the neurological exam - robert wood johnson medical...

The Neurological ExamThe Neurological ExamVikram Bhise, MDVikram Bhise, MD

A lesion of the facial nerve will NOT affect:1. Lacrimation (eye tearing)2. Hearing3. Speech4. Taste5. Eye closure

A motor score of 3 means:1. Full strength2. Movement laterally along a surface3. Partial resistance but otherwise able to move freely4. No resistance but movement against gravity5. No movement or a twitch

Steppage gait refers to:1. Pain-limited gait2. Short steps with poor foot elevation3. Staggering walk with a broad base4. Extended stiff leg that circumabducts5. Foot slapping and high step

ComponentsComponents1.1. Mental statusMental status2.2. Cranial NervesCranial Nerves3.3. MotorMotor4.4. SensorySensory5.5. CoordinationCoordination6.6. ReflexesReflexes7.7. GaitGait

Mental statusMental statusAwake and alertAwake and alertAgitatedAgitatedLethargicLethargic–– Arousable with Arousable with

VoiceVoiceGentle stimulationGentle stimulationPainful/vigorous stimulationPainful/vigorous stimulation

ComatoseComatose

AttentionAttentionDigit spanDigit spanSpelling forwards and backwardsSpelling forwards and backwardsMonths forwards and backwardsMonths forwards and backwardsSerial 7 subtractionSerial 7 subtraction

OrientationOrientationPersonPersonPlace Place TimeTime

LanguageLanguageFluencyFluencyNamingNamingRepetitionRepetitionReadingReadingWritingWritingComprehensionComprehension

MemoryMemoryImmediate Immediate –– 3 or 4 words3 or 4 wordsRemoteRemote–– Historical eventsHistorical events–– Personal events: School, summerPersonal events: School, summer

OtherOtherCalculationCalculationAbstractionAbstraction–– ProverbProverb–– Similarities & DifferencesSimilarities & Differences

Judgment and insightJudgment and insightAffect, mood, and behaviorAffect, mood, and behaviorPraxisPraxisVisuospatial Visuospatial –– L/R, clock drawingL/R, clock drawing

Cranial nervesCranial nervesI Olfactory nerveI Olfactory nerve–– Head traumaHead trauma

II Optic nerveII Optic nerve–– Visual acuity (corrected)Visual acuity (corrected)–– Visual fieldsVisual fields–– Fundoscopic examFundoscopic exam

MarginsMarginsColorColorSVPSVP

III Oculomotor III Oculomotor –– SR, IR, MR, IOSR, IR, MR, IOIV Trochlear IV Trochlear –– superior obliquesuperior obliqueV Abducens V Abducens –– lateral rectuslateral rectus

Pupil Pupil –– II in, III outII in, III outEyelid Eyelid –– III and sympathetic openIII and sympathetic open–– VII closeVII close

Cover/uncover test Cover/uncover test –– phoriaphoriaMaddox rodMaddox rod

Color vision Color vision –– Ishihara platesIshihara plates

SaccadesSaccades

V FacialV Facial–– V1 sensoryV1 sensory–– V2 sensoryV2 sensory–– V3 sensory and motor (muscles of V3 sensory and motor (muscles of

mastication)mastication)

Corneal Corneal –– V in, VII outV in, VII out

VII facialVII facial–– Facial asymmetry, smileFacial asymmetry, smile–– ForeheadForehead–– Lacrimation (greater petrosal nerve)Lacrimation (greater petrosal nerve)–– Whistle, pucker, close eyes, cheeksWhistle, pucker, close eyes, cheeks–– Hearing for hyperacusis (stapedius)Hearing for hyperacusis (stapedius)–– Taste anterior 2/3 tongue (chorda Taste anterior 2/3 tongue (chorda

tympani)tympani)

VIII VestibulocochlearVIII Vestibulocochlear–– HearingHearing–– Rinne & WeberRinne & Weber

IX GlossopharyngealIX Glossopharyngeal–– Taste posterior 1/3Taste posterior 1/3–– Sensory tonsils, middle ear, posterior Sensory tonsils, middle ear, posterior

1/3 tongue1/3 tongue

X VagusX Vagus–– Voice quality, pitchVoice quality, pitch–– Gag reflex IX in, X outGag reflex IX in, X out

XI Spinal AcessoryXI Spinal Acessory–– Sternocleidomastoid muscle and bulkSternocleidomastoid muscle and bulk–– Trapezius muscleTrapezius muscle

XII HypoglossalXII Hypoglossal–– StrengthStrength–– Right genioglossus muscle thrusts Right genioglossus muscle thrusts

forward and to leftforward and to left

Motor ExamMotor Exam1.1. StrengthStrength2.2. ToneTone3.3. BulkBulk4.4. Adventitious movementsAdventitious movements

StrengthStrength–– 5 full strength5 full strength–– 4 resistance but not full4 resistance but not full–– 3 can lift against gravity3 can lift against gravity–– 2 can move laterally2 can move laterally–– 1 flicker1 flicker–– 0 no movement0 no movement

Upper versus lower extremitiesUpper versus lower extremitiesProximal versus distalProximal versus distalUpper motor neuron distributionUpper motor neuron distributionSubtle signsSubtle signs–– DriftDrift–– Arm roll (orbiting)Arm roll (orbiting)

Shoulder abduction Shoulder abduction –– deltoiddeltoidShoulder adduction Shoulder adduction –– latissimuslatissimusArm flexion Arm flexion –– bicepsbicepsArm extension Arm extension –– tricepstricepsWrist flexion Wrist flexion –– FCU, FCRFCU, FCRWrist extension Wrist extension –– ECU, ECRECU, ECR

Hip extension Hip extension –– gluteus maximusgluteus maximusHip flexion Hip flexion –– iliopsoasiliopsoasHip abduction Hip abduction –– gluteus medius and gluteus medius and minimusminimusHip adduction Hip adduction –– gracilis, adductor gracilis, adductor L/M/BL/M/BKnee extension Knee extension –– quadricepsquadricepsKnee flexion Knee flexion –– hamstringshamstringsAnkle dorsiflexion Ankle dorsiflexion –– tibialis anteriortibialis anteriorAnkle plantarflexion Ankle plantarflexion –– gastrocnemiusgastrocnemiusFoot inversion Foot inversion –– tibialis anterior and tibialis anterior and posteriorposteriorFoot eversion Foot eversion –– peroneus longus and peroneus longus and brevisbrevis

Tone Tone –– proximal and distalproximal and distalSpasticitySpasticityAdventitious movementsAdventitious movements–– FasciculationsFasciculations–– Myoclonic jerksMyoclonic jerks–– ChoreoathetosisChoreoathetosis–– TremorTremor–– DystoniaDystonia

Bulk Bulk –– atrophy, hypertrophyatrophy, hypertrophy

SensorySensoryLight touchLight touchSpinothalamicsSpinothalamics–– PinprickPinprick–– TemperatureTemperature

Dorsal columnsDorsal columns–– VibrationVibration–– Joint position senseJoint position sense

Higher cortical sensoryHigher cortical sensoryGraphesthesiaGraphesthesiaStereognosisStereognosisDouble simultaneous stimulationDouble simultaneous stimulation22--point discriminationpoint discriminationBarognosisBarognosisTopognosiaTopognosiaRombergRomberg

Coordination (Cerebellar)Coordination (Cerebellar)RhythmRhythm–– Finger counting and tappingFinger counting and tapping–– Foot tappingFoot tapping–– Rapid alternating movementsRapid alternating movements

MeterMeter–– FingerFinger--nosenose--fingerfinger–– HeelHeel--kneeknee--shinshin–– FootFoot--toto--fingerfinger

Rebound (check)Rebound (check)

ReflexesReflexesStrengthStrength–– 0 absent0 absent–– 1 reduced1 reduced–– 2 normal 2 normal –– 3 brisk 3 brisk –– 4 associated clonus4 associated clonus

DTRsDTRsBiceps [C5/C6]Biceps [C5/C6]Brachioradialis [C5/C6]Brachioradialis [C5/C6]Triceps [C7Triceps [C7--T1]T1]Knees [L3/L4]Knees [L3/L4]Ankles [S1/S2]Ankles [S1/S2]

Primitive reflexesPrimitive reflexesJaw jerkJaw jerkFrontal release Frontal release –– snout, suck, grasp, snout, suck, grasp, palmomental, glabellarpalmomental, glabellar

PectoralsPectoralsHoffmanHoffman’’ssFinger flexorsFinger flexorsCrossCross--adductorsadductorsBabinski/Chaddock/OppenheimBabinski/Chaddock/Oppenheim

Moro (28 wks GA to 3 m)Moro (28 wks GA to 3 m)Propping (5Propping (5--7m) 7m) –– anterior then lateralanterior then lateralParachute (5 m, by 11 m) Parachute (5 m, by 11 m) Fencing (asymmetric tonic neck reflex)Fencing (asymmetric tonic neck reflex)

(34 wks GA to 4m, max 2 m) (34 wks GA to 4m, max 2 m) Stepping (34 wks GA to 4 m)Stepping (34 wks GA to 4 m)Crawling (to 2m)Crawling (to 2m)Blink (5 m)Blink (5 m)

Grasp palmar/plantar (28 wks GA to 6m)Grasp palmar/plantar (28 wks GA to 6m)Rooting (28 wks GA to 4m)Rooting (28 wks GA to 4m)Suck (28 wks GA to 2m)Suck (28 wks GA to 2m)Gallant (to 4m)Gallant (to 4m)Righting reflex Righting reflex –– clears head and noseclears head and noseWithdrawal to painWithdrawal to painProtective Protective –– clears clothclears clothBabkin Babkin –– hand to mouthhand to mouthSwim/divingSwim/diving

GaitGaitBaselineBaseline–– BaseBase–– ArmswingArmswing

ToeToeHeelHeelTandem and reverse tandemTandem and reverse tandem

Rise from squattingRise from squattingRise from seated positionRise from seated positionStep upStep upBalance or hop on one legBalance or hop on one legPull testPull test

TypesTypeshemiparetichemipareticataxicataxicantalgicantalgichystericalhystericalsteppagesteppageshuffling/festinationshuffling/festinationmagneticmagnetic

A lesion of the facial nerve will NOT affect:1. Lacrimation (eye tearing)2. Hearing3. Speech4. Taste5. Eye closure

A motor score of 3 means:1. Full strength2. Movement laterally along a surface3. Partial resistance but otherwise able to move freely4. No resistance but movement against gravity5. No movement or a twitch

Steppage gait refers to:1. Pain-limited gait2. Short steps with poor foot elevation3. Staggering walk with a broad base4. Extended stiff leg that circumabducts5. Foot slapping and high step

AnswersAnswersQuestion 1: 3 speechQuestion 1: 3 speechQuestion 2: 4 movement against Question 2: 4 movement against gravitygravityQuestion 3: 5 foot slapQuestion 3: 5 foot slap