Focused Neurological Exam Focused Neurological Exam (Questions and Answers) Brodus Franklin and Jaime Gasco 10.1 Basic Concepts What are the six components of a full neurological exam? What is a “focused neurological exam”? Answers available here https://bit.ly/3cmb3gK What three deficits may a physician observe by careful observation alone? How long should a focused neurological exam last? What are the four objectives of a focused neurological exam? Why is both a focused and rapid neurological exam especially important in a trauma patient with multiple injuries? Answers available here https://bit.ly/3cmb3gK When would extensive examination of higher cerebral functioning, cerebellar functioning, and cranial nerve function be deemed unnecessary? 10.2 Level of Consciousness/Mental Status When should one use the Glasgow Coma Scale (GCS) or Full Outline of Unresponsiveness (FOUR) scale?1 Answers available here https://bit.ly/3cmb3gK What is the maximum number of points that one can receive in the GCS? What is the minimum number? 3 What does “T” mean in GCS scoring? How are points awarded for verbal responses? Answers available here https://bit.ly/3cmb3gK When applying the GCS, who receives a “best eye opening” score of 4? When applying the GCS, how is best eye opening to pain only (a score of 2) tested? When assessing the “best motor response” of the GCS, what is meant by “withdrawal to pain” (a score of 4)? When assessing the “best motor response” of the GCS, what is meant by “localization to pain” (a score of 5)? Answers available here https://bit.ly/3cmb3gK How would a physician recognize decorticate posturing (a score of 3) when estimating level of consciousness? How would a physician recognize decerebrate posturing when estimating level of consciousness? Answers available here https://bit.ly/3cmb3gK Fig. 10.2 Hyperextension of both the upper and lower extremities. What is the most important feature of consciousness? What is gained by the nature in which a patient recollects the events of his or her history? When should one check orientation? What are the six components of the mini–mental state exam? What is the maximum score obtained through the mini–mental state exam? What is assessed by the clock-drawing test? Answers available here https://bit.ly/3cmb3gK What are the four orientation parameters in order from last to be lost to the first? What questions should be asked to test the four aforementioned parameters? English/Spanish 1. Person: “Sir … (Ma’am …) tell me your name?”/“Senor … (Senora …) ¿Cómo te llamas?” 2. Place: “Where are we?”/“¿Dónde estamos?” “What city?”/“¿Qué ciudad?” “What state?”/“¿Qué estado?” “What country?”/“¿Qué país?” “What is this place?/“¿En qué lugar estamos?” If the patient is able to give a correct answer to the above question, ask: “What hospital?”/“¿Qué hospital?” Answers available here https://bit.ly/3cmb3gK “What floor?”/“¿Qué piso?” 3. Time: “What year is it?”/“¿Qué año es?” “What season is it?”/“¿Qué temporada es?” “What month?”/“¿Qué mes?” “What is today’s date?”/“¿Cúal es la fecha de hoy?” “What day of the week is it?”/“¿Qué día de la semana es?” 4. Situation: “Why are you here?”/“¿Por qué está usted aquí?” How are memory and intellectual functioning routinely tested at bedside or within a clinical setting? How are speech and language disorders explored during testing of higher cortical functioning? Answers available here https://bit.ly/3cmb3gK 10.3 Cranial Nerves Which cranial nerve (CN) controls the following: Secretomotor to the parotid gland causing salivation Glossopharyngeal (CN IX) via the otic ganglion Motor to the sternocleidomastoid (SCM) muscle Spinal accessory (CN XI) Sensation from the tonsils, pharynx, and middle ear Glossopharyngeal (CN IX) Afferent motor and efferent sensory of the GI tract Vagus (CN X) Sensation from the face, sinuses, and teeth Trigeminal (CN V) Information from the carotid sinus and body Glossopharyngeal (CN IX) Motor for accommodation Oculomotor (CN III) Motor for pupillary constriction Oculomotor (CN III) Motor to the lateral rectus of the eye Abducens (CN VI) Efferent sensory from the heart and lungs Vagus (CN X) Afferent motor to the heart and lungs Vagus (CN X) Sensory from the vestibule conveying balance Vestibulocochlear (CN VIII) Secretomotor to submandibular glands for salivation Facial (CN VIII) via the submandibular ganglion Motor to the superior oblique muscle of the eye Facial (CN VII) Motor to the stylopharyngeus muscle and muscles of the Glossopharyngeal (CN IX) upper pharynx Motor to the muscles of the tongue Hypoglossal (CN XII) Taste and sensation of the back of the mouth Vagus (CN X) Sensory and motor to and from the pharynx, larynx, trachea, Vagus (CN X) and bronchi Sensation from the cochlea allowing one to hear Vestibulocochlear (CN VIII) Secretomotor to the lacrimal glands Facial (CN VIII) via the pterygopalatine ganglion Motor innervation to the strap muscles Answers available here https://bit.ly/3cmb3gK Hypoglossal (CN XII) via the ansa cervicalis Sensation of smell Olfactory (CN I) Taste from the anterior two thirds of the tongue and soft Facial (CN VIII) via the chorda palate tympani nerve Sensation from the anterior two thirds of the tongue and soft Trigeminal (CN V), mandibular palate Taste and sensation from the posterior one third of the division Glossopharyngeal (CN IX) tongue Answers available here https://bit.ly/3cmb3gK Supplies motor to the majority of extraocular muscles Oculomotor (CN III) Sensory from the eye, responsible for sight Optic (CN II) Touch sensation of the eye Trigeminal (CN V), ophthalmic division Supplies motor to the muscles of mastication Trigeminal (CN V), mandibular division Supplies motor to the muscles of facial expression Facial (CN VII) Motor to the trapezius muscle Spinal accessory (CN XI) In what manner should cranial nerves be examined? What simple test can be done to rule out evidence of raised intracranial pressure? How may a patient’s visual fields (CN II) be examined? How is CN I (the olfactory nerve), governing smell, tested? How is CN VII (the facial nerve) examined? Answers available here https://bit.ly/3cmb3gK What does weakness to the lower face only signify? What does weakness involving the forehead signify? How is CN III (oculomotor function) examined? What are three indicators of CN III dysfunction by exam? .Fig. 10.3 Ptosis of the levator palpebrae muscle may indicate either a CN III palsy (in which it is more apparent) or a lesion to the sympathetic system (less apparent). 2. The affected pupil is both fixed and dilated when light is shined. Fig. 10.4 When the pen light is shined in the affected eye, the contralateral pupil constricts, but not on the affected side. Answers available here https://bit.ly/3cmb3gK Fig. 10.5 When light is shined in the normal eye, only this pupil will constrict. 3. The affected eye is deviated laterally and inferiorly, causing diplopia. What else should be observed while testing for oculomotor function? How are CNs III (oculomotor nerve), IV (trochlear nerve), and VI (abducens nerve) examined? What is a trochlear nerve (CN IV) palsy? What are the four most common causes of trochlear nerve (CN IV) palsy? What is an abducens (CN VI) palsy? What does an abducens (CN VI) palsy potentially signify? How is CN V (facial sensation) examined? Answers available here https://bit.ly/3cmb3gK What else should be observed while testing for facial sensation? How are facial movements tested? How is CN VIII (hearing function) examined? If a dysfunction is noted on examination of CN VIII, what two tests should be performed? How is information from the two aforementioned tests used? How is conductive deafness differentiated from sensorineural deafness via Weber’s test? How is conductive deafness differentiated from sensorineural deafness via Rinne’s test? How are CNs IX and X (pharyngeal motor and sensation) examined? How is CN XI (the spinal accessory nerve) examined? Answers available here https://bit.ly/3cmb3gK How is CN XII (the hypoglossal nerve) examined? How do you localize the lesion with CN XII dysfunction? 10.4 Motor Exam Which motor strength grade, as set by the Royal Medical Research Council of Great Britain, corresponds with the following description: Answers available here https://bit.ly/3cmb3gK Normal strength 5/5 No contraction 0/5 Antigravity movement 3/5 Flicker contraction 1/5 Movement against slight resistance 4–/5 Movement against strong resistance (but less than normal) 4+/5 Movement against moderate resistance 4/5 Movement only with gravity eliminated 2/5 What are the standard levels tested in a motor exam? Answers available here https://bit.ly/3cmb3gK Level Muscle Action C5 Deltoid (D) Shoulder abduction C5 Biceps (B) Elbow flexion C6 Wrist extensors (WE) Cock up wrist C7 Triceps (T) Elbow extension C8 Flexor digitorum profundus (grip) Squeeze hand T1 Hand intrinsics (interosseous, I) Abduct fingers L2 Iliopsoas (IP) Flex hip L3 Quadriceps (Q) Straighten knee L4 Tibialis anterior (TA) Dorsiflex foot L5 Extensor hallucis longus (EHL) Dorsiflex big toe S1 Gastrocnemius (G) Plantarflex foot4 What is the first objective of a proper motor examination, often overlooked? How is the inspection of muscle groups assessed? What is the ideal setting for the testing of motor function? How is pronator drift examined? What does difficulty with the pronator drift exam signify? 10.5 Sensory Exam Answers available here https://bit.ly/3cmb3gK What key spinal segment receives sensory information from the following area: Xiphoid? T6 Neck? C2 Shoulder? C4 Umbilicus? T10 Nipple? T4 Perianal area? S4–5 Middle finger? C7 Pinky finger? C8 Medial arm? T1 Knee? L4 Thumb and lateral forearm? C6 Lateral leg and great toe? L5 Lateral malleolus? S1 Medial leg? L33 The sensory examination should include conscious testing of functions controlled by which three tracts or pathways? How is the sensation of touch usually tested? Answers available here https://bit.ly/3cmb3gK How is the sensation of touch sensed by thicker glabrous skin different from that of thinner hirsute skin? How is pain usually assessed? How is thermal sense tested? Where is the perception of passive motion (proprioception) most sensitively tested? How is vibration testing performed? Where is vibration sense most commonly diminished? Answers available here https://bit.ly/3cmb3gK On what anatomical structures or pathways are two-point discrimination, graphesthesia, and stereognosis dependent? What are the three common anatomical patterns of distribution seen with sensory loss? 10.6 Reflexes What root, nerve, and muscle are being tested with the following common reflexes? Which muscle stretch reflex grade, as set by Wexler’s 5-point scale, corresponds with the following description5: Answers available here https://bit.ly/3cmb3gK Brisk 3+ Sustained clonus 5+ Absent reflex 0 Trace, or seen only with reinforcement 1+ Normal 2+ Nonsustained clonus (i.e., repetitive vibratory movements) 4+ What is necessary of the patient when testing deep tendon reflexes? How can a questionable lack of response or barely perceptible reflex be facilitated? What is Hoffman’s sign (finger flexor reflex)? How is Hoffman’s sign elicited? What is the pathological response of Hoffman’s sign? What is the plantar reflex (aka Babinski sign)? How is the plantar reflex elicited? What is the pathological response of the plantar reflex? When is the plantar reflex no longer a normal finding? In what two ways can the plantar response be confounded by the patient? What is the Chaddock maneuver? What is the Schaeffer maneuver? What is the Oppenheim maneuver? down the patient’s shin.6 What is the Gordon maneuver? What is the Bing maneuver? Answers available here https://bit.ly/3cmb3gK What is the Gonda or Stronsky maneuver? What is the jaw jerk maneuver? How is the jaw jerk maneuver elicited? What is the pathological response of the jaw jerk? How do the signs of upper motor neuron (UMN) lesions differ from those of lower motor neuron (LMN) lesions? Sign UMN Lesion LMN Lesion Weakness Present Present Atrophy Absent Present Fasciculations Absent Present Reflexes Hyperreflexive Hyporeflexive Tone Increased Decreased4 10.7 Coordination and Gait Name the three simple tests of coordination commonly performed in a neurological exam? 1. Finger-to-nose (FTS) exam: 2. Heel-to-shin (HTS) exam: having the patient run a How should the examiner evaluate a patient’s ability to complete these tests of coordination? When are gait and stance testing usually done as a component of the neurological exam? What are the four types of walking that an examiner requests the patient to do to identify balance abnormalities in gait and stance testing? Answers available here https://bit.ly/3cmb3gK When may an abnormality of gait and stance be the only neurological abnormality noticed on exam? Why is the observation of tandem walking an important aspect of gait and stance testing? What is indicated by disequilibrium while standing with eyes closed (Romberg test)? 10.8 Neurological Examination of the Comatose Patient What is the primary objective of the neurological examination of a comatose patient? What are two exam findings that indicate a structural lesion? How may CN V (the trigeminal nerve) be examined in a comatose patient? How may CN VII (the facial nerve) be examined in a comatose patient? How may CNs IX and X (the glossopharyngeal and vagus nerves) be examined in a comatose patient? Answers available here https://bit.ly/3cmb3gK How is the motor exam completed in the comatose patient? When applying passive manipulation/range of motion, what is the sign of upper motor neuron (UMN) disease? What is the clasp-knife response? How is the sensory exam completed in the comatose patient? References Answers available here https://bit.ly/3cmb3gK 1. Teasdale G, Jennett B. Assessment and prognosis of coma after head injury. Acta Neurochir (Wien) 1976;34:45–55 PubMed 2. Folstein MF, Folstein SE, McHugh PR. “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. J Psychiatr Res 1975;12:189– 198 PubMed 3. Nolte J. The Human Brain: An Introduction to Its Functional Anatomy. St. Louis: Mosby, 2002 4. Greenberg M. Peripheral nerves. In: Greenberg M, ed. Handbook of Neurosurgery. New York: Thieme, 2010 5. Dyck PJ, Boes CJ, Mulder D, et al. History of standard scoring, notation, and summation of neuromuscular signs. A current survey and recommendation. J Peripher Nerv Syst 2005;10:158–173 PubMed Answers available here https://bit.ly/3cmb3gK 6. Greenberg M. Neuroanatomy and physiology. In: Greenberg M, ed. Handbook of Neurosurgery. New York: Thieme, 2010
