Liaoning Medical University Affiliated First Hospital NEUROLOGICAL EXAMINATION Liaoning Medical University Affiliated First Hospital He Xin

IMPORTANTCE! ---Despite recent advances in neuroscience and the continuing development of sensitive diagnostic procedures, the essential skill required for the diagnosis remains the clinical neurologic examination ---Most neurologic diagnosis can be made on the basis of the history alone

SIX PARTS OF THE NEURO EXAM 一、Mental State & Cognitive Function 二、Cranial Nerves 三、Motor System 四、Sensory System 五、Reflexes

一、Mental State & Cognitive Function

---Level of consciousness( Mental State) --NORMAL patient awake and alert, attentive to surrounding and to the examiner --DEPRESSED Sleepy Lethargic Stuporous-arousing only briefly in response to pain stimulation Comatose-not arousable by verbal and pain stimulation

---Cognitive function check list A. Orientation to person, place, and time. B. Common knowledge such as “ who is the president” C. Memory: Short term-name three common objects, then recall them again after 5 minutes; Long term-verifiable events from the past

D. Calculations: Serial sevens: count backward from 100, taking away 7 each time. Real-life problem E. Abstract thought: “ How is an apple different from –or the same as – an orange F.Other: Insight and judgment, concentration, verbal fluency, patients mood, content of thought, appropriateness of behavior, and so on

---Language functioning check-up --Broca’s Aphasias expressive aphasias --Wernicke’s Aphasias receptive aphasias --Conductional Aphasias

MMSE

二、CRANIAL NERVES

---Olfactory (I) --Ask the patient to identify common scents such as coffee,vanilla,etc, with eyes closed --Do not use irritants. In testing olfactory nerve function, it is less important to determine whether the patient can correctly identify a particular odor than whether the presence or absence of the stimulus is perceived

---Optic (II) --Visual Acuity-pocket card or wall chart or any reading matter such as news paper --Visual Field Confrontation Testing-Patient and examiner stand at eye level at about arm’s length. Have the patient cover his own eye Threat Testing- applied when the patient is less than fully alert or is uncooperative --Fundus ( Ophthalmoscopic ) Examination

---Pupillary Reflexes (II, III) A normal pupil will constrict --in response to direct light --as a consensual response to light in the opposite eye --to accommodation ( convergence to focus on a close object)

---Control of Extraocular Muscle Movements (III, IV, VI) --Extraocular muscle movements are controlled by the oculomotor (III), trochlear ( IV), and abducens (V) nerves --Volitional Eye Movement-Follow my finger, just with your eyes. Tracing the Letter H --Ask about Diplopia --Nystagmus is rthythmic oscillation of the eyes

--Unilateral ptosis occurs in Horner’s syndrome, with a small pupil; or in a III cranial nerve lesion, with a large pupil and loss of adductive and vertical eye movement

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---Trigeminal Nerve (V) --Facial Sensation --Corneal Reflex-Sweep a wisp of cotton lightly across the lateral surface of the eye ( out of the direct visual field) from sclera to cornea- V, VII --Motor V Testing- Observe the symmetry of opening and closing of the mouth. Ask the patient to clench the teeth and then attempt to force jaw opening --Jaw jerk-brisk indicates UNL

---Facial Strength (VII) --Facial Symmetry-observe the patient’s face for symmetry of the palpebral fissures and nasolabial folds at rest. Ask the patient to wrinkle the forehead, then to squeeze the eyes tightly shut, then to smile or snarl, saying show your teeth Supernuclear lesion Nucleus or peripheral lesion --Bilateral Facial Weakness

---Auditory (VIII) --Auditory acuity can be tested crudely by rubbing thumb and forefinger together about 5cm from each ear. If the patient cannot hear the rub, proceed to the follow tests --Rinne Test-hold the base of tuning folk on the mastoid process until the sound is no longer perceived, then bring the still vibrating fork up close to the ear. Sensorineural loss Conductive loss --Weber Test

for positional nystagmus --Weber Test-lightly strike a tuning fork and place the handle on the midline of the forehead -Conductive loss -Sensorineural loss --Vestibular Function- need to be tested only if there are complaints dizziness or vertigo or evidence of nystagmus -Nylen-Barany( Dix-Hallpike) maneuver test for positional nystagmus

---Glossopharyngeal(IX) & Vagus(X) Test the function of the palate, pharynx, and larynx --Palatal elevation- say “ah” --Gag reflex ( afferent IX, efferent X)- gently touch each side of the posterior pharyngeal wall with a cotton swab --Sensory function-lightly touch each side of the soft palate with the tip of a cotton swab --Voice quality-listen for hoarseness or “breathiness”, suggesting laryngeal weakness

---Accessory (XI) --Sternocleidomastoid- press a hand against the patient’s jaw and have the patient rotate the head against resistance. Pressing against the right jaw tests the left sternocleidomastoid and vice versa --Trapezius-have the patient shrug shoulders against resistance and assess weakness

---Hypoglossal (XII) Tests for hypoglossal nerve function include the following --Atrophy or Fasciculations-with the patient’s tongue resting in the floor of the mouth, first inspect for atrophy or fasciculations. Then ask the patient to protrude the tongue, and observe for deviation to the weak side --Subtle Weakness-have the patient push the tongue into each cheek against external resistance (opposite hypoglossal m.) --Subtle Dysarthria- Ask the patient to repeat difficult phrases

三、 MOTOR SYSTEM

---Muscle Tone ---Muscle Bulk Decreased( floppy, flaccid, hypotonic) Normal Increased( Spastic vs. Rigid) ---Muscle Bulk Atrophy ( or with fasciculation)

---Muscle Strength -The classic grading system scores as follows 5--full strength 4--movement against gravity and & resistance 3--movement against gravity only 2--movement horizontally along the surface of the bed 1--palpable contraction but little visible movement 0--no contraction 38

---Motor Coordination & Gait Cerebellar hemisphere are responsible for coordinating and fine-tuning movements (ipsilateral ) 1.Finger-to-Nose 2.Rapid Alternating Movements 3.Rebound 4.Heel-Knee-Shin 5.Romberg’s test is a quick and excellent screen for loss of proprioceptive feedback neuropathy or spinal cord disease 39

四、Sensory System

---Large-fiber & Dorsal Column Function Vibration Sense Joint Position Sense Romberg’s Test ---Small-fiber & Spinothalamic Function Temperature Sensation Superficial Pain Sensation Light Touch Sensation ---In the lesion of the somatosensory cortex joint position perception is loss but vibration sensation is not

五、REFLEXES

---Deep Tendon Reflexes Bicep Reflex(C5-6) Tricep Reflex ( C7-8) Quadiceps ( Patellar, Knee Jerk) Reflex ( L3-4) Achilles ( Ankle Jerk) Reflex (S1-2) ---Pathologic Reflexes Babinski Sign ---Frontal Release Sign Grasp Sign Suck Sign Snout Sign Glabellar Sign

---Brisk tendon reflexes signify upper motor lesions, absence reflexes occur in peripheral nerve or nerve root lesions ---An extensor plantar or Babinski response is a definite immediate sign of an upper motor neuron lesion, presents well before clonus or hyperreflexia ---Ankle clonus, when sustained or unsustained but of more than six beats duration, provides definite evidence for an upper motor neuron lesion

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