nervous system disease.


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Coordination & Gait

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Cerebellum

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Cerebellum
Anterior receives input from the limbs and trunk - spinocerebellar tracts Posterior - corticopontocerebellar tracts Flocculonodular - receives input about the movement of the head and its position in relation to the pull of gravity - vestibulocerebellar tracts
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Finger-to-nose test

Patient is asked to touch his/her own nose with their index finger and then to touch the examiner's finger This movement is repeated several times
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Cerebellar

Rapid alternating movements used for testing cerebellar function (the cerebellum coordinates muscle actions to produce organized activities such as walking)

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Heel-to-shin Test
Ask patient to repeatedly run the heel down the shin to the big toe Look for jerky or wobbling movements or note if the heel constantly falls off to the side
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Overshooting & checking tests of the arms


Wrist tapping test
Have the patient stand with the eyes closed and arms outstretched The examiner strikes the back of the patients wrist a sharp blow, strong enough to displace the arm Normal arms returns quickly to its initial position Overshoots patients arm oscillates back and forth

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Four cerebellar syndrome


Cerebellar syndrome Hemisphere syndrome Rostral vermis syndrome Caudal vermis syndrome Pancerebella r syndrome Dysarthria Arm overshoot Hypotonia Arms Gait & trunk Legs Nystagmus bidirectional Lobes affected Mainly posterior, variably anterior lobe Anterior lobe

variable

Flocculonodular & posterior All lobes

variable

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Gait
Natural On toes On heels Tandem along straight line

Let the patient walk across the room under observation Note length of step, width of base, abnormal leg movements, instability (gait ataxia) and associated postural movements Ask the patient to walk heel to toe (tandem walking) across the room to exaggerate any instability

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Ask your patient to walk on their toes, then, on their heels These can demonstrate weakness of the gastrocsoleus and/or tibialis anterior

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Meningeal Signs

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Meningeal signs
Neck Rigidity
Ask patient to touch chin to chest Positive when patient feels pain upon doing so

Brudzinski Test

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Kernigs Sign

Allow patient to lie flat on the table, with the knee flexed Raise the upper leg until it is perpendicular to the floor and extend the lower leg while keeping the upper leg stationary Positive when the patient raises their head or scream in pain while the maneuver is done
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Upper motor neuron


Paralyzes movement in hemiplegia, paraplegia Paralyzes individual muscles or sets of muscles in root or peripheral nerve distribution Atrophy of disuse only Atrophy of denervation Fasciculations & fibrillations Hyperactive MSRs Hypoactive or absent MSRs Clonus Clasp-knife spasticity Hypotonia Absent abdominal/cremasteric reflexes Extensor toe sign

Lower motor neuron

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References DeMyer W. Technique of the Neurologic Examination. 5th ed. Bates. Guide to Physical Examination & History Taking.

Brazis P, Masdeu J. Localization in Clinical Neurology. 5th ed.

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