This document provides guidance on performing a neurologic examination, including: 1. Assessing mental status, cranial nerves, motor function, reflexes, sensory system, cerebellar function, and meningeal signs in 3 pages of detailed instructions. 2. It outlines the specific tests, procedures, and grading scales for each component of the neurologic exam. 3. The neurologic exam assesses many areas of neurologic function through tests of mental status, cranial nerves, motor skills, reflexes, sensation, coordination, and signs of meningeal irritation.

1. NEUROLOGIC EXAMINATION
Second Year Anesthesia Physical Examination
Dr. Eyob. K(MD)

2. INSTRUMENTS
2
Measuring tape Otoscope
Stethescope 128-Hz tuning fork
Penlight 10 cc syringe, cotton wisp, 2 test tubes
Transparent mm ruler Disposable straight pins
Ophthalmoscope Reflex hammer
Tongue blades, Opaque vials of
coffee, salt and sugar
Coin, key, page of figures
BP cuff
8/4/2022 Dr. Eyob.k

3. APPROACH TO NEUROLOGIC
EXAMINATIONS
1. MENTAL STATUS EXAMINATION
2. CRANIAL NERVES
3. MOTOR
4. REFLEXES (DTRs, Superficial & released reflexes)
5. SENSORY (Primary and Cortical sensations)
6. COORDINATION, BALANCE & GAIT
7. MENINGEAL IRRITATION SIGNS
3
8/4/2022 Dr. Eyob.k

4. 1. MENTAL STATUS EXAMINATION
• GENERAL EXAMINATION
– Appearance – Gait and Posture
– Behavior – Facial expressions and acts, Dress, Grooming, and
Personal Hygiene
– Cognition – memory status
– Thought content (Flight of Ideas, Neologisms, Echolalia )
– Mood (sadness, joy, euphoria, and anger, anxiety)
• LEVEL OF CONSCIOUSNESS
• GLASGOW COMA SCALE /BCS/
• MINI MENTAL STATE EXAMINATION
4
8/4/2022 Dr. Eyob.k

5. Levels of Consciousness
5
8/4/2022 Dr. Eyob.k

6. Glasgow Coma Scale
6
8/4/2022 Dr. Eyob.k

7. Mini Mental State Exam
7
ORIENTATION
5 What are the day, date, month, season, and year?
5 Where are we? Country, state, city, hospital, floor?
REGISTRATION
3 Name three objects: 1 second to say each.
Then ask patient to repeat all three. Give 1 point for each correct
answer. Then repeat until all three are registered.
ATTENTION & CALCULATION
5 Serial 7s. One point for each correct. Stop after five answers.
Alternatively, spell WORLD backward.
RECALL
3 Ask for the three objects repeated above. Give 1 point for each
correct.
LANGUAGE
9 Name a pencil and a watch. (2 points)
Repeat the following: “No ifs, ands, or buts.” (1 point)
Follow a three-stage command: “Take a piece of paper in your
right hand, fold it in half, and put it on the floor.” (3 points)
Read and obey the following: “Close your eyes.” (1 point)
“Write a sentence” (1 point)
“Copy design” (1 point)
8/4/2022 Dr. Eyob.k

8. 2. CRANIAL NERVES
8
8/4/2022 Dr. Eyob.k

9. Cranial Nerve I
• RESPONSIBLE FOR SMELL
SENSATIONS
• Receptors located in the
upper 1/3 of the nasal
septum.
• Examination under
adequate light
• Avoid noxious substances
• Test each nostril separately
and Identify familiar odors.
9
8/4/2022 Dr. Eyob.k

10. Cranial Nerve II
• RESPONSIBLE FOR VISUAL SENSATION
• VISUAL ACUITY TEST!! a scaled version
of the Snellen chart , called the
Rosenbaum card held at 20 feet
distance.
– Ishihara Color Plates used to detect color
blindness
• VISUAL FIELDS
– Peripheral vision test : Confrontation &
Permetry
• FUNDOSCOPIC EXAMINATION
– Papilledema, Hemorrhages10
8/4/2022 Dr. Eyob.k

11. • Cranial Nerves II and III— pupillary reactions to light
• Cranial Nerves III, IV, and VI —Oculomotor, Trochlear, and Abducens.
Test the extraocular movements
8/4/2022 Dr. Eyob.k 11

12. Cranial Nerve V
• SENSORY
– Ophthalmic branch (sensory)
• Conjunctiva, Ciliary body, nasal cavity, sinuses, skin of
eyebrows/forehead/
– TEST CORNEAL REFLEX
– Maxillary branch (sensory)
• Side of nose, lower eyelid, upper lip
12
8/4/2022 Dr. Eyob.k

13. – Mandibular branch (mixed)
• Sensory – skin of jaw regions,
auricles, lower lip, anterior 2/3 of
tongue, mandibular gums/teeth
– TRIGEMINAL SENSATIONS
• Motor – innervation to the
muscles of mastication
• Corneal Reflex
13
8/4/2022 Dr. Eyob.k

14. Cranial Nerve VII
• MOTOR INNERVATION
– Note any asymmetry
– Muscles of the face, scalp, and
ears
– Tested by Elevation of eyebrows
,Close eyes, teeth Show, Whistle
and Smile
14
8/4/2022 Dr. Eyob.k

15. Cranial Nerve VIII
• Composed of the COCHLEAR & VESTIBULAR
NERVES
• Responsible for sense of hearing and balance
:Romberg test/sign
• Test hearing and Otoscopic Examination
15
8/4/2022 Dr. Eyob.k

16. 16
CONDUCTIVE LOSS SENSORINEURAL LOSS
Distortion of sound Minor Present with loss of upper
tones
Noisy environment Hearing may seem to improve Hearing typically worsens
Patient’s voice Generally normal* Loud
Ear canal/TM Visible abnormality Normal
Weber Lateralizes to the impaired ear Lateralizes to the normal ear
Rinne BC > AC AC > BC
8/4/2022 Dr. Eyob.k

17. CN IX and X
• These tests will evaluate certain structures in the
mouth.
• Ask the patient to say "aah" and can detect abnormal
position of certain structures such as the palatel-uvula.
• The examiner will also assess the sensation capabilities
of the pharynx, by stimulating the area with a wooden
tongue depressor, causing a gag reflex.
17
8/4/2022 Dr. Eyob.k

18. Cranial Nerve IX
• MOTOR innervation to
– Muscles of the pharynx
• SENSORY
– Pharynx, tonsils, TM
• CHECK FOR
– Elevation of the uvula
– Gag reflex
18
8/4/2022 Dr. Eyob.k

19. Cranial Nerve X
• Motor, autonomic, and sensory functions
– Palate, pharynx, larynx
• Motor and sensory branches to – Pharynx ,Larynx
and soft palate
• Examination of the vocal cords ;Lesions cause:
– Hoarseness/aphonia/
– Dyspnea/stridor/
19
8/4/2022 Dr. Eyob.k

20. Cranial Nerve XI
• Provides motor to
– SCM
– Upper Trapezius
• Testing:
– Shoulder shrug against resistance
– Head rotation and movement against resistance
20
8/4/2022 Dr. Eyob.k

21. Cranial Nerve XII
• Motor innervation to tongue test
for:
– Tongue positions : Midline or
deviation
– Tongue movements: Tremors or
fascullations
– Atrophy
– Lingual speech
21
8/4/2022 Dr. Eyob.k

22. 3. MOTOR FUNCTION
• INSPECTION
– Position
– Symmetry
• Muscle bulk; size and unilateral or bilateral; proximal or
distal
• Atrophy
– Involuntary Movements
• PALPATION
– Muscle Tone
• Normotonic, Hypotonic or Hypertonic
• Feel muscle’s resistance to passive movement /stretch
22
8/4/2022 Dr. Eyob.k

23. • PERCUSSION
– Fasciculation
• MUSCLE STRENGTH
– Test by asking patient to actively resist movements
23
8/4/2022 Dr. Eyob.k

24. Grading Muscular Response
24
8/4/2022 Dr. Eyob.k

25. 25
8/4/2022 Dr. Eyob.k

26. 26
8/4/2022 Dr. Eyob.k

27. 4. SPINAL /DTRs/ REFLEXES
• 3 TYPES OF REFLEXES
– DTRs (e.g. knee reflexes)
– Superficial (abdominal, plantar and Cremasteric reflex),
Anal Reflex (S2,3,4)
– Visceral (Pupillary response to light)
27
8/4/2022 Dr. Eyob.k

28. Triceps Reflex
28
C6, C7, C8
Elbow
Extension
8/4/2022 Dr. Eyob.k

29. Biceps Reflex
29
C5,C6
Elbow Flexion
8/4/2022 Dr. Eyob.k

30. Brachioradialis Reflex
30
C5, C6
Forearm semi-flexion/semi-pronation
(NO wrist/hand flexion)
8/4/2022 Dr. Eyob.k

31. Patellar Reflex
31
L2, L3, L4
Knee Extension
8/4/2022 Dr. Eyob.k

32. Achilles Reflex
32
S1, S2
Ankle Plantar Flexion
8/4/2022 Dr. Eyob.k

33. Jendrassik’s Maneuver
• If the patient’s reflexes are
symmetrically diminished or
absent, use reinforcement
technique
• Upper extremities
– clench teeth
– squeeze thigh
• Lower extremities
– lock fingers and pull one against
the other
33
8/4/2022 Dr. Eyob.k

34. 8/4/2022 Dr. Eyob.k 34
• Clonus
• If the reflexes seem hyperactive, test for ankle clonus

35. Superficial Reflexes
Abdominal Reflexes
35
T8, T9, T10:
ABOVE
umbilicus
T10, T11, T12:
BELOW
umbilicus
8/4/2022 Dr. Eyob.k
Anal Reflex.

36. Plantar Reflex
36
L5, S1, S2
Babinski's
Sign
8/4/2022 Dr. Eyob.k

37. Deep Tendon Reflexes: Grading
• Grade DTR Response
• 4+ Very brisk, hyperactive, with
Clonus
• 3+ Brisker than average, slightly
hyperreflexic
• 2+ Average, expected response;
normal
• 1+ Somewhat diminished, low normal
• 0 No response, absent
37
8/4/2022 Dr. Eyob.k

38. Recording the Examination
38
8/4/2022 Dr. Eyob.k

39. 5. SENSORY SYSTEM
• With eyes closed
– Interpret sensations
– Discriminate side to side
• Examine in detail if:
– Reduced sensation
– Numbness or pain
– Motor or reflex abnormal
– Skin changes
• Be specific: “tell me where I touch”
39
8/4/2022 Dr. Eyob.k

40. Sensory Function Tests
• Touch
– Light touch 1st then Pain
& T°
• Vibration
• Position Sense
– Proprioception
• Cortical Sensations
– Stereognosis
– Graphesthesia
– 2-point discrimination
• Light Touch
40
8/4/2022 Dr. Eyob.k

41. • Vibration
41
8/4/2022 Dr. Eyob.k

42. • Proprioception: Position Sense
42
8/4/2022 Dr. Eyob.k

43. • Cortical Sensations: Stereognosis
43
8/4/2022 Dr. Eyob.k

44. • Graphesthesia
44
8/4/2022 Dr. Eyob.k

45. • Two-point discrimination
45
8/4/2022 Dr. Eyob.k

46. 6. CEREBELLAR FUNCTION
• Requires integration of:
– Motor system
– Cerebellar system
– Vestibular system
– Sensory system
• Assessed by:
– Rapid alternating
movements
– Finger-to-Nose / Heel-
to-Knee Test
– Romberg’s Test
– Gait
46
8/4/2022 Dr. Eyob.k

47. Gait
47
Heel Walk L4/L5
Hop on one foot
Heel & toe walking
Stepping up on stool L3-
Walk across room,
turn and walk back
8/4/2022 Dr. Eyob.k

48. Finger-to-Nose Test
48
Finger-to-nose with moving target
Stationary finger-to-nose and
Finger-to-nose with eyes closed
8/4/2022 Dr. Eyob.k

49. Heel-to Sheen-Knee Test
49
8/4/2022 Dr. Eyob.k

50. Rapid Alternating Movements
50
8/4/2022 Dr. Eyob.k
Dysdiadochokinesis = slow, irregular, clumsy movements

51. Romberg’s Test
51
8/4/2022 Dr. Eyob.k
Station & Stance
Pt stand with feet together
First, eyes open
Romberg Test
Then, close eyes
If okay with eyes open, but sways with
eyes closed = + Romberg
Vision can compensate for loss of
position sense
Be prepared to protect client from
falling!

52. Pronator Drift
52
8/4/2022 Dr. Eyob.k
Often performed in conjunction with
Romberg test
PRONATOR DRIFT
Muscular strength
Coordination
Position sense

53. 7. MENINGEAL IRRITATION
• Neck stiffness
– Flex the head Marked pain in the neck
• Brudzinski’s Sign
– Passive flexion of the head flexion of
knees and hips
• Kernig’s Sign : flexion of hip with
sudden extension of knee
– Pain sensation in the cuff muscles.
53
8/4/2022 Dr. Eyob.k

54. • Straight-Leg Raise - Lumbosacral Radiculopathy
8/4/2022 Dr. Eyob.k 54

55. • Asterixis
8/4/2022 Dr. Eyob.k 55