1. THE NEUROLOGICAL EXAMINATION
Prof Mohammad Abduljabbar

2. Tools

3. NEUROLOGICAL EXAM
1- MENTAL STATUS 2- CRANIAL NERVES 3- MOTOR EXAM - Tone - Strength (Power) - Reflexes - Cerebellum ( Gait ) 4- SENSATION

4. MOTOR EXAMINATION

5. Motor Examination

6. Motor Examination
Observe: 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.

7. MUSCLE OBSERVATION ( Inspection )
Atrophy (wasting)
Abnormal movement
Deformity
Fasciculation

8. ABNORMAL MOVEMENTS TREMOR CHOREA ATHETOSIS REST WITH ARMS OUTSTRETCHED
INTENTION
CHOREA
ATHETOSIS

9. TONE Normal. Hypotonia: in lower motor neuron lesion
Hypertonia: in upper motor neuron lesion
- Cogwheel
- Clasp knife

10. Motor Examination
Test for subtle weakness first by checking pronator drift and pronation/supination movements.
Then check individual muscles for strength using the MRC scale to rate strength

11. STRENGTH GRADING( 0-5 ) 0 - NO MOVEMENT 1 - FLICKER
2 - MOVEMENT WITHOUT GRAVITY MOVEMENT AGAINST GRAVITY
4 - MOVEMENT AGAINST RESISTANCE
5 - NORMAL STRENGTH

12. STRENGTH EXAM UPPER AND LOWER EXTREMITIES DISTAL AND PROXIMAL MUSCLES
GRIP STRENGTH IS A POOR SCREENING TOOL FOR STRENGTH

13. REFLEXES

14. MUSCLE STRETCH REFLEXES (DEEP TENDON REFLEXES)
(GRADED 0–5)
0 – Absent.
1 - Present with reinforcement.
2 - Normal
3 - Enhanced
4 – Unsustained clonus
5 - Sustained clonus

15. Deep tendon reflexes
Biceps
Brachioradialis
Triceps
Knee
Ankle

16. OTHER REFLEXES Upper motor neuron dysfunction Frontal release signs
BABINSKI
HOFMAN’S
JAW JERK
Frontal release signs
GRASP
SNOUT
SUCK
PALMOMENTAL

17. Plantar Response
Test the plantar response by scraping an object across the sole of the foot beginning from the heel, moving forward toward the small toe, and then arcing medially toward the big toe. The normal response is downward contraction of the toes. The abnormal response, called Babinski's sign, is characterized by an upgoing big toe and fanning outward of the other toes. The presence of Babinski's sign is always abnormal in adults, but it is often present in infants, up to the age of about 1 year.

19. CEREBELLAR FUNCTION Gait ( TANDEM ) RAPID ALTERNATING MOVEMENTS
FINGER TO FINGER TO NOSE TESTING
HEEL TO SHIN
Gait ( TANDEM )

20. Gait evaluation Include walking and turning Examples of abnormal gait
High steppage
Waddling
Hemiparetic
Shuffling

21. Romberg Sign
Stand with feet together - assure patient stable - have them close eyes
Romberg is positive if they do worse with eyes closed
Measures:
Cerebellar function
Frequently poor balance with eyes open and closed
Proprioception
Frequently do worse with eyes closed
Vestibular system

22. SENSORY EXAMAMINATION

23. Sensory Examination
The sensory exam relies to a large extent on the ability or willingness of the patient to report what he is feeling. It can therefore often be the most difficult and unreliable part of the neurologic exam

24. Primary Sensation - Superficial: •Light touch •Pinprick •Temperature
- Deep:
•Vibration
•Joint position

25. Start distally and move proximally
Sensory Examination
Start distally and move proximally
PIN PRICK
TEMPERATURE
VIBRATION ( 128 HZ TUNING FORK )
JOINT POSITION SENSE

26. HIGHER CORTICAL SENSATIONS
GRAPHESTHESIA
STEREOGNOSIS
DOUBLE SIMULTANEOUS STIMULATION
BAROSTHESIA
TEXTURES

27. Cortical sensation Graphesthesia Sterognosis
Double Simultaneous Stimulation
Intact primary sensation with deficits in cortical sensation such as agraphesthesia or astereognosis suggests a lesion in the contralateral sensory cortex. Note, however, that 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