Complete Neurologic Examination

1. The Neurologic
Examination

2. Objectives
 Understand the Basic Concepts of Neurologic
Examination
 Learn the Different Parts of Neurologic Examination
 Familiarize the techniques of Eliciting
Abnormalities

3. Outline
 Basic Concepts of Neurologic Examination
 Mental Status Examination
 Cranial Nerve Examination
 Motor Examination
 Sensory Examination
 Examination of the Reflexes
 Cerebellar Examination
 Miscellaneous Examination

4. Neurologic Examination
 The cornerstone in the evaluation of Neurologic
patients

5. Goals
 To facilitate communication
 To provide a baseline examination
 To direct testing and guide the physician on what
laboratory tests to request for the patients.
 To localize the lesion

6. Instruments for a Neurologic
Examination
 Must have:
 Pocket Snellen chart
 Neurologic hammer
 Pen light
 Disposable pin/toothpicks/cotton
 Tongue Depressor
 Tuning Fork (128 or 256 cps)
 Stethoscope
 BP Apparatus
 Ophthalmoscope
 Otoscope

7. Guidelines
 Perform the Neurologic Examination in an orderly
fashion
 Finish the examinations for one system before
starting another
 Always examine the left and the right side of the
body and compare
 Compare the proximal against the distal findings

8. Three Basic Steps
 Data Gathering
 Anatomic Localization
 Etiologic Diagnosis

9. Parts of Neurologic Examination
 Mental Status
 Cranial Nerves
 Motor Exam
 Sensory Exam
 Reflexes
 Cerebellar Function
 Miscellaneous

10. I. Mental Status Examination
 During history taking
 Formal cerebral function tests
 Mini-Mental State Exam

11. I. Mental Status Examination
 Frontal: Sensorium, Speech, Ability to follow
commands, Attention Span, Insight and Judgement,
Fund of Knowledge
 Parietal: Left/Right Orientation, finger agnosia,
Calculation, writing, stereognosis, graphesthesia,
hemineglect, Praxis
 Temporal: Orientation to time/place/person, Memory,
Comprehension
 Occipital: Ability to Identify familiar faces, colors and
Objects

12. II. Cranial Nerve Exam
 I. Olfactory: test one nostril at a time with eyes closed.
Avoid alcohol as a test material, Use (Vanilla, Coffee,
Tobacco)
 II. Optic: Visual Acuity (with and without glasses),
visual field examination, Fundoscopy (fundus, disc,
vessels, venous pulse, retina)
 II, III Reaction to light, direct and consensual
 III, IV, VI Oculomotor, Trochlear, Abducens Primary
gaze, Extra Ocular Muscle Movement

16. Cranial Nerve Exam
 V. Trigeminal Sensory on V1-V2-V3 Motor - jaw
movement (masseter, pterygoids)
 V, VII Corneal Reflex
 VII. Facial – motor - raise eyebrows, close eyes, show
teeth; sensory - taste (ant. 2/3 of tongue)

17. II. Cranial Nerve Exam
 VIII. Auditory –Rubbed fingers, Tuning fork tests -
Weber’s, Rinne’s, Schwabach’s
 IX, X. Glossopharyngeal, Vagus - gag, swallowing,
uvula, hoarseness, taste (posterior 1/3 of tongue)

18. II. Cranial Nerve Exam
 XI. Spinal Accesory - raise shoulders, turn head
against resistance
 XII. Hypoglossal - tongue deviation, atrophy,
fasciculation,

19. III. Motor Exam
 Strength: uppers and lowers, left and right, distal and
proximal
upper: proximal - arms outstretched, distal - grasp
lower: ask patient to walk, proximal - rise from chair,
distal - tiptoe

20. Scale in grading muscle
strength
0 No movement
1
Flicker or trace of contraction but no
associated movement at a joint
2 Movement with gravity eliminated
3
Movement against gravity but not against
resistance
4- Movement against a mild degree of resistance
4 Movement against moderate resistance
4+ Movement against strong resistance
5 Full power

21. III. Motor Exam
 Tone - passive movement; Increased: spasticity,
rigidity; Normal, Decreased: hypotonia
 Inspection - atrophy, fasciculations, tenderness or
hypertrophy and any involuntary movements

22. IV. Sensory Exam
 Touch
 Pin
 Position sense
 Vibration sense
 Temperature
 Graphesthesia
 Stereognosis
 Two-point discrimination
 Lateralization: double
simultaneous stimulation
 Romberg’s

23. V. Reflexes:
 DTRs
 biceps (C5-C6)
 triceps (C7-C8)
 brachioradialis (C6-C7)
 knee (L2-L4),
 ankle (S1-S2),
 Primitive - snout, suck, grasp
 Babinski, Hoffman’s

24. Grading Reflexes
Grade Description
4+
3+
2+
1+
0
Hyperactive (with clonus)
Brisker than average, not necessarily
Abnormal
Average, normal
Diminished, low normal
No response

25. VI. Cerebellar Function
 Coordination: finger-to-nose, alternating pronation-
supination, hand patting, finger tapping
Nystagmus
Tremor
 Gait and Stance
* stand with feet together with eyes open
* normal walking
* tandem walk

26. VII. Miscellaneous:
 Examination of head and spine: Inspection of the
neck and spine, straight-leg raising sign
 Meningeal signs: Neck rigidity, kernigs, brudzinski
 Carotids: bruits, palpation

27. Preceptorial Group Activity
 Form into 7 groups
 Each group is assigned a specific part of neurologic
exam to perform.
 Group I: Mental Status Examination
 Group II: Cranial Nerves I, II, III, IV, V, VI
 Group III: Cranial Nerves VII, VIII, IX, X, XI, XII
 Group IV: Motor Examination
 Group V: Sensory Examination
 Group VI: Reflexes
 Group VII: Cerebellar Examination
 Assign a Group leader

28. Preceptorial Group Activity
 Make a Video Clip on how you perform the assigned
Neurologic Examination
 Criteria: Mastery and Content 50% Creativity 30%
Participation of members 10% Submission on time 10%
 Due on March 19, 2021
 To be submitted in a Google drive together with all the
groups