NEUROLOGICAL EXAMINATION
(1)
Dr. Sema Saltık
Ass. Prof of Child Neurology
Neurological Examınatıon
Consciousness level assessment, cooperation Disorders of speech and language Neck stiffness and evidences of meningeal irritation Cranial nerves Motor system Muscle power Muscle tone Sensation Reflexes Posture-gait disorders Cerebellar tests Higher cerebral function Movement disorders Other….
Consciousness
is the quality or state of being aware of an external object or something within oneself.
Consciousness is assessed by observing a patient's arousal and responsiveness.
The abnormal state of consciousness ;
Clouding of consciousness is a very mild form of altered mental status in which the patient has inattention and reduced wakefulness.
Confusional state is a more profound deficit that includes disorientation, bewilderment, and difficulty following commands.
Abnormal state of consciousness
Lethargy consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep.
Obtundation is a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states.
Stupor means that only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back to the unresponsive state.
Coma is a state of unarousable unresponsiveness.
Glasgow Coma Scale
Motor response Obeys commands 6 Localizing to pain 5 Withdraws to pain 4 Flexing to pain 3 Extending to pain 2 None 1
Verbal response Orientated 5 Confused 4 Words 3 Sounds 2 None 1
Eye opening Spontaneous 4 To speech 3 To pain 2 None 1
< 7 coma
<5 deep coma
Modified Pediatric Glasgow Coma Scale
Verbal response
Smiles, orients to sounds, follows objects, interacts 5
Cries but consolable, inappropriate interactions 4
Inconsistently inconsolable, moaning 3
Inconsolable, agitated 2
No verbal response 1
Language and speech disorders
Anarthria-Dysarthria; Loss of the ability to vocalize words
as a result of an injury to the part of the brain that is responsible for controlling the larynx or "voice box." (Cerebellar, Extrapyramidal,
IX. X. Cranial nerve palsies)
Aphasia, Dysphasia; a disorder caused by damage to the
parts of the brain that control language. It can make it hard for you to read, write, and say what you mean to say.
Broca’s aphasia (Motor aphasia) (+right hemiparesis)
Wernicke aphasia (Sensorieal aphasia)
Meningeal Irritation Evidences
Neck stiffness
Kerning’s sign
Brudzinski’s sign
Meningeal Irritation Evidences
I. Cranial Nerve- Olfactory Nerve
Smell is tested in each nostril
separately by placing stimuli under
one nostril and occluding the opposing
nostril. The stimuli used should be
non-irritating and identifiable.
II. Cranial Nerve- Optic Nerve
Visual acuity; is tested in each eye separately.
The patient is asked to read progressively smaller lines
on the near card or Snellen chart.
Visual fields; are assessed by asking the patient to cover one eye while the examiner tests the opposite eye. The examiner wiggles the finger in each of the four quadrants and asks the patient to state when the finger is seen in the periphery. (Confrontation)
Fundoscopy;
Pupills; size, shape, equality, reaction to light, accommodation and convergence.
Oculomotor (III), Trochlear (IV), Abducens (VI) Cranial Nerves
Extraocular muscle movement
♦ Upward movement, looking out - superior rectus (Oculomotor nerve)
♦ Upward movement, looking in – inferior oblique (Oculomotor nerve)
♦ Downward movement, looking out - inferior rectus (Oculomotor nerve)
♦ Medial movement– medial rectus (Oculomotor nerve)
♦ Lateral movement – lateral rectus ( Abducens nerve)
♦ Downward movement, looking in – superior oblique (Trochlear nerve)
Oculomotor (III), Trochlear (IV), Abducens (VI) Cranial Nerves
Diplopia; ask patient about diplopia and if present note the direction of maximum displacement of the images and determine the pair of muscles involved.
Conjugate movements; is the ability of the eyes to act together to the horizontal or vertical direction
Nystagmus; upset in the normal balance of eye control.
Horizontal-vertikal
Direction (e.g. Nystagmus to the right)
Gaze direction where nystagmus is maximal (e.g. max. to
lateral gaze)
Ptosis;
V. Cranial Nerve-Trigeminal Nerve
Motor fibres: innervate the muscles of
mastication (Temporalis, masseter and pterygoid muscles)
(Jaw jerk)
Sensory fibres: subserves facial sensation
Ophthalmic division
Maxillary division
Mandibular division
CORNEAL REFLEX
VII. Cranial Nerve- Facial Nerve
Motor fibres: supply the muscles of facial
expression
Visceral afferent fibres: convey sensations of
taste from the anterior two-thirds of the tongue.
Visceral efferent (parasympathetic) fibres:
Salivation (sublingual, submaxillary, tears)
VIII. Cranial Nerve-Statoacustic Nerve
Cochlear nerve: hearing
Vestibular nerve: balance
IX. Glossopharyngeal nerve X. Vagus nerve
These nerves are considered jointly since they are examinated together and their actions are seldom individually impaired.
Swallowing difficulty, nasal regurgitation of fluids?
Ask patient to open mouth and say ‘aa’, note any asymmetry of palatal movements.
Note the patient’s voice
Taste in the posterior 1/3 of the tounge is impractical to test (IX)
GAG REFLEX
XI. Cranial Nerve-Accessory nerve
Sternocleidomastoid : ask the patient to rotate head against resistance. Compare power and muscle bulk on each side.
Trapezius; ask the patient to ‘shrug’ shoulders and to hold them in this position against resistance. Compare power on each side.
XII. Hypoglossal Nerve
Motor nerve of the tongue
Inspect tongue (atrophy, fasciculation)
Ask the patient to protrude the tongue, note any difficulty or deviation. Tongue deviates towards side of the weakness.
Motor System Examination
any asymmetry or deformity
muscle wasting
muscle hypertrophy
muscle fasciculation
power
tone
Motor System Examination
Upper Limbs
Shoulder abduction- m.deltoideus
Shoulder adduction- m. pectoralis major, latissimus dorsi
Elbow flexion- m. biceps, brachioradialis
Elbow extension- m. triceps
Wrist Extension- ext.carpi radialis longus, ext. carpi ulnaris
Finger extension
Finger flexion
Interosseous muscles
Motor System Examination
Lower Limbs
Hip flexion - Iliopsoas
Hip extension- Glutei
Hip abduction- Glutei and tensor fascia lata
Hip adduction- Adductors
Knee flexion- Hamstrings
Knee extension- Quadriceps
Plantar flexion- Gastrocnemius, tibialis posterior
Plantar dorsiflexion- tibialis anterior,extensor hallucis longus,ext. Digitorum longus
Strength of Muscle Groups
0/5: no contraction
1/5: muscle flicker, but no movement
2/5: movement possible, but not against gravity (test the joint in its horizontal plane)
3/5: movement possible against gravity, but not against resistance by the examiner
4/5: movement possible against some resistance by the examiner
5/5: normal strength
Tone
Ensure that the patient is relaxed, and assess tone by alternately flexing and extending the muscles.
Normal tone
İncrease in tone
Spastisity
Rigidity
Decrease in tone
Posture and Gait
Posture (decerebration, decortication, hemiplegic…)
Gait
Spastic
Ataxia Cerebellar ataxia
Sensory ataxia (Romberg’s test)
Steppage
Parkinsonian
Waddling gait - a duck-like walk
Sensory Exam
I. SUPERFICIAL SENSATION
Light touch
Pain
Temperature
Sensory Exam
II. PROPRIOCEPTIVE SENSATION
Position Sense Ask the patient close the eyes and report if their large toe is "up" or "down" when the examiner manually moves the patient's toe in the respective direction.
Vibratory Sense
A positive Romberg test suggests that the ataxia is sensory in nature, that is, depending on loss of proprioception.
Sensory exam
III. CORTICAL SENSATION: (Parietal lobe)
Stereognosia: Ask the patient to close their eyes and identify the object you place in their hand. Place a coin or pen in their hand.
Two-point discrimination is the ability to discern that two nearby objects touching the skin are truly two distinct points, not one.
Graphesthesia: Ask the patient to close their eyes and identify the number or letter you will write with the back of a pen on their palm.
Touch localization (topognosis): ability to localize stimuli to parts of the body. Topagnosia is the absence of this ability.
Reflexes
I- Deep Tendon Reflexes
0 No response, absent
± A reflex that is only elicited with reinforcement
+ Diminished
++ Normal
+++ Hyperactive
++++ Hyperactive with clonus
Jaw Reflex
N. trigeminus (V. CN)
Pons
The lower jaw—is tapped at a downward angle just
below the lips at the chin while the mouth is held slightly open. In response, the masseter muscles will jerk the mandible upwards.
Normal response; this reflex is absent or very slight.
Upper motor neuron lesions; the jaw jerk reflex can be quite pronounced
Biceps Reflex
Normal response; forearm flexion
Peripherial nerve: N. musculocutaneous
Spinal segment: C5, C6
Palpate the biceps
tendon
Triceps Reflex
Normal response; forearm extension
Peripherial nerve : N. radialis
Spinal segment: C6, C7
Strike the patient’s elbow a
few inches above the
olecranon process.
Brachioradial Reflex
Normal response; flexion and slight supination of elbow, slight flexion of fingers
Peripherial nerve : N. radialis
Spinal segment: C5, C6
Strike the lower end of the
radius
Patellar Reflex (Knee jerk)
Normal response; sudden extension of the leg.
Peripherial nerve : N. Femoralis
Spinal segment: L2 - L4
Achille Rejlex (Ankle jerk)
Normal response; plantar flexion
Peripherial nerve : N. Tibialis
Spinal segment: S1-S2
Externally rotate the leg
Hold the foot in slight dorsiflexion
Palpate the tendon of tibialis anterior
(ensure the foot is relaxed)
Tap the achille tendon
Superficial Neurological Reflexes
Abdominal reflex
Stroke or lightly scratch the skin towards the umblicus in each
quadrant in turn.
Look for abdominal muscle contraction and note if absent or impaired.
Spinal segment: T7-T12
Cremasteric reflex
Scratch inner thigh.
Observe contraction of cremasteric muscle causing testicular elevation.
Spinal segment: L1
Anal reflex
Scratch on the skin beside the anus.
Observe a reflex contraction of the anal sphincter.
Spinal segment: S4, S5
Superficial Neurological Reflexes
Plantar Reflex
Stroke the lateral aspect of the sole and across the ball of the foot. Watch for the first movement of the big toe.
Clonus
Series of involuntary, rhythmic, muscular contractions and relaxations
Clonus is most commonly found at the ankle specifically with a dorsiflexion/plantarflexion movement (up and down).
Clonus at the ankle is tested by rapidly flexing the foot into dorsiflexion (upward), inducing a stretch to the gastrocnemius muscle.
Cerebellar tests
Dysmetria
Finger-to-nose test
Ankle-over-tibia test
Dysdiadochokinesis
Rapid pronation-supination
Ataxia
Assessment of gait
Nystagmus
Intention tremor
Staccato speech
Movement disorders
Chorea
Athetosis
Hemiballismus
Dystonia
Tremor
Tic
Myoclonus
Fasciculation