The Adult Neurologic Examination
- Level
of consciousness:
- Alert,
verbal, conversant, oriented
- Falls
asleep when not stimulated
- Opens
eyes to noxious stimuli only
- Follows
multi-step commands
o Groans/grimaces/localizes/postures
to noxious stimuli
o Normal
o Flat/abulic (c/w frontal lesion)
o Emotionally incontinent
(pseudobulbar)
- Orientation: Time, place, and person
deteriorate in that order.
- Calculation: Making change is a useful test
in addition to routine school figures.
- Attention: Tested with serial 7’s or by
spelling “WORLD” backwards.
- Memory: Test recall, both
recent and remote.
- Language:
o Evaluation includes noting speech
delivery and content and technically reading, and writing.
o Evaluate for aphasia: Should check
naming of objects, repetition, and comprehension (single and multi-step
commands).
- Dysarthria
(impairment of articulation) can be localized using the following
phrases:
- Pa Pa
Pa (CN7, lips/labial)
- Ta
Ta Ta (CN
12, tongue/lingual)
- Ka
Ka Ka (CN 10, throat)
- Cranial
Nerves (foramina through which nerve exits skull is bracketed)
- I Olfactory
nerve [cribiform plate]
- Generally
not tested; when done, use aromatic non-noxious odors (coffee, mint,
tobacco)
- II Optic
nerve [optic canal]
- Pupils,
fundoscopic, visual fields and acuity
- III, IV,
VI Oculomotor, trochlear and abducens nerves [superior
orbital fissure]
- EOM’s,
gaze palsy, gaze preference, nystagmus
- V Trigeminal
nerve [V1 (ophthalmic): superior orbital fissure; V2
(maxillary): foramen rotundum; V3 (mandibular): foramen ovale]
- Corneal
sensation (blink reflex), PP and LT in all 3 divisions, muscles of
mastication
- VII Facial
nerve [internal auditory meatus-stylomastoid foramen]
- Facial
symmetry, taste (anterior 2/3 of the tongue), salivation, stapedius
muscle, and lacrimation
- Remember: Central VIIth involves
only lower half of face while peripheral VIIth involves entire face.
- VIII Vestibulocochlear
nerve [internal auditory meatus]
- Easy
bedside tests are ticking watch or fingers rubbing
- Use a
512 Hz tuning fork for Weber/Rinne tests: Weber tests lateralization,
Rinne tests bone vs. air conduction
- IX, X Glossopharyngeal
and vagus nerves [jugular foramen]
- Test
gag, symmetry of palate, taste (posterior 1/3 of tongue), salivation
- XI Accessory
nerve [jugular foramen]
- Trapezius
and SCM function
- XII Hypoglossal
nerve [hypoglossal canal]
- Tongue
protrusion, check for fasciculations
- Remember: Tongue deviates toward
side of nerve lesion
- Motor
o Check for tone, weakness, fasciculations
and atrophy
o Subtle weakness may manifest as arm
rift, abnormal orbiting, or decreased RAM’s
o Grading:
- 5/5
= Normal
- 4/5
= Patient can be overcome (intermediate grades of
4+ and 4- may be used to better quantify this level)
- 3/5
= Resistance against gravity only
- 2/5
= Can move with gravity removed
- 1/5
= Muscle contraction seen or palpated only
- 0/5 =
No function
- Cerebellar
- Nystagmus,
finger-to-nose (FTN), heel-to-shin (HTS), wide-based gait, intention
tremor, tandem walking, RAM’s, ataxia (truncal and extremity), dysmetria,
Romberg test
- Romberg
is described either “present” or “absent;” never as positive or negative.
- Gait
o Test regular, tandem, toe and
heel. Types include:
§ Antalgic (painful, guarding)
§ Ataxic (wide-based, unsteady)
§ Spastic (scissoring with short
steps)
o Test all primary sensory modalities
– pin, light touch, joint position, temperature, and vibration
o Cortical sensory functions –
Extinction to double simultaneous stimulation (DSS), graphesthesia (ability to
recognize numbers traced on palm), and stereognosis (ability to recognize
objects placed into hand)
o Deep Tendon Reflexes:
- Biceps
(C5)
- Brachioradialis
(C6)
- Triceps
(C7)
- Patellar
(L4)
§ Achilles (S1)
- Grading
of Deep Tendon Reflexes:
- 0 =
Absent
- 1 =
Present, but decreased
- 2 =
Normal
- 3 =
Hyperactive
- 4 =
Hyperactive with clonus
- Superficial
Reflexes:
§ Abdominal (T6 to T12)
§ Cremasteric (L12)
§ Anal wink (S345)
§ Bulbocavernosus (S34)
- Pathologic
Relfexes:
- Upper
motor neuron injury signs = Babinski and Hoffman
- Again,
never describe Babinski as positive or negative. Just state “toes
upgoing” or “toes downgoing.”
- “Frontal
release” signs = sucking (rooting), glabellar, snout, grasp,
palmar-mental