THE NEUROLOGICAL

EXAMINATION
 NEUROLOGICAL EXAM
• MENTAL STATUS
• CRANIAL NERVES
• MOTOR EXAM
– STRENGTH
– GAIT
– CEREBELLAR
• REFLEXES
• SENSATION
MENTAL STATUS
 Level of Consciousness

• Awake and alert

• Agitated
• Lethargic
– Arousable with
• Voice
• Gentle stimulation
• Painful/vigorous stimulation
• Comatose
 GLASGOW COMA SCALE
• Eye Opening Response - 4
• Verbal Response - 5
• Motor Response - 6
 GLASGOW COMA SCALE
• Eye Opening Response
Spontaneous Eye opening 4

Eye opening to call 3

Eye opening to pain 2

No eye opening 1
 GLASGOW COMA SCALE
• Verbal Response
Oriented to time,place and person 5

Confused 4

Inappropriate verbal response 3

Incomprehensible verbal response 2

No verbal response 1
 GLASGOW COMA SCALE
• Motor Response
Obeys command 6

Localzes pain 5

Withdrawa lresponse to pain 4

Abnormal flexion(Decorticate response 3

to pain)
Abnormal extension(Decerebrate 2
response to pain)
No response6 1
 LANGUAGE
• FLUENCY
• NAMING
• REPETITION
• READING
• WRITING
• COMPREHENSION
Aphasia vs. dysarthria
 THOUGHT CONTENT
• Spontaneous
• Natural
• Clear
• Relevant
• Coherent
 MEMORY
• IMMEDIATE
– REALLY A MEASURE OF ATTENTION
RATHER THAN MEMORY
• REMOTE
• 3 OBJECTS AT 0/3/5 MINUTES
• HISTORICAL EVENTS
• PERSONAL EVENTS
 ORIENTATION
• PERSON
– NOT WHO THEY ARE BUT WHO YOU
ARE
• PLACE
• TIME
 OTHER COGNITIVE
FUNCTIONS
• CALCULATION
• ABSTRACTION
• SIMILARITIES/DIFFERENCES
• JUDGEMENT
• PERSONALITY/BEHAVIOR
CRANIAL NERVES
 CRANIAL NERVE EXAM
• I - OLFACTORY
– DON’T USE A NOXIOUS STIMULUS
– COFFEE, LEMON EXTRACT
 CRANIAL NERVE EXAM
• III/IV/VI OCULMOTOR,
TROCHLEAR, ABDUCENS
– PUPILLARY RESPONSE
– EYE MOVEMENTS
• 9 CARDINAL POSITIONS
– OBSERVE LIDS FOR PTOSIS
 CRANIAL NERVE EXAM
• V - TRIGEMINAL
– MOTOR - JAW STRENGTH
– SENS - ALL 3 DIVISIONS
 CRANIAL NERVES
• VII - FACIAL
– OBSERVE FOR FACIAL ASYMMETRY
– FOREHEAD WRINKLING, EYELID
CLOSURE, WHISTLE/PUCKER
• VIII - VESTIBULAR
– ACUITY
– RINNE, WEBER
 CRANIAL NERVES
• IX/X - GLOSSOPHARYNGEAL,
VAGUS
– GAG
• XI - SPINAL ACCESSORY
– STERNOCLEIDOMASTOID M.
– TRAPEZIUS MUSCLE
XII - HYPOGLOSSAL
TONGUE STRENGTH
RIGHT XII THRUSTS TONGUE TO LEFT
MOTOR EXAMINATION
• Muscle Size
• Muscle Tone
• Muscle Strength
• Balance and Co-ordination
• Gait and Posture
 MUSCLE SIZE
• Bilateral symmetry in muscle size
• Look for atrophy or hypertrophy
 MUSCLE TONE
• Tension present in the muscle at rest
• Palpate various muscle group at rest and at
passive motion
• Abnormalities-
• Spasticity-increased muscle tone
• Rigidity-Resistance to passive stretch
• Flaccidity
SPASTICITY
RIGIDITY
 STRENGTH
• STRENGTH
– GRADED 0 - 5
– 0 – Complete paralysis
– 1 – Weak muscle contraction
– 2 – Full ROM when gravity is eliminated
– 3 – Full ROM against gravity only
– 4 – Full ROM against gravity & moderate
resisitance
– 5 – Full ROM against gravity & resistance
 STRENGTH EXAM
• UPPER AND LOWER EXTREMITIES
• DISTAL AND PROXIMAL MUSCLES
• GRIP STRENGTH IS A POOR
SCREENING TOOL FOR STRENGTH
• SUBTLE WEAKNESS
– TOE WALK, HEEL WALK
– OUT OF CHAIR
– DEEP KNEE BEND
MUSCLE STRENGTH
 Gait evaluation

• Include walking and turning

• Examples of abnormal gait
– High stepping gait
– Waddling
– Hemiparetic/Circumductory
– Shuffling
Shuffling Gait
 MUSCLE OBSERVATION
• ATROPHY
• FASCIULATIONS
ABNORMAL MOVEMENTS
• TREMOR
– REST
– WITH ARMS OUTSTRETCHED
– INTENTION
• CHOREA
• ATHETOSIS
• ABNORMAL POSTURES
 BALANCE &CO-ORDINATION
• RAPID ALTERNATING MOVEMENTS
• FINGER TO FINGER & NOSE TESTING
• HEEL TO SHIN
• GAIT
– TANDEM WALKING
 Romberg Sign
• Stand with feet together - assure patient
stable - have them close eyes
• Romberg is positive if they do worse with
eyes closed
• Measures
– Cerebellar function
– Frequently poor balance with eyes open and
closed
– Proprioception
– Frequently do worse with eyes closed
– Vestibular system
ROMBERG’S TEST
REFLEXES
 MUSCLE STRETCH
REFLEXES (DEEP TENDON
REFLEXES)
• GRADED 0 – 5
• 0 -No response
• 1+ -Diminished(hypoactive)
• 2+ -Normal
• 3+ -Increased(may be interpreted as
normal)
• 4+ -Hyperactive(hyperreflexia)
 SUPERFICIAL REFLEXES
• Corneal Reflex
• Gag Reflex
• Abdominal Reflex
• Anal Reflex
• Crimasteric Reflex
• Babinski’s Reflex
DEEP TENDON REFLEXES
( DTR)
• BICEPS
• BRACHIORADIALIS
• TRICEPS
• KNEE
• ANKLE
BICEPS
TRICEPS
BRACHIORADIALIS
KNEE
ANKLE
SENSORY EXAM
 SENSORY EXAM
• VIBRATION
– 128 hz tuning fork
• JOINT POSITION SENSE
• PIN PRICK
• TEMPERATURE
• LIGHT TOUCH

Start distally and move proximally

 HIGHER CORTICAL
SENSATIONS
• GRAPHESTHESIA
• STEREOGNOSIS
• DOUBLE SIMULTANEOUS
STIMULATION/TWO POINT
DISCRIMINATION
• PROPRIOCEPTION
• TEXTURES
GRAPHESTHESIA
STEREOGNOSIS
PROPRIOCEPTION
 DOUBLE SIMULTANEOUS
STIMULATION/TWO POINT
DISCRIMINATION
• THANK YOU