Basic Clinical Skills | Physical Exam Study Guides

Neurologic Examination



Equipment Needed

General Considerations

Mental Status

The Mini Mental Status Examination is a useful screening tool. The full mental status exam is discussed in much more detail during the second year.

Cranial Nerves

Observation

I - Olfactory

Not Normally Tested [1]

II - Optic

III - Oculomotor

IV - Trochlear

Test Extraocular Movements (Inward and Down Movement, See Above)

V - Trigeminal

VI - Abducens

Test Extraocular Movements (Lateral Movement, See Above)

VII - Facial

VIII - Acoustic

IX - Glossopharyngeal

See Vagus Nerve

X - Vagus

XI - Accessory

XII - Hypoglossal

Motor

Observation

Muscle Tone

  1. Ask the patient to relax.
  2. Flex and extend the patient's fingers, wrist, and elbow.
  3. Flex and extend patient's ankle and knee.
  4. There is normally a small, continuous resistance to passive movement.
  5. Observe for decreased (flaccid) or increased (rigid/spastic) tone.

Muscle Strength

Grading Motor Strength
Grade Description
0/5 No muscle movement
1/5 Visible muscle movement, but no movement at the joint
2/5 Movement at the joint, but not against gravity
3/5 Movement against gravity, but not against added resistance
4/5 Movement against resistance, but less than normal
5/5 Normal strength

Pronator Drift

  1. Ask the patient to stand for 20-30 seconds with both arms straight forward, palms up, and eyes closed.
  2. Instruct the patient to keep the arms still while you tap them briskly downward.
  3. The patient will not be able to maintain extension and supination (and "drift into pronation) with upper motor neuron disease.

Coordination and Gait

Rapid Alternating Movements

  1. Ask the patient to strike one hand on the thigh, raise the hand, turn it over, and then strike it back down as fast as possible.
  2. Ask the patient to tap the distal thumb with the tip of the index finger as fast as possible.
  3. Ask the patient to tap your hand with the ball of each foot as fast as possible.

Point-to-Point Movements

  1. Ask the patient to touch your index finger and their nose alternately several times. Move your finger about as the patient performs this task.
  2. Hold your finger still so that the patient can touch it with one arm and finger outstretched. Ask the patient to move their arm and return to your finger with their eyes closed.
  3. Ask the patient to place one heel on the opposite knee and run it down the shin to the big toe. Repeat with the patient's eyes closed.

Romberg

  1. Be prepared to catch the patient if they are unstable.
  2. Ask the patient to stand with the feet together and eyes closed for 5-10 seconds without support.
  3. The test is said to be positive if the patient becomes unstable (indicating a vestibular or proprioceptive problem).

Gait

Ask the patient to:

  1. Walk across the room, turn and come back
  2. Walk heel-to-toe in a straight line
  3. Walk on their toes in a straight line
  4. Walk on their heels in a straight line
  5. Hop in place on each foot
  6. Do a shallow knee bend
  7. Rise from a sitting position

Reflexes

Deep Tendon Reflexes

Tendon Reflex Grading Scale
Grade Description
0 Absent
1+ or + Hypoactive
2+ or ++ "Normal"
3+ or +++ Hyperactive without clonus
4+ or ++++ Hyperactive with clonus

Clonus

If the reflexes seem hyperactive, test for ankle clonus: ++

  1. Support the knee in a partly flexed position.
  2. With the patient relaxed, quickly dorsiflex the foot.
  3. Observe for rhythmic oscillations.

Plantar Response (Babinski)

  1. Stroke the lateral aspect of the sole of each foot with the end of a reflex hammer or key.
  2. Note movement of the toes, normally flexion (withdrawal).
  3. Extension of the big toe with fanning of the other toes is abnormal. This is referred to as a positive Babinski.

Sensory

General

Vibration

Subjective Light Touch

Position Sense

  1. Grasp the patient's big toe and hold it away from the other toes to avoid friction. ++
  2. Show the patient "up" and "down."
  3. With the patient's eyes closed ask the patient to identify the direction you move the toe.
  4. If position sense is impaired move proximally to test the ankle joint. ++
  5. Test the fingers in a similar fashion.
  6. If indicated move proximally to the metacarpophalangeal joints, wrists, and elbows. ++

Dermatomal Testing

If vibration, position sense, and subjective light touch are normal in the fingers and toes you may assume the rest of this exam will be normal. ++

Pain

Temperature

Light Touch

Discrimination

Since these tests are dependent on touch and position sense, they cannot be performed when the tests above are clearly abnormal. ++


Notes

  1. For more information refer to A Guide to Physical Examination and History Taking, Sixth Edition by Barbara Bates, published by Lippincott in 1995.
  2. Visual acuity is reported as a pair of numbers (20/20) where the first number is how far the patient is from the chart and the second number is the distance from which the "normal" eye can read a line of letters. For example, 20/40 means that at 20 feet the patient can only read letters a "normal" person can read from twice that distance.
  3. You may, instead of wiggling a finger, raise one or two fingers (unialterally or bilaterally) and have the patient state how many fingers (total, both sides) they see. To test for neglect, on some trials wiggle your right and left fingers simultaneously. The patient should see movement in both hands.
  4. Additional Testing - Tests marked with (++) may be skipped unless an abnormality is suspected.
  5. PERRLA is a common abbreviation that stands for "Pupils Equal Round Reactive to Light and Accommodation." The use of this term is so routine that it is often used incorrectly. If you did not specifically check the accommodation reaction use the term PERRL. Pupils with a diminished response to light but a normal response to accommodation (Argyll-Robertson Pupils) are a sign of neurosyphilis.
  6. Nystagmus is a rhythmic oscillation of the eyes. Horizontal nystagmus is described as being either "leftward" or "rightward" based on the direction of the fast component.
  7. Testing Pain Sensation - Use a new object for each patient. Break a wooden cotton swab to create a sharp end. The cotton end can be used for a dull stimulus. Do not go from patient to patient with a safety pin. Do not use non-disposable instruments such as those found in certain reflex hammers. Do not use very sharp items such as hypodermic needles.
  8. Central vs Peripheral - With a unilateral central nervous system lesion (stroke), function is preserved over the upper part of the face (forehead, eyebrows, eyelids). With a peripheral nerve lesion (Bell's Palsy), the entire face is involved.
  9. The hearing screening procedure presented by Bates on page 181 is more complex than necessary. The technique presented in this syllabus is preferred.
  10. Deviation of the tongue or jaw is toward the side of the lesion.
  11. Although it is often tested, grip strength is not a particularly good test in this context. Grip strength may be omitted if finger abduction and thumb opposition have been tested.
  12. The "anti-gravity" muscles are difficult to assess adequately with manual testing. Useful alternatives include: walk on toes (plantarflexion); rise from a chair without using the arms (hip extensors and knee extensors); step up on a step, once with each leg (hip extensors and knee extensors).
  13. Subjective light touch is a quick survey for "strange" or asymmetrical sensations only, not a formal test of dermatomes.

Prepared with assistance from Edward Valenstein, MD


   Author: Richard Rathe, MD / rrathe@dean.med.ufl.edu
Copyright: 1996 by the University of Florida
 Location: http://www.medinfo.ufl.edu/year1/bcs/clist/neuro.html
  Created: January 15, 1996   Modified: December 19, 2000

Basic Clinical Skills | Physical Exam Study Guides