1. Remaining Neurologic System

2. Review of Systems Decreased LOC Confusion Headache/Pain
History of head injury or major trauma
Clumsiness/decreased coordination or balance
Seizures
Fainting spells
Dizziness
Physical disability
Numbness or tingling
Sudden change in vision or hearing
Behavioral changes
Attention, mood, speech, insight, judgment, orientation, or memory
Psychiatric symptoms
Aphasia

3. Complete Neurological Assessment
Cerebral Function
Mental Status
Cranial Nerve Function
Sensory Function
Motor Function
Reflexes

4. Sensory Function

5. Sensory Function- A&P Review

6. Common Sites for Referred Pain
© Pat Thomas, 2006.

7. Dermatomes
A band of skin innervated by the sensory root of a single spinal nerve

9. Sensory Function- Spinothalamic Tract
Superficial sensation
Pain
Assess sharp and dull
Allow at least 2 sec between
Temperature
Test only when pain sensation abnormal
Light (crude) touch
Apply wisp of cotton to arms, forearms, hands, chest, thigh, an legs
Sharp and dull and light touch intact

10. Sensory Function- Spinothalamic Tract
Scatter stimuli so as to sample most dermatomes and peripheral nerves
Both shoulders (C4)
Inner and outer aspects of forearm (C6, T1)
Thumbs and little finger (C6, C8)
Front of both thighs (L2)
Medial and lateral aspects of both calves (L4, L5)
Little toe (S1)
Medial aspect of each buttock (S3)

12. Sensory Function- Posterior Column Tract
Deep sensation
Vibration
Use low pitch tuning fork (128 0r 256Hz)
Place over bony surface of fingers and great toe
Vibration intact
Position (Kinesthesia)
Move finger or big toe up or down and ask which way move
Kinesthesia intact

13. Sensory Function- Posterior Column Tract
Discriminatory sensations
Stereognosis
Recognize objects
Stereognosis intact.
Graphesthesia
Read number traced on hand
Graphesthesia intact
Two-point discrimination
Distinguish separation of two stimuli
No longer perceives two separate points at ___mm

14. Motor Function

15. Motor Function- A&P Review

16. Motor Function- Muscles
Muscle size & symmetry
Palpate major muscle groups of arms & legs
Muscle Tone
While at rest and with passive movement
Normal, flaccid, spastic, or rigid

17. Muscle Strength Muscle Strength Testing
Arm Flexion & Extension
Grip Strength
Hip Flexion & Extension
Thigh Adduction and Abduction
Knee Flexion & Extension
Ankle Dorsiflexion & Plantar Flexion
Ask to lift extremity against gravity and the against resistance
5/5- Full ROM against gravity, full resistance
4/5- Full ROM against gravity, some resistance
3/5- Full ROM with gravity
2/5- Full ROM with gravity eliminated (passive)
1/5- Slight contraction
0/5- No contraction No atrophy, weakness,or tremors

18. Motor Function- Cerebellar Function
Balance tests
Gait
Walk feet, turn, and walk back the other way
Gait smooth & coordinated
Tandem walk
Able to tandem walk
Romberg Test
Feet together, arms at side, and eyes closed and hold 20 seconds
No swaying = negative Romberg

19. Motor Function- Cerebellar Function
Coordination & Skilled Movements
Rapid alternating movements (RAM)
Patient pats knees with front and back of hands quickly
Rapid alternating movements quick and accurate
Finger-to-finger test
Touch thumb to each finger on same hand quickly
Watch for cerebellar tremor (intention tremor)
Tremor of extremity that occurs at end of purposeful mvmt. Caused by lesion/damage to cerebellum from stroke, tumor, MS, inherited degenerative disorders
Finger to finger test smooth and accurate

20. Motor Function- Cerebellar Function
Touch thumb to each finger on same hand
Thumb opposition quick and accurate
Finger-to-nose test
With eyes closed patient touches tip of his/her nose quickly with index finger, alternating hands
Finger to nose smooth and accurate

21. Reflexes

22. Reflexes- A&P Review

23. Reflexes Deep Tendon Reflexes (DTR) Superficial Reflexes
Biceps (C5-C6)
Triceps (C7-C8)
Brachioradialis (C5-C6)
Quadriceps (Patellar) (L2-L4)
Achilles (L5-S2)
Superficial Reflexes
Plantar Reflex/Babinski (L4-S2)
Abdominal Reflexes
(Upper T8-T10) (Lower T10-T12)
Crematic Reflex (L1-L2)

24. Biceps Reflex Place your thumb or finger firmly on the biceps tendon.
Strike with the reflex hammer so that the blow is aimed through your thumb toward the biceps tendon
Observe flexion at the elbow, and watch for and feel the contraction of the biceps muscle
Biceps reflex 2+ bilaterally

25. Triceps Reflex Strike the triceps tendon above the elbow
Watch for contraction of the triceps muscle and extension at the elbow
Triceps reflex 2+ bilaterally

26. Brachioradialis Reflex
Strike forearm approximately 2-3cm above radial styloid process
Watch for flexion and supination of the forearm
Brachioradialis reflex 2+ bilaterally

27. Quadriceps (Patellar) Reflex
Briskly tap the patellar tendon just below the patella
Note contraction of the quadriceps with the extension at the knee
Patellar reflex 2+ bilaterally

28. Achilles Reflex Dorsiflex the foot at the ankle Have the patient relax
Strike the Achilles tendon
Watch and feel for plantar flexion at the ankle
Achilles reflex 2+ bilaterally

29. Plantar Reflex
Stroke the lateral aspect of the sole from the heel to the ball of the foot, curving medially across the ball
Note movements of the toes, normally plantar flexion
Plantar reflex with down going
toes/Negative Babinski

30. Basic Neurological Exam/Recheck
Affect
Level of Consciousness
Degree of wakefulness/ responsiveness to environment
Orientation
Speech Pattern
Facial Symmetry
Ability to Follow 1 Step Commands
Direct & Consensual Pupillary Response & Accomodation
Hand Grasps & Foot Pushes

31. Testing for Meningitis
Kernig’s sign
In supine position flex knee and hip of one leg to 90 degrees, then gently try to straighten leg.
Positive if pain in low back and hamstring and of knee won’t straighten more than 135 degrees
Negative Kernig’s sign
Brudzinski’s sign
In supine position place one hand behind patient’s neck and lift off of bed trying to touch chin to chest.
Positive if hips and knees involuntarily flex
Negative Brudzinski’s sign