NEUROLOGICAL

EXAMINATION

Presented by:

Mr. Umar Hayat

Nursing Instructor
LEARNING OBJECTIVES

• By the end of the unit, learners will be able to

– Review Structure and function of Nervous System.
– Perform mental status examination of a client.
– Assess cranial nerve, sensory, sense of
proprioception and cerebellar functions and deep
tendon reflexes.
– Document findings.
– List the changes in the nervous system that are
characteristics of the aging process.
 NEUROLOGICAL
EXAMINATION MCCMSR
MCCMSR
M Mental status
C Cranial nerves
C Cerebellar function
M Motor function
S Sensory function
R Reflexes
NEURON
 SUBJECTIVE DATA — HEALTH
HISTORY QUESTIONS
 Headache
 Head injury
 Dizziness/vertigo
 Seizures
 Tremors
 Weakness
 Incoordination
 Numbness or tingling
 Difficulty swallowing
 Difficulty speaking
 Significant past history
 Environmental/ occupational hazards
MENTAL STATUS ASSESSMENT

 Level of Consciousness(LOC):
Alert,stuporous, comatose.
 Orientation: person,place,time

 Memory:

 – Immediate, recent andremote.

COGNITIVE ASSESSMENT

• Thought process
• Calculations
• Current events
• Response to proverbs
• Judgment & problem solvingability
• Communication abilities
• Emotion- Mood and affect
 OBJECTIVE DATA - THE PHYSICAL
EXAMINATION
• Preparation
– Screening neurologic examination
– Complete neurologic examination
– Neurologic recheck
• Equipment needed
– Penlight
– Tongue blade
– Cotton swab
– Cotton ball
– Tuning fork (128 Hz or 256 Hz)
– Percussion hammer
– Occasionally need: familiar aromatic substance
 HISTORY OF NEUROLOGICAL
SYMPTOMS
Vertigo: A feeling of spinning, either the patient or the
surroundings . Disturbance of the vestibular system is the most
common cause.
Syncope: There is sudden loss of strength. The patient tends
to fall down & loose consciousness but recovers as soon as he
is horizontal. Reduced cerebral blood flow is the underlying
mechanism.
Dizziness: Two common symptoms, described as dizziness by
the patient are vertigo and fainting (syncope).
Seizures (convulsions): An abrupt alteration in cortical
electrical activity.
 HISTORY CONT…

Epilepsy: Recurrent seizures over months or years.

Common types are:

In which there are jerky movements of the

Tonic Clonic Seizures
whole body with loss of consciousness.

In which there are repeated contractions of a

Jacksonian Seizures
part of the body, usually face and hand.

In which there are hallucinations and patient

Psychomotor Seizures
looses consciousness.
 HISTORY CONT…

Motor Weakness
Paralysis Means complete loss of power while
Paresis Means partial loss of power.
Monoplegia Means weakness of one limb
Hemiplegia Means weakness of one half of the body
(Both are caused by intracranial diseases)
Paraplegia Means weakness of both lower limbs
Quadriplegia Means weakness of all the four limbs
(Both are caused by spinal cord lesions)
 HISTORY CONT…
Sensory Symptoms

Positive Phenomena:
These may be spontaneous (paresthesias) or induced by some
stimuli like touch (dysesthesia).
These include tingling, pins & needles, pricking, burning,
constriction, tightness, electric current like sensations,
warmth/cold or pain.

Negative Phenomena:(hypoesthesia/Decreased
Sensations).
Patient feels that sensations like pain, touch and temperature
are diminished or absent on the affected side e.g. in diabetic
neuropathy
 HISTORY CONT…

Headache
This is a common symptom.

Tension Headache Is the most common type. It is pressing in character &

worse in the evening

Vascular Headaches (E.G. Migraine) are throbbing in character and are

episodic.

Headache Due To Is associated with signs of meningeal irritation

Meningitis And
Subarachnoid
Hemorrhage
 Mental status (ABCI)

Mental status (ABCI)

A Appearance
B Behavior
C Cognitive Functions
I Intellectual Functions
 APPEARANCE

Posture
Anxiety Tense posture, restlessness
Agitated Crying, hand wringing (wetting), pacing

Depression Slumped (collapsed) posture, slow movements

Manic Singing, dancing, expansive movements

Dressing, Grooming & Personal Hygiene

Is appearance appropriate for the season, climate and
occasion? Observe the patient's hair, teeth, nails, skin,
facial hair, use of cosmetics and body odor.
Deterioration in grooming & personal hygiene in a previously
well-groomed person suggest an emotional, psychiatric or
organic brain disorder (Alzheimer's disease).
 APPEARANCE

Level Of Consciousness
Alert
Lethargic Patient is drowsy but answers questions appropriately
before falling asleep again.
Obtunded The word ’obtund’ means "dulled or less sharp“. Patient
opens his eyes and looks at you but gives slow,
confused responses, typically as a result of head
trauma.
Stupor A stuporous patient is arousable for short periods but is
not aware of his surroundings e.g. in schizophrenia,
severe depression, brain tumors.

Coma A coma is a prolonged state of unconsciousness.

 BEHAVIOR

 Facial Expressions
 Eye Contact: Poor, Good,
 Angry, Tense
 Elated
 Apathy

 Mood: A subjective emotional state. It is what the

patient tells you e.g. feeling sad, good, angry, fantastic
etc.

 Affect: An observed emotional expression or response.

In some situations, anxiety would be considered an
inappropriate affect.
 BEHAVIOR

Characteristics of speech
Normal speech
is inflected (varied, rise and fall in voice), clear & strong, fluent and
articulate, and varies in volume.
Fluency
Hesitancy
Avoidant personality disorder depression may account for the hesitant
speech
Stammers
Halting articulation with interruptions to the normal flow of speech and
repetitions in speaking. Stammers can be due to stroke or other brain
trauma or may be due to lack of proper language development in the
childhood.
 BEHAVIOR

Characteristics of speech
Circumlocution
The use of unnecessarily wordy indirect language to avoid
getting to the point. Contrast with conciseness.
Circumlocution may be present in patients with psychosis
Paraphasias
A condition in which a person hears and comprehends words
but is unable to speak correctly.
Incoherent words are substituted for intended words, thereby
creating sentences that are incomprehensible. Brain tumors
can cause paraphasias
 BEHAVIOR

Characteristics of speech
Paraphasias
A condition in which a person hears and comprehends words but is unable
to speak correctly.
Incoherent words are substituted for intended words, thereby creating
sentences that are incomprehensible. Brain tumors can cause paraphasias

 Phonemic or literal paraphasias are word errors that sound very close
to the intended word (e.g. coke for coat).
 Semantic paraphasia occurs when a word that is related in meaning to
the target word is substituted (e.g., plum for peach).
 Neologism - A newly created word whose meaning is unknown to
others. It is indicative of brain damage or a thought disorder like
schizophrenia, when present in adults.
 BEHAVIOR

Characteristics of speech
Quantity/quality
Rate (average rate of speech is estimated to be between 150 and 160 words per
minute
Articulation of words
Dysarthria
Difficulty in articulating words due to emotional stress or paralysis, incoordination,
or spasticity of the muscles used in speaking .
Dysarthria can be caused by stroke, Parkinson Disease, Myasthenia Gravis,
cerebellar Disease etc.
Aphasia
Either partial or total loss of the ability to communicate verbally or using written
words.
Aphasia is always due to injury to the brain, most commonly from a stroke, but also
may be due to head trauma, brain tumors or infections.Volume: e.g. loud, soft, mute
 COGNITIVE FUNCTIONS

Orientation (To Time, Place And Person)

Thought Process

Logic ("If Naveed is taller than Imtiaz, and Ahmed is taller than Naveed,
who's the tallest?“

Coherence (A quality of sentences when all parts are clearly connected

and speech is progressing towards a logical goal)

Relevance (Pertinence to the matter at hand)

Organization: How the thoughts flow and are connected

 COGNITIVE FUNCTIONS

Abnormalities In Thought Process

Circumstantial: Provide unnecessary detail but eventually get to the point.
Tangential: Move from thought to thought that relate in some way but never
get to the point.
Flight of ideas: Quickly moving from one idea to another. It is observed in
patients with mania.
Thought Blocking: Thoughts are interrupted
Perseveration: Repetition of words, phrases or ideas
Word Salad: Randomly spoken words e.g. “Windows books dogs hands
run”. Associated disorders include; Dementia, Schizophrenia, brain injury
 COGNITIVE FUNCTIONS

Thought Content
Compulsions (Mental acts that a person carries out continuously in an
attempt to neutralize anxiety; e.g. repetitive hand washing based on a
fear of contamination.
Obsessions (Persistent, recurrent and unwanted thoughts or images or
impulses that cause anxiety but cannot be controlled
Delusions (A fixed, false belief not based in reality and cannot be
altered by rational arguments, Grandiose, Persecutory, somatic, religious
(causes are schizophrenia, manic- depressive disorder, psychosis).
 COGNITIVE FUNCTIONS

Delusions Classification
Grandiose: inflated sense of self-worth, power or supreme, or otherwise
very powerful
Persecutory: others are trying to cause harm
Somatic: patient has a physical defect
Religious: Patients thinks that he is God, a prophet etc.
Erotomanic: thinking that a person, usually of higher status, is in love with
the patient
Control: outside forces are controlling actions
 COGNITIVE FUNCTIONS

Perception
Illusions
A false perception due to misinterpretation of the stimuli arising from an
object; e.g. a patient may interpret the conversation of others as the
voices of enemies conspiring to destroy him
Hallucinations
A false perception of something that is not really there. These
sensory impressions are generated by the mind rather than
by any external stimuli and may be visual, auditory, olfactory
gustatory, tactile, nociceptive and thermoceptive. Causes are
schizophrenia, epilepsy, stroke, substance abuse etc.
 COGNITIVE FUNCTIONS
(CONTD..)

Insight
Insight is the ability to understand the true nature of
one’s situation & accept some personal responsibility
for that situation.
 Ask the patient “What do you feel is causing your
problem”?
 why are you here (in the hospital)?
Judgment
The ability to anticipate the consequences of one’s
behavior and make decisions to safeguard your well
being and that of others.
 Ask the patient “What would you do if you found a
stamped letter on the sidewalk?” Placing it in the
mailbox is the correct answer; opening the letter
suggests a personality disorder
 COGNITIVE FUNCTIONS
(CONTD..)

Concentration/Attention span
Ask the patient to spell a 5-letter word forward and backward. “World” is
commonly used. Or
Ask for naming the months forward & then backward.
Normal digit span is 6 or more forward, and 4 or more backward, depending
slightly on age and education.

Memory
 Immediate- Ask the patient to recall 3 objects after a 3-minutes delay.
 Recent-What is the weather like today?
 Remote-Where were you born?
 INTELLECTUAL FUNCTIONS

Abstraction ability- proverbs

 A bird in the hand is worth two in the bush.
 All that glitters is no gold
Comprehension
Ask the patient to follow a 3 step command e.g. touch your nose, then the
table, then my ear.
Computation
 Subtract 7 from 100
 Add 4 and 13
Ability to read
Ask the patient to read few phrases from a nearby newspaper
Constructional Ability
Draw a square or a circle & ask the patient to copy.
‘Asking the patient to construct a clock-face with numbers is a good test of
constructional ability.
 INTELLECTUAL FUNCTIONS

Acalculia
The inability to perform simple mathematical tasks, such as adding,
subtracting, multiplying and even simply stating which of two numbers is
larger. It is due to an acquired neurological injury e.g. stroke
 OBJECTIVE DATA – THE
PHYSICAL EXAMINATION
Cranial nerves – 12 pairs, motor, sensory, mixed function.
Test Cranial Nerves
 I—Olfactory (sensory) – smell.
 II—Optic (sensory) – sight
 III—Oculomotor, (motor) – eye movements
 IV— Trochlear, (motor) – eye movements
 V—Trigeminal (motor & sensory) chewing
and pain sensations of face.
 Motor function
 Sensory function
 Corneal reflex VI
 VI—Abducens (motor) eye movements
 OBJECTIVE DATA – THE PHYSICAL
EXAMINATION
VII—Facial
 Motor function: facial expressions
 Sensory function: - taste
VIII—Acoustic (vestibulocochlear) – hearing
IX—Glossopharyngeal, – swallowing
X—Vagus – swallowing, gag
 Motor function
 Sensory function
XI—Spinal accessory – trapezius, sternomastoid muscles
XII—Hypoglossal, – motor – tongue
III—OCULOMOTOR ASSESSMENT
 CRANIAL NERVE ASSESSMENT

 Trigeminal Nerve V
 sensory function
 Corneal Reflex Test
 Cotton ball light touch &
Sharp and dull test on Face
 Facial Nerve VII
 motor function
 Eye Blinking
 PERRLA
• PERRLA: pupil, equal, round, reactive to
light and accommodation
• Trigeminal Nerve Motor Test
MOTOR FUNCTION ASSESSMENT

• Motor function- Test motor strength and compare

bilaterally. AssessROMagainst resistance.
• Scale used:
– 5 =Full ROMfull resistance
– 4 =Full ROMsome resistance
– 3 =Full AROM(active range of motion)
– 2 =Full PROM(passive range of motion)
– 1 =trace movement, flicker finger.
 OBJECTIVE DATA THE PHYSICAL
EXAMINATION

Motor System—Inspectand Palpate

Muscles
 Size
 Strength
 Tone
 Involuntary movements
 OBJECTIVE DATA THE PHYSICAL
EXAMINATION

 Balance tests
 Gait – steady gait with arm swing, balance maintained.
 Tandem walking
 Romberg test– Have pt. stand, feet together, arms
side, eyes closed.
 Shallow knee bend
 Coordination and skilled movements
 Rapid alternating movements (RAM)
 Finger-to-finger test
 Finger-to-nose test – Eyes closed touch his finger to
nose. Have pt. touch his fingertip to your fingertip,
alterposition.
 Heel-to-shin test
 OBJECTIVE DATA- THE PHYSICAL
EXAMINATION
SENSORYSYSTEM • POSTERIORCOLUMNTRACT
• Person is alert, cooperative, – Vibration – tuning fork to bony
prominence
and comfortable
– Position (kinesthesia) – Grasp toe or
• Guidelines for sensorytesting finger and move it up/down or side/
• Spinothalamic tract side.
– Pain – Tactile discrimination
(fine touch)
– Temperature
• Stereognosis– place object in handto
– Light touch identify (coin, paperclip).
• Graphesthesia – trace letter or
number on palm to identify.
• Two-point discrimination
• Extinction
• Point location
• Stereognosis : Ability to Graphesthesia: the
perceive the form of solid ability to recognize
objects by touch symbols when they're
traced on the skin.
FINGER-TO-NOSE TEST
RAPID ALTERNATING
MOVEMENT Heel to shin test
 OBJECTIVE DATA- THE
PHYSICAL EXAMINATION
Test the stretch or deep Test the superficial reflexes
tendon reflexes (DTRs)
 Abdominal reflex
 Technique
 Cremasteric reflex
 Grading
 Plantar reflex
 Reinforcement
 Biceps reflex
 Triceps reflex
 Brachioradialis reflex
 Quadriceps reflex
 Achiles reflex (―ankle jerk‖)
 Clonus
BICEP REFLEX
TRICEPS REFLEX
 PATELLAR REFLEX

 Let the Lower Legs Dangle Freely to Flex the Knee and
Stretch the Tendons. Strike the Tendon Directly Just Below
the Patella.
 BRACHIORADIALIS REFLEX

In a positive response, tapping on the brachioradialis

muscle fails to flex the elbow but instead flexes the
fingers
ACHILLES REFLEX (“ANKLE JERK”)

The ankle jerk reflex, also known as the Achilles

reflex, occurs when the Achilles tendon is tapped
while the foot is dorsiflexed. It is a type of stretch
reflex that tests the function of the gastrocnemius
muscle and the nerve that supplies it.
 TEST THE REFLEXES

Copare right and left

The response should be equal
 4+ Very brisk, hyperactive with clonus (short
jerking contraction of the samemuscle),
indicative of disease
 3+Brisker than average,may indicate disease
 2+ average, normal
 1+ diminished, low normal
 0 no response
 OBJECTIVE DATA- THE PHYSICAL
EXAMINATION

 Neurologic recheck
 Level of consciousness
 Person
 Place
 Time
 Motor function
 Pupillary response
 Vital signs
 Glasgow coma scale (GCS)
GLASGOW COMA SCALE
DECORTICATE VS. DECEREBRATE
POSTURE
 ABNORMAL FINDINGS
ABNORMALITIES IN MUSCLE MOVEMENT

 Paralysis
 Loss or impairment of the ability to move a body part,
usually as a result of damage to its nerve supply. Loss
of sensation over a region of the body.
 Hemiplegia
 paralysis of one side of the body
 Paraplegia
 paralysis of both lower limbs due to spinal disease or
injury
 Quadriplegia
 paralysis of all four limbs or of the entire body below
the neck.
 FASCICULATION

Benign eyelid fasciculations are involuntary,

usually brief, repetitive contractions of part of
the circular muscle that surrounds the eye
(Orbicularis oculis muscle) that are not
associated with any disease.
 TIC

Repetitive twitching of a muscle group.

 MYOCLONUS

Myoclonus refers to sudden, brief

involuntary twitching or jerking of a
muscle or group of muscles.
 TREMOR

A tremor is a rhythmic shaking movement in one

or more parts of your body. It is involuntary,
meaning that you cannot control it. This shaking
happens because of muscle contractions. A
tremor is most often in your hands, but it could
also affect your arms, head, vocal cords, trunk,
and legs
 CHOREA

Chorea is a movement disorder that causes

involuntary, irregular, unpredictable muscle
movements. The disorder can make you look
like you're dancing (the word chorea comes
from the Greek word for “dance”) or look
restless or fidgety.
 ATHETOSIS

Athetosis refers to the slow, involuntary, and

writhing movements of the limbs, face, neck,
tongue, and other muscle groups. The fingers
are also affected, with their flexing happening
separately and irregularly. The hands move, and
the toes and feet may also experience the effect
 ABNORMAL GAITS

• Spastic hemiparesis
• Cerebelar ataxia
• Parkinsonian (festinating)
• Scissors
• Steppage or footdrop
• Waddling
• Short leg
 COMMON PATTERNS
OF SENSORY LOSS

• Peripheral neuropathy
• Individual nerves or roots
• Spinal cord hemisection (Brown- Séquard
syndrome)
• Complete transection of spinalcord
• Thalamus
• Cortex
 ABNORMAL FINDINGS
ABNORMAL POSTURES

• Decorticate rigidity
• Decerebrate rigidity
• Flaccid quadriplegia
• Opisthotonos
 REFERENCES
1. Bickley, L. S., Szilagyi, P. G., & Bates, B.
(2007). Bates' guide to physical examination
and history taking (11th Edi). Philadelphia:
Lippincott Williams & Wilkins. Chapter
No.06 & 07 p.n 171-250

2. Weber, Kelley's. (2007). Health Assessment

in Nursing, 3rd Ed: North American Edition.
Lippincott Williams & Wilkins. Chapter
No.14 &15 p.n 239-294
CRANIAL
NERVES
CN Name Type Function Method

Ask client to identify different

I Olfactory Sensory Sense of smell nonirritating aromas such as coffee
and soap presented to each nostril.
Visual acuity, Color For visual acuity, use Snellen chart or
II Optic Sensory
vision, Field of vision ask client to read printed material.
Extra-ocular eye Assess directions of gaze. Measure
movement. Pupil pupil reaction to light reflex (direct light
III Oculomotor Motor
constriction and reflex & consensual light reflex) and
dilatation accommodation reflex.
Upward & downward
IV Trochlear Motor Assess directions of gaze
movement of eyeball
S = Assess corneal & conjunctival
Sensory nerve to skin reflex.
Sensory
of face, cornea and Measure sensation of light pain and
and
V Trigeminal intraocular structures. touch across skin of face (forehead,
motor
Motor nerve to the cheeks & chin).
muscles of jaw M = Palpate temples as patient
clenches teeth.
Motor Lateral movement of Assess directions of gaze (ask the
VI Abducens
eyeballs patient to follow your finger laterally)
CN Name Type Function Method
VII Facial Sensory Facial M= As client smiles, frowns, puff out
and expression cheeks and raises and lowers the
motor Taste eyebrows look for asymmetry.
S= Have client identify salty or sweet taste
on front of tongue
VIII Auditory Sensory Hearing Assess ability to hear spoken word
(Acoustic) (whisper test), Weber & Rinne’s test.
IX Glosso- Sensory Taste patient’s S= Ask client to identify sour or sweet
pharyngeal and motor ability to taste on the back of the tongue
swallow M= Give sip of water to elicit gag reflex.

X Vagus Sensory Sensation of Only its motor function is tested. Ask the
and pharynx client to say “ah”. Observe the soft palate
motor Movement of and pharynx movement. Assess speech
vocal cords for hoarseness.
XI Spinal Motor Movements of Ask the client to shrug shoulders to test
accessory head and the power of trapezius & turn head against
shoulders passive resistance to check SCM.
XII Hypoglossal Motor Position of Ask client to stick out tongue to midline
tongue and move it from side to side
 CRANIAL NERVES-HOW TO
REMEMBER

1 Olfactory On Some
2 Optic Old Say
3 Oculomotor Olympus Marry
4 Trochlear Towering Money
5 Trigeminal Top But
6 Abducens A My
7 Facial French Brother
8 Acoustic And Says
9 Glossopharyngeal German Bad
10 Vagua Viewed Boys
11 Spinal Some Marry
12 Hypoglossal Hops Money
 CEREBELLAR FUNCTION
Point to point testing
 Finger to nose test
 Heel to knee test
 Heel to toe test of gait
 Rapid alternating movement
Pat knee
Thumb to finger
 Romberg test
Balance standing with eyes closed and feet
together
 Pronation drift
 DIFFERENT ABNORMAL TYPES OF
GAIT

 Natural Gait: Patient should be able to walk with a

smooth,coordinated gait. There should be normal
associated movement of the upper extremities.
 Cerebellar Ataxia (Drunken Gait)
Wide based, unsteady gait. Romberg test results are
positive (clients cannot stand with feet together). It seen
in patients with cerebellar lesion or alcohol or drug
intoxication.
 Parkinsonian Gait
Shuffling gait, turns accomplished in very stiff manner.
Stooped over posture with flexed hips and knees .
Typically seen in Parkinson’s disease.
 DIFFERENT ABNORMAL TYPES OF
GAIT

 Scissors Gait
Stiff, short gait, thighs overlap each other with each
step. It is seen in patients with partial paralysis of the
legs.
 Spastic Gait
Patient does not lift the feet from the ground completely
so that toes remain in contact with the ground. Legs
swing forward & outward in a circular fashion. Seen with
upper motor neuron paraplegia (weakness of both
lower limbs).
 High Stepping Gait (Foot Drop): Patient lifts the
Foot high to clear the toes from the ground & then
returns it with a loud slapping noise. It is the
characteristic of LMN lesions.
 MOTOR FUNCTION

Muscle tone
Normal state of muscle tension
Hypotonia (Flaccidity) – flabby & soft…a decreased tone
Spasticity: increase resistance initially with movements, decreasing
suddenly as movement continues
Rigidity: continuous resistance to passive movements
Involuntary muscle movement
Fasciculations; seen in wasted muscles resulting from disease of
lower motor neuron.
Muscle mass, size
Wasting; may be due to lesion of lower motor neuron or may be a
disuse atrophy due to joint disease.
 Atrophy
 Hypertrophy
 MUSCLE STRENGTH GRADING
(0 - 5 SCALE)
0. no muscular contraction detected
1. a barely detectable flicker or trace of contraction
2. active movement of the body part with gravity eliminated
3. active movement against gravity
4. active movement against gravity and some resistance
5. active movement against full resistance without evident
fatigue
 REFLEXES
 Superficial reflexes
 Pathological primitive reflexes
 Deep Tendon Reflexes
Reinforcement / Augmentation to distract the conscious thought
– teeth clenching or hooking
fingers and pulling fingers
Biceps C5 – C6 (Cervical Spinal Nerves 5 & 6)
Triceps C7 – C8 (Cervical Spinal Nerves 7 & 8)
Bracheo radialis
Patellar
Ankle / Achilles
REFLEX ACTION
 PATHOLOGICAL / PRIMITIVE
REFLEXES
 Grasp reflex
Palmer stimulation lead to grasp
Ask the patient to release to determine voluntary adults.

 Snout reflex
The pouting or pursing of the lips in response to light
tapping of the closed lips near the midline

 Sucking reflex
Sucking movement of the lips in response to tactile
stimulation while suctioning or mouth care.
 DEEP TENDON REFLEXES

Biceps----C5, C6
(flexion of elbow)

Triceps---C6, C7
(extension of elbow)
 DEEP TENDON REFLEXES

Brachio-radialis---C5,6
(flexion and supination of the forearm)

Patellar---L3,4
(knee extension)
Ankle/Achilles---S1,2
(planter flexion)
 DEEP TENDON REFLEXES
GRADING

 Graded on a scale of 0-4:

 +4 Hyperactive, clonus may be present
 +3 Brisker than average
 +2 Average, normal
 +1 Diminished
 0 Absent response
 REFERENCES

 Nasir SA & Inayatullah M. Bedside Techniques: Methods of

clinical examination. 2006; 3 rd edition: Saira publishing;
Multan. Pp. 106-136.
 Lynn S. Bickle y MD. Bates' Guide to Physical Examination
and Histor y Taking. 2008; 10 th edition: Lippincott Williams &
Wilkins.
 Clinical Methods, 3rd edition: The History, Physical, and
Laboratory Examinations [online data base] retrieved from;
http://w w w.ncbi.nlm.nih.gov/bookshelf/br.fcgi? book=cm