KABERA René,MD

PG Y III Resident
Family and Community Medicine
National University of Rwanda

October 2010

Initial approach

Mental Status

Cranial Nerves

Motor Exam

Reflexes

Coordination and Gait

Sensory Exam

References

The Neurologic History

• Temporal course of the illness

• Patients' descriptions of the complaint.
• Corroboration of the history by others
• Family history
• Medical illnesses
• Drug use and abuse and toxin exposure.
• Formulating an impression of the patient.
1.Level of consciousness, attention and comprehension

AVPU-GCS

Awake and alert

Agitated

Lethargic

Comatose

Test attention by seeing if the patient can remain focused on a simple
task, such as spelling a short word forward and backward (R-W-A-N-D-A
/A-D-N-A-W-R) is a standard.

Comprehension: Can the patient understand simple questions and
commands? Comprehension of grammatical structure should be tested
as well
2.Speech and Language

Spontaneous speech: Note the patient's fluency, including phrase length,

rate, and abundance of spontaneous speech. Also note

Tonal modulation and whether paraphasic errors (inappropriately
substituted words or syllables), neologisms (nonexistent words), errors in
grammar are present, Aphasia or dysarthria

Naming: Ask the patient to name some easy (pen, watch, tie, etc.) and
some more difficult (fingernail, belt buckle, stethoscope, etc.) objects

Repetition: Can the patient repeat single words and sentences (a
standard is "no ifs ands or buts")?

Reading: Ask the patient to read single words, a brief passage, and the
front page of the newspaper aloud and test for comprehension.

Writing: Ask the patient to write their name and write a sentence.
3.Memory

Immediate memory :say a list of 3 objects at 0/3/5 minutes

short-term memory :ask the patient to recall the same three items 5 and
15 min later

long-term memory: Ask the patient about historical or verifiable personal
events.

If immediate recall is intact, then difficulty with recall after about 1 to 5
minutes usually signifies damage to the limbic memory structures
located in the medial temporal lobes and medial diencephalon.
4.Orientation :person, place, time
5. Calculations and right/left orientation, finger agnosia , and agraphia .
6. Apraxia
7. Constructions and neglect
8. Logic and abstractions(preoccupation)
9. Sequencing tasks and frontal release signs
10. Delusions and Hallucinations
11. Mood
I - Olfactory

With eyes closed, ask the patient to sniff a mild stimulus such as
toothpaste or coffee and identify the odorant.

Testing is usually omitted unless there is suspicion for inferior frontal lobe
disease.

II - Optic

Visual Acuity (test with hand card)

Color Vision (loss of color vision especially red is an important symptom
of optic neuritis)

Visual Fields (can be tested at the bedside by counting fingers in each
quadrant)

Visual Extinction (to detect visual neglect)

Funduscopic Examination
II and III –Optic/Oculomotor

The size and shape of the pupil should be recorded at rest. Under normal
conditions, the pupil constricts in response to light.

Note the direct response, meaning constriction of the illuminated pupil,
as well as the consensual response, meaning constriction of the opposite
pupil.

Test the pupillary response to accommodation. Normally, the pupils
constrict while fixating on an object being moved from far away to near
the eyes.
III/IV/VI-Oculomotor/Trochlear/Abducens

Observe the eyes at rest to see if there are any abnormalities such as
spontaneous nystagmus or dysconjugate gaze (eyes not both fixated on
the same point) resulting in diplopia (double vision).

Test smooth pursuit by having the patient follow an object moved across
their full range of horizontal and vertical eye movements.

Test convergence movements by having the patient fixate on an object
as it is moved slowly towards a point right between the patient's eyes.

In comatose or severely lethargic patients, the vestibulo-ocular reflex can
be used to test whether brainstem eye movement pathways are intact.

The oculocephalic reflex, a form of the vestibulo-ocular reflex, is tested
by holding the eyes open and rotating the head from side to side or up
and down.

Pupillary response, eye movements,9 cardinal positions, observe lids for
ptosis.
V – Trigeminal

Three branches : Ophthalmic, maxillary, mandibular.

Facial sensation and muscles of mastication.

Test facial sensation using a cotton wisp and a sharp object. Also test for
tactile extinction using double simultaneous stimulation.

The corneal reflex, which involves both CN 5 and CN 7, is tested by
touching each cornea gently with a cotton wisp and observing any
asymmetries in the blink response.

Feel the masseter muscles during jaw clench. Test for a jaw jerk reflex by
gently tapping on the jaw with the mouth slightly open.
VII – Facial

Muscles of Facial Expression and Taste.

Look for asymmetry in facial shape or in depth of furrows such as the
nasolabial fold. Also look for asymmetries in spontaneous facial
expressions and blinking.

Ask patient to smile, puff out their cheeks, clench their eyes tight,
wrinkle their brow, and so on. Old photographs of the patient can often
aid your recognition of subtle changes.

Check taste with sugar, salt, or lemon juice on cotton swabs applied to
the lateral aspect of each side of the tongue.

Like olfaction, taste is often tested only when specific pathology is
suspected, such as in lesions of the facial nerve, or in lesions of the
gustatory nucleus.
VIII – Acoustic

Mediates Hearing and vestibular function

Test to see can the patient hear fingers rubbed together or words
whispered just outside of the auditory canal and identify which ear hears
the sound?

A tuning fork can be used to perform the Weber and Rinne’s test to
evaluate sensorineural and conductive hearing loss respectively.

Vestibular : Evaluate the dizziness.
Weber's test

the stem of a vibrating tuning fork is placed on the midline of the head
and the patient indicates in which ear the tone is heard louder.

A patient with a unilateral conductive hearing loss hears the tone louder
in the ear with the conductive hearing loss, or reasons that are unclear.

In contrast, a patient with a unilateral sensorineural hearing loss hears
the tone louder in the normal ear because the tuning fork stimulates
both inner ears equally and the patient perceives the stimulus with the
more sensitive, unaffected end organ and nerve.
Rinne's test

It compares hearing by air conduction with that by bone conduction.

The stem of a vibrating tuning fork is placed in contact with the mastoid
process (for bone conduction); then the tines of the still vibrating fork are
held near the pinna (for air conduction), and the patient is asked to
indicate which stimulus is louder.

Normally, the stimulus is heard louder by air conduction (AC) than by
bone conduction (BC), so the relationship is AC > BC.

With a conductive hearing loss, the relationship is reversed; the bone
conduction stimulus is perceived louder than the air conduction stimulus
(BC > AC).

With a sensorineural hearing loss, both air and bone conduction
perceptions are reduced, but the ratio remains the same as that for
normal hearing (AC > BC).
IX/X - Glossopharyngeal/Vagus

Mediate sensory and motor functions of palate ,pharynx, larynx.

Palatal Elevation and Gag Reflex

Does the palate elevate symmetrically when the patient says, "Aah"?

Does the patient gag when the posterior pharynx is brushed?

The gag reflex needs to be tested only in patients with suspected
brainstem pathology, impaired consciousness, or impaired swallowing.

Palate elevation and the gag reflex are impaired in lesions involving CN 9,
CN 10, the neuromuscular junction, or the pharyngeal muscles.
XI - Spinal accessory

Ask the patient to shrug their shoulders, turn their head in both
directions, and raise their head from the bed, flexing forward against the
force of your hands.

Sternocleidomastoid muscle, Trapezius muscle.

XII – Hypoglossal

Note any atrophy or fasciculation (spontaneous quivering movements

caused by firing of muscle motor units) of the tongue while it is resting
on the floor of the mouth.

Ask the patient to stick their tongue straight out and note whether it
curves to one side or the other.

Ask the patient to move their tongue from side to side and push it
forcefully against the inside of each cheek.

Look for any twitches, tremors, abnormal movements or postures.

Look carefully for hypokinesia, decreased eye blinking or staring which
could be indicative or an extrapyramidal disorder such as Parkinson’s
disease.

In suspected lower motor neuron disorders, look for muscle wasting or
fasciculation.

Palpate muscles in cases of suspected myopathy to check for muscle
tenderness.

Passively move each limb to check muscle tone. Ask the patient to relax
before beginning.

Then check individual muscles for strength using the MRC scale to rate
strength.
MRC(Medical Research Council) scale

0 No contraction
1 Flicker or trace contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity and resistance
5 Normal power
Romberg test

With the eyes open, three sensory systems provide input to the
cerebellum to maintain truncal stability. These are vision, proprioception,
and vestibular sense.

If there is a mild lesion in the vestibular or proprioception systems, the

patient is usually able to compensate with the eyes open.

When the patient closes their eyes, however, visual input is removed and
instability can be brought out.

If there is a more severe proprioceptive or vestibular lesion, or if there is

a midline cerebellar lesion causing truncal instability, the patient will be
unable to maintain this position even with their eyes open.
Gait

It involves multiple sensory and motor systems. These include vision,
proprioception, lower motor neurons, upper motor neurons, basal ganglia,
the cerebellum, and higher-order motor planning systems in the
association cortex
Observe:

Stance, how far apart are the feet, posture, stability, how high the feet are
raised off the floor.

Trajectory of leg swing and whether there is circumduction (an arced
trajectory in the medial to lateral direction).

Leg stiffness and degree of knee bending, arm swing, tendency to fall or
swerve in any particular direction, rate and speed.

Difficulty initiating or stopping gait, and any involuntary movements that
are brought out by walking, turns…

The patient's ability to rise from a chair with or without assistance should
also be recorded.
Reflexes are graded according to the following scale

0 : absent reflex
1+ : trace, or seen only with reinforcement
2+ : normal
3+ : brisk
4+ : no sustained clonus (i.e., repetitive vibratory movements)
5+ : sustained clonus
Muscle Stretch Reflexes

Pectoral C5

Jaw Jerk Trigeminal, Facial

Biceps C5,C6

Triceps C6,C7

Brachioradialis C7

Patellar L3,L4

Achilles Tendon S1

Cutaneous Reflexes

Abdominal reflexes T9-T12

Cremasteric L1-L2

Anal S1-S3-S4

Extensor plantar response or Babinski sign

Primitive Reflexes

Grasp, suck, palmomental
Primary sensation

Light Touch

Pinprick

Vibration

Joint Position

Temperature

Two point discrimination

The pattern of sensory loss can provide important information that helps
localize lesions to particular nerves, nerve roots, and regions of the spinal
cord, brainstem, thalamus, or cortex.
Cortical sensation

Graphesthesia, Stereognosis, Double Simultaneous Stimulation

Intact primary sensation with deficits in cortical sensation such as
agraphesthesia or astereognosis suggests a lesion in the contralateral
sensory cortex.

Severe cortical lesions can cause deficits in primary sensation as well.

Extinction with intact primary sensation is a form of hemineglect that is
most commonly associated with lesions of the right parietal lobe.

Extinction can also be seen in right frontal or subcortical lesions, or
sometimes in left hemisphere lesions causing mild right hemineglect.

www.neuroexam.com

Harrison’s Principles of Internal Medicine ,17th Ed

Rudolph’s Paediatrics,21st Ed

The Merck manual of diagn0sis and therapy,18th Ed

Family medicine: Principles and Practice,6th Ed