The document discusses the neurologic exam. It covers neuroanatomy, central vs peripheral lesions, upper motor neuron vs lower motor neuron deficits. It then discusses the different components of the neurologic exam including mental status, cranial nerves, motor exam, sensory exam, coordination, and reflexes. It provides examples of different clinical scenarios and focuses on localizing lesions based on exam findings.

1. The Neurologic Exam
by
Dr. Rajaneesh kumar

2. Overview
 Neuroanatomy
 History
 Physical
 Clinical Scenarios

3. Introduction
Facilitates Communication
Provides Baseline
Directs Testing
Identifies Need For Life-Saving Therapies
Risk Management

4. Neuroanatomy
 Central versus peripheral
 symmetrical vs asymmetrical
 If central, what is the level:
 Cerebrum
 Brain Stem
 Spinal cord
 If peripheral, is it
 Nerve
 Muscle
 NMJ

5. Neuroanatomy

6. Central lesions
 Lesions in the cerebral cortex result in contralateral
deficits of the face and body
 Lesions at the midbrain result in contralateral
hemiplegia and ipsilateral peripheral paralysis of
III and IV
 Lesions at the pons result in contralateral hemiplegia
and ipsilateral deficits of V, VI, VII, VIII
 Lesions at the medulla result in contraleral
hemiplegia and ipsilateral deficits of IX, X, XI, XIII

7. Anatomy of the Spinal Cord
Corticospinal Tracts: motor from
cerebral cortex: cross in the lower
medulla
Spinothalamic Tracts: pain and
temperature: cross 1 or 2 levels
above entry
Posterior Column: proprioception
and vibration

8. Spinal Cord : Vascular Supply
 Single Anterior
 Paired posterior from vertebral arteries (Except in
cervical cord)
 Radicular Arteries from aorta:
 Varying degrees of contribution
 Great radicular artery of Adamkiewicz T-10 to L-2 (Major
source of blood flow to 50% of anterior cord in 50% of
patients)
 Anterior perfuses anterior and central cord

9. UMN vs LMN
 UMN increased DTR (after SS) LMN decreased DTR
 UMN muscle tone increased
LMN tone decreased, atrophy
 UMN no fasciculations LMN fasciculations

10. UMN vs LMN Weakness
 Myelopathy = Spinal Cord Process = UMN findings
(spasticity, weakness, atrophy, sensory findings,
bowel and bladder complaints)
 Radiculopathy = Nerve Root Process = LMN
findings (Paresthesias, Fasciculations, Weakness,
decreased DTR)
 Patient may have a radiculopathy with mylopathy
below the lesion

11. The Neuro Exam: History
 Neuro complaints may be primary or secondary to other system
disease
 Infection
 Overdose
 Metabolic Disorder

12. The Neuro Exam: History
 History often provides the key since the neuro exam may be
normal
 Subarachnoid Hemorrhage
 Carbon Monoxide Poisoning
 Subdural Hematoma
 Nonconvulsive Seizures

13. The Neuro Exam: History
 Time of Onset
 Type of Onset
 Progression
 Trauma
 Associated Symptoms

14. The Neuro Exam: History
 Factors that make it better/worse
 Past Symptoms / Events
 Past Medical History
 Occupational / Environ Exposures

15. The Neuro Exam: Physical
Vital Signs
Head: Evidence of Trauma
Neck: Bruits, Rigidity
Heart: Murmurs
Abdomen: Masses / Distention
Skin / Scalp: Lesions / Tenderness

16. The Neuro Exam: Physical
Mental Status
Cranial Nerves
Motor
Sensory
Coordination
Reflexes

17. The Neuro Exam: Initial Approach
 Posture
 Decorticate
 Decerebrate
 Facial or body asymmetry
 Hemiparesis results in external rotation of the foot of the affected side

18. Mental Status Exam
 GCS
 Orientation
 Speech (dysarthria vs aphasia)
 Comprehension

19. Mental Status Exam
 Confusion assessment method (CAM)
 Acute onset / fluctuating course
 Inattention
 Disorganized thinking
 Altered level of consciousness
 Mini-mental status exam
 Score affected by education and age
 <20 = cognitive impairment

20. Acute Altered Mental Status
Intracranial lesion
Metabolic disorder
Toxin
Infection
Ictal state
Postictal state
Psychogenic

21. Cranial Nerve Exam
 Focus exam on II - VIII
 Symmetrical vs asymmetrical

22. Evaluation of II, III, IV, VI
 Visual acuity
 Visual fields
 Examine the cornea, pupil, fundi
 Check afferent function
 Extraocular movements
 Accentuated when looking in the direction of the
paralyzed muscle
 Differentiation can be facilitated by placing a colored
glass over one eye

23. Cranial Nerve II
 Visual acuity
 Visual fields
 Fundoscopy
 Swinging flashlight test

24. III Nerve
 Emerges from brainstem next to posterior cerebral artery
 May be compressed by herniation
 Runs in the lateral wall of the cavernous sinus

25. LR MR MR LR
IO IO SRSR
IR SO SO IR
III Cranial Nerve
 Parasympathetics
 Levator Palpebrae
 Inferior Obliques, Medial, Inferior, and Superior Rectus Muscles

26. LR MR MR LR
IO IO SRSR
IR SO SO IR
III Cranial Nerve Paralysis
Ptosis
Dilated Pupil
Paralyzed eye is deviated out and down;
SO and LR control eye

27. III Cranial Nerve Lesions
 Progressive lesions after passage
through the dura usually usually
causes a ptosis and pupil dilatation
first
 Lesions in the nucleus cause motor
deficits first
 Intact pupil indicates a peripheral
ischemic lesion

28. LR MR MR LR
IO IO SRSR
IR SO SO IR
IV Cranial Nerve
 Superior oblique
 Causes eye to turn in and down
 When paralyzed, eye can not turn down when it is rotated in

29. LR MR MR LR
IO IO SRSR
IR SO SO IR
VI Cranial Nerve
 Lateral rectus
 Long course; goes through the cavernous sinus, not within the wall
 Paralysis impairs abduction

30. Conjugate Gaze
Controlled by supranuclear
connections
Medial longitudinal fasciculus is
responsible for coordinating the
oculomotor nerves; lesions result in
impairment of LR and MR moving in
synchrony, ie, contralateral eye
does not pass the midline
Multiple sclerosis

31. Causes of III, VI, VI CN Paralysis
 Isolated cases usually due to vascular causes:
HTN, DM, Atherosclerosis
 Tumors
 Increased intracranial pressure
 Colloid cyst of the III ventricle
 Wernicke-Korsakoff syndrome
 Myasthenia, Botulism
 Toxic drug reactions

32. Cranial Nerve V
 Sensory: corneal reflexes
 Motor: jaw strength and muscle bulk
 Corneal reflex may be abnormal in cerebellopontine angle
lesions: test in patients with hearing deficits or vertigo

33. Cranial Nerve VII
 Motor
 Smile
 Nasolabial fold
 Forehead has bihemispheric innervation centrally
 Taste anterior 2/3

34. Cranial Nerves VIII - XII
 VIII - vestibular function / hearing
 IX & X - taste / sensation posterior pharynx, bulbar muscles
 XI – Sternocleido mastoid, chin to opp. side
 XII - tongue

35. Motor Exam
 Strength
 Primary concern: can patient breathe
 Key test: drift of extremity
 Tone
 Hypertonia: subacute or chronic corticospinal lesion
 Hypotonia: LMN lesion or acute UMN
 Rigidity: basal ganglia disease

36. Motor Exam
Bulk
Wasting correlates with LMN
Fasciculation
Anterior horn cell lesion
Tenderness
Metabolic / inflammatory muscle
disease

37. Motor Exam
0 = no movement
1 = flicker but no movement
2 = movement but can not resist gravity
3 = movement against gravity but can not
resist examiner
4 = resists examiner but weak
5 = normal

38. Sensory Exam
Pain / Temp - cross at entrance,
ascend in spinal thalamic tract
Light touch - ascend in posterior
column, cross in the brain stem
Vibration - posterior column, cross
in the brain stem
Cortical sensations

39. Sensory Exam
 Dermatomal deficit accompanied with pain suggests peripheral
lesion
 Central deficits are not dermatomal and usually result in loss of
sensation not pain
 Thalamic pain syndrome

40. Sensory Exam
Distribution
Right vs left vs bilateral
Dermatomal
Distal versus proximal
Stocking glove
Cape like
Pinprick versus light touch

41. Sensory Exam
Double simultaneous testing
Establish sharp / dull
Check cheek, dorsum of hands, dorsum of feet
Test both sides simultaneously with pin
lateralizes pain, significant sensory deficit
initially no lateralization but on repeat 15 sec later,
lateralization suggests subtle deficit

42. Coordination
 Requires integration of cerebellar, motor, and
sensory functions
 Balance requires (2 of 3)
 vision
 vestibular sense
 proprioception
 Falling with eyes open or closed = cerebellar
 Falling only with eyes closed = posterior column
or vestibular

43. Reflexes
 Symmetry / upper vs lower
 0 = absent
 1 = hyporeflexia
 2 = normal
 3 = hyperreflexia
 4 = clonus (usually indicates organic disease)
 Superficial reflexes (corneal, pharyngeal,
abdominal, anal, cremasteric, bulbocavernosus)
 Pathologic reflexes: babinski

44. Hysteria
(conversion vs malingering)
 Blindness: opticokinetic test
 Hand drop on face test for coma
 Hemianesthesia: if real, patient cannot perform
finger-to nose with eyes closed; vibration remains
intact (if bony skeleton intact)
 Weakness: elbow extension or flexor test; wrist
extensor test
 Unilateral leg elevation weakness: thigh abduction
test, hoover test

45. Pitfalls In The Neurologic Exam
Not getting a complete history utilizing
family or observers
Not performing a systematic exam
Jumping to conclusions before gathering all
the data
Misinterpreting old lesions for new
Misinterpreting limitations from pain as
neurologic deficits

46. Pearls
Lesions of the cerebral cortex result in
sensory and motor defects confined to the
contralateral side of the body
Brain stem and spinal cord lesions result in
ipsilateral as well as contralateral defects
due to varying patterns of crossover

47. Pearls
 Unilateral pain syndromes without motor
deficits suggest possible thalamic
pathology
 A careful exam of CN II, III, IV, and IV is
indicated in patients with headache or
suspected processes that cause increased
ICP
 Testing for pronator drift is the best
screen for muscle weakness of central
origin

48. The Neurologic Exam
Case Scenarios

49. Case Scenario #1
A 46-year-old female with a long
history of migraine headaches
presented c/o a severe occipital head
ache that was different from her past
headaches in location and intensity.
If an aneurysm is suspected to be
causing the patient’s symptoms,
which cranial nerve should your exam
focus on?
A. III B. VI C. VII D. IV

50. III NERVE
Emerges from brainstem next to posterior cerebral
artery
Runs in the lateral wall of the cavernous sinus
May be compressed:
Herniation
Aneurysm
Posterior communicating artery
ICA in the cavernous sinus (IV, V and VI nerves
also involved)

51. Case Scenario #2
A 64-year-old male presented C/0 low
back pain which has become
progressively worse over the past 2
weeks. The pain was primarily in the
low back without radiation; C/O
nonspecific numbness in the legs.
Which nerve root is responsible for
plantar flexion and the ankle jerk?
A. L3 B. L4 C. L5 D. S1 E. S2

52. Lower Extremity Innervation
 L 3 / L 4 = Patellar reflex
 L 5 = Big toe extension
 S 1 = Achilles reflex

53. Case Scenario #3
A 30-year-old female is in an accident hitting her
head on the dash. The next day she developed a
sudden onset severe right frontal head ache, that
persisted. One day later she developed left sided arm
weakness that lasted 2 hours. In the ER she had an
OD ptosis and OD miosis. Her motor / sensory exam
was “WNL”. What is your initial impression?
A. Hysteria B. Subarachnoid bleed
C. Epidural hematoma D. Carotid artery dissection
E. Entrapment syndrome

54. Pupil Constriction
Disruption of the sympathetics
Horner’s
Carotid artery dissection
Pontine hemorrhage
Toxins
Narcotics
Cholinergics

55. Case Scenario #4
A 50-year-old female c/o a diffuse headache for two
months that is constant. There is no past head ache
history. She claims that intermittently her vision seems
blurred but otherwise denies symptoms. On exam: VA:
20/40.
Cranial Nerves: diplopia on far lateral gaze bilaterally.
Which of the following is the most likely diagnosis.
A. Occipital Lobe Stroke B. Pituitary Adenoma
C. Multiple Sclerosis D. Myasthenia Gravis
E. Intracranial Hypertension

56. Idiopathic Intracranial Hypertension
(Benign Intracranial
Hypertension, Pseudotumor Cerebri)
 Syndrome Defined By Signs And Symptoms Of High ICP
Without Apparent Intracranial Mass
 50% Have An Identifiable Underlying Etiology
 Altered Absorption Of CSF At The Arachnoid Villus
 Alteration Due To Either:
 Elevated Pressure Within The Sagittal Sinus
 Increased Resistance To Drainage Of CSF Within The Villus

57. Physical Findings
Papilledema
Visual disturbance 50 - 80%
Blindness in 10%
Decreased visual acuity 30%
Transient visual obscuration 68%
Enlarged blind spot
Scotomas
VI nerve palsy (false localizing) 38%

58. Case Scenario #5
A 20-year-old college student flips his car, hitting head on
the dash. He arrives in the ER in full spinal immobilization.
On exam he has 2/5 strength in his wrists, 3/5 strength in
his deltoids, 5/5 strength in his Leg Extensors. He
complains of numbness in his arms but is able to distinguish
sharp from dull. DTRs intact. What is your leading
diagnosis?
A. Central Cord Syndrome B. Anterior Cord Syndrome
C. Spinal Epidural Hemorrhage D. Subdural Hemorrhage
E. Brown - Sequard Syndrome

59. Central Cord Syndrome
 Hyperextension injuries, tumor, syringomyelia
 Paresis or plegia of arms > legs
 Posterior column spared

60. Central Cord Syndrome
 sacral sparing
 Perforating branches of anterior spinal artery at greatest risk
for vascular insult
 Good prognosis

61. Case Scenario #6
A 23-year-old female presents complaining of feeling
generally weak with the sensation that she is dragging
her feet when she walks. On exam her sensation is
intact; motor strength is 5/5 in all major muscle
groups; deep tendon reflexes are 2/2 in the Upper
limb, 2/2 at the knees, and and 0/2 at the ankles.
What is your major concern?
A. Spinal Stenosis B. Conus Medularis
C. Guillian Barre D. Polymyalgia Rheumatica
E. Myasthenia Gravis

62. Guillain-Barre
Acute polyneuropathy
Symmetric ascending weakness
Arrflexia (LMN)
No meningeal signs, fever, signs of
systemic illness
CSF: increased protein without
pleocytosis

63. Case Scenario #7
A 30-year-old male with AIDS complains of diffuse weakness
that is progressive in the Lower limbs associated with
paresthesias; there is no back pain. On exam he has 4/5 upper
extremity strength, 2/5 lower extremity strength; DTRs are
2/2 in the Upper limbs and 4/2 in the Lower limbs. His
plantar reflexes are upgoing bilaterally.
Which of the following is the most likely diagnosis?
A. Myelopathy B. Neuropathy C. Myopathy
D. Neuromuscular Junction Disease
E. Radiculopathy

64. HTLV-1 Associated Myelopathy
Progressive lower extremity weakness
(arms more than legs)
Spasticity
Paresthesias are common; sensory deficits
are rare
Symmetric upper motor neuron paraparesis
Sphincter disturbances

65. Risk Management: Case #1
 A 46-year-old female with a long history of
migraine headaches presented c/o a severe
occipital head ache that was different form her
past headaches in location and intensity. Neuro
exam “WNL”. Patient was treated with
Compazine, 10 MG IV, with “Resolution of
Headache” and discharged home to
“Follow-Up With doctor”.
 18 hours later, patient was brought in by
EMR comatose

66. Risk Management: Case #2
 A 64-year-old male presented with lower back pain which
had become progressively worse over the past 2 weeks. The
pain was primarily in the lower back without radiation, with
nonspecific numbness in the legs.
 Past h/o: presently being treated for prostatitis.
 Exam: “Mild Paralumbar Tenderness”, “SLR -”, “Motor /
Sensory Intact”, Knee DTR +2. patient was prescribed
Motrin and told to follow-up with his doctor.
 Patient developed irreversible renal damage.