1. Physiology Lab THE NEUROLOGICAL EXAMINATION
" Three stations will be from this tutorial "

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

3. Tools: A. The reflex hammer. B. The tuning fork.
It is used to illicit deep tendon reflexes throughout the body.
B. The tuning fork.
It is used to test vibration sense throughout the body.
C. The ophthalmoscope.
It is used to examine the interior of the eye.
D. Visual acuity card.
E. Q-tip.
The tip is used to test the corneal reflex.

4. * SEARCH FOR OTHER PICTURES.
D B A E C

5. EXANINATION RULES: 1. Start with upper limb DISTAL  PROXIMAL.
) Ex: joints. “wrist – elbow – radioulnar” ) *no examination for the shoulders because there are lots of muscles.
2. Compare right  left .
)Ex: right wrist  left wrist(
*do not move to the other joint until you compare
3.Lower limb DISTAL  PROXIMAL.
)Ex: joints: ankle – knee – hip(
)Ex: right ankle  left ankle(

6. Physical examination steps:
Inspection or Observation.
Palpation or Touching.
Percussion.
Auscultation.

7. MOTOR examination 1. Inspection or Observation.
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.
2. Palpation or Touching.
Tone and power of muscles in cases of suspected myopathy to check for muscle tenderness.
3. Percussion.
By the hammer. Passively move each limb to check muscle tone. Ask the patient to relax before beginning.
* no auscultation for motor examination.

8. Tremor ( at rest – or with arms outstretched – or intention tremor (.
1- Inspection (MUSCLE OBSERVATION(
Total of inspection 1 minute
Choose big muscle
Atrophy (wasting(
Abnormal movements:
Tremor ( at rest – or with arms outstretched – or intention tremor (.
Chorea ( dance like movement(
Athetosis.
Deformity:
Drop wrist.
Drop foot.
Fasciculation:
Abnormal twitching of the muscle.
*Normally occur after exercising of changing weather.

9. 2) Palpation: (TONE: normal resistance )
Passively move the joint:
A- Upper limb first then lower limb.
B- Start from distal  proximal. Choose single joint
Observe for 20 sec
C- compare.(zigzag movement)
D- You will see :
Normal.
Hypotonia (Flaccid): lower motor neuron lesion ( from anterior horn cell of spinal cord goes to muscles(
Hypertonia (spasticity): upper motor neuron lesion.( cerebral cortex to anterior horn cell of spinal cord )

10. A- Wrist. B- Elbow. C- Radioulnar )by shake hand ( D- shoulder
Upper joints:
A- Wrist.
B- Elbow.
C- Radioulnar
)by shake hand (
D- shoulder

11. Lower joints:
A- ankle.
B- Knee.
C-Hip.

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

13. The first action you do when assess or examine strength (power) is asking the patient to raise his hand or foot
GRIP STRENGTH IS A POOR SCREENING TOOL FOR STRENGTH
Example of OSPE questions : 60 years old patient , you asked him to move his hands then he moves it to left and right without moving his hand against gravity. What is the grade of his power ?
Answer : grade 2

14. 3 - Enhanced (hyper reflexia) The last two grades for later stages
(GRADED 0–5)
0 – Absent.
1 - Present with reinforcement. ( يعني تبين ردة الفعل اذا كان المريض يفكر بشيء ثاني ومو مركز على الاهتزاز اللي يسويه الدكتور )
2 - Normal
3 - Enhanced (hyper reflexia)
The last two grades for later stages
4 – Unsustained clonus
5 - Sustained clonus

15. Biceps (tap on your finger)
Brachioradialis
Root : C5-C6 you should mention 5 - flexion and extension of elbow sometimes called pronation and supination
Triceps - flexion and extension of semi pronation
Root : C6-C7 you should mention 7
Knee
Root : L2-L4
Ankle : S1

19. Achilles deep tendon reflex

20. Upper motor neuron dysfunction (cervical spinal cord)
BABINSKI
HOFMAN’S
JAW JERK
Frontal release signs (lumbosacral spinal cord)
GRASP
SNOUT
SUCK
PALMOMENTAL

21. 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.

24. Gait ( TANDEM ) RAPID ALTERNATING MOVEMENTS
FINGER TO FINGER TO NOSE TESTING
HEEL TO SHIN
Gait ( TANDEM )

25. RAPID ALTERNATING MOVEMENTS

26. FINGER TO FINGER TO NOSE TESTING

27. HEEL TO SHIN

28. Include walking and turning Examples of abnormal gait
High steppage
Waddling
Hemiparetic
Shuffling

29. Tandem gait

30. Romberg is positive if they do worse with eyes closed Measures:
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

31. Romberg sign (Sensory ataxia)
Posterior column disease

34. 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
Posterior column of spinal cord

35. - Superficial: •Light touch (umbilicus T10, nipple T4) •Pinprick
•Temperature
- Deep:
•Vibration
•Joint position

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

37. PIN PRICK

38. TEMPERATURE sensory examination

39. Vibration sensory examination
Put the tuning fork on prominent bony area :
Lower limb : medial malleolus , tuberosity of tibia, superior iliac spine
Upper limb : styloid process

40. Upper limb joint position sense

41. Lower limb joint position sense

42. GRAPHESTHESIA
STEREOGNOSIS
DOUBLE SIMULTANEOUS STIMULATION
BAROSTHESIA
TEXTURES

43. Sterognosis : recognizing objects while eyes closed
Graphesthesia : recognizing letter or number in the hand while eyes closed
Sterognosis : recognizing objects while eyes closed
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

44. graphesthesia

45. Stereognosis