Chapter 16: The Neurological Exam — Comprehensive Study Notes

What is a Neurological Exam?

  • A systematic examination of the nervous system performed by a neurologist.
  • Purposes:
    • To identify abnormalities in the nervous system.
    • To differentiate CNS (central nervous system) from PNS (peripheral nervous system) problems.
  • Why consider it?
    • There is significant overlap with an SLP exam.

Neurological Exam Tools

  • Reflex Hammer and Pin
  • Tuning Fork
  • Ophthalmoscope
  • Visual Acuity Card
  • Q-tip
  • Soap

Overview of the Neurological Exam

  • 1. Interview
  • 2. Physical Exam
  • 3. Neurological Exam
  • 4. Laboratory Tests

The Interview

  • Chief complaint (CC)
  • History of present illness (HPI)
  • Past medical history (PMH)
  • Review of systems (ROS)
  • Family history (FHx)
  • Social and environmental history (SocHx/EnvHx)
  • Medications and allergies
  • Note: Underlining notes overlap with SLP exam.

The Physical Exam

  • Level of consciousness
  • Personal hygiene and dress
  • HEENT (Head, Eyes, Ears, Nose, Throat)
  • Major systems
  • Posture and motor activity
  • Height and weight
  • Dysmorphic observation
  • Vital Signs
  • Note: Underlining notes overlap with SLP exam.

The Neurologic Exam

  • Mental state evaluation
  • Cranial nerves evaluation
  • Motor system evaluation
  • Reflex testing
  • Sensory system evaluation
  • Equilibrium evaluation
  • Note: Underlining notes overlap with SLP exam.

Laboratory Tests

  • Body tissue/fluid tests (e.g., blood)
  • Imaging studies (e.g., CT, MRI)
  • Note: SLPs do not order either of these, but are consumers of imaging studies.

SIGNS OF NEUROLOGICAL DISEASE

  • Cranial Nerves overview and problems are foundational in identifying site and type of lesion.
  • Note: Different signs point to CNS vs PNS involvement; patterns across nerves and systems guide localization.

Cranial Nerves

  • Olfactory nerve (I)
  • Optic nerve (II)
  • Trigeminal nerve (V)
  • Common oculomotor nerve (III), trochlear nerve (IV), and external oculomotor nerve (VI)
  • Facial nerve (VII)
  • Vagus nerve (X)
  • Accessory nerve (XI)
  • Auditory nerve (VIII)
  • Glossopharyngeal nerve (IX)
  • Hypoglossal nerve (XII)
  • Note: The text lists these with emphasis on the nerves highlighted as important to speech and hearing.

Cranial Nerve Problems (1 of 2)

  • CN I: Anosmia
  • CN II: Decreased vision; blindness
  • CN III: Loss of pupillary light reflex; papilledema; ptosis
  • CN IV: Diplopia; nystagmus
  • CN V: Loss of face sensation; abnormal corneal reflex; abnormal jaw-jerk reflex
  • CN VI: Diplopia; nystagmus
  • Note: Highlighted nerves important to speech and hearing.

Cranial Nerve Problems (2 of 2)

  • CN VII: Facial plegia/paresis; taste loss
  • CN VIII: Loss of hearing acuity
  • CN IX: Absent gag and swallow reflex; loss of taste; loss of velar movement
  • CN X: Absent gag and swallow reflex; loss of velar movement; loss of voice
  • CN XI: Droopy shoulder
  • CN XII: Loss of tongue movement; tongue fasciculations, tongue atrophy
  • Note: Highlighted nerves important to speech and hearing.

Major Motor Problems (overview)

  • 1. Bradykinesia, Hypokinesia, Akinesia
    • Bradykinesia: slowed movements
    • Hypokinesia: reduced movements
    • Akinesia: without movement
  • 2. Rigidity
    • Stiff or tight muscles that resist passive movement to a limb
    • Example: a relaxed joint will resist being bent or straightened
  • 3. Dystonia
    • Abnormal, sustained, involuntary muscle contractions
    • Results in distorted body postures
  • 4. Chorea and Athetosis
    • Chorea: quick involuntary movements of hands/feet with a dance-like quality
    • Athetosis: slow, twisting involuntary movements of hands/feet
  • 5. Ballismus
    • Quick, involuntary flinging of a limb
    • Hemiballismus if on one side of the body
  • 6. Tics
    • Involuntary, repetitive motor or vocal behaviors
    • Associated with conditions like Tourette syndrome
    • Example: vocal tic can be a barking noise
  • 7. Myoclonus
    • Sudden, involuntary muscle jerks
    • Example: hiccups
  • 8–9. Tremor
    • Tremor: rhythmic shaking
    • Intention tremor: occurs when trying to do something voluntarily
    • Resting tremor: occurs at rest and diminishes with purposeful use
    • Pill-rolling tremor: associated with Parkinson disease; looks like rolling something with thumb and first two fingers
    1. Fasciculations
    • Muscle twitches
    • When occurring in the tongue, may resemble worms or snakes quivering in a bag
    1. Ataxia
    • Uncoordinated motor movement
    • May look like drunken stupor with staggering gait and slurred speech
  • Visual: Motor Problems are often summarized as Slow vs Fast (progression and severity)

Motor Problems (detailed progression)

  • 1. Bradykinesia/hypokinesia/akinesia
  • 2. Rigidity
  • 3. Dystonia
  • 4. Chorea/Athetosis
  • 5. Ballismus
  • 6. Tics
  • 7. Myoclonus
  • 8. Intention Tremor
  • 9. Resting Tremor
    1. Fasciculations
    1. Ataxia
  • Note: Some slides categorize Tremor as slow vs fast alongside other signs.

Reflex Problems

  • Absent, diminished, or exaggerated:
    • Gag reflex
    • Swallow reflex
    • Corneal reflex
    • Light reflex (pupillary reflex)
    • Plantar reflex (Babinski sign)
    • Patellar reflex

Sensory Signs

  • Paresthesias: tingling, prickling, or burning sensations
  • Anesthesia: loss of feeling
  • Pain

Other Problems (1 of 2)

  • Muscle tone and strength problems
    • Hypertonia (spasticity)
    • Hypotonia (flaccidity or rag doll)
    • Loss of range of motion
    • Loss of muscle strength
  • Syncope (fainting)
  • Seizures

Other Problems (2 of 2)

  • Equilibrium problems (e.g., vertigo)
  • Loss of consciousness or altered mentation
  • Confusion
  • Lethargy
  • Amnesia
  • Speech and language disorders (aphasia, apraxia of speech, dysarthria)
  • Anxiety and other emotional problems

For Further Study

  • www.neuroexam.com
  • www.jblearning.com

title

Chapter 16: The Neurological Exam — Comprehensive Study Notes