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The Neurologic Exam

Nicholas Mallett

Higher Integrative functions - Attention: are they awake, asleep but arouse, drowsy, somnolent, sedated, etc. Can they participate in the exam? Can test attention direction by spelling “world” backwards or giving days of week or months of year backwards

  • Orientation: to person, place, time, and ± situation

  • Memory/Fund of knowledge: do not formally assess unless part of complaint. For memory, can be bedside testing of 3 or 5 word recall after 5 minutes

  • Language: look for dysarthria (slurred speech), aphasia (nonsensical speech or inability to produce words, often test by asking to name objects), repetition

Cranial Nerves

  • CN1: smell, typically do not test this

  • 2: vision, check with pupillary light response, visual field testing, or visual acuity if complaint

  • 3, 4, 6:: extraocular movements. 6 abducts, 4 raises in and up and helps with intorsion, 3 does rest and is in pupillary light reflex (constricts pupil)

  • 5: facial sensation in V1, V2, and V3, compare left and right

  • 7: facial movements/strength, compared left and right, upper (eyes) and lower (mouth)

  • 8: hearing. Can do finger rub or just assess when talking during interview

  • 9, 10: palate elevation, cough/gag if intubated

  • 11: shoulder shrug from trapezius and head turn from sternocleidomastoid

  • 12: tongue protrusion: should be midline. If abnormal, deviates to side of injury

Motor

  • Strength: manual muscle testing (MMT) scale ranging from 0 to 5 0 = No muscle activation 1 = trace muscle activation (eg muscle twitch) but unable to move across ROM of joint 2 = muscle action with gravity eliminated (eg in plane of bed), with full ROM in that plane 3 = action against gravity only and not against resistance 4 = action against some resistance 5 = full strength against resistance

  • Other aspect of motor: muscle tone (decreased, normal, increased), tremor (at rest, with action, or with sustained antigravity position [posture]), pronator drift, any other abnormal movements (if not sure what it is, just describe what you see)

  • If altered or sedated – look for spontaneous movement, compare left and right sides, assess response to noxious stimuli (ie nailbed pressure)

Sensation

  • Light touch is simplest -- is it the same left and right and in uppers and lowers

  • Unless sensation loss or changes is part of chief complaint, typically do not assess other modalities which include pinprick, temperature (hot or cold), vibration, proprioception

Reflexes

  • Grading scale: 0 = areflexia, 1+ = decreased but present, 2+ = normal, 3+ increased without clonus but often with spread to adjacent joints, 4+ increased with clonus (sustained response to one tap) Increased reflexes often indicate central etiology, but 3+ can be normal in young adults Decreased reflexes often indicate lower motor neuron or peripheral etiology, can be normal in older adults

  • Biceps: C5-C6, musculocutaneous nerve

  • Brachioradialis: C5-C6, radial nerve

  • Triceps: C7-C8, radial nerve

  • Patellar: L2-L4, femoral nerve

  • Achilles: S1, tibial nerve

  • Babinski – scrap along lateral edge of foot then across top in lower case “r” motion. Often easier to describe by direction big toes moves – up or down

Coordination

  • Finger-nose-finger and heel-knee-shin testing, looking for smooth, non-ataxic movements, and can also pick up on tremor with FNF

Gait

  • Station: can stand still with feet with feet less than shoulder width apart, assess posture

  • Natural gait: Smooth coordinated with normal arm swing

  • Symmetric? Stride length? Narrow or wide based? Speed?

  • Lateralizing findings (ie circumduction, shoulder droop)?

  • Toe walk: tests balance, strength of distal lower extremities

  • Tandem walk (heel to toe): should be able to balance without falling or stepping to the side, can help detect ataxia