Neurology Clinical Exam Notes

Neurology Clinical Exam

History and Current Status Questions

• Headache?
  • Location: unilateral or bilateral
  • Onset: acute or gradual
  • Nature: constant or chronic recurrence
  • Progression: worsening over time or stable in intensity
  • Timing: time of onset, duration
  • Triggers: precipitating or associated factors
  • Exacerbation: effect of head movement
  • Associated symptoms: nausea, vomiting, nasal congestion, fever
• Injury?
• Dizziness
• Fainting?
• Seizures?
• Tremor or other involuntary movements
• Paresis or paralysis?
• Coordination problem
• Paresthesias? (loss of sensation)
• Difficulty speaking?
  • Type: difficulty forming words
• Difficulty swallowing?
  • Solids or liquids
• History of nervous system disease
• Medications?
• Alcohol use?
• Drug abuse?
• Exposure to environmental or occupational hazards?

Physical Exam in Neurology

• Mental status
• Cranial nerves
• Motor
• Sensory
• Reflexes
• Coordination

Mental Status

• Level of consciousness
  • Normal: Patient awake and alert, attentive to surroundings.
  • Depressed: Patient lethargic, stuporous, or in a coma (use Glasgow Coma Scale).
• Orientation
  • Orientation to time, place, and person.
  • Common knowledge: e.g., "Who is the president?"
• Memory
  • Short-term memory: Repeat the names of three objects, then repeat them after 5 minutes.
  • Long-term memory: Recount verifiable events from the past.
• Language
  • Spontaneous speech
  • Comprehension
  • Naming, repetition
  • Reading and writing

Cognitive Functioning

• Concentration
  • Ask patient to spell "world" backward.
• Calculation
  • Serial sevens: Count backward from 100, subtracting 7 each time.
  • Real-life problem: If an apple costs $1, how many can you buy for $20?
• Judgment
  • Compare-and-contrast tasks: e.g., "How is an apple different from an orange?"
• Delusions or hallucinations
• Mood

Motor Examination

• Muscle mass and size
  • Ask patient to lie down and relax.
  • Inspect and palpate each muscle group, comparing muscles on the right side of the body with counterparts on the left side.
  • Verify any differences in size with a tape measure.
• Muscle tone
  • Passively move each extremity through a full range of motion, noting any hypotonia or hypertonia.
• Movement
  • Check voluntary and involuntary movement.

Motor Strength Grading Scale

Motor Examination Tests

• Romberg test
• Arm drift test

Specific Motor Examinations

• C8/T1: Finger squeeze
• C6-7: Fist
• T1: Finger abduction (ulnar nerve), finger spread
• Thumb adduction: median nerve
• Finger adduction: median nerve
• Wrist extension: Radial nerve
• Wrist flexion: Median nerve
• L2-3: Hip flexion
• L3-4: Knee extension
• L4-5: Hip extension
• L2-4: Hip adduction
• L4-5, S1: Hip abduction
• L5, S1: Knee flexion
• L4-5: Ankle dorsiflexion
• S1-2: Ankle plantarflexion
• L5: Extensor hallucis longus
• Pronator drift

Assessment of Balance and Coordination

• Coordination
  • Rapid alternating movements
  • Precise finger tap
  • Finger-nose-finger test
  • Heel-shin test
• Gait
  • Ordinary gait
  • Tandem gait (cerebellum)

Coordination Tests

• Finger-nose-finger
• Rapid alternating movements
• Heel-shin
• Tandem gait

Sensory Examination

• Light touch
• Superficial pain sensation
• Temperature sensitivity
  • Ask patient to close eyes.
  • Touch a stopper vial of hot water to the patient’s abdomen for 1 second, and then touch with cold water to the abdomen for 1 second.
  • Ask patient to state which was hot and cold.
• Positional sense
  • Move the fingers or toes up and down, one by one. Ask patient to state in which direction the digit has been moved.
  • Check three or four digits on each hand and foot.
• Vibration sense
  • Ask patient to close eyes.
  • Tap the tines of a tuning fork on the heel of your hand to set it vibrating.
  • Place it firmly over the distal interphalangeal joint of the patient's finger. Ask the patient what he or she feels.
  • Repeat for distal joint of the patient's great toe.
  • Test more proximal bony prominences if vibration sense is impaired.

Sensory Tests

• Pain/Pinprick
• Stereognosis (ability to identify by feeling)
• Positional sense
• Light touch
• Graphesthesia
• Extinction
• 2-point discrimination

Dermatomes

Dermatomes Innervated (Sensory Root of Spinal Nerve):

• C2 - Occiput
• C3 - High back of the neck
• C4 - Low back of neck/shoulder area
• C5 - Shoulder and upper lateral arm
• C6 - Thumb
• C7 - Middle finger
• C8 - Pinky finger and medial forearm
• T1 - Medial elbow area
• T2- L1 - Torso dermatomes are sequential
• L2 - Upper and Outer Thigh
• L3 - Medial Knee Area
• L4 - Medial Malleolus of Ankle
• L5 - Dorsum of foot
• S1 - Plantar aspect of foot, lateral malleolus.
• S2-S5 Perineal area.

Specific Nerves and Sensory Innervation:

• Supraclavicular
• Upper lateral brachial cutaneous (axillary)
• Posterior brachial cutaneous (radial) & lower lateral brachial cutaneous
• Lateral antebrachial cutaneous (musculocutaneous)
• Medial brachial cutaneous & intercostobrachial
• Medial antebrachial cutaneous
• Posterior antebrachial cutaneous (radial)
• Median
• Ulnar
• Radial

Additional Sensory Examinations

• Stereognosis
• Graphesthesia
• Two-point discrimination
• Extinction
  • Touch the same area on the right and the left side of the body simultaneously.
  • Ask patient where and how many touches were felt.
• Point location
  • Touch skin quickly.
  • Ask the patient to put the finger where the skin was just touched.

Reflexes

• Deep tendon reflexes
• Plantar reflex
• Superficial reflexes

Cranial Nerves

Cranial Nerve Examination Details

CN I: Olfactory

• Close the patient's eyes.
• Close one nostril.
• Have him smell a cup of coffee.

CN II: Optic

• Visual acuity
  • Stand 6 meters away from the Snellen chart.
  • Test one eye at a time from top letter down.
  • Finish by testing color.
• Visual field
  • Have the patient fix his eyes on your nose which is about 1 meter away.
  • Have him say how many finger(s) he sees.
• Funduscopy
  • Need a lot of practice.
  • Check for AV ratio (normal 3/4), AV nicking, exudates (soft and hard, SE and HE), hemorrhage and papilledema (PE).

Visual Acuity

VA =
ewline \frac{6}{18}
Patient with reduced vision (a) has to stand at 6 meters to see the same object that a normal-sighted individual (b) can see at 18 meters = 6/18 vision.

Visual Field Defects

• Optic nerve: Scotomata, blind eye
• Optic chiasm: Bitemporal hemianopsia
• Optic tract: Left homonymous hemianopsia
• Lower occipital radiation: Left upper homonymous quadrantanopsia
• Upper occipital radiation: Left lower homonymous quadrantanopsia

M = macula, HE = ischemia of retina, SE = leaking of serum, PE = papilledema

CN III, IV, and VI: Oculomotor, Trochlear, Abducens

• Have the patient follow your finger which moves in an H direction.
• Remember: lateral rectus (CN VI), superior oblique (CN IV), the rest (CN III).
• In CN III palsy, the affected eye is ptosis with mydriasis.

CN V: Trigeminal

• Sensory
  • Corneal reflex: eye blinks when touched.
  • 3 facial sensory divisions.
• Motor
  • Have the patient clench his teeth.
  • Unilateral weakness: jaw deviates toward the side of the lesion.

CN VII: Facial

• Motor
  • Grimaces
  • Blow
  • Open the eye
• Motor central
  • Cortex to pons
• Motor peripheral
  • Pons to face
• Sensory
  • Tastes at the anterior 2/3 of the tongue
  • Frontal ridge = 0. Eye cannot close completely.

CN VIII: Acoustic (Vestibulocochlear)

• Rub your hand near the patient’s ear and ask whether he hears or not.
• Assess the Hearing test based on the fact that air conduction (AC) is better than bone conduction (BC).
• Goal: is it conduction hearing loss or sensorineural loss?
• 2 tests: Weber test (for unilateral hearing loss) and Rinne test (to compare AC to BC).
• Negative Rinne test (abnormal): he will hear no more the vibration (AC < BC) = conduction loss.
• Positive Rinne test (normal): he still hears the vibration (AC > BC) = sensorineural loss.
• Conduction loss: obstruction of external ear canal, otitis media, perforated tympanic membrane, osteosclerosis (sticky bony overgrowth of ossicles).
• Sensorineural loss: sustained exposure to loud noise, drugs, aging infection/trauma/tumor of inner ear.

Rinne and Weber Tests

Rinne Test: When the sound can no longer be heard, turn the tuning fork like this…
Weber Test: Conduction hearing loss: sound heard at the affected side. Sensorineural hearing loss: sound heard at the unaffected side.

Vibration 512 Hz tuning fork or on the top of the head
No concurrent room noise
Decreased pitch = sensorineural transmits impulse poorly.

CN IX and X: Glossopharyngeal and Vagus

• Use tongue depressor and have the patient say “Ah”.
• Observe uvula deviation and gag reflex.
• Speech: dysphonia and dysarthria (CN X).
• Tastes of posterior 1/3 of tongue.

CN XI and XII: Spinal Accessory and Hypoglossal

• CN XI
  • Have the patient push against your hand.
• CN XII
  • Stick out his tongue.

Neurological Exam in Patient with Coma

• Mental
  • Glasgow Coma Scale
  • Shake and call
  • Pen on nail-bed
• Cranial nerves/Brainstem reflexes
  • Pupil size (light reflex)
    • Light reflex intact in metabolic coma
  • Corneal reflex (CN V sensory, CN VII motor)
  • Doll’s eyes maneuver
    • Intact: eyes move in opposite direction to head
    • Non-intact: eyes fixed or cannot move pass midline
    • Equivocal => cold caloric test
  • Cold caloric test
    • Intact: eyes move to same side
  • Gag reflex
• Motor
  • Muscle tone
• Reflexes
• Malingering or hysteria (shine eyes with flashed light, hand drop on the face)

The Glasgow Coma Scale

• Eyes
  • Open spontaneously: 4
  • Open to call: 3
  • Open to pain: 2
  • No response: 1
• Verbal
  • Oriented and converses: 5
  • Disoriented and converses: 4
  • Inappropriate words: 3
  • Incomprehensible sounds: 2
  • No response: 1
• Motor
  • Obeys verbal command: 6
  • Localizes pain: 5
  • Flexion-withdrawal to pain: 4
  • Decorticate (flexion) posturing: 3
  • Decerebrate (extension) posturing: 2
  • No response: 1

Key Takeaways

• How to perform neurology physical exam
  • Motor; cerebellar; sensory; reflex
  • 12 cranial nerves exam
• Neurology exam in comatose patient
  • What is GCS?
  • What is Doll’s eye?
  • Brain stem and CN exam in coma patient