The Northern Neuroscience Centre

Chiang Mai University

NNC CMU
Neurological
examination
Surat Tanprawate, MD, FRCPT, MSc(Lond.)
Neurology Unit, Faculty of Medicine
Chiang Mai University
Brain function
Brain function
Neurological skill
• Chief complaint
• History taking
• Neurological examination
• screening neurological examination
• focused neurological examination
• Consequence of the exam
• Skill and method
Aim of neurological
exam
• To localized the lesion
• Central vs Peripheral nervous system
• symmetrical vs asymmetrical
• If central: cerebrum, midbrain, spinal cord
• If peripheral, is it: nerve, muscle, NMJ
 Equipment
• Penlight • Reflex hammer

• Tongue blade • Aromatic

substances
• Tuning fork
• Test tubes of hot
• Familiar and cold water
objects(coin, key,
paper clip)

• Cotton wisp
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Chiang Mai University
NNC CMU
Pen light Medical
Turning Fork
Reflex hammer
Consequence of Neurologic
Exam

• Conscious
• Cranial nerves
• Motor system/Coordination/Gait
• Reflex
• Sensory
• Mental status
Special test
Consciousness
Higher cortical function
: content of consciousness
: awareness
: orientation; time, place, person
: higher cortical function
: Mini-mental state examination

Ascending Reticular
Activating System(ARAS)
: level of consciousness
: wakefulness
: stimuli and response
: Glasglow Coma Score(GCS)
Level of consciousness

• Wakefulness
• Drowsiness
• Semi-coma
• Coma
Glasglow Coma Score
(GCS)

• Eye response
• Verbal response
• Motor response First published in 1974 by Graham
Teasdale and Bryan J. Jennett,
Professor of neurosurgery
University of Glascow
 Glasglow Coma Score
(GCS)
1. No eye opening

E 2. Eye opening in response to pain (Patient

fingernail bed; if this does not elicit a
response, supraorbital and sternal
pressure or rub may be used.)
3. Eye opening to speech. (Not to be
confused with an awaking of a sleeping
person; such patients receive a score of
4, not 3.)
4. Eyes opening spontaneously
 Glasglow Coma Score
(GCS)

V 1. No verbal response

2. Incomprehensible sounds. (Moaning but no words.)

3. Inappropriate words. (Random or exclamatory

articulated speech, but no conversational exchange)

4. Confused. (The patient responds to questions

coherently but there is some disorientation and
confusion.)

5. Oriented (Patient responds coherently and

appropriately to questions such as the patient’s name
and age, where they are and why, the year, month,
etc.)
 Glasglow Coma Score
(GCS)
1.No motor response

2.
M Extension to pain (abduction of arm, external rotation of
shoulder, supination of forearm, extension of wrist, decerebrate
posture)

3.Abnormal flexion to pain (adduction of arm, internal rotation of

shoulder, pronation of forearm, flexion of wrist, decorticate
posture)

4. Flexion/Withdrawal to pain (flexion of elbow, supination of

forearm, flexion of wrist when supra-orbital pressure applied ;
pulls part of body away when nailbed pinched)

5.Localizes to pain. (Purposeful movements towards painful

stimuli; e.g., hand crosses mid-line and gets above clavicle when
supra-orbital pressure applied.)

6.Obeys commands. (The patient does simple things as asked.)

 Consciousness
• Impairment of self awareness,
person, environment, time

• Clouding of consciousness
• Confusional state
• acute(delirium), chronic(severe
dementia)
 Consciousness
Level(arousal) and content(awareness) of
consciousness

Arousal and awareness, the two components of consciousness in coma, vegetative state,
minimally conscious state, and locked-in syndrome.
Cranial nerve
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NNC CMU
The Testing Order
• Disturbance of smell (1)

• Visual disturbance (2 , 3 , 4 , 6 )

• Orofacial paresthesia and difficulty in chewing (5th)

• Facial weakness and taste (7th)

• Hearing and equilibrium (8th)\

• Speech-swallowing-taste (9th, 10th, 12th)

• Limitation of neck movement (11th)

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Olfactory nerve
(CN I)

• Test each nose

with familiar
non-irritate smell

• Coffee bean
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Optic nerve
(CN II)

• Visual acuity

• Visual field

• Fundoscopy

• Swinging flashlight test

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Visual acuity
• Using hand held
card (14 inches) or
snellen wall chart,
assess each eye
separately

• Direct patient to
read aloud line
with smallest
lettering that
they’re able to see
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Visual acuity: Assessment

• 20/20 = patient can
read at 20` with same
accuracy as person
with normal vision.

• 20/400 = patient can

read at 20` what
normal person can
read from 400` (i.e.
very poor acuity).
Visual field
Pupillary response

Direct light reflex

Consensual light reflex

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Fundoscopic examination
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Cranial nerve III, IV, VI
Extraocular movement
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Trigeminal nerve
(CN V)

• Facial sensation

• Motor: jaw strength and muscle bulk

• Corneal reflex
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Masseter test
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Corneal Reflex
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Facial nerve (CN VII)

“Tear, Ear,
Taste, Face”
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The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
The Northern Neuroscience Centre
Chiang Mai University
NNC CMU
Rinne test

Weber test

Vestibulocochlear nerve
(CN VIII)
 Vagus nerve (CN IX, X)

A normal soft palate is illustrated on the left.

On the right, a right palatal palsy from a lower
motor neuron X nerve lesion has resulted in Hypoglossus nerve
deviation of the uvula to the left.
(CN XII)
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Motor system
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Motor examination
• Muscle bulk: normal, atrophy, hypertrophy

• Muscle fasciculation/cramp

• Muscle tone: normotonia, hypotonia, hypertonia

• Muscle strength: MRC grading system, paralysis,

paresis

• Movement: involuntary movement

• Convulsion?

• Gait / incoordination
Reflex
Reflex
Reflex
Superficial Reflexes
• Plantar reflex
• Stroke lateral side of foot from heel
to the ball, then across to the medial
side
• Normal response is a positive plantar
reflex
• Plantar flexion of all toes
• Abnormal response is the Babinski sign
in those 2 yoa
• Dorsiflexion of the great toe with or
without fanning of the other toes
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Cerebellar function
• Coordination and fine motor skill

• Rapid repetitive movement, and rhythmic alternating

movement

Diadochokinesia
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Cerebellar function
• Coordination and fine motor skill
• Accuracy of movement

• Finger-to-finger test with person’s eyes open

• Movements should be rapid, smooth, and accurate

• Consistent past pointing may indicate cerebellar impairment

• Heel-to-shin with person supine

• Should move heel from knee up and down the shin in a straight line,
without irregular deviations to the side
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Finger to Nose Test
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Heel to Shin Test
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Finger-to-nose test.
A. Normal: Smooth trajectory throughout movement.
B. Cerebellar hemisphere dysfunction: Tremor increases in amplitude as finger approaches target.
C. Parkinsonian: Tremor may be present at initiation of movement, but smoothes out as finger approaches target.
D. Essential tremor: Low-amplitude fast tremor throughout trajectory, may worsen as finger approaches target.
The Northern Neuroscience Centre
Chiang Mai University
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Cerebellar function

• Stance and gait

• Gait

• Tamdem walk

• Romberg’s test
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Gait
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Romberg’s test
The Romberg test is a
test of the body's sense of
positioning
(proprioception), which
requires healthy
functioning of the dorsal
columns of the spinal cord.
The Romberg test is used
to investigate the cause of
loss of motor coordination
(ataxia).
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Sensory Function

• Sensory System: pain, lightning

pain, paresthesia, hyperesthesia,
anaesthesia, numbness
Sensory function
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Sensory function
• Primary sensory functions

• Always with the person’s eyes closed

• Sites
• Hands
• Lower arms
• Abdomen
• Feet
• Lower legs
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Sensory function
• Superficial touch
• Use a cotton wisp

• Have the person point to

the area touched

• Superficial pain
• Sharp and dull sensations

• Allow 2 seconds between

each stimulus
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• Vibration

• Place stem of tuning

fork (128 Hz) against
bony prominences

• Begin distally

• Sites:
Bony
prominence: hallux,
medial malleolus)
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Proprioception
• Proprioception

• The sensation of position and muscular activity

originating from within the body which provides
awareness of posture, movement, and changes in
equilibrium

• Test

• Joint position test: digit, toe

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Sensory function
• Cortical Sensory Functions

• Always with the person’s eyes closed

• Stereognosis

• Ability to identify a familiar object by touch and manipulation

• Tactile agnosia: inability to recognize objects

• Graphesthesia

• With a blunt pen, draw a letter or number on the palm

• Should be readily recognized

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Mental status
 Higher Cortical
Function
• Memory
• Language
• Calculation
• Higher motor function(Praxis)
• Higher sensory function(Gnosis)
 Memory

• Short term memory

• ถามคำให้ทวน 3 คำ “ต้นไม้ รถยนต์ มือ”
• Long term memory
• ชื่อประเทศ ชื่อพ่อแม่
 Language
• Fluency: ความคล่องของการพูด

• Comprehension: 1 step, 2 step, 3 step

• Repetition “ยายพาหลาน ไปซื้อขนมที่ตลาด”

• Naming: ปากกา นาฬิกา แก้วน้ำ

• Reading

• Writing
 Aphasia
• Aphasia refers to an impairment in
linguistic communication produced by
brain dysfunction

• It must be distinguished from other

disorders of verbal output such as
dysarthria, mutism, and the abnormal
language production of patients with
thought disorder
 transcortical Transcortical
motor aphasia sensory aphasia

Motor Sensory
aphasia aphasia

A: Wernicke's area Conduction aphasia

B: concept center
M: Broca's area

a--> A Articulatory Pure

-auditory input to Wernicke's area disorder word
(aphemia) deafness
M --> m
-motor output from Broca's area
A --> M
-tract connecting Wernicke's and Broca's
areas
A --> B Lichtheim's diagram of the language system
-pathway essential for understanding spoken
input
B --> M
-pathway essential for meaningful verbal
output.
Praxis

Gnosis
 Mini-Mental
State
Examination
(MMSE)

< 24/30 : Dementia

 Surat Tanprawate, MD, MSc(Lond.), FRCP(T)
CertHE(Hist Med)
Neurology staff,
Division of Neurology, CMU
The Northern Neuroscience Center, CMU

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Kind Attention