Neurological

examination
Submitted to
AskTheNeurologist.Com
in 2008
http://www.asktheneurologist.com/Study-Neurology.html

3 questions of neurological
diagnosis
1) Is there a lesion ?
- Presence of neurological abnormality

2) Where is the lesion ?

- Location of problem
- Requires knowledge of neuroanatomy

3) What is the lesion ?

Why perform the

neurological examination
1. Detect the presence of neurological
abnormality
2. Localise the abnormality within the
nervous system ( may later be
confirmed by investigations)

Systematic approach to
weakness e.g. bilateral leg
weakness
Muscle
NMJ
Nerve
Nerve roots
Spinal cord
Brainstem
Cerebrum

Basic Plan
General examination ( vital signs etc)
Conscious state
Cognition
Meningeal signs
Cranial nerves
Motor
Sensory
Cerebellum
Extrapyramidal

DONT DO EVERYTHING!
Screening tests vs detailed testing
Problem orientated approach
Screen all systems
Concentrate on systems relevant to
complaint
Formal cognitive testing may be skipped
if patient is cognitively intact during
history and problem seems unrelated
E.g. foot-drop

Conscious state
Glasgow coma scale

Eyes /4
Verbal
Motor

/5
/6

Normal = 15
Created to reflect measure of global brain function
Limited value in neurological patients
- Many processes selectively affect components
above
- e.g. aphasia in a fully conscious patient
Therefore best to record functions individually

Cognition
MMSE
Score out of 30
Broad screening test of cognitive function
including attention, memory, language
Good for diagnosing / monitoring certain
types of dementia especially A.D.
Other types of dementia / cognitive
problems require different tests

Cognition 2
Frontal functions

Attention & concentration ( digit span )

Abstraction ( explain proverb )
Judgment
child lost in street..what would you do?
Planning
How to plan a holiday
Draw a clock

Cognition 3
Frontal release signs

Glabellar tap
Pouting
Rooting
Sucking
Grasp
Palmomental

Other cognitive functions

Neglect:
Failure to pay attention to area of space
Usually due to right parietal lesions
where neglect left-sided space

Praxis:
ability to perform learned action

- e.g. dressing , combing hair

Meningeal signs
Neck stiffness
Brudzinski
Kernig
Most frequently found in patients with
meningitis or SAH

Cranial nerves (a)

I - smell
II - Acuity ( Snellen chart)
- Fundi
- Fields ( confrontation)
- Pupil resting state and reaction to light
- Direct
- Consensual
- Swinging flashlight test

- Pupil reaction to accommodation

Cranial Nerves (b)

III, IV, VI

Ptosis?
Pupils (already examined)
Movement ( H and X)
Saccades and smooth pursuit
? Diplopia
? Nystagmus

Cranial nerves (c)

V

Facial sensation
Muscles of mastication
Jaw jerk
Corneal reflex
Afferent = V
Efferent = VII

Cranial nerves (d)

VII
Muscles of facial expression
Taste ant 2/3 tongue
Tensor Tympani

Cranial nerves (e)

VIII
Nystagmus already noted
Hearing

IX, X
Say ahh (X)
Gag reflex
Afferent = IX
Efferent = X

Cranial nerves (f)

XI
sternocleidomastoid & trapezius

XII ( tongue motor examination)

Observation ( atrophy, fasciculations)

Midline protrusion ( ? Deviation)
Power
Dexterity ( fast movement side-to-side)

Upper motor neuron

Cell body within motor cortex
(prefrontal gyrus)

Axon terminates :
Cranial nerve motor nucleus

corticobulbar
Anterior horn of spinal cord

corticospinal

Lower Motor Neuron

Cell body of
Motor cranial nerve nucleus
Anterior horn cell

Axon terminates
Motor end plate ( skeletal muscle)
AKA Neuromuscular junction ( NMJ)

Diagram of motor
pathways

Inspection of
muscles
Tone
Power (MRC
scale)
0-5 /5
Tendon Reflexes
Pathological
reflexes

Upper Motor
Neuron
Normal
(disuse
atrophy)
Increased
(unless acute)
decreased

Lower Motor
Neuron
Atrophy
Fasciculatio
ns
Decreased
(or normal)
decreased

Increased
(unless acute)
Present

Decreased
or Normal
Absent

Sensory System
Modalities
Pain
Temperature

Spinothalamic

Vibration
Proprioception

Post. columns

Sensory examination II
Problem orientated approach

Left vs Right
Spinal sensory level
Radicular / dermatomal
Nerve distribution
Distal vs Proximal

Which method would you

concentrate on?
1. Sudden onset of dysphasia and
2.
3.
4.

right sided weakness

Numbness and paraesthesia in feet
with absent ankle jerks
Acute bilateral leg weakness with
loss of sphincter control
Drop foot

Symptoms and signs of

cerebellar disease
(VANISHD)

Vertigo
Ataxia - usually falls towards lesion
Nystagmus increased with gaze towards

lesion
Intention Tremor
Scanning speech
Hypotonia
Dysdiadochokinesia + Dysmetria

Stability and Gait

Check ability to stand straight with eyes open
Check ability to stand straight with eyes
closed

If significantly worse than with eyes open =

positive Romberg sign
Usually signifies defect in pathways involved in
proprioception
May signify vestibular disease

Check gait

Extrapyramidal TRAP
Tremor ( rest, pill-rolling)
Rigidity ( lead-pipe, cog-wheel)
Akinesia / bradykinesia
Postural instability

Normal examination
Patient fully conscious, orientated in

time and place with no meningeal signs

PEARLA, Fundi intact, ( acuity and visual
fields intact)
Eye movements normal
Facial sensation normal
Face symmetrical
(Hearing normal)
Palate / uvula rises symmetrically
Gag preserved bilaterally
Tongue central

Normal examination 2
No atrophy / fasciculations
(muscle inspection)

Tone preserved
Power 5/5 in all 4 limbs
Reflexes symmetrical
No pyramidal signs

Normal examination 3
Sensation preserved
No cerebellar signs
Romberg negative
Gait normal

How to present
Keep to order
Mention all abnormalities
Include core points ( just described)
Mention all important negative points
Leg weakness no sensory level
History of MS with optic neuritis no RAPD
Complains of difficulty chewing
Mention power of masticatory muscles

THE END