OBJECTIVES:

Understanding the importance of the basic

The Basic Neurologic
Examination
Sally De Castro Tilsen, P.A.-C, MSCS
Hoag Neuroscience Center and
MS Center of Southern California
Newport Beach, California
neurologic history and examination
• To Teach How to Conduct a Basic Neurologic
Examination
• Review the Use of Instruments Needed for a Complete
NE
• Review Specific Clinical Testing and Techniques
• Discuss Abnormal Findings
• Learn How to Conduct Specific Tests for the Following
Disorders:
Dementia
Multiple Sclerosis
Parkinson’s Disease

A mechanic does not need to use every tool on every project

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 Tools of the Trade Take a Good HISTORY
• Steel measuring tape • Much of the NE comes from the History
• Stethoscope
• Flashlight • Assess the Pts. word articulation, content of speech,
• Ophthalmoscope and overall mental status.
• Tongue blades • Inspect facial features.
• Vials of coffee, salt, sugar
• Cotton wisp
• Inspect eye movements, facial movements and any
• Two stopped tubes asymmetry.
• Disposable straight pins • Observe how a Pt. swallows saliva and breathes.
• Reflex hammer
• Penny, nickel, dime, key
• Inspect the posture, look for tremors
• Blood pressure cuff • The history and observation can help you focus on
• Forms for various tests specific systems: motor, sensory, cranial nerves or
cerebral functions.

Neurologic Examination
• Mental Status Exam
• Cranial Nerve Examination
• Motor Examination
• Reflexes
• Sensory
• Coordination
• Gait

http://www.cbu.edu/~mcondren/IRM/Stop-Look-Listen-sign-IRM-7-7-07.jpg

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 Level of Consciousness
• Awake and alert
• Agitated
MENTAL STATUS • Lethargic
– Arousable with
• Voice
• Gentle stimulation
• Painful/vigorous stimulation
• Comatose

Outline of Mental Status

ORIENTATION
Examination
• PERSON
– NOT WHO THEY ARE BUT WHO YOU ARE
• General behavior and appearance
• PLACE
• Stream of talk
• TIME
• Mood and affective responses
• Content of thought
• Intellectual capacity
• Sensorium

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 LANGUAGE Mental Status Exam
• FLUENCY
• NAMING • Family story of memory loss
• REPETITION • Orientation
• READING • General Information
• WRITING • Spelling &/or numbers
• COMPREHENSION • Recognition of objects
Aphasia vs. dysarthria

Mental Status Exam

• When there is a history of cognitive decline

• What tests?
– Mini-mental State Examination
– Halstead-Reitan Performance Test
– Full Cognitive and Neuropsychological testing

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 C.N. 1 (olfactory)

• Each nostril separately

CRANIAL NERVES – non-irritating substances : ideally coffee/aromatic oils;
practically soap/toothpaste
• Anosmia (olfactory) vs. Ageusia (taste)
• First consider nasal disorders

CRANIAL NERVE EXAM C.N. II (optic)

• I - OLFACTORY
• Ophthalmoscopy:
– DON’T USE A NOXIOUS STIMULUS
– Optic atrophy, papilledema
– COFFEE, LEMON EXTRACT
• Visual acuity
• II - OPTIC – Snellen chart or
– VISUAL ACUITY – Hand-held card
– VISUAL FIELDS
– FUNDOSCOPIC EXAM Color Vision

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 C.N. II (optic) CRANIAL NERVE EXAM
• Visual fields • III/IV/VI OCULMOTOR, TROCHLEAR,
– Outline perimetry : misses relative defect or inattention ABDUCENS
– Other confrontation – PUPILLARY RESPONSE
techniques(Beck): – EYE MOVEMENTS
• 9 CARDINAL POSITIONS
– OBSERVE LIDS FOR PTOSIS
• V - TRIGEMINAL
– MOTOR - JAW STRENGTH
– SENS - ALL 3 DIVISIONS

Pupillary reflexes (CN 2 & 3) CN 3, 4 , 6

• Parasympathetic (pupillo-constrictor) in CN 3
• Eyes looking in the distance, bright light
• CN 3,4,6 are under “central” control; Ex:
• “ Swinging flashlight test “ – Medial longitudinal fasciculus
– e.g. is there a relative afferent pup. defect? Internuclear ophthalmoplegia: ipsilateral eye fails to adduct,
– a sensitive test for optic neuropathy contra lateral eye shows nystagmus
– Frontal eye fields
• Horner syndrome (oculo-sympathetic) Tend to direct gaze contra laterally : with a frontal lesion,
– miosis, ptosis, anhydrosis eyes are deviated ipsilaterally (“towards the lesion”)

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 Extraocular movements
C .N. VII
Special visceral frontalis, corrugator, inspect facial muscles
efferent orbicul oris & ocul. > 8 maneuvers
Buccin., platysma e.g. raise eyebrows
stapedius smile, frown, etc.

General visceral lacrimal gland inspect eye

efferent submandigular gland Schirmer test

Special visceral taste buds test taste

afferent anterior 2/3 tongue salt, sugar, acetic a.
& quinine solutions
General somatic external ear test light touch
afferent in post ext. ear canal

C.N. 5 (trigeminal)
• Test light touch and/or pinprick in 3 divisions
• Corneal reflex
– cotton / kleenex on cornea (not conjunctiva)
– Avoid visual threat
• Palpate contracting masseter & temporalis m
• Jaw jerk

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 CRANIAL NERVES CRANIAL NERVES
• VII - FACIAL • IX/X - GLOSSOPHARYNGEAL, VAGUS
– OBSERVE FOR FACIAL ASYMMETRY – GAG
– FOREHEAD WRINKLING, EYELID CLOSURE, • XI - SPINAL ACCESSORY
WHISTLE/PUCKER – STERNOCLEIDOMASTOID M.
• VIII - VESTIBULAR – TRAPEZIUS MUSCLE
– ACUITY • XII - HYPOGLOSSAL
– RINNE, WEBER – TONGUE STRENGTH
– RIGHT XII THRUSTS TONGUE TO LEFT

Rinne test C.N. 9 & 10

• Is there dysphonia?
• Assess palatal movement with phonation
• IF there is dysarthria, dysphagia, dysphonia:
– Test gag reflex

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 C.N. 11 (spinal accessory) C.N. 12 (hypoglossal)
• Inspect tongue at rest
• Two muscles: – atrophy, fasciculations
– trapezius: shoulder shrug ; abduction of arm beyond • Tongue protrusion
90 degrees – deviation towards paretic side
– sternocleidomastoid: turn chin to opp shoulder

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 STRENGTH
• STRENGTH
– GRADED 0 - 5
MOTOR EXAMINATION – 0 - NO MOVEMENT
– 1 - FLICKER
– 2 - MOVEMENT WITH GRAVITY REMOVED
– 3 - MOVEMENT AGAINST GRAVITY
– 4 - MOVEMENT AGAINST RESISTANCE
– 5 - NORMAL STRENGTH

Motor Examination STRENGTH EXAM

• UPPER AND LOWER EXTREMITIES
• DISTAL AND PROXIMAL MUSCLES
• GRIP STRENGTH IS A POOR SCREENING
TOOL FOR STRENGTH
• SUBTLE WEAKNESS
– TOE WALK, HEEL WALK
– OUT OF CHAIR
– DEEP KNEE BEND

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 MUSCLE OBSERVATION ABNORMAL MOVEMENTS
• ATROPHY • TREMOR
• FASCIULATIONS – REST
– WITH ARMS OUTSTRETCHED
– INTENTION
• CHOREA
• ATHETOSIS
• ABNORMAL POSTURES

TONE CEREBELLAR FUNCTION

• INCREASED, DECREASED, NORMAL • RAPID ALTERNATING MOVEMENTS
• COGWHEELING • FINGER TO FINGER TO NOSE TESTING
• CLASP KNIFE • HEEL TO SHIN
• GAIT
– TANDEM

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 Romberg Sign
• Stand with feet together - assure patient
Gait Evaluation
stable - have them close eyes • Include walking and turning
• Romberg is positive if they do worse with • Examples of abnormal gait
eyes closed
– High steppage
• Measures – Waddling
– Cerebellar function – Hemiparetic
– Frequently poor balance with eyes open and
closed
– Shuffling
– Proprioception – Turns en bloc
– Frequently do worse with eyes closed
– Vestibular system

Gait:
• Normal Walking
• Toe Walking
• Heel Walking REFLEXES
• Inversion Walking
• Eversion Walking
• Tandem Walking
• Romberg

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 MUSCLE STRETCH REFLEXES OTHER REFLEXES
(DEEP TENDON REFLEXES) • Upper motor neuron dysfunction
– BABINSKI
• present or absent
• GRADED 0 - 5
• toes downgoing/ flexor plantar response
– 0 - ABSENT
– HOFMAN’S
– 1 - PRESENT WITH REINFORCEMENT
– JAW JERK
– 2 - NORMAL
• Frontal release signs
– 3 - ENHANCED
– GRASP
– 4 - UNSUSTAINED CLONUS
– SNOUT
– 5 - SUSTAINED CLONUS
– SUCK
– PALMOMENTAL

MSR / DTR
• BICEPS
• BRACHIORADIALIS
• TRICEPS SENSORY EXAM
• KNEE
• ANKLE

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 SENSORY EXAM
• VIBRATION Mini-Mental State Examination
– 128 hz tuning fork Halstead-Reitan Battery Test
• JOINT POSITION SENSE
• PIN PRICK
• TEMPERATURE
Cognitive Impairment
Start distally and move proximally

HIGHER CORTICAL SENSATIONS

• GRAPHESTHESIA
• STEREOGNOSIS
• DOUBLE SIMULTANEOUS STIMULATION
• BAROSTHESIA
• TEXTURES

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 Expanded Disability Unified Parkinson’s
Status Scale Disease Rating Scale
Neurostatus scoring
Comprehensive
For Multiple Sclerosis
Parkinson’s Disease Tool

EDSS: Scoring to Quantify Impairment

Associated with Multiple Sclerosis
10.0 = Death due to MS

9.0-9.5 = Completely dependent

8.0-8.5 = Confined to bed/chair; self-care with help

7.0-7.5 = Confined to wheelchair

6.0-6.5 = Walking assistance is needed

5.0-5.5 = Increasing limitation in ability to walk

4.0-4.5 = Impairment is relatively severe

3.0-3.5 = Impairment is mild to moderate

2.0-2.5 = Impairment is minimal

1.0-1.5 = No impairment

0 = Normal neurologic exam

7. Kurtzke JF. Neurology. 1983;33:1444-1452.

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 References
• The Technique of the Neurologic Examination
by W. DeMyer, 2004, McGraw Hill, 5th edition
• Basic Clinical Neuroscience by P. Young, P.H.
Young, D. Tolber, 2008, Lippincott, Williams and
Wilkins
• Neurology for Dummies, 2008
• Neuroanatomy Through Clinical Cases, Hal
Blumenfeld, 2010

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