The neurological examination evaluates several domains including mental status, cranial nerves, motor function, reflexes, sensation, and coordination. It begins with tests of orientation, attention, memory, and language to assess mental status. Cranial nerves are tested individually for strength and sensation. The motor exam evaluates strength, gait, muscle tone, and abnormal movements. Reflexes including deep tendon reflexes are graded. Coordination is assessed using tests like finger-to-nose. Sensation is tested for vibration, proprioception, temperature, and pain. Subtle signs can indicate conditions like stroke or multiple sclerosis.
6. MEMORY
• Immediate
– Really a measure of attention rather than memory
• Remote
• 3 objects at 0/3/5 minutes
• Historical events
• Personal events
Orientation
• Person
– Not who they are but who you are
• Place
• Time
8. CRANIAL NERVE EXAM
• I - olfactory
– Don’t use a noxious stimulus
– Coffee, lemon extract
• Ii - optic
– Visual acuity
– Visual fields
– Fundoscopic exam
9. CRANIAL NERVE EXAM
• Iii/iv/vi oculomotor, trochlear, abducens
– Pupillary response
– Eye movements
• 9 cardinal positions
– Observe lids for ptosis
• V - trigeminal
– Motor - jaw strength
– Sensory - all 3 divisions
– A lesion that effects C5 will usually effect all three segments
(ophthalmic, maxillary, & mandibular) so the exam light
touch on both cheeks. By cotton.
10. CRANIAL NERVES
• Vii - facial
– Observe for facial asymmetry
– Forehead wrinkling, eyelid closure, whistle/pucker
– Bell’s Palsy- Where the nerve is injured between pons &
face there is total facial paralysis i.e., weakness of a
corner of the mouth + closing the eye + wrinkling the
brow.
• Viii - vestibular
– Acuity
– Rinne, weber
– Rubbing your fingers together next to the patients ear.
11. CRANIAL NERVES
• Ix/x - glossopharyngeal, vagus
– GAG reflex check
• Xi - spinal accessory
– Sternocleidomastoid m.
– Trapezius muscle
• Xii - hypoglossal
– Tongue strength
– Right xii thrusts tongue to left
– stick out your tongue
– The tongue will deviate to the side of weakness.
13. STRENGTH
• Strength
– Graded 0 - 5
– 0 - no movement
– 1 - flicker
– 2 - movement with gravity removed
– 3 - movement against gravity
– 4 - movement against resistance
– 5 - normal strength
14. STRENGTH EXAM
• Upper and lower extremities
• Distal and proximal muscles
• Grip strength is a poor screening tool for strength
• Subtle weakness
– Toe walk, heel walk
– Out of chair
– Deep knee bend
15. Motor exam, cont
• Subtle signs of weakness on a cortical/subcortical
basis
– Pronator drift
– Orbiting
16. Gait evaluation
• Include walking and turning
• Examples of abnormal gait
– High steppage
– Waddling
– Hemiparetic
– Shuffling
– Turns en bloc
19. CEREBELLAR FUNCTION
• RAPID ALTERNATING MOVEMENTS
• FINGER TO FINGER TO NOSE TESTING
• HEEL TO SHIN
• GAIT
– TANDEM
20. Romberg Test
• Key test:
• Be sure to check orthostatic (B/P) for changes first
• Balance is maintained by vision, vestibular sense &
proprioception. These feed into the cerebellum either
directly or indirectly. If a patient sways with eyes open or
close it is considered +.
21. Coordination
• Key Test:
• Finger to nose & heel to shin motions
• Alternating rapid movements of hand & foot.
Examples of tapping thumb & index fingers
together, or heel on floor & tap toes on floor.
• Balance test- Tandem gait or Romberg test.
25. Reflexes
• Key tests:
• Triceps, biceps, knee jerk, Achilles & Babinski are the major
reflexes.
• Asymmetry is usually a sign of major pathology.
• Babinski- This points to a upper motor neuron lesion. A
positive test is when the lateral aspect of the foot is
scratched & the big toe dorsiflexes & the other toes fan out
31. Sensory Extremity Examination
• Key Test:
• Pain Sensation- Use simultaneous stimulation
(sharp, dull, etc.)
• Proprioception- Test big toe (position).
MS, neurosyphilis, & pernicious anemia may cause
loss of lower extremity proprioception.