Neurologic Examination

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2. • Posture, gait, coordination: perform
Rhomberg test
• Personal hygiene and grooming
• Check speech/communication:
•
•
•
•
Check speech: rapid, slow, halting
Clarity: slurred or distinct
Tone: high-pitched, rough
Vocabulary: appropriate choice of words

3. Mental Status
General appearance and behavior
Level of consciousness
• Oriented to person, place and time
• Appropriate response to verbal and tactile
stimuli
• Memory, problem solving abilities.
Mood
Thought content & intellectual capacity

4. Pupils and EOM:
Size of pupils should be equal
Reaction of pupils
•
•
•
Accommodation: pupillary constriction to
accommodate near vision
Direct light reflex: constriction of pupil when light
is shone directly into the eye
Consensual reflex: constriction of the pupil in the
opposite eye when the direct light reflex is
tested.
Evaluate EOM:
•
•
•
Note nystagmus
Ability of eyes to move together
Resting position of iris should be at mid-position
of the eye socket

5. 
Neurologic examination is an indirect evaluation
that assesses the function of specific body part
controlled
f
5 COMPONENTS OF
NEURO ASSESSMENT
(1) Cerebral function
(2) Cranial Nerves
(3) Motor system
(4) Sensory System
(5) Reflexes

6. Cerebral abnormalities cause:
- disturbance in mental status
- Intellectual function
- Thought content
- Pattern of emotional behavior
- Alteration in perception, motor and
language ability
- Lifestyle changes

7.  Should
be specific and non-judgemental
 Avoid using the terms
“inappropriate” or “demented”
 Specific records on observations
regarding orientation, level of
consciouness, emotional state or thought
content

8.  patient’s
appearance & behavior
 dress, grooming & personal hygiene
 Posture, gesture, movements, facial
expression & motor activity
 manner of speech & level of
consciousness
 orientation to time, place & person

9. Average IQ of a person can:
- Recite 5 digits backwards
- Serial 7’s (Subtract 7 from 100, then
7 from that, and so forth)
 Interpret proverbs
 Ability to recognize similarities
 Situational analysis

10. Are the patient’s thought…





Spontaneous
Natural
Clear
Relevant
Coherent
f
- hallucinations, preoccupation with death
and morbid events, paranoid ideation
requires further evaluation

11.  Is
the patient’s affect natural or even?
 Does his or her mood fluctuate
normally?
 Are verbal communications
consistent with nonverbal cues?

12.  Agnosia
- inability to recognize objects
seen through the special senses
◦ a patient may see a pencil but knows not what to do with it
or what it’s called
 Screening
for visual and tactile agnosia
provides insight into the patient’s
cortical interpretation ability
◦ Placing a familiar object (key) in the patient’s hand, have him identify
it with eyes closed

13.  normal
neurologic function: understand
and communicate in spoken and written
language.
 Aphasia is a deficiency in language
function
Type of Aphasia
Brain area involved
Auditory-receptive
Temporal Lobe
Visual-receptive
Parietal-occipital lobe
Expressive speaking
Inferior posterior frontal areas
Expressive writing
Posterior frontal area

14.  Ask
the patient to perform a skilled act
(throw a ball, move a chair)
 Performance
requires
- the ability to understand the activity
desired and normal motor strength
 Failure signals cerebral dysfunction

16. CRANIAL NERVES
On
Old
Olympus
Towering
Tops
A
Finn
And
German
Viewed
Some
Hops
Olfactory (I)
Optic (II)
Occulamotor (III)
Trochlear (IV)
Trigemenal (V)
Abducens (VI)
Facial (VII)
Acoustic (VIII)
Glossopharyngeal (IX)
Vagus (X)
Spinal Accessory (XI)
Hypoglossal (XII)
M
S
M
M
M/S
M
M/S
S
M/S
M/S
M
M

17. Before testing nerve function, ensure
patency of each nostril by occluding in turn
and asking patient to sniff
 ask patient to close eyes
 Occlude one nostril and hold aromatic
substance (coffee) beneath nose
 Ask patient to identify substance
 Repeat with other nostril


18. Normal:
■ Patient is able to identify substance.
Abnormal:
■ Anosmia - loss of sense of smell.


inherited and non-pathological: chronic rhinitis, sinusitis,
heavy smoking, zinc deficiency, or cocaine use.
It may also indicate cranial nerve damage from facial
fractures or head injuries, disorders of base of frontal
lobe such as a tumor, or artherosclerotic changes .

19. Snellen chart to check/test:
- distant vision
- color
Client should be 20 feet distant from the
chart
Use an object to occlude one eye
Evaluate the vision one eye at a time

20. Test for ocular rotations, conjugate movements,
nystagmus
- Trochlear Nerve (IV): Pupillary Light Reflex and Ptosis using direct & consensual pupillary reaction to light

21. Abnormal:
Normal:
■ Able to read without ■ CN II deficits
difficulty
■ Visual acuity intact
20/20, both eyes
Hippus phenomenon:
Brisk constriction of
pupils in reaction to
light, followed by
dilation and
constriction
- may be normal or
sign of early CN III
compression.
- can occur with stroke or
brain tumor.
■ Changes in pupillary
reactions
- can signal CN III deficits.
■ Increased ICP causes
changes in pupillary
reaction

22. a.
Test motor function:
- patient to move jaw from side to side
against resistance and then clench jaw as
you palpate contraction of temporal and
masseter muscles, or to bite down on a
tongue blade.

23. Testing sensory function:
- patient to close eyes
- Touch the face with the wisp of cotton
- Instruct to tell you when he or she feels
sensation on the face.
- Repeat the test using sharp and dull
stimuli (toothpick or tongue blade)
- Instruct to say “Sharp” or “Dull”

24. Testing corneal reflex:
- Gently touch cornea with cotton wisp.
o Alternative approach is to:
> puff air across cornea with a needless syringe
> gently touch eyelash
and look for blink reflex

25. Abnormal:
Normal:
 Full range of motion
(ROM) in jaw and
strength.

Patient perceives
light touch and
superficial pain
bilaterally

Weak or absent contraction
unilaterally:
-
Lesion of nerve, cervical spine,
or brainstem

Inability to perceive light touch
and superficial pain
-
may indicate peripheral nerve
damage.
■ Trigeminal Neuralgia:
-
Neuralgic pain of CN V caused
by the pressure of degeneration
of a nerve
■ Corneal reflex test used in
patients with decreased LOC
- to evaluate integrity of
brainstem.

26. a.
Testing motor function:
- patient to perform these movements:
smile, frown, raise eyebrows, show upper
teeth, show lower teeth, puff out cheeks, purse
lips, close eyes tightly while trying to open
them.

27. Testing sensory function:
Test taste on ant two-thirds of tongue for sweet, sour,
salty.
Sweet: Tip of the tongue
Sour: Sides of back half of tongue
Salty: Anterior sides and tip of tongue
Bitter: Back of tongue

28. Normal:
Facial nerve intact
Able to make faces.
Taste sensation on anterior tongue intact
Abnormal:
Asymmetrical or impaired movement:
Nerve damage, such as that caused by Bell’s palsy or
stroke.
Impaired taste/loss of taste:
Damage to facial nerve, chemotherapy or radiation
therapy to head and neck.

29. 





Do Weber and Rinne tests for hearing
watch-tick test by holding watch close to patient’s ear.
Perform Rhomberg test for balance
- Stay at the back / side of the pt.
- Instruct: to stand straight, feet together, hands at
the side and eyes closed.
(Evaluates the balancing function of the CN VIII)

30. Normal:
 Hearing intact.
 Negative Rhomberg test.
Abnormal:
 Hearing loss, nystagmus, balance disturbance,
dizziness/vertigo:
- Acoustic nerve damage.
■ Nystagmus:
- CN VIII, brainstem, or cerebellum problem or
phenytoin toxicity.

31. a. Observe ability to cough, swallow, and
talk.
b. Test motor function:
- patient to open mouth and say “ah”
while you depress the tongue with a
tongue blade.
- Observe soft palate and uvula.
- Soft palate and uvula should rise
medially.

32. c. Test sensory function of CN IX and motor
function of CN X by stimulating gag reflex.
 Tell patient that you are going to touch interior
throat
 Then lightly touch tip of tongue blade to posterior
pharyngeal wall.
 Observe the pharyngeal movement.

Ask the client to drink a small amount of water
- ease & difficulty of swallowing
- quality of the voice or hoarseness
when speaking

33. Normal:

Swallow and cough
reflex intact.

Speech clear.

Elevation and
constriction of
pharyngeal
musculature and
tongue retraction
(+) gag reflex
Abnormal:
 Unilateral movement:
Contralateral nerve damage.
- Damage to CNs IX and X also
impairs swallowing.
■ Changes in voice quality (e.g.,
hoarseness): CN X damage.
■ Diminished/absent gag reflex:
Nerve damage
- Risk for aspiration
■ Impaired taste on posterior
portion of tongue:
Problem with CN IX

34. a.
motor function of shoulder and
neck muscles:
- Ask patient to shrug shoulders upward against
your resistance. (Trapezius muscle)
- Then ask pt to turn head from side to side
against your resistance.
(Strenoclaidomastoid muscle)

35. Normal:

Movement symmetrical, with patient moving against resistance
without pain.
■ Full ROM of neck with +5/5 strength.
Abnormal:





Asymmetrical
Diminished
Absent movement
Pain
unilateral or bilateral weakness: Peripheral nerve CN
XI damage.

36. a. Let patient say “d, l, n, t” or a phrase
containing these letters.
b. Ask the patient to protrude the tongue.
Observe any deviation from midline, tumors,
lesions, or atrophy.
c. Now ask the patient to move the
tongue from side to side.

37. Abnormal:
Asymmetrical/diminished/
absent movement/deviation from
midline/protruded tongue: - Peripheral nerve CN
XII damage.
■ Tongue paralysis results in dysarthria.
Normal:
 Can protrude tongue medially.
 No atrophy, tumors, or lesions.

38.  Assessing
the patient’s ability to flex or
extend the extremities against resistance
tests muscle strength.
g
 The
evaluation of muscle strength
compares the sides of the body with each
other

f
This way, subtle differences in muscle strength
can easily be detected and described.

39. 

Muscle tone is evaluated by palpation
Abnormalities in tone include:
◦ Spasticity (increased muscle tone)
◦ Rigidity (resistance to passive strength)
◦ Flaccidity

40. 
Cerebellar influence on the motor system is reflected
in balance and coordination.

Coordination of the hands and extremities is tested
by:
◦ Rapid, alternating movements
◦ POINT TO POINT TESTING

41. Balance and Coordination
a. Rapid Alternating Movements (RAM)
Ask the person to pat the knees with both hands, lift
up, turn hands over, and pat the knees with the backs
of the hands.
Then ask to do this faster.
Abnormal:
Lack of coordination
Dysdiadochokinesia
- Slow, clumsy, and sloppy response
- occurs with cerebellar disease
Normal:
 done with equal turning and quick rhythmic pace

42. Finger-to-Finger test
With the persons eyes open, ask that he or she use index
finger to touch your finger, then his own nose.
After a few times move your finger to a different spot.
Abnormal:
Dysmetria
- clumsy movement with overshooting the mark
- occurs with cerebellar
disorder
Past-pointing
- constant deviation to one side
Normal:
 Movement is smooth and accurate

43.  Coordination
in the lower extremities is
tested: run heel down the anterior surface
of the tibia of the other leg. Each leg is
tested
 Ataxia is incoordination of voluntary
muscle groups in action
 Tremors are rhythmic, involuntary
movements
=>The presence of these movements suggests
cerebellar disease

44. Cerebellum: for balance and coordination.
Rhomberg’s Test
 screening test for balance
 pt stands with feet together and arms at the side,
first with eyes open and eyes closed for 20 to 30
seconds
 sway is normal but loss of balance is abnormal
and considered (+) Rhomberg Test

45. Abnormal:
Sways, falls, widens base of feet to avoid falling
Positive Rhomberg sign
-Loss of balance that occurs when closing the eyes.
-Occurs with cerebellar ataxia (multiple sclerosis,
alcohol intoxication)
-Loss of proprioception, and loss of vestibular
function
Normal:
Negative Romberg test

46. Tandem Walking
- ask the person to walk a straight line in a heel-to-toe fashion.
- This decreases the base of support and will accentuate any
problem with coordination.
Normal:
Person can walk straight
& stay balanced
Abnormal:
Crooked line walk
Widens base to maintain balance
Staggering, reeling, loss of balance
An ataxia that did not appear now.
Inability to tandem walk is sensitive for an upper motor neuron
lesion, such as multiple sclerosis.

47. 



Motor reflex are involuntary contraction of muscles
in response to abrupt stretching near the site of
muscle insertion
Technique: A reflex hammer is used to elicit a
deep tendon reflex.
The tendon is struck briskly, and the response is
compared with the opposite side of the body (right
and left)
Response should be equal

48. GRADING :
The absence of reflex is significant, although ankle
jerks (achilles reflex) may be absent on older
people.

Some uses the terms:
◦ PRESENT
◦ ABSENT
◦ DIMINISHED

49. Deep tendon reflex grades
Deep tendon reflex grades
0 absent
0 absent
+ present but diminished
+ present but diminished
+ + normal
+ + normal
+ + + increased but not necessarily pathologic
+ + + increased but not necessarily pathologic
+ + + + hyperactive or clonic (involuntary contraction
+ + + + hyperactive or clonic (involuntary contraction
and relaxation of skeletal muscle)
and relaxation of skeletal muscle)
Superficial reflex grades
Superficial reflex grades
0 absent
0 absent
+ present
+ present

50. Biceps Reflex
- is elicited by striking the biceps tendon of
the flexed elbow.
- the examiner supports the forearm with
one arm while placing the thumb against
the tendon and striking the thumb with the
reflex hammer.
Normal:
■ Flexion at the elbow and
contraction of the biceps

51. b. Triceps Reflex
- flex pt’s arm to 90° angle and
positioned in front of the chest
■ Abduct patient’s arm and flex it at the elbow.
■ Support the arm with your non-dominant hand.
■ Identify triceps tendon by
palpating 2.5 to 5cm
(1-2 in) above the elbow
Normal:
■ Contraction of triceps with
extension at elbow

52. c. Patellar Reflex
■ Have patient sit with legs dangling.
■ Strike tendon directly below patella.
Normal:
■ Contraction of
quadriceps with
extension of knee.

53. d. Ankle
- Achilles reflex
- foot is dorsiflexed at the ankle and
the hammer strikes the stretched
Achilles tendon
Normal:
■ Plantar flexion of foot.

54. Test for Clonus
• When reflexes are very hyperactive, a
phenomenon called clonus may be elicited
• If a foot is abruptly dorsiflexed, it may continue
to “beat” two to three times before it settles into
a position of rest
• The presence of clonus always indicates the
presence of CNS disease and requires further
evaluation
Normal:
■ No contraction

55. Superficial Reflexes
Abdominal Reflex
■ Stroke patient’s abdomen diagonally from
upper and lower quadrants toward umbilicus.
■ Contraction of rectus abdominis. Umbilicus
moves toward stimulus.

56. Perianal Reflex
■ Gently stroke skin around anus with gloved finger.
Normal:
■ Anus puckers.
Cremasteric Reflex
■ Gently stroke inner aspect of a male’s thigh.
Normal:
■ Testes rise.
Bulbocavernosus Reflex
■ Gently apply pressure over bulbocavernous
muscle on dorsal side of penis.
Normal:
■ Bulbocavernosus muscle contracts.

57. BABINSKI REFLEX
■ Stroke sole of patient’s foot in an arc from
lateral heel to medial ball.
•
•
•
Fanning of toes when stroked laterally
Normal in newborn (found until 16 – 24 mos)
Indicates CNS disease of motor system
Normal:
■ Flexion of all toes.

58. The examiner should be familiar with dermatomes
 Most sensory deficits results from peripheral
neuropathy and follow anatomic dermatomes

Assessment involves:
 Tactile sensation
 Superficial pain
 Vibration
 Position sense
** pt eyes are kept closed

59. Tactile Sensation or Light Touch
- Brush a light stimulus: cotton wisp over
patient’s skin in several locations, including
torso and extremities.
Normal:
 Identifies areas
stimulated by light
touch.
Abnormal:
Hypesthesia: diminished capacity for
physical sensation (esp. skin)
■ Hyperesthesia: Increased sensitivity
■ Paresthesia: Numbness & tingling
■ Anesthesia: Loss of sensation.

60. PAIN and TEMPERATURE
•Stimulate skin lightly with sharp and dull ends of
toothpick/ paper clip
•Apply stimuli randomly and ask patient to identify
whether sensation is sharp or dull
•Touch patient’s skin with test tubes filled with hot or
cold water.
•Apply stimuli randomly, and ask patient to identify
whether sensation is hot or cold.

61. VIBRATION and PROPRIOCEPTION
- Place a vibrating tuning fork over a finger joint,
and then over a toe joint.
- Ask patient to tell you when vibration is felt and
when it stops.
- If patient is unable to detect vibration, test
proximal areas as well.

62. Normal:

Vibratory sensation intact bilaterally in upper and
lower extremities.
Abnormal:

Diminished/absent vibration sense:
- Peripheral nerve damage caused by alcoholism,
diabetes, or damage to posterior column of spinal
cord.

63. Stereognosis
Normal:
Stereognosis intact bilaterally.
Abnormal:
■ Abnormal findings suggest a lesion or other disorder
involving sensory cortex or a disorder affecting posterior
column.

64. Sensory Extinction
■ Simultaneously touch both sides of patient’s
body at same point.
■ Ask patient to point to where she or he was
touched.
Normal:
Abnormal:
 Extinction intact. Identification of stimulus on
only one side suggests lesion
or other disorder involving
sensory cortical region in
opposite hemisphere.

66. Level of Consciousness :
♦Alert – fully awake; appropriate responses to external and
internal stimuli; oriented to person, place and time
s
♦Lethargic – somnolent, drowsy, listless, indifferent to
surroundings, very sleepy, can be aroused from sleep but
when stimulation ceases, falls back to sleep; may be
oriented or confused
d
♦Stuporous – unconscious most of the time but makes
spontaneous movements and response is evoked only by a
strong, continuous, noxious stimuli; loud noises or sounds,
bright light, pressure to sternum, response is usually a
purposeful attempt to remove the stimulus
f
♦Comatose – absence of voluntary response to stimuli
including painful stimuli; no response, no eye opening –
score of 7 or less on GCS

67. Fully alert- 15, a score of 7 or less reflects coma. (Kozier p. 703-704)

68. Test orientation to time, place, and person
Normal:
 Awake, alert, and oriented to time, place, and
person (AAO x 3)
 Responds to external stimuli
Abnormal:
 Disorientation may be physical in origin
 Disorientation can also be psychiatric in origin
(schizophrenia)
 Lathargic or somnolent
 Obtunded
 Stupor
 Coma

69. Paralysis
 Loss or impairment of the ability to move a body part,
usually as a result of damage to its nerve supply.
 Loss of sensation over a region of the body.
Hemiplegia
paralysis of one side of the body
Paraplegia
paralysis of both lower limbs due to spinal disease or
injury
Quadriplegia
paralysis of all four limbs or of the entire body below
the neck
Paresis
partial motor paralysis

70. Fasciculations
Rapid, continuous twitching of resting muscle
Tic
Repetitive twitching of a muscle group
Myoclonus
Rapid, sudden jerk at a fairly regular intervals
Tremor
Involuntary contraction of opposing muscle groups
Rest tremor
Intention tremor

71. Chorea
Sudden, rapid, jerky, purposeless movement
involving limbs, trunk, or face
Athetosis
Slow, twisting, writhing, continuous movement,
resembling a snake or worm

72. Brudzinski’s sign
- neck stiffness
- involuntary flexion of hips and knees
when flexing neck is positive sign for
meningeal irritation

73. Positive Kernig’s sign
-excessive pain in the lower back
when examiner attempts to straighten
knees with client supine and knees
and hips flexed

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