Approach to the Neuro Exam

By
Sam Gharbi
UBC Internal Medicine, R3
 Overview
Basics:
• Cranial Nerves
• Motor
• Sensory
• Reflexes

Additional:
• Pronator drift
• Romberg
• Gait
 Cranial Nerves
Cranial Nerve I:
• Olfactory Nerve
• Not routinely tested
 Cranial Nerve II: Optic Nerve

Sensory:

1) Visual Acuity:

– Use a hand-held eye chart or Snellen’s chart on the wall.

– If a hand-held eye chart is used, ask patient to hold 14 inches

from eye. If a Snellen chart is used, patient must stand 6 metres
from the chart.

– Ask the patient to cover one eye and read progressively smaller
lines until no longer able to.

– Test each eye separately.

 Cranial Nerve II: Optic Nerve
2) Visual Fields:

– Remove the patient’s eyeglasses.

– Stand approximately 1 metre in front of patient. Your head

should be level with the patient’s.

– Ask the patient to cover their right eye. Cover your left eye.
Ensure the patient looks into your uncovered eye while testing
visual fields.

– Use wiggling fingers and present the test object in the four
corners of the peripheral visual field.

– Moving diagonally towards the central field of vision, ask the

patient to identify when they see the pen or your fingers.
 Cranial Nerve II: Optic Nerve
3) Fundoscopy: (usually deferred)

– Dim the lights and ask the patient to fixate on a

distant target.

– Search for the optic disc (normally a yellow shallow

cup with a clearly outlined rim).

– Examine for abnormalities such as papilloedema,

optic disc atrophy (pallor), exudates and
hemorrhages.
 Cranial Nerve II: Optic Nerve
Reflex:

• Pupillary Light Reflex:

– CN II: Afferent
– CN III: Efferent
– See next section
 CN III, IV, & VI
Know the names:

• Cranial Nerve III (Oculomotor)

• CN IV (Trochlear)
• CN VI (Abducens)
 CN III, IV, & VI
• Motor – Extra-ocular muscles:

– Inspect the eyes for position and ptosis.

– Smooth pursuit: Without moving their head, ask the

patient to follow a target such as a pen or finger in an
“H” pattern. Note any failure of movement of either
eye. Ask the patient to report if diplopia occurs.

– Nystagmus: Observe for involuntary rhythmic eye

movements.
 CN III, IV, & VI
IMPORTANT:

• CN IV innervates Superior Oblique

 moves eye down and in

• CN VI innervates Lateral rectus

 moves eye laterally outwards

• CN III responsible for all other EOM

innervation and movements

CN III lesions causes:

 Eye position down and out
 Ptosis
 Pupillary Dilatation
 CN III, IV, & VI
Reflex:

• Pupillary Light Reflex (CN II & III):

– Ensure the lights are dimmed.

– Inspect the pupils for size, shape and asymmetry.
– Ask the patient to fixate on a distant target.
– Approaching the patient from the side, shine a penlight into one of the pupils and
assess its reaction to light. Observe for pupillary constriction in the same eye
(direct response) and in the opposite eye (consensual response).

• Accomodation Reflex:

– Ask the patient to look into the distance and focus on your finger at a distance.
– Bring your finger towards the tip of their nose.
– Pupils should constrict and eyes should converge
 Cranial Nerve V: Trigeminal
Motor (V3 division): Muscles of mastication

Temporalis and Masseter:

– Inspect for wasting of temporalis and masseter muscles.

– Ask the patient to clench the teeth.
– Palpate for contraction of the masseter and temporalis.

Pterygoids:

– Ask the patient to open their mouth.

– Attempt to close the mouth with upward pressure on the jaw. Ask the
patient to resist you. The jaw will deviate to the weak side if a unilateral
lesion is present.
Cranial Nerve V: Trigeminal
Sensory:

• Light touch:

– Ask the patient to close their eyes.

– With a piece of cotton, touch the

patient’s skin in the V1, V2 and V3
cutaneous distributions of the
nerve. Compare both sides.
 Cranial Nerve V: Trigeminal
Reflex:

• Corneal Reflex:

– CN V: Afferent Limb of Corneal Reflex

– CN VII: Efferent
 Cranial Nerve VII: Facial Nerve
Motor: Muscles of Facial Expression

– Inspect the face for asymmetry

– Ask the patient to raise their eyebrows (frontalis)

– Ask the patient to close their eyes tightly. Attempt to pull their
eyes open and ask them to resist you. (orbicularis oculi)

– Ask the patient to show you their teeth. Then ask them to close
their mouth tightly. Attempt to pull their lips open and ask them to
resist you. (orbicularis oris)

– Ask the patient to show you just their bottom teeth. (platysma)
 Cranial Nerve VII: Facial Nerve
Sensory:

• Taste for Anterior 2/3 of Tongue

Reflex:

• Corneal Reflex
– With a cotton wisp, touch the cornea of one eye lightly.
– Observe for a blink in the same and opposite eye.
– Afferent defect: No blink in same or opposite eye.
– Efferent defect: No blink in same eye, but blink in opposite eye.
 Cranial Nerve VIII:
Vestibulocochlear

Sensory: Hearing

– Lightly rub your fingers next to each ear

– If hearing loss is suspected, perform Rinne’s

and Weber’s tests (requires tuning fork)
 Cranial Nerve IX
Glossopharyngeal
Sensory:

• Taste for Posterior 1/3 of Tongue (CN IX)

Reflex:

• Gag Reflex (CN IX & X):

– CN IX: Afferent limb of gag reflex

– CN X: Efferent limb of gag reflex
– With a tongue depressor, touch the soft palate on each side. A reflex
contraction of the soft palate should be noted. If contraction is absent
but sensation is normal, this suggests a CN X palsy.
– The gag reflex is absent on the affected side.
 Cranial Nerve X: Vagus
Motor:

• Palatal Elevation (CN X):

– Ask the patient to open their mouth and say ‘Ahhh’

– Observe for displacement of the uvula
– The uvula deviates to the non-affected side (ie: a unilateral right sided
CN X palsy results in deviation of the tongue to the left)

• Articulation and Phonation (CN X):

– Assess patient’s speech for hoarseness

– Ask the patient to say “Ka, Ka, Ka” (palatal articulation)
– Ask the patient to say “Go, Go, Go” (guttural articulation)
– Ask the patient to say “Pa, Pa, Pa” (labial articulation)
 Cranial Nerve XI: Accessory
Motor:

• Trapezius:

– Ask patient to shrug the shoulders against resistance.

• Sternocleidomastoid Muscles:

– Ask patient to turn their head to either side against resistance.

– Observe and palpate the sternocleidomastoid muscles.
– Remember that the right CN XI controls the right SCM, which
turns the head to the left.
 Cranial Nerve XII: Hypoglossal
Motor:

• Muscles of the tongue:

– Observe the tongue at rest for fasciculations

– Ask the patient to stick out their tongue.

– Observe for deviation of the tongue to one side. The

tongue deviates to the weaker side & side of the
lesion.
 Cranial Nerves Review
• If you get stuck or go blank, go over the
following 3 components for each Cranial
Nerve:

– Sensory
– Motor
– Reflex
 Neuro Exam- Overview
• Cranial nerves

• Sensory
• Motor
• Tone
• Reflexes
• Gait

• Special tests
– Romberg
– Pronator drift
– Coordination
Sensory
 Motor
• Test muscle strength:
• Upper limbs
– Arm flexion and extension
– Wrist flexion and extension
– Finger adbuction and adduction

• Lower limbs
– Hip abduction and adduction
– Knee flexion and extension
– Ankle dorsiflexion(L4) and plantar flexion(L5)
– Big toe dorsiflexion (S1)
 Motor
• Grading of muscle strength:
– 0 = absent
– 1 = slight contraction
– 2 = movement with gravity eliminated
– 3 = movement against gravity
– 4 = movement against gravity with some
resistance
– 5 = Normal
 Tone
• Have patient relax muscle, and passively
manipulate muscle
• Examine upper and lower limbs for tone

• Normal vs Rigidity/Spasticity
– Cogwheeling
– Lead pipe
 Reflexes
• Deep tendon
– Biceps (C5-6)
– Triceps (C6-7)
– Brachioradialis (C5-6)
– Patellar (L4)
– Achilles (S1)

• Plantar reflexes (Babinski)

 Reflexes
• Grading:

– 0 = No response
– 1+ = Reduced
– 2+ = Normal
– 3+ = Increased
– 4+ = Hyperactive/Clonus
 Gait
• Make patient do the following:
– Walk regularly
– Walk on toes
– Walk on heels

Note: Observe for gait abnormalities,

particularly shuffling gait (Parkinson’s)
 Special Tests
• Romberg

• Pronator drift
• Have the patient stretch out the arms so that they are level and fully
extended with the palms facing straight up, and then close the eyes.
• Watch for 5 to 10 seconds to see if either arm tends to pronate (so
that the palm turns inward) and drift downward.
• A unilateral pronator drift in one arm suggests an upper motor
neuron lesion affecting that arm.
 Coordination
3 main tests:

• Finger to nose testing

• Rapid alternating movements
• Heel to shin testing
 Common scenarios
• Patient presents with acute confusion.
Please perform history and physical

• Patient with back pain. Please perform a

detailed physical examination

• Patient with Parkinson’s disease. Please

perform a detailed history and physical
 The End

Thank you