1. The Neurological Examination
Robin Meek, M.D.
Introduction to the Medical Profession
March 22, 2006

2. Objectives:
1. List and discuss the 3 essential questions to consider when assessing neurological function.
2. Describe the 6 components of the neurological exam.

3. Three Key Questions
Is there evidence of nervous system disease or dysfunction?
Where is the problem located?
What is the nature of the problem?

4. 1. Is there evidence of nervous system disease or dysfunction ?
Focal – stroke
Diffuse – multiple sclerosis
Systemic –peripheral neuropathy
Focal- affects only anatomically related structures in a certain area regardless of their structure or function
Diffuse - incomplete involvement in which some nerve cells are affected more than others
Systemic - only anatomically and functioally related sytem of cells or fibers are affected

5. 2. Where is the problem? CNS vs. PNS Tracts vs. neurons UMN vs. LMN
Cortical vs. subcortical

6. Peripheral vs. Central Peripheral CNS - Muscle
- Neuromuscular junction
- Spinal or cranial nerves
- Plexus
- Nerve roots
CNS
Spinal cord
Brainstem
Cerebellum
Cerebrum
Right vs. left
Cortex vs. subcortical

7. 3. What is the nature of the problem?
PIT VET 3-D

8. PIT VET 3 - D PIT - pressure VET 3 - D - demyelinating - infection
- toxic or metabolic
VET
- vascular
- epilepsy
- trauma
3 - D
- demyelinating
- degenerative
- developmental

10. Six Components 1. Mental status 2. Cranial nerves 3. Motor 4. Sensory
5. Reflexes
6. Coordination

11. Six Components 1. Mental status 2. Cranial nerves 3. Motor 4. Sensory
5. Reflexes
6.Coordination

12. Mental Status
Alertness or awareness
Orientation

13. Six Components 2. Cranial nerves 1. Mental status 3. Motor 4. Sensory
5. Reflexes
6.Coordination

14. The Cranial Nerves I Olfactory II Optic III Oculomotor IV Trochlear
V Trigeminal
VI Abducens
VII Facial
VIII Acoustic
IX Glossopharyngeal
X Vagus
XI Spinal accessory
XII Hypoglossal

16. Olfaction (CN I) Almost never tested Smell
Coffee, mint, essence of orange
Impaired olfaction:
Inflammation (allergies or colds)
Smoking
Aging
Anosmia

17. CN II - Vision Three steps: 1.Visual fields by confrontation
2. Visual acuity testing – patient should wear their usual corrective lenses
3. Funduscopic examination –red reflex, optic disc, retinal vessels
Visual fields - 3 ft. from patient, cover one eye of yours and the opposite one of the patient. Ask them to tell you the sum of the fingers you hold out.
Nasal
Temporal
Superior
Inferior
Draw pictures

18. II Optic and III Oculomotor
Pupillary light reflex
Opening the eye
Most extraocular movements - CN III innervates 4 extraocular muscles (superior, medial, inferior rectus, and the inferior oblique) and the levator palpebrae

19. Pupillary Light Reflex (CN II,III)
Check pupil symmetry
Swinging penlight– pupils should remain equally constricted
Anisocoria – one pupil is larger than the other
- Normal variant
- Sympathetic vs. parasympathetic

20. Sympathetic – responsible for dilation
- asymmetry greatest in the dark
Parasympathetic – responsible for constriction
- asymmetry greatest in the light

24. IV Trochlear Downward and inward movement of the eye
Innervates the superior oblique

25. VI Abducens
Lateral deviation of the eye
Innervates the lateral rectus

27. Nystagmus

28. Experiment on your buddy!

29. V Trigeminal Mixed nerve – somatic sensory and somatic motor
Sensory nucleus – pons and medulla, becoming continuous with the posterior horn of the spinal cord
Motor nucleus – confined to the pons

30. Trigeminal - Sensory Three branches: opthalmic, maxillary, mandibular
Sensory input from the face and mucus membranes (ocular, nasal, and oral) excluding the external ear and the posterior head, via the trigeminal ganglion

31. Trigeminal - Motor
Supplies the muscles of mastication (masseter, temporal, internal and external pterygoid) muscles and other minor pharyngeal muscles

32. Trigeminal Examination
Pinprick and fine touch sensation in forehead, cheek, and mandible bilaterally
Corneal reflex
Jaw movements and jaw reflex
Palpation of jaw muscles for tone and strength with teeth clenched

35. VII Facial
Mixed nerve
Motor – facial musculature except for levator palpebrae (CN III)
Superior salivatory nucleus – submandibular and sublingual glands

36. VII Facial Sensory
Nucleus solitarius – taste from anterior 2/3 of the tongue ( sweet and salty)
Sensory nucleus 5 – sensation from the external ear

37. VII – Three Steps Inspection at rest and with facial expression
Wrinkling the forehead – differentiates central from peripheral lesion
Identifying sweet and salty tastes on both sides of the tongue

41. Try it out!

42. VIII Acoustic Hearing - cochlear division
Balance – vestibular division
- seldom tested in basic neuro. exam

43. VIII – Two Steps Assess hearing, covering opposite ear:
whispered words
rubbing your fingers
ticking watch
Rinne test – bone and air conduction

46. IX Glossopharyngeal Mixed nerve Motor – pharynx
Sensory – posterior portions of the eardrum and ear canal, the pharynx, and the posterior tongue (salty, sweet, sour, and bitter)

47. X Vagus Mixed Motor – palate, pharynx, and larynx
Sensory – pharynx and larynx

48. Testing IX and X
Listen to the patient’s voice – is it hoarse or does it have a nasal quality?
Say “ah” – look at the soft palate and the pharynx.
Gag reflex – stimulate both sides of the back of the throat and note the gag response (warn the patient)

49. XI Spinal accessory Shoulder and neck movements
Look for atrophy or fasiculations in the trapezius muscles, compare one side to the other
Shrug shoulders
Turn head against your hand

52. XII Hypoglossal Somatic motor – muscles of the tongue
Observe the tongue for muscle atrophy or fasiculations
Ask patient to protrude tongue and move it from side to side – ? symmetry, deviation from the midline

54. Your turn!

55. Six Components 3. Motor 1. Mental status 2. Cranial nerves 4. Sensory
5. Reflexes
6.Coordination

56. Motor Exam
Body position – abnormal positions alert you to deficits such as paralysis
Involuntary movements – tremors, tics, or fasiculations
Muscle bulk – atrophic, symmetric or asymmetric? Especially shoulders, hands, thighs
Tone and strength

59. Muscle Strength Grade 5 - full strength
Grade 4 - weak against resistance
Grade 3 - movement against gravity
Grade 2 – movement with gravity eliminated
Grade 1 – minimal contraction
Grade 0 – no contraction

60. Muscle Tone flaccid – a decrease in tone
normal – slight resistance to passive movement
spastic – increased tone that varies, often worse at the extremes of the range
rigid – resistance that persists throughout the range of motion and in both directions

61. Lower Motor Neurons
Corticospinal tract or pyramidal system – - mediates voluntary movements
- crosses over at the junction of the brainstem and the spinal cord
Reticulospinal or rubrospinal tracts –
- extrapyramidal system
- connects basal ganglia with the LMN
- integrate motor activity and posture

62. UMN vs. LMN UMN LMN Paralysis spastic flaccid Muscle atrophy no yes
Fasiculations
Reflexes
Hyper-reflexic
Hypo-reflexic
Babinski sign
May be present
Not present

63. Upper extremity nerve roots                                                                                                 

64. Lower extremity nerve roots                                                                                                  

65. Demonstration

66. Flexion – C5 & C6 (biceps)

67. Extension – C6, C7, C8 (triceps)

68. Extension – C6, C&, C8, radial nerve

69. Grip – C7, C8, T1

70. Finger abduction – C8, T1, ulnar nerve

71. Thumb Opposition – C8, T1, median nerve

72. Screening of Motor Function of the Upper extremity
1. Radial nerve – thumb abduction
2. Ulnar nerve – little finger abduction
3. Median nerve – strong pinch

73. Flexion at the hip – L2, L3, L4 - iliopsoas

74. Adduction of the Hip L2, L3, L4 - adductors
Place hands between the patient’s knees and ask them to bring them together

75. Abduction of the Hip L4, L5, S1 gluteus medius and minimus
Place hands on the outside of patient’s knees and ask them to spread both legs against your hands

76. Extension of the Hips S1 – gluteus maximus
Have patient push the posterior thigh down against your hand

77. Flexion at the Knee L2, L3, L4 - quadriceps

78. Flexion of the Knee L4, L5, S1, S2 - hamstrings

79. Symmetric weakness of the proximal muscles – myopathy or a muscle disorder
Symmetric weakness of the distal muscles suggests a polyneuropathy or a disorder of the peripheral nerves

80. Dorsiflexion of the foot L4 & L5

81. Plantar flexion – S1

82. Six Components 4. Sensory 1. Mental status 2. Cranial nerves 3. Motor
5. Reflexes
6.Coordination

83. Sensory Examination Superficial pain and touch Temperature
Deep pain or pressure
Vibration
Position
Discriminative functions

84. Ascending Tracts
Lateral spinothalamic – superficial pain and temperature
Posterior columns – vibration, deep pressure, position sense, point location, stereognosis, and two-point discrimination
Spinocerebellar – proprioception
Ventral spinothalamic – superficial touch and deep pressure

85. Superficial pain – pinprick , “sharp or dull”
Light touch – fingertips or wisp of cotton
(Temperature – ice and warm water in test tubes)

87. Deep pain – squeezing the calf or biceps muscle
Vibration sense – vibrating tuning fork against bony prominences with patient’s eyes closed, “When does it stop?”
Position sense – holding a distal joint of the fingers and toes and moving up or down

90. Discriminative Function
Reflects the ability of the sensory cortex to correlate, analyze, and interpret sensations
Sterognosis – identify an object (coin)
Two-point discrimination - find the distance where the patient no longer perceives two stimuli

91. Graphesthesia – recognize numbers or letters drawn on skin
Extinction – touch both sides of the body simultaneously with closed eyes
Point location – with the patient’s eyes closed, touch an area on the body, withdraw the stimulus, and then ask the patient to point to the area touched

93. Six Components 5. Reflexes 1. Mental status 2. Cranial nerves 3. Motor
4. Sensory
5. Reflexes
6.Coordination

94. Reflexes Superficial reflexes:
- abdominal reflex – contraction toward the stimulus
- cremasteric reflex – elevation of the ipsilateral scrotum and testicle by touching the thigh

96. Deep Tendon Reflexes 0 Absent 1+ Hyporeflexic 2+ Normal
3+ Hyperreflexic
4+ Clonus

97. Eliciting Reflexes Biceps (C5, C6) Brachioradialis (C5, C6)
Triceps (C6, C7)
Patellar (L2, L3, L4)
Achilles (ankle – S1)
Plantar (L5, S1)
Clonus – indicates CNS disease

98. Demonstration

100. Babinski sign

101. Six Components 6.Coordination 1. Mental status 2. Cranial nerves
3. Motor
4. Sensory
5. Reflexes
6.Coordination

102. Coordination Four areas that need to work together: 1. Motor system
2. Cerebellum – for rhythmic movement and steady posture
3. Vestibular system – for balance & for coordinating eye, head, and body movements
4.Sensory system – for position sense

103. Coordination Rapid alternating movements Point to point movements
Gait – walk down the hall, heel to toe, walk on toes, and then on heels
Standing – Romberg test

104. Pronator Drift

106. Changes With Aging
Motor system – move and react with less speed and agility, muscle mass decreases
Benign essential tremor
Vibration sense decreased or lost in feet or ankles
Reflexes – gag, ankle reflexes decreased
“Benign forgetfulness”

107. Demo

108. Six Components 1. Mental status 2. Cranial nerves 3. Motor 4. Sensory
5. Reflexes
6.Coordination