NEUROLOGICAL

EXAMINATION
INTRODUCTION:
A examination is the
assessment
neurological
of sensory neuron andmotor
responses, especially reflexes, to
determine
whether the nervous system is impaired.
This typically includes a physical examination
and a review of the patient's medical history
but not deeper investigation such as
neuroimaging. It can be used both as a
screening tool and as an investigative tool.
Examples of
Definitions
•Alert: looks about responds in a meaningful manner to
awake,
verbal instructions or gestures
•Drowsy:
oriented when awake but if left alone will sleep
•Confused:
disoriented to time, place, or person o memory difficulty is
common
has difficulty with commands
exhibits alteration in perception of stimuli, may be agitated
• Stuporous:
generally unresponsive except to vigorous stimulation
may make attempt at verbalization to vigorous/repeated
stimuli
Opens eyes to deep pain
•Comatose:
unarousable and unresponsive some localization or
movement may be acceptable within the comatose
category depending on the coma definitions e.g. light coma
to deep coma
Does not open eyes to deep pain
The difference between Coma and Sleep:

•sleeping persons respond to unaccustomed stimuli

•sleeping persons are capable of mental activity
(dreams)
•sleeping persons can be roused to normal
consciousness
•cerebral oxygen uptake does not decrease during
sleep as it often does in coma
Special States of Altered Levels of
Consciousness
• Brain Death:
An irreversible loss of cortical and brain stem activity.
• Persistent Vegetative State:
A condition that follows severe cerebral injury in which the
altered state becomes
chronic or persistent.
• Locked-in Syndrome:
A state of muscle paralysis, involving voluntary muscles,
while there is preservation of full
consciousness and cognition.
Indications:
A neurological examination is indicated
whenever a physician suspects that a patient
may have a neurological disorder. Any
new symptom of any neurological order
may be an indication for performing a
neurological examination.
 Signs &/or symptoms that cannot be faked must
be examined closely.
 Examples include, asymmetry in pupils,
abnormal retinal exams, nystagmus, muscle
atrophy, and muscle fasciculation.

ORGANİC DİSEASE?
 Upper Motor Neurons (UMN) are defined as the
connections of motor nerves before they leave
the spinal cord
 Lower Motor Neurons (LMN) are defined as
after the synapse (connection) into the
peripheral nerve cell bodies.
 Objectives

 Organize Exam into the 6 Subsets of

Function
 Concept of Screening Examination
 Understand Afferent and Efferent
Pathways for Brainstem Reflexes
 Differentiate Between Upper and Lower
Motor Neuron Findings
Six Subsets of the Neuro
Exam

Here’s what you need to

examine.
Mental Status

Cranial Nerves

Motor

Sensory

Coordination

Reflexes
 Concept of a Screening Exam

 Screening each of the subsets allows one to check

on the entire neuroaxis (Cortex, Subcortical White
Matter, Basal
Ganglia/Thalamus, Brainstem, Cerebellum, Spinal
Cord, Peripheral Nerves, NMJ, and Muscles)
 Expand evaluation of a given subset to either
• Answer questions generated from the History
• Confirm or refute expected or unexpected findings
Neurological Examination
Mental Status
Exam
“FOGS”
Family story of
memory loss
Orientation

General Information

Spelling &/or
numbers
1. INTERVIEW

The patient/family interview will allow to:

•ƒ gather data: both subjective and objective about the
patient's previous/present health state
•ƒ provide information to patient/family
•ƒ clarify information
•ƒ make appropriate referrals
•ƒ develop a good working relationship with both the patient
and the family
•ƒ initiate the development of a written plan of care which is
patient specific
Interview to identify presence
•of:headache
• difficulty with speech
• inability to read or write
• alteration in memory
• altered consciousness
• confusion or change in thinking
• disorientation
• decrease in sensation, tingling or pain
• motor weakness or decreased strength
• decreased sense of smell or taste
• change in vision or diplopia
• difficulty with swallowing
• decreased hearing
• altered gait or balance
• dizziness
• tremors, twitches or increased tone
 Physical Examination
Considerations
• Level of Consciousness
– Most important aspect of neurologic examination
– Level of consciousness first to deteriorate; changes
often subtle, therefore requiring careful monitoring.
• Consciousness:
– Composed of Two Components:
• Arousal (Alertness)
• Awareness (Content)
– Assessment: Orientation vs. Disorientation
» Person, Place & Time
» Varying sequence of questions is important !!
 Assessing
LOC
• Glasgow Coma Scale (GCS)
– Three Categories:
• Eye opening
• Best motor response
• Best verbal response
– Scoring
• Highest or best possible score
15
• A score of < 8 indicates coma
• Lowest or worst possible score 3
Glasgow Coma Scale
 Pupillary Examination
• The examination can be quickly and easily
performed
pupillary in the unconscious or minimally responsive
patient when a TBI is suspected, and can provide valuable
information about the degree of initial or progressing brain
injury. Several types of TBI’s may cause pupillary
changes, which indicate the need for rapid interventions to
decrease ICP caused by cerebral bleeding and/or edema.
Nurses are in a key position to detect early changes in a
patient's condition and administer or advocate for
immediate interventions.
Check pupil size in lighted room, and
reactivity to light in a darkened room.
Unequal
pupil size
can be a sign
of a serious
brain injury.
 Brain
Injury with
bleeding
or swelling

Rapid interventions
are needed to prevent
death or permanent
brain damage – TBI’s
can progress rapidly!
 Mental Status
Level of Alertness
•Subjective view of Examiner
•Definition of Consciousness
•Terminology for Depressed Level of Consciousness
•Concept of Coma
•Delerium

Degree of Orientation
•To what?
 Mental Status

Concentration
•Serial 7’s or 3’s
•“WORLD” backwards
•Months of the Year Backwards
•Try to quantify degree of impairment

* A and O and Concentration need to be intact for other

aspects of the Mental Status Exam to have localizing
value!
 Mental Status
Memory

Immediate Recall
•A task of concentration
Short-Term Memory
•“3/3 objects after 5 minutes”
Long-Term Memory
•Last thing to go
 Mental Status
Language
Aphasia vs Dysarthria
Receptive Language
•Command Following
Expressive Language
•Fluency
•Word Finding
Repetition
•Screens for Receptive, Expressive, and Conductive
Aphasias
Language
 Mental Status
 Calculations, R-L confusion, finger agnosia,
agraphia
• Gerstmann’s Syndrome (Dominant Parietal Lobe)
 Hemineglect
• Non-Dominant Parietal Lobe
 Delusional Thinking, Abstract Reasoning, Mood,
Judgement, Fund of Knowledge, etc
• Important for Psychiatry
• Does not localize well to one region of the cortex
• Neurocognitive Testing required to get at more specific
deficits
OLFACTORY NERVE -
I
 Distinguish Coffee from
Cinnamon
 Smelling Salts irritate
nasal mucosa and test V2
Trigemminal Sense
 Disorders of Smell result
from closed head injuries

OLFACTORY
NERVE
OPTİC
NERVE
CRANİAL
NERVE II
 Optic Nerve
Visual
 Acuity
Visual Fields
 Afferent input to Pupillary Light
Reflex
• APD
 Look at the Nerve
(Fundoscopic Exam)
“VA equals 20/20 OU at near”
“PERRLA”
 Abducens Nerve
Cn VI
Oculomotor Nerve
Cn III

Trochlear Nerve
c.n. IV
CN III Oculomotor: moves
eyes in all directions except
outward and down & in;
opens eyelid; constricts pupil

CN IV Trochlear:
moves eyes
down and in…..
CN VI Abducens: moves eyes outward

EOM’s:
(extraoccular movement)

assessment of eye
movement in all
directions ( III, IV
VI)
TRİGEMİNAL NERVE - V
CN V Trigeminal:
3 branches; sensation to the
face, cornea and scalp;
opens jaw against
resistance
FACİAL NERVE-VII
CN VII Facial:
moves the
face; taste.

CN VII paralysis
VESTİBULOCOCHLEAR
NERVE-VIII
 Vestibulocochlear
Nerve
• Hearing
Patients will complain of and Balance
tinnitis, hearing loss, and/or
vertigo
 Weber and Renee Test
• Differentiates Conductive vs Sensorineural hearing loss
 Afferent input to the Oculocephalic Reflex
• Doll’s Eye Maneuver
• Cold Calorics
Glossopharyngeal and Vagus
Nerves
c.n.’s IX and X
CN IX Glossopharyngeal:
moves the pharynx
(swallow, speech & gag)

CN X Vagus:
voice quality
 Spinal Accessory
Nerve
c.n. XI
Sternocleido-
Mastoid Trapezius
strength strength
 Shoulder
Shrug

CN XI SPİNAL ACCESSORY:
TURNS HEAD AND ELEVATES SHOULDERS
Hypoglossal Nerve
c.n. XII
 Hypoglossal Nerve

Protrudes the tongue

to the opposite side
Tongue in cheek
(strength) Hemi-atrophy and
fasiculations (LMN)
Strength
Tone
DTR’s
Plantar Responses
Involuntary Movements
 Strength
Medical Research Council Scale
5/5 = Full Strength
4/5 = Weakness with Resistance
3/5 = Can Overcome Gravity Only
2/5 = Can Move Limb without Gravity
1/5 = Can Activate Muscle without Limb
0/5 = Cannot Activate Muscle
Describe the Distribution of Weakness
•Upper Motor Neuron Pattern
•Peripheral neuropathy Pattern
•Myopathic Pattern

WEAKNESS
 Tone is the resistance appreciated when moving a
limb passively
 “Normal Tone”
 Hypotonia
• “Central Hypotonia”
• “Peripheral Hypotonia”
 Increased Tone
• Spasticity (corticospinal)TONE
• Rigidity (Basal Ganglia, Parkinson’s Disease)
• Dystonia (Basal Ganglia)
 DTR’s
0/4 = Absent
1-2/4 = Normal Range
3/4 = Pathologically Brisk
4/4 = Clonus
 Involuntary Movements
Hyperkinetic
• Chorea Movements
• Athetosis
• Tics
• Myoclonus
 Bradykinetic Movements
• Parkinsonism (Bradykinesia, Rigidity,
Postural Instability, Resting Tremor)
• Dystonia
 Drift
Assessment
Drift Assessment: test for motor
weakness

Arm: hold arms out with palms up; eyes closed

•Pronator drift: hands pronate (roll over);
•Motor drift: arm “drifts” downward
•Cerebellar drift: arm “drifts” back
toward head or out to side

Leg: no need to close eyes motor: leg

“drifts”toward bed
 Movement
Assessment
 Movements are purposeful or non-purposeful
 tubings or bed linens, scratching nose
 localizing: moving toward or removing a painful stimulus; must cross the
midline; occurs in the cortex
 withdrawal: pulling away from pain; occurs in the hypothalamus

purposeful: picking at
non-purposeful: do not cross the midline
abnormal flexion: (decorticate) rigidly flexed
arms and wrists; fisted hands; occurs in Decorticate
upper brainstem abnormal extension:
(decerebrate) rigidly, rotated inward
extended arms with flexed wrists and fisted
hands; occurs in midbrain or pons.
Decerebrate
 Light Touch (Multiple Pathways)
 Pain/Temperature Sensation (Spinothalamic Tract)
 Vibration/Position Sensation (Posterior Columns)
 Cortical Sensory Modalities
 Stereognosis
 Graphesthesia
 Two-Point Discrimination
 Double Simultaneous Extinction

 Primary Sensory Modalities

 Pain and
Temperature
• Pinprick (One pin per patient!)
• Sensation of Cold
• Look for Sensory Nerve or
Dermatomal Distribution
 Vibration Sensation
• C-128 Hz Tuning Fork (check great
toe)
 Joint Position Sensation
• Check great toe
•
 Higher Cortical Sensory Function
Graphesthesia
 Stereognosis
 Two-Point Discrimination
 Double Simultaneous Extinction
 Gerstmann’s Syndrome (acalculia, right-
left confusion, finger agnosia, agraphia)
• Usually seen in Dominant Parietal Lobe lesions
 Dysmetria on Finger-Nose-Finger Testing*
 Irregularly-Irregular Tapping Rhythm*
 Dysdiadochokinesis*
 Impaired Check*
 Hypotonia*
 Impaired Heel-Knee-Shin*
 Falls to Side of Lesion*
 Nystagmus (Variable Directions)
* All Deficits are Ipsilateral to the side of the lesion

HEMİSPHERE
DYSFUNCTİON
 Truncal Ataxia
 Titubation
 Ataxic Speech
 Gait Ataxia
• Acute Ataxia (unsteady Gait)
• Chronic Ataxia (wide-based, steady
Gait) MİDLİNE
DYSFUNCTİON
REFLEXES
MUSCLE STRETCH REFLEXES (DEEP
TENDON REFLEXES)

• GRADED 0 - 5
– 0 - ABSENT
– 1 - PRESENT WITH
REINFORCEMENT
– 2 - NORMAL
– 3 - ENHANCED
– 4 - UNSUSTAINED CLONUS
– 5 - SUSTAINED CLONUS
 MSR /
DTR
• BICEPS
• BRACHIORADIALIS
• TRICEPS
• KNEE
• ANKLE
 OTHER REFLEXES
• Upper motor neuron dysfunction
– BABINSKI
• present or absent
• toes downgoing/ flexor plantar response
– HOFMAN’S
– JAW JERK
• Frontal release signs
– GRASP
– SNOUT
– SUCK
– PALMOMENTAL
 Abmornal Reflexes
Abnormal Reflexes:
Babinski: initial inflection of great toe in response
stroking of sole; upgoing toe is abnormal
Grasp: involuntary grasp in response to stimulation of palm; abnormal in
an adult
Doll’s eyes: impairment of eye movement to opposite side when head
is turned = damage to brainstem; no movement = loss of
brainstem
 Neuro Aessessment
• 1. Peripheral Nervous System (PNS)
is made up of theQuiz
following except::
object, the coup injury occurs at the site of
• Cranial nerves (12)
• Ventricles
• Axons and Neurons
• Spinal nerves (31)
• Cerrebellar nerves
• 2. The Autonomic Nervous System
contains both the Sympathetic
Division of nerves and the
Parasympathetic Division of nerves.
True or False _.
• 3. Intracranial Hemorrhage can
occur in the following places except:
• Epidural space
• Subdural space
• Subarachnoid space
• Ethmoid space
• .4. A Coup Contracoup injury is defined
as: When the head strikes a fixed
impact and the contrecoup injury occurs
at the opposite side. True or
False_
• 5. The Facial nerve controls:
• Movement of the chin, tongue and parotid
glands.
• Movement of the tongue, soft palete and
eyebrows.
• Movement of the chin and cheeks
muscles.
• Movement of all the facial expression
muscles.
• 6. Which nerve controls movement on the
neck and shoulders?
• Abducens
• Accoustic
• Spinal Assesory
• Occulomotor
• 7. A serious injury to the cervical spine
and spinal cord most likely will result in
the following condition:
• Hemiplegia
• Quadraplegia
• Paraplegia
• Contralateral paralysis
• 8. Any suspected head, neck or spine
injured victim should immediately be
given spinal immobilization precautions,
except:
• When the victim complains of pain only
upon turning his head to one side.
• When the victim refuses to allow spinal
immobilization even after listening
carefully to multiple attempts to explain
the dangers and risk involved.
• When the victim is intoxicated on
alcohol and cannot speak clearly.
• When the victim was never unconscious
and denies any pain.
• 9. When assessing a patient with altered
LOC, you feel his state of awareness/arousal is
best described as “Obtunded”, this means:
• Very drowsy, when not stimulated, but can
follow simple commands when stimulated (i.e.
shaking or shouting); verbal responses include
one or two words, but will drift back to sleep
without stimulation.
• A state of drowsiness; client needs increased
external stimuli to be awakened but, remains
easily arousable; verbal, mental & motor
responses are slow or sluggish.
• Awakens only to vigorous and continuous
noxious (painful) stimulation; minimal
spontaneous movement; motor responses to
pain are appropriate but, verbal responses are
minimal and incomprehensible (i.e. moaning).
• Vigorous external stimulation fails to produce
any verbal response; both arousal and
awareness are lacking; no spontaneous
movements but, motor responses to noxious
stimuli maybe be purposeful
• 10. The Glasgow Coma scale tests for • 13. A constricted “pin point” pupil indicates:
three kinds of responses, they are: (best answer)
• Eye Opening a) Brain Stem herniation
• Motor Response b) Cardiac Arrest
• Verbal Response c) Cerebral Infarction of the parietal lobe
• Auditory Response d) Cerebral Infarction of the occipital lobe
• 11. The best and worst possible score on e) A wide variety of conditions, some being
the GCS is: extremely life threatening.
• 15 and 0 f) 14. What Cranial nerve(s) controls the
• 13 and 3 movement of the eyes down and in?
• 15 and 3 g) CN VI Abducens
• 18 and 5 h) CN III Oculomotor
• 12. When assessing pupillary response, i) CN IV Trochlear d)
you are looking for the following • CN II Optic
conditions except:
15. The Motor strength scale goes from 0/5 to
• Coordinated eye movement and bilateral 5/5, 0 being no strength at all and 5 being
blinking. normal strength. A person with a motor
• Reactivity to and accommodation to strength of 4/5 would be:
light. •overcomes gravity; offers no resistance
• Symmetry of pupils and accommodation •strong against resistance
to light. •weak against resistance
• Abnormal pupil shape. •no muscle movement
• 16. Match the following postures with
its definition: • Answers
• Decerebrate_ • 1 e
• Decorticate_ • 2 True
• 3 d
a) Abnormal flexion: rigidly flexed arms and • 4 True
wrists; fisted hands; occurs in upper •
brainstem 5 d
b) Abnormal extension: rigidly, rotated • 6 c
inward, extended arms with flexed wrists • 7 b
and fisted hands; occurs in midbrain or • 8 b
pons. • 9 a
c) 17. The Babinski reflex is the initial • 10 d
inflection (extension) of great toe in
response stroking of the sole of the foot, • 11 c
select the correct answer: • 12 a
d) An upgoing great toe is abnormal. • 13 e
e) An upgoing great toe is normal. • 14 c
f) An upgoing great toe is abnornal in • 15 c
adults. • 16 Decer = b. Decor = a
a) An upgoing great toe is normal in • 17 c&d
infants.