2. Neurologic Examination

Neurologic Examination

Stephen Jo T. Bonilla, RN, MD Department of Surgery St. Luke’s Medical Center

Neurologic Examination  Mental

Status Examination  Cranial Nerves  Motor System  Sensory System  Cerebellar System  Reflexes

Mental Status Examination  Appearance

and behavior  Speech and language  Mood  Thoughts and perceptions  Cognitive functions - Memory - Attention - Information & vocabulary - Calculations - Abstract thinking - Constructional ability

Appearance and Behavior  Level

of Consciousness  Posture and Motor Behavior  Dress, Grooming, and Personal Hygiene  Facial Expression  Manner, Affect, and Relationship to Persons and Things

Level of Consciousness  Alert

- speak to px in a normal tone of voice - opens eyes, looks at you, responds fully & appropriately  Lethargy - speak in a loud voice (“How are you?”) - drowsy, opens eyes, looks at you, responds to questions and falls asleep

Level of Consciousness  Obtundation

- shake the px gently as if awakening a sleeper - opens eyes, looks at you, responds slowly, & is somewhat confused  Stupor - apply a painful stimulus (rub the sternum)  Coma - apply repeated painful stimuli - remains unarousable w/ eyes closed

Posture and Motor Behavior  Does

the px lie in bed or walks around?  Note body posture and ability to relax  Observe pace, range & character of movements  Voluntary control?  Are certain parts immobile?

Dress, Grooming, and Personal Hygiene  Grooming

& personal hygiene may deteriorate in depression, schizophrenia, & dementia  Excessive fastidiousness may be seen in an obsessive-compulsive disorder  One-sided neglect may result from a lesion in the opposite parietal cortex, usually the non-dominant side

Facial Expression  Observe

the face, both at rest & when interacting with others  Are they appropriate?  Anxiety, depression, apathy, anger, elation  Facial immobility of parkinsonism

Manner, Affect, and Relationship to Persons and Things  Assess

the patient’s affect & its appropriateness

 Blunt  Flat  Does

the patient seem to hear or see things that you do not?  Does the patient seem to be conversing with someone who is not there?

Speech and Language    

Quantity Rate Loudness Articulation of words - Dysarthria – defect in the muscular control of speech apparatus (lips, tongue, palate or pharynx) (nasal, slurred, or indistinct) - Aphasia – disorder in producing or understanding language - Aphonia – loss of voice accompanying disease affecting the larynx or its nerve supply - Dysphonia – less severe impairment in volume, quality or pith of voice

Aphasia Wernicke’s (receptive) - fluent, rapid, effortless - articulation are good but sentences lack meaning - impaired word/reading comprehension, repetition, naming, writing - posterior superior temporal lobe

Broca’s (expressive) - nonfluent, slow, laborious - articulation are impaired but words are meaningful - impaired repetition & writing - fair word/reading comprehension - posterior inferior frontal lobe

Testing for Aphasia  Word

comprehension - “point to your nose” - “point to your eye, then knee”  Repetition - “ask px to repeat a phrase (“no ifs, ands, or buts”)  Naming - parts of a watch  Reading comprehension - read a paragraph aloud  Writing - write a sentence

Speech and Language  Fluency

- rate, flow, melody of speech, content & use of words - hesitancy & gaps - monotonous - circumlocutions (phrases or sentences are substituted for a word the person can not think of) - paraphasia – words are malformed (“I write w/ a den”); wrong (“I write w/ a beer”); or invented (“I write w/ a zar”)

Mood  Sadness  Contentment  Joy  Euphoria  Anger  Anxiety  Attachment

Thought and Perceptions  Thought

Processes - logic, relevance, organization, & coherence  Circumstantiality  Derailment (Loosening of Associations)  Flight of Ideas  Neologisms  Blocking  Confabulation  Perseveration  Echolalia  Clanging

Thought Content  Compulsions  Obsessions  Phobias  Anxieties  Feelings

of Unreality  Feelings of Depersonalization

Thought Content  Delusions

- persecution - grandiosity - jealousy - reference - being controlled - somatic

Perceptions  Illusions  Hallucinations

Insight and Judgment  Insight

- “what seems to be the problem?”  Judgment - process of forming an opinion or evaluation about something - “how do you plan to get the help you’ll need after leaving the hospital?”

Cognitive Functions  Orientation

- time - place - person  Attention - digit span - serial 7s - spelling backward

Cognitive Functions  Memory

(ability to register, store, & retrieve information) - immediate - recent (short-term) - remote (long term) - retrograde, antegrade, psychogenic amnesia)  New Learning Ability

Higher Cognitive Functions  Information

and Vocabulary  Calculating ability  Abstract thinking - proverbs - similarities  Constructional ability - ability to reproduce figures or draw a figure on command

Cranial Nerve Examination I Olfactory II Optic III Oculomotor IV Trochlear V Trigeminal Ophthalmic Maxillary Mandibular VI Abducens VII Facial

Se Se Mo Mo Mi

VIII Vestibulocochlear IX Glossopharyngeal

Se

X Vagus

Mi

XI Accessory XII Hypoglossal

Mo Mo

Mo Mi

Mi

Smell Vision EOM except lateral rectus & sup oblique; pupil & ciliary muscle of lens Sup oblique muscle (S) Cornea, nasal mucous membrane, skin of face & scalp (S) Skin of face, mucous membrane of mouth & nose, teeth (M) Muscles of mastication; (S) skin of face, mouth, teeth Lateral rectus muscle (M) Muscles of facial expression; (S) taste (ant 2/3 of tongue); lacrimal, submandibular & sublingual glands Equilibrium Hearing (M) Stylopharyngeus muscle; (S) taste (post 1/3 of tongue); pharynx; parotid gland (S) External meatus, pharynx, larynx, aortic sinus, thoracic & abdominal viscera; (M) pharynx & larynx Trapezius, SCM, muscles of pharynx & larynx Muscles of tongue

Cranial Nerves  I:

Olfactory - present patient w/ familiar & nonirritating odors (coffee, soap, vanilla) - with eyes closed, test each nostril one at a time & ask px to identify

Cranial Nerves  II:

Optic - inspect both optic fundus (optic disc) w/ ophthalmoscope - check visual fields by confrontation test

Cranial Nerves  III:

Oculomotor - pupillary reactions to light

Cranial Nerves  III:

Oculomotor  IV: Trochlear  V: Abducens

Cranial Nerves  V:

Trigeminal - Motor (palpate temporal & masseter muscles while patient clenches teeth) - Sensory (light touch & corneal reflex)

Cranial Nerves  VII:

Facial - raise both eyebrows - frown - close both eyes tightly & try opening - show both upper & lower teeth - smile - puff out both cheeks

Cranial Nerves  VIII:

VestibuloCochlear - Hearing (Weber’s & Rinne’s test) - specific tests of vestibular function are seldom included in the usual neuro exam

Cranial Nerves  IX:

Glossopharyngeal  X: Vagus - voice - swallowing - movements of soft palate & pharynx - gag reflex

Cranial Nerves  XI:

Spinal Accessory - shoulder shrug - turn head side-toside

Cranial Nerves  XII:

Hypoglossal - move tongue from side to side

Motor System  Body

Position - during movement & at rest  Involuntary Movements - tremors, tics, or fasciculations  Muscle Bulk - compare size & contour of muscles - check for atrophy

Motor System  Muscle

Tone - feel the muscle’s resistance to passive stretch - spasticity (increased muscle tone) - rigidity (increased resistance)  Muscle strength - ask px to move actively against your resistance or to resist your movements *muscle is strongest when shortest & weakest when longest

Muscle Strength Grading 5 4

3 2 1 0

Active movement against gravity & full resistance; normal muscle strength Active movement against gravity & some resistance; examiner can overcome resistance Active movement against gravity Active movement of the body part when gravity is eliminated Very weak muscle contraction; no active movement No muscle contraction is detectable

Muscle Strength (Upper Extremities)  Flexion

(C5, C6—biceps)  Extension (C6, C7, C8—triceps)  Grip (C7, C8, T1)  Finger abduction (C8, T1, ulnar nerve)  Thumb opposition (C8, T1, median nerve)

Muscle Strength (Trunk & Lower Extremities) Flexion, extension & lateral bending of the spine  Thoracic expansion & diaphragmatic excursion during respiration  Hip flexion (L2, L3, L4—iliopsoas)  Adduction at the hips (L2, L3, L4—adductors)  Abduction at the hips (L4, L5, S1—gluteus medius & minimus)  Hip extension (S1—gluteus maximus)  Knee extension (L2, L3, L4—quadriceps)  Knee flexion (L4, L5, S1, S2—hamstring)  Dorsiflexion (L4, L5)  Plantarflexion (S1) 

Motor System  Coordination

- rapid alternating movements - point-to-point movements - gait - standing & balance - walk heel-to-toe - walk on toes & heels - hop in place - rising from sitting position

Sensory System Superficial  Pain and temperature (spinothalamic test)  Light touch (both pathways) Deep  Position and vibration (posterior columns)  Two-point discrimination  Stereognosis

Cerebellar System  Finger-to-nose  Dysmetria

test

– inability to control accurately the range of movement in muscle action with resultant overshooting the mark (past-point)

Reflexes  4+

Very brisk, hyperactive,with clonus  3+ Brisker than average; possibly but not necessarily indicative of disease  2+ Average; normal  1+ Somewhat diminished; low normal  0 No response

Reflexes  Biceps

(C5, C6) - pxs arm is partially flexed at the elbow w/ palm down - place thumb or finger firmly on biceps tendon - strike w/ reflex hammer - observe flexion at the elbow, & watch for & feel contraction of biceps muscle

Reflex  Triceps

(C6, C7) - flex px’s arm at the elbow, w/ palm toward the body, pull it slightly across the chest - strike the triceps tendon above the elbow - watch for contraction of the triceps muscle & elbow extension

Reflex  Brachioradialis

or Supinator (C5, C6) - px’s hand should rest on the abdomen or lap, w/ the forearm partly pronated - strike the radius about 1-2 inches above the wrist - watch for flexion & supination of forearm

Reflex  Abdominal

reflexes - briskly stoke each side of abdomen above the umbilicus (T8, T9, T10), and below umbilicus (T10, T11, T12) - use a key, wooden end of cotton applicator, or tongue blade - note contraction of abdominal muscles & deviation of umbilicus toward the stimulus

Reflex  Knee

(L2, L3, L4) - sitting or lying down as long as the knee is flexed - briskly tap the patellar tendon just below the patella - note contraction of quadriceps with extension at the knee

Reflex  Ankle

(S1) - if px is sitting, dorsiflex the foot at the ankle - persuade the px to relax - strike the Achilles tendon - watch & feel for plantar flexion at the ankle - if px is lying down, flex one leg at both hip and knee & rotate it externally so that the lower leg rests across the opposite shin - dorsiflex the foot at the ankle & strike the Achilles tendon

Reflex 

Plantar (L5, S1) - with an object such as key or wooden end of applicator stick, stroke the lateral aspect of the sole from the heel to the ball of the foot, curving medially across the ball - use lightest stimulus that will provoke a response - note movement of toes, normally flexion

Thank You.