INTRODUCTION

TO
NEUROLOGICAL
EXAMINATION

Adrian Pace
Neurology Registrar
 Why neurological exam is different
1. The CNS cannot be directly palpated, percussed, auscultated etc, so its
intactness is only induced indirectly via functional testing.

2. Major part of the exam is stimulus-response testing.

3. Exam findings must then be correlated with (1) patient symptoms and (2)
knowledge of neuroanatomy to come to a diagnosis

DIFFICULTIES:

- Neuroanatomy is complex
- Neurology covers a very wide area of disease
- Exam very reliant on patient cooperation
- Functional tests are potentially endless

IMPRESSIONS

- Neurology is medical ‘voodoo-land’

- Neurologists all have OCD
 (SOME) NEUROLOGICAL SYMPTOMS

• Headache • Altered mobility

• Dizzyness • Sphincter control disorders
• Seizures • Sleep disorders
• Altered • Facial palsy
consciousness • Coordination difficulties
• Personality change
• Memory loss
• Weakness and so on.....
• Stiffness
• Disordered sensation
• Loss of vision
• Loss of hearing
• Loss of smell
• Abnormal
movements
• Speech problems
• Swallowing problems
 REFERRAL LETTER

The GP
The GP Practice
Somewhere in Plymouth
PL& $XY

Dear Neurology,

I would be grateful if you would see this gentleman/lady I am concerned

about......

.....unexplained collapse........peculiar movements........history of funny

turns.......possibly confused........ there might have been some weakness........

Neurological examination appeared grossly normal

Could there be something going on (aka a tumour??)

 3 questions of neurological diagnosis
1) Is there a problem ?
- Presence of neurological abnormality

2) Where is the problem ?

- Location of problem (CNS / PNS)

3) What is the problem ?

- structural / chemical
- intrinsic / extrinsic
- benign / malignant
NOTE : THIS PRESENTATION
DOES NOT COVER HISTORY
 Basic Plan
• OBSERVE - gait
- appearance
- general inspection
• Conscious state
• Cognition
• Head / Arms / Legs
- Cranial nerves
- Motor (tone / power / reflexes)
- Sensory
- Coordination
OBSERVATION
SOME ABNORMAL GAITS
• Spastic
• Hemiparetic
• Parkinsonian
• Foot drop
• Ataxic
• Waddling (myopathic)
SOME ABNORMAL FACIES
 ABNORMALITIES ON CLOSER INSPECTION

• Muscle wasting
• Muscle fasiculations
• Abnormal posture
• Tremors
• Involuntary movements
- Focal seizures
- Chorea
- Athetosis
- Myoclonic jerks
 LEVEL
OF
CONSCIOUSNESS
Created to reflect measure of global brain function

Limited value, many processes selectively affect components

Omitted in OP settings, mainly used on acute admissions

COGNITION
MMSE

Broad screening test of

cognitive function
including attention,
memory, language

Good for diagnosing /

monitoring certain types
of dementia especially A.D.

Other types of dementia / cognitive problems require

different tests
• “ Frontal” functions
– Attention & concentration ( digit span )
– Abstraction ( explain proverb )
– Judgment
• child lost in street..what would you do?
– Planning
• How to plan a holiday / draw a clock

• Neglect
– Failure to pay attention to area of space (usually due to
parietal lesions with neglect of contralateral space.

• Praxis:
– ability to perform learned action (e.g. dressing , combing
hair)
• ‘Frontal release’ signs during neuro exam

Glabellar tap Rooting Pouting

Palmomental reflex Grasping

CRANIAL NERVES
• I - smell (rarely tested)

• II - Acuity (Snellen chart)

- Fundi
- Fields ( confrontation)
- Pupils

• III, IV, VI
- Ptosis
- Movement
- Saccades and smooth pursuit
- Diplopia / Nystagmus
• V
- Facial sensation
- Muscles of mastication
- Jaw jerk
- Corneal reflex
Afferent = V
Efferent = VII

• VII
- Muscles of facial expression
- Taste ant 2/3 tongue
- Tensor Tympani
• VIII • XI
- Nystagmus - sternocleidomastoid &
- Hearing
trapezius
• IX, X
- Say ahh (X) • XII ( tongue)
- Gag reflex - Observation ( atrophy,
fasciculations)
- Protrusion (?deviated)

- Power
- Dexterity ( fast
movement side-to-
side)
THE MOTOR SYSTEM
 Upper motor neurone
• Cell body within motor cortex
• Axon terminates :
– Cranial nerve motor
nucleus (corticobulbar)
– Anterior horn of spinal cord
(corticospinal)

Lower motor neurone

• Cell body of
– Motor cranial nerve nucleus
– Anterior horn cell
• Axon terminates on
neuromuscular junction
 TONE
• Reduced muscle tone.

• Increased tone:
1) SPASTICITY (ie pyramidal)
2) RIGIDITY (ie extrapyramidal)
 POWER
• The standard neurological examination involves testing power
of two movements at each joint (agonists and antagonists)

• The history may suggest more localised problems which

require examination of individual muscles (eg nerve lesions of
the hand)
MRC GRADING OF MUSCLE POWER

• GRADE 5: NORMAL POWER

• GRADE 4: WEAK BUT SOME RESISTANCE

• GRADE 3: JUST OPPOSES GRAVITY
• GRADE 2: MOVES BUT CANNOT OPPOSE GRAVITY
• GRADE 1: VISBLE/ PALPABLE MUSCLE FLICKER
• GRADE 0: NOTHING
 PATTERNS OF WEAKNESS
• Weak arm and leg (same side): HEMIPARESIS

• Weak legs, normal arms: PARAPARESIS

• All four limbs weak: TETRAPARESIS

• One limb weak: MONOPARESIS

• Proximal muscle weakness

• Distal muscle weakness
 EXAMPLES OF LESIONS CAUSING
PATTERNS
• Hemiparesis: hemispheric stroke, tumour, abscess

• Paraparesis: spinal cord lesion below cervical spine

• Tetraparesis: cervical cord lesion
• Monoparesis: Tumour at brachial plexus
• Proximal weakness: myopathy
• Distal weakness: peripheral neuropathy
 REFLEXES
A reflex, is an involuntary and nearly instantaneous movement in response to a
stimulus.

Reflex actions are mediated via the reflex arc, comprised of sensory neurone
that perceives the stimulus signal and transfers the signal to inter neurone(s) in
your spinal cord then out to motor neurone and to an effector, like muscle to
react to the stimulus.
 REFLEXES
UPPER MOTOR NEURON LESIONS: increased tendon reflexes, reflex spread
and extensor plantar responses

LOWER MOTOR NEURON LESIONS:

reduced or absent reflexes.
may be generalised eg neuropathy,
or focal eg single nerve or root lesion
 Upper Motor Lower Motor
Neurone Neurone
Inspection of Normal Atrophy
muscles (disuse atrophy) Fasciculations

Tone Increased Decreased

(unless acute) (or normal)
Power (MRC scale) decreased decreased
Tendon Reflexes Increased Decreased or
(unless acute) Normal

Pathological reflexes Present Absent

THE SENSORY SYSTEM
 SENSORY EXAM

• VIBRATION
– 128 hz tuning fork
• JOINT POSITION SENSE
• PIN PRICK
• TEMPERATURE

Start distally and move proximally

 HIGHER CORTICAL SENSATIONS

• GRAPHESTHESIA
• STEREOGNOSIS
• DOUBLE SIMULTANEOUS STIMULATION
• TEXTURES
COORDINATION
 CO-ORDINATION
• Two main types of ataxia:
• Cerebellar ataxia (lesions of the cerebellum
and its connections)
• Sensory ataxia: peripheral neuropathies and
spinal cord lesions where dorsal columns are
affected
 COORDINATION TESTS

• Tandem gait
• Romberg’s test
• Finger to nose test
• Rapid alternating movements (looking for
dysdiadochokinesis)
• Heel to shin test
THANK YOU