The Neurological
examination
General frame
Reduced your neurological differential
diagnosis
• How the symptoms started?
• How they progressed over time?
• What is the localization?
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Mental status, cognition & language
Signs of meningeal irritation.
Cranial nerves
Motor system
Sensory system
Cerebellar functions
Gait and balance
• Remember that normal range of findings
dynamically changes with age.
• We all have some soft neurological signs – be
symptoms oriented and try to look at the
entire picture and not on a soft abnormal
finding.
The technique
and expected
findings
Mental status,
cognition & language
• Define the patient mental status - alert?
Confused? Lethargic? comatose?
• Be sure your patient is oriented to time and
place.
• If during conversation you suspect any
language abnormality test spontaneous
conversation (fluency, paraphasia),
understanding commands, low and high
frequency naming, repetition, reading,
writing. Distinguished and define dysarthria.
Look for nuchal rigidity (meningial irritation)
Cranial
Nerves
•(I), II-XII
CN II - Ophthalmic
Test each eye separately
Visual
Acuity
Visual fields
(confrontation)
Close your eye and
Use printed text,
Move your finger from
your fingers or
Outside in (4 quarters)
hand-palm, light.
Do not remove glasses
Pupils
(also CN III)
Optic
discs
Light from aside
Don't ask and
we won't tell
CN II - Ophthalmic
Visual
Acuity
Visual fields
(confrontation)
Pupils
(also CN III)
Optic
discs
No difference from
baseline
Visual fields as good
as yours
Equal and responsive
Sharp borders
CN III(Oculomotor) , IV(Trochlear) & VI (Abducens)
Distant large movements in 6 directions plus convergence
Full coordinated movements, no pathological nystagmus
CN V - Trigeminal
Pinprick to compare
sides in the distribution
of the 3 branches
CN VII - Facial
Lower face
Smile or blow chicks
Upper face
Forcefully close eyes
or lift eye browses
CN VIII - Vestibulocochlear
Rub fingers, hair or paper near each hear separately
CN IX & X – Glossopharyngeal and vagus
Look for deviation of the uvula,
lowering of palatal arch or a
coarse voice
CN XI - Accessory
Sternocleidomastoid – ask
patient to turn head against
resistance (contralateral to
turning direction)
Trapezius - press shoulder
against patient resistance
CN XII - Hypoglossal
Look for atrophy or fasciculations
while mouth slightly open and
tongue rests on the floor of the
mouth
Ask patient to stick tongue out
Motor
System
• Observe
• Passive tone
• Muscle force
• Reflexes
• Babinski
Observe exposed limb / trunk
No asymmetry, atrophy (hypertrophy)
or fasciculations. No involuntary movements,
or abnormal posture.
Test passive tone by asking the patient to relax and
moving his upper and lower limbs.
Look for mild weakness by asking patient to close his
eyes, stretch his arms with his palms up.
Compare muscle force on both sides:
Deltoid
Biceps
Triceps
Grip (many muscles)
Iliopsoas
Quadriceps femoris
Gastrocnemius
Tibialis anterior
Hamstrings (opposite)
Deep Stretch reflexes
Muscle
Nerve
Root
Biceps
Musculocutaneous
C 5-6
Triceps
Radial
C 6-8
Brachioradialis
Radial
C 5-6
Quadriceps femoris Femoral
L 2-4
Gastrocnemius
S 1-2
Tibial
Use reflex hammer as a pendulum:
Biceps
Triceps
Quadriceps femoris
Gastrocnemius
Brachioradialis
Test for pathological pyramidal release sign (Babinski):
Equivalent signs:
Plantar-flexion of toe
Sensory
Exam
Pinprick to compare sides and proximal vs. distal sensation.
Ignore uncertain differences.
Ask patient to stand, close eyes and stretch arms
(Romberg test)
Remember you are testing proprioception (large diameter fibers, posterior spinal columns)
and the integrative function of the vestibular system rather then cerebellar functions.
Cerebellar
functions
Finger to nose test (slow):
Alternating palm movements:
Finger on target without significant
corrections (dysmetria) or tremor at
the end of the movement (intention
tremor)
Smooth and regular movements
(no dysdiadochokinesia)
Gait &
Balance
While patient is bared-foot (if possible):
Natural walking:
Tandem walking (heel to toe):
Steps are regular and in normal
length, base in narrow and posture
is errect.
Patients younger than 65 years
are expected to succeed
Abnormal
findings
Cranial
Nerves
•(I), II-XII
CN II - Ophthalmic
Visual
Acuity
Finger counting?
Hand movements?
Light perception?
Visual fields
(confrontation)
Pupils
(also CN III)
Optic
discs
CN III(Oculomotor) , IV(Trochlear) & VI (Abducens)
CN VII - Facial
CN IX & X – Glossopharyngeal and vagus
CN XII - Hypoglossal
Motor
System
Lower motor neuron, acute upper
Motor neuron or (cerebellar)
Exam tone
Decreased passive tone
Increased passive tone
Not uniform throughout the
range of movement , varied
with speed of movement,
‘clasp knife’ phenomenon,
more severe in upper limb
pronators and knee
extensors.
Spasticity
Upper motor neuron
(corticospinal , pyramidel)
Uniform throughout
movement, not speed
dependent, feels like
‘cogwheel’ or lead-pipe’,
increases with movements
of other limb
Patients does not relax, he
increases his resistance
proportionally with the force
you apply. Patient continues
repetitive movements after
you stop
Rigidity
Basal ganglia (parkinsonian sign)
Paratonia
Frontal release sign
Pronator drift
What is the origin of muscle weakness?
Upper motor neuron
Lower motor neuron
Atrophy (in chronic disease)
Severe with fasiculations
None or mild due to disuse
Tone
Decreased
Spastic in chronic stage,
spastic or decreased in
acute stage
Deep tendon reflexes
Decreased
Increased
Babinski sign
Negative
Positive
Remember – motor system is not just about weakness but also deals with abnormal
involuntary movements, fine movements etc and possible localization is not just upper vs.
lower motor neurons but also frontal lobes, basal ganglia and cerebellum.
Sensory
Exam
Cerebellar
functions
Gait &
Balance
Few more tests
you should apply
when relevant
Mental status,
cognition & language
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Glasgow coma scale
Mini-mental test
Drawing clock
Many others.
Cranial
Nerves
CN I - Olfactory
Apply a pleasant smell to each nostril separately when
suspecting frontal space occupying lesion (or certain
neurodegenerative disease)
CN II - Ophthalmic
In case you suspect optic nerve injury:
Test relative afferent papillary
defect (RAPD) using light swing
test
Use red object to test for red
saturation
CN V - Trigeminal
Suspect weakness of jaw
muscles? Test jaw muscle
Force.
Suspect pyramidal involvement
above the foramen magnum?
Check jaw jerk reflex.
Motor
System
Suspect pathological increased reflexes or wish to better
localize lesion?
Hoffman
Tromner
Ankle clonus:
Abruptly dorsoflexed ankle.
Supra-patellar reflex
Pectoral reflex
Cross-adductors reflex
Suspect frontal lesion? Neurodegenerative disease? Check
frontal release signs.
Palmo-mental
Snout
Grasp
Glabellar tap
Sensory
Exam
Suspect peripheral neuropathy, spinal posterior
columns involvement or hemi-spinal syndrome?
Use you tuning fork.
Test for extinction when you suspect non-dominant
parietal involvement. You can apply the test while
checking visual fields
Visual extinction
Tactile extinction
Cerebellar
functions
Heel-to-shin test is the equivalent to finger-tonose test
Gait &
Balance
Use pull test when patients gait is impaired or when
falls are reported. Stand with a wall on your back!
Thanks,