NEUROLOGIC EXAMINATIONS

Step 1: Collecting Basic Patient Information

A. General Data D. Past Medical History
 Name  Illnesses experienced (Childhood/Adult)
 Age  Past hospitalizations/operations
 Sex  Medications being taken
 Handedness  95% have LEFT cerebral dominance  Allergies
 Civil Status
 Occupation E. Personal and Social History
 Educational level
 Race
 Lifestyle
 Religion
 Personal Interests

B. Chief Complaint
F. Family History
 Reason for consultation
 Ask for illnesses present on both maternal and paternal sides of the family
 PATIENT’S description of what he/she feels
G. Systems Review
 “Why are you here? How are you feeling?”
 Cephalocaudal approach

C. History of Present Illness

 Onset
H. Tools  I.P.P.A
 Duration  Inspection
 Palpation
 Frequency
 Regularity  Percussion
 Progression  Auscultation

 Location. “Where is it?” In collecting information from the patient:

 Quality. “What is it like?”
 DO NOT say, “Are you Juan de la Cruz?” This can be answered with a yes or a no, and
 Quantity or Severity. “How bad is it?”
sometimes may lead you to assessing the wrong person. Let the patient say his/her
 Timing. “When does it start? How long does it last? How often does it come?”
name instead.
 Setting in which the symptoms occur. “What were you doing when it first
 DO NOT finish the patients sentences. Let them describe how they feel, and do not
happened/ when it happens?”
 Remitting or exacerbating factors. “Is there anything that makes it better or interrupt until they are done. A series of “yes-no” questions makes the patient feel
worse?” restricted and passive, leading to significant loss of detail.
 Associated manifestations. “Have you noticed anything else that accompanies
it?” Note that these appear on the ACTUAL patient’s chart and are necessary to document. Do
not overlook any of these as any of the proctors may be strict with technicalities.

Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
 Step 2: Neurologic Exam Proper
I. Mental Status Exam V. Reflexes
II. Cranial Nerve Examination VI. Cerebellar Function
III. Sensory Tests VII. Meningeal Test
IV. Motor Tests

MENTAL STATUS EXAM

 General Behavior and Appearance
 Stream of talk
 Mood and Affect B. Attention Span
 Content of thought  Assess if the px can attend to stimuli long enough to comprehend and to
 Intellectual capacity respond
 Sensorium  please refer to Dr. Corral’s notes for elaborate info  Asses if the px can attend to a task long enough to complete it

FUNCTIONS AREA OF THE NERVOUS SYSTEM  Spell WORLD backwards

 Consciousness ARAS—ascending reticular activating system  Recite months backwards
 Attention Span of the brainstem
Medial Temporal Lobe C. Orientation
 Recent memory Hippocampal-fornix-mamillary body circuit  Person. “What is your name?”
 Orientation Basal forebrain  Place. “Where are you right now? What city and province?”
White matter
 Time. “What time is it? What day of the week? What month and year?”
 Calculation Left Angular Gyrus
 Insight Frontal lobes
D. Memory
 Judgment
 Planning  Ask the patient to recall a remote memory.
example: “Where did you attend preschool?”
 Ask the patient to recall a recent situation.
A. Level of Consciousness
 Awareness of self and environment example: “What did you eat for breakfast?”
LOC TECHNIQUE  Provide patient with three words and ask them to repeat them and then
Alert  Speak to the patient in a normal tone of voice ask again at the end of the neuro exam.
Lethargic  Speak to the patient in a loud voice example: “Baso, Bola, Papel.”

Obtunded  Shake the patient gently as if awakening a sleeper E. Fund of Information

 Apply painful stimulus  Ask about current events/ general knowledge

Stupor  Example: pinch a tendon, sternal rub, roll a pen  “Who is the current president of the Philippines?”
across a nailbed

Comatose  Apply painful stimulus

Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
F. Insight, Judgment, Planning G. Calculation
 Ask what the patient would do if placed in a certain situation  Paper and pencil calculation
 Ask if the patient recognizes the illness and implications  Is the patient able to balance a checkbook?
 “What would you if a fire would occur at home?”  Serially subtract 7 from 100
LOCALIZATION OF LESIONS Additional Information Mentioned by Dr. Corral
SYMPTOMS PRESENTED or SYNDROME LOCATION Binswanger’s Dementia White Matter

Visual Hallucination Occipital Cortex Dementia Medial Temporal

Basal Forebrain
Olfactory Hallucination Uncus
Gerstmann’s Syndrome Left Angular Gyrus
Sensory Hallucination Post-central Gyrus
Inferomedial Temporo-occipital Region Hypoxic Ischemic Encephalopathy White Matter
Prosopagnosia
(IMTO)
Autotopagnosia/Asomatognosia Left Angular Gyrus
Posterior part of the L superior Temporal
Auditory Agnosia
Gyrus
Right Parietal Lobe
Left Hemispatial Neglect
 Line Bisection Test
Anosognosia
Sensory Suppression
Right/Left Parietal Lobe
Extinction
Inattention
Broca’s Aphasia (Motor) L posterior Frontal cortex
L posterior, superior, middle Temporal
Wernicke’s Aphasia (Fluent)
cortex
L Parasylvian Cortex/connection with the
Global Aphasia
Caudate-Putamen or Thalamus

Conduction Aphasia L superior Temporal and supramarginal gyri

Anterior or Superior to Broca’s area

Transcortical Motor Aphasia

Transcortical Sensory Aphasia Posterior or Inferior to Wernicke’s area

Mixed Transcortical Aphasia Overlap of TCM and TCS areas

Apraxia Pyramids

Dyslexia Posterior end of the Aphasic Zone

Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
 DISORDER AREA OF LESION COMMENT

Agnosia Organic Cerebral Lesion Not knowing; inability to understand meaning,

important or symbolic significance
Dyscalculia Left Angular Gyrus
Blunted Affect Bi-frontal Lobe Lesion Could also be manifested by px with Hysteria
or Schizophrenia
Affective Lability Bilateral UMN Seen in Pseudobulbar Palsy, Diffuse Brain Dse,
Manifested by on-off laughing & crying
Agraphognosia/ Agraphesthesia Somatosensory Cortex Unable to recognize letters written on skin
and has destroyed sensory pathway
Prosopagnosia Inferomedical Temporo-Occipital Region Inability to recognize faces of persons/in
photos
Autotopagnosia/Asomatognosia Left Angular Gyrus Right-Left disorientation; finger agnosia
Left-Sided Hemispatial Neglect Right Parietal Lesion Px ignores person, object, or any stimuli from
affected side
Inattention To Double Simultaneous Cutaneous Stimuli Right Parietal Lesion Fails to attend to stimulus on the LEFT
Left Parietal Lesion Fails to attend to stimulus on the RIGHT
Gerstmann’s Syndrome Left Posterior Parasylvian Lesion 1. Finger agnosia
2. R-L Disorientation
3. Dyscalculia
4. Dysgraphia
Akinetic Mutism/ Bradylalia Bilateral Lesions of Thalamus, Basal Nuclei, or Upper Brainstem
Dressing Apraxia Right Parietal Lesion Neglect Syndrome
Broca’s Aphasia/ Expressive/ Motor/ Non-Fluent Left Poseterior Inferior Frontal Cortex Non-fluent
Dysprosody
“No ifs, ands or buts”
Wernicke’s Aphasia/ Sensory/ Receptive Posterior Parasylvian Temporal Operculum Fluent but with World Salad
Global Aphasia Entire Left Parasylvian Area (Massive Left Parasylvian Lesion) Entirely mute with expressive and receptive
aphasia
Congenital Dyslexia Parieto-Occipital Temporal Confluence Agnosia for meaning of written words
Acquired Dyslexia Posterior End Of Aphasic Zone (Parieto-Occipital Temporal Confluence)
Auditory Agnosia Posterior Part Of Left Superior Temporal Gyrus Failure to understand spoken words
Dysprosody Parasylvian Zone Of Right Hemisphere Impairment of px to invest his own speech
with emotional inflection
Anosognosia R/L Parietal Lesion Px unaware of his neurologic deficits
Transcortical Motor Anterior or Superior to Broca’s Area Non-fluent; good understanding; good
repetition and meaning
Transcortical Sensory Inferior or Posterior to Wernicke’s Area Fluent; poor understanding; good repetition
and naming

Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
 CRANIAL NERVE EXAMINATION
“Some Say Marry Money But My Brother Says Big Brains Matter More” SUMMARY OF CRANIAL NERVE TESTS

Sensory: 1, 2, 8
I Smell
Motor: 3, 4, 6, 11, 12
II Visual acuity, visual fields, ocular fundi
Both: 5, 7, 9, 10
II, III Pupillary reactions
Parasympathetic Fibers: 3, 7, 9, 10
III, IV, VI EOMs
CRANIAL NERVE ORIGINS
V Corneal reflexes, facial sensation, and jaw movements
I Olfactory Bulb
VII Facial movements
II Optic Chiasm
VIII Hearing
III Midbrain, anteriorly
IX, X Swallowing and rise of the palate, gag reflex

IV Midbrain, posteriorly then winds around V, VII, X, XII Voice and speech

V Pons, anteriorly XI Shoulder and neck movements

VI XII Tongue symmetry, position, and movement

VII Between medulla and pons
VIII
IX CN I  Olfactory Nerve
X Medulla, between olives and ICP
XI
 Test for the Sense of Smell
XII Medulla, between olives and pyramid
 Use familiar and non-irritating odors
 Make sure that each nasal passage is patent by compressing 1 side of the
nose and asking the patient to sniff
Brain I, II
 Then ask patient to close eyes
Midbrain III, IV  Occlude 1 nostril and test smell in the other with chosen substance

Pons V, VI, VII, VIII (ex: coffee)

 Ask the patient to identify the odor
Medulla IX, X, XI, XII
Abnormalities may indicate:

Sinus conditions, Head Trauma, Smoking, Aging, Cocaine use, Parkinson’s disease

Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
CN II  Optic Nerve Pupillary abnormalities may indicate:

 Visual Acuity – Cover 1 eye at a time Pupils stay in midposition, NRTL  Midbrain lesion

 Snellen’s Chart 20 feet away Pupils are unilaterally deviated, NRTL  Uncal Herniation
 Rosenbaum’s pocket card 14 inches away
Pupils pinpoint, reactive  Pontine lesion, Opiates, Pilocarpine
 Central Vision—Amsler Grid 30 cm away
 Tumbling E chart is also used for illiterate patients
 Ophthalmoscopy
 Blindspot is increased with papilledema
 Darken room, and shine the light on the back of your hand to check the

When asked by Dr. Canto if there are none of these tools are available, you will use type of light and desired brightness

(IN ORDER)  Turn the lens to 0 diopter (at this diopter, the lens neither converges or
diverges light)
1. Reading material (Newspaper, magazines, etc)
 Hold the scope in your right hand and use your right eye to examine the
2. Signage
patient’s right eye; do the same w/ the left
3. Count fingers
 Instruct the px to look over your shoulder or a point behind the wall
4. Wiggling fingers
 Look for the RED REFLEX: Place yourself about 15 inches away, shine the
5. Hand movement
beam of light on the pupil, and look for an orange glow on the pupil; Look
6. Light and no light perception (make sure that the room is dim when
for signs of opacity!
performing this step)
 Keep the beam of light focused on the red reflex, and approach the px on
 Visual Fields
a 15o angle towards the pupil (You may lower the brightness to make the
 Confrontation Test  Peripheral vision
px comfortable)
 Test each eye separately, and then both eyes together!
 Check for normal A : V ratio
 Eye to eye, 50 cm away
 2A : 3V  Veins pulsate
 Test midpoint of quadrants
 Arteries are lighter and smaller; Veins are darker and larger
 Hands should be 1 foot away from the px ears
 Inspect the optic disc; note for the ff:
 Pupillary Reactions
 Sharpness, color, size of the central cup, comparative symmetry
 Swinging flashlight test
Abnormalities may indicate:
 Used to test for relative afferent pupillary defect/ Marcus Gunn pupil
 Direct and Consensual light reflex Absence of red reflex  Cataract, Opacity by the vitreous, Detached Retina (less
common), Retinoblastoma in children
 Check for PERRLA  Pupils Equally Round and Reactive to
Light and Accommodation Swelling of the optic disc  Papilledema; this pressure is transmitted to the optic
nerve, and causes stasis of the axoplasmic flow, intra-axonal
 Normal size is approximately 3 mm edema, and swelling of the optic nerve head

Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
  Inspect the macula: direct your beam laterally and ask the px to look
directly into the light
 Darker, avascular area lateral to the optic disc
 Fovea centralis – center of the macula
 Cones – visual acuity, color vision
 Systematically look at the optic disc, vessels, retinal background and fovea
 If ICP is high:
 Absent venous pulsations ( ICP above 190 mmHg)
 Dilated veins
 Edema
CN III, IV, VI  Occulomotor, Trochlear, Abducens Nerves
 Inspection and Ocular Alignment
 Inspect both eyes
 Look for ptosis
 Ocular alignment: stand 2 feet directly in front of the px and shine a light
into the px eyes; the reflection of your light source should fall on the same
location of each eyeball. They should be visibly slightly nasal to the center
 Test for Saccades
 Hold up your two hands about 3ft apart and instruct the px to look at
the finger that is wiggling without moving their head
 Px eyes should be able to quickly, smoothly, and accurately jump
from target to target
 Test for Smooth Pursuit
 Ask px to keep watching the target without moving their head
 Move target slowly from side to side, and up and down
 Note for lagging or jerking
 Test for Optokinetic Nystagmus
 Vestibulo-ocular Reflex
 Have the px visually fixate on an object straight ahead
 Rapidly turn the px head from side to side, and up and down
 Px eyes should stay fixed on the object and turn in the opposite
direction of the head movement
 Test for Vergence
 Check for simultaneous eye movements—inward (convergence) or
outward (divergence)—in order to maintain an image on the fovea
 Convergence is tested as a part of the Near Triad Test
 Ask px to follow an object that is brought from a distance to the tip
of their nose, the eyes should converge; the pupils will constrict and
the lens will round up for accommodation
Abnormalities may indicate:

of the pupils Third Nerve Palsy Ptosis, Pupil Dilatation, Strabismus, Diplopia
 Versions & Ductions Horner’s Syndrome “HORNY PAMELa” Ptosis, Anhydrosis, Miosis, Enophthalmos, Loss
 Test for EOM’s range of motion with both eyes open and following the
of ciliospinal reflex (damage to sympathetic NS)
target  Conjugate Gaze
Argyll Robertson Pupil  Constricts to accommodation but not to light
 Perform the Six Cardinal Directions of gaze: Draw a wide H in the air to
lead the patient’s gaze  2o to Syphilis

 Note for any misalignment of the eyes or complaint of diplopia
 If there is misalignment or diplopia, examine each eye with the other
covered
 Supranuclear Gaze Systems
 To insure that the image that is being looked at is centered on the fovea of
the macula
Nystagmus  Seen in cerebellar dysfunction, vestibular d/o,
internuclear ophthalmoplegia
In testing for light reactions,
Constriction abnormalities may be found in Tonic Pupils and CNIII Paralysis
Dilatation abnormalities may be found in Horner’s Syndrome and Argyll Robertson Pupils

Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
CN V  Trigeminal Nerve CN V & VII  Trigeminal and Facial Nerve

 Sensory Function Tests in the 3 Sensory Div. (forehead, cheek, jaw)  Corneal Reflex
 Ask px to look up and away from you
 Light Touch with a cotton tip applicator
 Approach from the opposite side, out of px line of vision
 Pain with a sharp object  Avoid touching the eyelashes
 Motor Function Tests with the muscles that close the jaw  Lightly touch the cornea (limbal junction) with a fine cotton wisp
 Afferent  Ophthalmic division of CN V
(masseter, temporal, medial pterygoid)
 Efferent  CN VII branch to the oribicularis oculi
 Inspect
CN VII  Facial Nerve
 Palpate
 Ask px to clench the jaw  Motor Function Tests
 Wrinkle the forehead  Frontalis Muscle
 Check the temporalis and masseter muscles as the px bites  Close eyes tight and don’t let me open them  Orbicularis Oculi
 Test for jaw closure. Ask px to open the mouth and resist the examiner’s  Smile  Zygomaticus Major
 Frown  Mentalis
attempt to close
 Show both upper and lower teeth  Risorius
 If there is weakness of the pterygoids, the jaw will deviate towards  Puff out cheeks  Buccinator
the side of the weakness  Sensory Function Test
 Dip a cotton tip in a solution that is sweet, salty, sour, or bitter.
 Test for lateral pterygoid muscle
 Apply to one side then the other side of the extended tongue
 Ask px to move the jaw from side to side  Have px decide on the taste before they pull their tongue back in
 Parasympathetic Functions
 If weak, jaw deviates to ipsilateral side
 Tearing  lacrimal glands via pterygopalatine ganglion
 Snotting  nasal mucosa via pterygopalatine ganglion
 Salivating  submandibular ganglion
Abnormalities may indicate: Abnormalities may indicate:
Absent Blinking in both eyes  CN V Lesions
Jaw Jerk  UMN Lesion

Absent Blinking on the side of weakness  CN VII Lesions

Unilateral Weakness in CN V  Pontine Lesion

Bilateral Weakness in CN V  Bilateral Hemispheric Disease Absent blinking with sensorineural hearing loss  Acoustic Neuroma

Ipsilateral Facial and Body Sensory

 Contralateral Cortical/Thalamic Lesions
Loss

Ipsilateral face, but Contralateral

 Brainstem Lesions
Body Sensory Loss

Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
CN VIII  Vestibulocochlear Nerve CN IX & X  Glossopharyngeal and Vagus

 Auditory Acuity  CN IX
 Rub your fingers lightly near each ear  Efferent  Stylopharyngeus
 Use a ticking watch  Afferent  Carotid SINUS: baroreceptive reflexes; Carotid BODIES:
 Whisper Test baroreceptive & chemoreceptive reflexes
 Stand 2 feet behind the px
 Occlude the nontest ear  CN X
 Whisper a combination of 3 numbers and letters; use a different  Palatal M with CN V
combination for the other ear  Pharyngeal constrictors with CN IX
 Weber Test  Lateralization  Laryngeal M
 Place a vibrating tuning fork on the middle of the head  Palate  Pharynx  Larynx
 Ask if the px feels or hears it best on one side or the other
 NORMAL  px hears it on both ears  Motor Function Tests
 Have the px say “Ah” or “Kah”
 Watch the movements of the soft palate (levator veli palatine) and the
Weber Test abnormalities may indicate:
pharynx
Unilateral Neurosensory Hearing Loss  sound is heard better in the good ear  The palate should rise symmetrically
 There should be minimal nasal air escape
Unilateral Conductive Hearing Loss  sound is heard best in the abnormal ear

Abnormalities may indicate:

 Rinne Test  Comparing AC and BC
 Uvula deviates toward the normal side because that
 Place the base of the vibrating tuning fork on the mastoid, behind the ear at Unilateral Weakness
is the side of the palate that is pulled up higher
level with the canal
 When the px can no longer hear the sound, quickly place the fork close to Bilateral Weakness  Neither side of the palate will elevate and there will
 the ear canal, and ask if px hears a vibration be marked nasal escape
 NORMAL  sound is hear longer through air than through bone Absent rising of Palate  Bilateral CN X Lesion

Absent Gag Reflex  Unilateral absence suggests a CN IX Lesion (and

Rinne Test abnormalities may indicate:
perhaps CN X)
Conductive Hearing Loss  sound is heard through bone longer than it is thru air
 Sensory and Motor Function Test: Gag Reflex Test
 BC = AC or BC > AC
 Touch the back of the pharynx with the tongue depressor
Sensorineural Hearing Loss  sound is heard longer through air  Observe for the elevation of the palate, elevation of the tongue, and
constriction of the pharyngeal muscles
 AC > BC

 Vestibular Test
 Vestibulo-ocular Reflex
 Ice Water Caloric Test is indicated for:
 px w vertigo or balance problems
 Comatose px when testing for brainstem function

Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
CN XI  Spinal Accessory SENSORY EXAMINATION
 Inspect for atrophy or fasciculation of the trapezius The general senses tested in the Standard Neurological Examination consist of touch,
 Ask px to shrug both shoulders upward against your hands pain, temperature, position, vibration, and stereognosis. Unique receptors and unique
 Note the strength and contraction of the trapezii pathways mediate each of the special senses.
 Ask px to turn his or her head to each side against your hand
SENSATIONS PATHWAY
 Observe contraction of the opposite SCM
 Pain
 Note the force of the movement against your hand Spinothalamic Tracts
 Temperature
 Position
Abnormalities may indicate: Posterior Columns
 Vibration
Trapezius Weakness with atrophy and
 Light Touch Both pathways mention
 Peripheral Nerve Disorder
fasciculations Cortex, and may depend on some of the
 Discriminative Sensations
Drooped shoulder, downward and lateral sensations mentioned above
 Trapezius Muscle Paralysis
displacement of the scapula
CN V Testing

CN XII  Hypoglossal Nerve  Wisp of Cotton

 LISTEN to the articulation of the px words (CN V, VII, IX, X are involed in this
function as well)
 Inspect the tongue at rest
 Note for atrophy or fasciculations (you may palpate)
 Test for Tongue Motility and Deviation
 When protruded, look for asymmetry, atrophy, or deviation from midline
 Ask px to move from side to side, and note the symmetry of movement
 Ask px to push the tongue against the inside of each cheek
 Ask the px to say “touch” in response to each touch
 Lightly brush area of the 3 sensory divisions of CN V
 Touch alternate sides of the face randomly
 Change the time between touches to keep the patient from getting into a
rhythm or answering
 If the history indicates a specific area of sensory loss, start in the middle of
the abnormal area and work outwards
Corneal Reflex

 Afferent – CN V; Efferent – CN VII

Abnormalities may indicate:  Free piece of cotton
Protruded tongue will deviate towards the weak  Hold lids apart – avoid stimulating the eyelashes
 Unilateral Weakness
side  Bring cotton directly in from the side; avoid px line of vision

Ipsilateral atrophy, Ipsilateral deviation  LMN Lesion Abnormalities may indicate:

Contralateral deviation, Moderate weakness  UMN Lesion Absent contralateral corneal reflex  Acute Hemispheric Lesions

Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
 PERIPHERAL NEUROPATHIES
Corneomandibular Reflex – von Solder phenomenon
Occipital Neuralgia Pain from the base of the skull to the occiput
 Stimulation of one cornea causes contraction of the ipsilateral lateral
Carpal Tunnel Syndrome Median nerve;
pterygoid muscle and a twitch of the jaw to the opposite side
Pain, tingling, and numbness at the palmar aspect of
Glabellar Blink Reflex the thumb to radial half of 4 th digit
() Tinel’s Sign – percussing over the median nerve
 Percussion of glabella with fingertip or percussion hammer at the wrist
 Note for bilateral contraction of orbicularis oculi () Phalen’s Sign – flex hands at right angle and hold
for a minute by pressing the backs of the hands
Spinothalamic Tract Tests (Temperature Disc and Pain Perception) together
Ulnar Condyle and Ulnar nerve; flexion of arm trigger sensations in the
 The forehead is the most sensitive area for temp discrimination Cubital Tunnel Syndromes little finger
 If the px discriminates temperature normally, and the hx does not suggest Meralgia Paresthetica Lateral femoral cutaneous nerve; under inguinal
neurologic disease, you do not need to prick every px with a pin to test for p ain ligament
perception Sensory disturbances at anterolateral aspect of the
 Tuning fork or Finger Test thigh
 Ask px to close eyes Obesity, pregnancy, diabetes
 Apply the shaft of the tuning fork to the px cheek for a few seconds, and then Common Peroneal Palsy Foot drop
remove it
Tarsal Tunnel Syndrome Posterior tibial nerve;
 Apply the side of your little finger to the same spot
Flexor retinaculum
 Ask the px whether each is warm or cool
Pain at lateral foot, toes, and sole esp when
 Randomly alternate your finger and fork to the 3 sensory areas of CN V
standing or walking
 Test over the dorsum of both hands and feet Morton’s Metatarsalgia Interdigital nerve
 Warm and Cold Tube Test Pain, numbness, tingling at ball of foot, toe 2 and 3,
 Pin Prick Test or 3 and 4 when walking or wearing shoes that are a
 Show the px the pin with a sharp and dull end bit tight
 Ask the px to respond with “sharp” or “dull” when you apply Pain at Lateral Foot S1
 Have the px close eyes Pain at Medial Foot L5
 Alternate touching the px with the sharp and dull ends CHECK DEMYER’S FOR AN ELABORATE DISCUSSION P. 393
 Start with a normal area
 Test the face and dorsum of the hands and feet
 DISCARD THE PIN AFTER USE Dorsal Column Tests
Body and Extremities  Test for Digital Position Sense—Proprioception
 Separate the digit being tested
 Test Light Touch Sensation
 4th digit is best tested for position sense—less innervations and cortical
 Test the face and dorsum of the hands and feet
representation
 NOTE: Touch impulses ascend to the somesthic cortex by two spinal pathways: 1)
 Demonstrate as you move the finger up, down, left, right
dorsal columns—f. gracilis and cuneatus; 2) ventrolateral columns—spinothalamic
 Ask the px to close eyes and then proceed with testing
tract/spinal lemniscus
 If normal distally, it will be normal proximally

Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
 Test for Vibration  Two-Point Discrimination
 Vibration sense is often the first sensation lost in peripheral neuropathy and  You may use the two ends of an opened paper clip
increases the likelihood of peripheral neuropathy  Fingertips 2-4mm
 Hand vibrations feel vibration much better  Dorsum of fingers 4-6mm
 Use a 128 Hz tuning fork  Palm 8-12mm
 Tap it on the heel of your hand and place it firmly over a distal  Dorsum of the hand 20-30m
interphalangeal joint of the px finger, then over the interphalangeal joint of  Alternate the double stimulus regularly with a one-point touch
the big toe  Stereognosis
 Ask what the px feels  Present different objects of different shapes to the patient for recognition
 If not sure whether the px feels pressure or vibration, ask when the vibration
stops instead
 If vibration sense is impaired, proceed to more proximal bony prominences
like the ulnar styloid process or internal malleolus or shin
 Romberg Test
 Stand with feet together
 Ask px to close eyes

Abnormalities may indicate/suggest:

Loss of Position  Tabes dorsalis, multiple sclerosis, or B12
Sense/Vibration Sense deficiency from posterior column disease
Loss of Vibration Sense  Pallanesthesia

Sways to the side of lesion Unilateral vestibular disease

Sway much with eyes closed  Tabes dorsalis

Gyrate wildly but does not fall  Hysteria

Inability to recognize objects  Astereognosis

placed in the hand
Alternative tests for Dorsal Column Dysfunction

 Directional Scratch Test

 Draw two transverse lines 2 cm apart across the distal shin and the dorsum of
the hand
 You may use your finger tip, a tongue blade, or the butt of a tuning fork
 Ask the px whether the object moved up or down
 You may do trials with the px eyes open, but the testing must be done with
the px eyes closed
 Make 10 trials in random up and down directions; a normal person gets all 10
correct. If the px errs increase the distance to 5cm and then to 10cm

Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
 MOTOR EXAMINATION  Test for Shoulder Girdle Muscles
 Trapezius
When assessing the motor system, focus on:  Free movements
1. Body Position  Strength
2. Involuntary Movements - Arm elevation
3. Characteristics of the Muscles—bulk, tone, strength - Arm adduction downward
4. Coordination - Arm adduction across chest
- Scapular adduction
Initial Inspection - Scapular winging
 Arm abduction
 Test for Station and Gait - Initiated by supraspinatus
 Observe the px body position when moving or at rest - Carries arm to shoulder height and scapular rotation (Deltoid)
 Watch the px walk—single MOST IMPORTANT part of the entire neuro exam - Holds scapula in place (Serratus Anterior and Trapezius)
 Observe the px  Latissimus Dorsi
 Inspect rostrocaudally; check for symmetry - Have the px cough
 Watch for involuntary movements like tremors, tics, chorea, or fasciculations.  Upper Arm Muscles
Note the location, quality, rate, rhythm, and amplitude and their relation to  Start with the px elbow flexed
factors  Elbow flexors
 Inspect the size and contours of the muscles. Look for signs of atrophy or  Elbow extensors
hypertrophy  Forearm Muscles
 Wrist flexors – very strong antigravity m
Strength Testing (Rostrocaudal Approach)
 Wrist extensors – px forearm flat on thigh or tabletop
 In all strength tests, the px should exert maximum power, but they should pull to a  Finger Muscles
peak in slow crescendo without jerking  Thenar and Hypothenar eminences – size and asymmetry
 Matching Principle  Abduction and adduction of fingers – start with first doral interosseous
- Select movements that are not too strong nor too weak to judge resistance  Extension
 Length-Strength Principle  Flexion (Grip Test)
- Muscles are strongest when acting at their shortest - Offer 2 fingers and ask px to squeeze
 Antigravity Muscle Principle - Partialdorsiflexion of the wrist—strongest grip/functional position of the
- Powerful—postural antigravity system of a quadruped hand
- Triceps m  Abdominal Muscles
- Quadriceps femoris  Sit-up
- Neck extensors  Normally—umbilicus remains centered
- Buttocks and back extensors  Weak muscles—umbilicus may migrate towards the stronger muscles
- Pectoral m  Umbilical Migration Test—Beevor’s sign
- Latissimus dorsi Abnormalities may indicate/suggest:
- Hip adductors
Umbilicus migrates UPWARD T10 Lesion
 Test for Flexor and Extensor Strength of the Neck
 Place on hand on the px occiput or forehead and the other on the front or
back of the px chest to provide bracing and counterpressure  Back Muscles (Paraspinal Muscles)
 Start with the px head strongly extended, and resist the neck flexion  Ask px to lie on a prone position, and ask to arch back
 Then test for flexor strength with the px head tightly flexed, chin on chest,  Ask px to bend forward at waist and straighten up
then try to extend it
Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
 Hip Girdle Results of Direct Percussion of Muscle
 Hip flexion
- Ask px to sit, and to lift a knee off and to hold the thigh in a flexed 1. Percussion Irritability
position - Faint dimple or ripple
 Thigh abduction/adduction - Remains or may even increase post-denervation (Cannon’s law of
- With the px seated, have the px hold the legs abducted as you try to hypersensitivity of denervated structures
press them together - Absence—Duchenne’s Muscular Dystrophy
- With the legs adducted, place your hands on the knees and try to pull the 2. Percussion Myoedma
knees apart - Tiny hump
 Hip extension - Sarcoplasmic reticulum is slow in reuptake of calcium
- With the px prone, have the px lift the knee from the table surface and - May occur in some normal people
hold it up - Often occurs in debilitation or dysmetabolic states such as uremia and
- Place your hand on the popliteal space and try to press the knee back myxedema
down 3. Percussion Myotonia
 Thigh Muscles - Thumb slowly rises up after hitting thenar eminence
 Knee extensors 4. Muscle Contraction Mytonia
- Deep knee bend - Myotonia occus in px with myotonia dystrophica, myotonia congenital,
- With the px prone, ask the px to try to touch the heel to buttock to paramyotonia congenital, certain channelopathies, and some types of
induce extreme flexion of the knee periodic paralysis r/t distrubances in potassium metabolism
 Knee flexors  Ask px to tighten fist and hold for 10s and flip the fingers open as quickly as
- Have the px hold the knee at an angle of 90 o while you try to straighten it possible on command
by grasping the px ankle - Myotonic px cannot flip the fingers open rapidly and the wrist
 Ankle and Toe Movements involuntarily flexes
 Have the px dorsiflex, invert, and evert the feet  Ask the px to close the eyelids as tightly as possible for 5s
 Inspect and palpate the leg and check for the strength of these movements - Myotonia keeps the eyelids closed/ delays opening
by manual opposition
 Check for Plantar Flexion
- Have the px walk on the balls of the feet

SCALE OF GRADING MUSCLE STRENGTH

5 Normal strength

4 Moves against resistance

3 Moves against gravity

2 Moves without gravity

1 Flicker of contraction of muscle, no joint movement

0 Complete paralysis

Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
 REFLEXES
Muscle Stretch Reflexes (MSR) Clonus

1. Muscle Spindles are the receptors - To and fro rhythmic oscillation elicited by quick stretch
- Small bags of muscle fibers - Interruption of UMNs (pyramidal tract)
- Afferent/Efferent Note for:
2. MSRs depend on the integrity of the Reflex Arc
3. Flexion of Joint = Relaxation of Muscle Spindle - Patellar Clonus
4. All Spindles must fire rapidly and synchronously to discharge LMNs - Wrist Clonus
5. Percuss tendons at 90 o which is a standard angle for elbow, knee, and ankle joints - Patellar Clonus
- Neonates – Physiologic Clonus
 Jaw Reflex - Adults – Sustained Clonus (ABN); Abortive Clonus (Normal)
 Biceps Reflex
 Triceps Reflex Superficial Reflexes
 Brachioradioalis Reflex
 Corneal Reflex
 Finger Flexion Reflex
 Gag Reflex
 Tromner’s – flip distal phalanx UPWARD
 Abdominal Skin-Muscle Reflex
 Hoffman’s – flip finger DOWWARD
 Anal Wink and Bulbocavernous Reflex
 (  ) Clonus of Extremity
 Plantar Reflex—Most important!
 Quadriceps Femoris Reflex
 Babinski’s Sign/ Extensor Plantar Response
 Strike a crisp blow on the patellar tendon
 Goal: REPRODUCIBILITY
 Observe the degree of pendulousness
 Reflexogenous zone – S1 Dermatome
 Px with Hypothyroidism may have a hung up appearance
 Pain Receptors – L4 – S2
 Triceps Surae Reflex
 Place the px in supine position with the limbs completely relaxed and
 Toe Flexion Reflex (Rossolimo’s sign)
symmetrically arranged, and with the knees straight or slightly flexed
 Tap on Ball of foot
 Stroke the lateral side of the sole
If first attempts to elicit reflexes fail:  Watch for normal flexion of the big toe
 Remind the px that the procedure may be ticklish
SCALE OF GRADING REFLEXES 1. Strike a crisper blow  Hold the px ankle with one hand to keep the foot in place and control of the
2. Change mechanical tension plantar stroke
4 to 4+ Hyperreflexia 3. Reinforcement  AVOID THE BASE OF THE TOES; in order to increase length of the stroke, s wing
- Jendrassik’s maneuver the stroke across the ball of the foot
- Counterpressure method  Triple Flexion Synergy
2 to 3 Average
- Tensor Fasciae Latae
Absence of MRSs are pathologic, except for:
- Hamstrings
1 Hyporeflexia 1. Infants or girls—lack of prominent - Tibialis Anterior
tendons  Infants – toe response varies (1yo’s have more constant flexor response)
2. Lack of patellar development in infants  True Extensor Toe Sign
0 Areflexia 3. Diaschisis or neural shock - Anatomic or pathologic interruption of the pyramidal tract
- Toe extends AFTER plantar stroke has moved a few cm
- Remains tonically extended as stroke continues
- Floats back after release of the stroke
Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
 CEREBELLAR TESTS
BABINSKI EQUIVALENTS
Chaddock Move object along the lateral side of the foot 3 Basic Functions of the Cerebellum, control of:

Schaeffer Squeeze the Achilles tendon 1. Posture and Movement

2. Coordination
Oppenheim Press knuckles down on the skin and move them down 3. Muscle Tone

Gordon Squeeze the calf muscles momentarily Clinical Manifestations of Cerebellar Lesions
1. Ataxia
Bing Make multiple pin pricks on the dorsolateral surface of the
2. Postural, Positional, or static type of action tremor
foot
3. Intention, end-point, or kinetic tremor
Gonda, Stransky Pull the 4 th toe outward and downward for a brief time and
release suddenly 4. Dysarthria
5. Nystagmus
6. Hypotonia
 Superficial Abdominal Reflex (T8-T10) 7. Silly, illogical, disinhibited, socially inappropriate
 Stroke the skin of the abdominal quadrants Gait and Station
- Umbilicus twitches towards the quadrant stimulated  Station
- Used to localize lesion at T10  Ask px to stand erect with feet closed
- Absent in elderly, young infants, obese, multiparous women  Arms forward
 Cremasteric Reflexes (L1-L2)  Tandem Walk
 Stroke the inner thigh of the px - Most sensitive for gait ataxia
 Watch for elevation of ipsilateral testes  Ask px to walk in a straight line
 Anal Wink (S2-S4) and Bulbocavernous Reflex (S3-S4)  Observe precaution—hold the px shirt at the back
- This is the FIRST spinal reflex to return post-spinal shock  Heel and Toe Walking
 Pricking the skin around the anus can cause a quick, twitch-like Coordination
constriction of the anal sphincter  Rapid Alternating Movement
 Pricking the glans penis causes reflex contraction of the bulbocavernous  Thigh Patting
muscle  Finger Tapping
 If px has a urinary catheter, you may tug lightly on the cather and watch  Finger-to-Nose
for an anal wink  Heel to Shin & Heel Tapping
Muscle Tone
Abnormalities may indicate/suggest:
 Palpate!
Hyperreflexia  CNS lesions of the descending corticospinal tract  Check DTRs for pendulous MSRs
 Knee Jerk Reflex
Hyporeflexia/Areflexia  Lesions of the spinal nerve roots, spinal nerves,
 Arm pulling
plexuses, or peripheral nerves
 Wrist tapping
Foot drop Common Peroneal Palsy  EOMs
Positive Babinski sign CNS Lesion affecting the corticospinal tract  Watch for Nystagmus!
(dorsiflexion of the big toe) - The gaze points to the lesion
NOTE! Listen to the px speech as well. You may find dysarthria and scanning speech
Loss of Anal Reflex Lesion in the S2-3-4 Reflex Arc (Cauda Equina Lesions)

Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
 MENINGEAL TESTS ADDITIONAL NOTES
Meningeal Signs

 Neck Mobility/Nuchal Rigidity

- Inflammation in the subarachnoid space causes resistance to movement
that stretches the spinal nerves (neck flexion), the femoral nerve
(Brudzinski sign), and the sciatic nerve (Kernig sign)
 Check if there is no injury or fx to the cervical vertebrae or cervical cord
 With the px supine, place your hands behind the px head and flex the
neck forward
 Brudzinski Sign
- POSITIVE SIGN—flexion of hips and knees
 As you flex the neck, watch the hips and knees in reaction to your
maneuver
 NORMAL: Remain relaxed and motionless
 Kernig Sign
- POSITIVE SIGN—pain and increased resistance to knee extension
 Flex the px leg at both the hip and knee
 Slowly extend the leg and straighten the knee

Lumbosacral Radiculopathy Test

 Lasegue Test
 With the px supine, do straight-knee leg raising test
 Flex the hip with legs straight
 Keep raising until the px pronounces sensation of pain
 Move a little lower until pain is no longer felt
 Then dorsiflex foot
- Radiculopathy is usually from a herniated disc that occurs (>95% of the
time) at L4-L5 or L5-S1 where the spine angles are usually posterior
- Look for confirming ipsilateral leg wasting or weak ankle dorsiflexion
(sciatica)

Abnormalities may indicate/suggest:

Nuchal Rigidity  Acute Bacterial meningitis or Subarachnoid Hemorrhage

Cervical Rigidity  Cervical Osteoarthritis

Lhermitte’s sign  Cervical Cord Lesion; common in Multiple Sclerosis

Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination
Transcribed by: Pamela Anne Gustilo, RN; Elmor Gicaro III, PTRP; Erma Alindogan, RMT References: Professor’s Notes—Dr. Tulmo, Dr. Corral, Dr. Canto, Dra. Yusay;
Dr. Fred Ting’s Notes, Bate’s Guide to Physical Examination, DeMyer’s: The Neurologic Examination