Susan R. Winkler, Pharm.D. BCPS
Spring 1998

Neurologic Exam

1. Neurologic Terminology
2. Basic Components of the Neurologic Examination
3. History
4. Cerebral Function (Mental Status Exam)
5. Cranial Nerves
6. Motor Function
7. Sensory Function
8. Cerebellar Function
9. Reflex Function
10. Gait and Stance
11. Other Diagnostic Tests

Goals and Objectives:

1. Know and understand the terminology commonly used to describe neurologic signs and symptoms.

2. Recognize symptoms which suggest neurologic dysfunction.

3. Develop a plan for monitoring the neurologic status of patients with headache, epilepsy, Parkinson’s disease and cerebrovascular disease as it relates to drug therapy.

Required Reading:

Dalmady-Israel, C. Introduction to Neurology, in Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM (eds): Pharmacotherapy: A Pathophysiologic Approach. Third Edition. New York, Elsevier, 1997. Chapter 53, pp. 1161-1165.

I. Neurologic Terminology

II. Basic Components of the Neurologic Examination

1. History
2. Cerebral function (mental status)
3. Cranial nerve function
4. Motor function
5. Sensory function
6. Cerebellar function
7. Reflex function
8. Gait and stance

The neurologic exam is intended to test various parts of the nervous system separately; however, some tests may assess several parts of the nervous system. Abnormal findings can suggest which part of the nervous system is injured or impaired.

III. History

A neurologic history is concerned with the patient’s symptoms, their course over time, and other pertinent findings. Obtaining a complete history is very important in the evaluation of neurologic diseases. In many cases, the neurologic diagnosis depends entirely on the history, especially if the patient has had symptoms only transiently.

The following are guidelines for interviewing patients. This includes the types of questions to ask and the findings to note.

1. change in level of consciousness

• awake
• lethargic
• stuporous
• comatose

2. change in mental functioning or mood

• orientation to person, place, time
• confusional state
• depression
• dementia
• aphasia

3. headaches

• location, duration, severity
• association with nausea/vomiting, photophobia
• what aggravates the pain and what helps relieve the pain
• number per month

4. visual changes

• monocular vs binocular
• hemianopsia
• diplopia
• nystagmus

5. hearing and/or tinnitus

6. dizziness/vertigo

• intermittent or constant
• positional
• what aggravates the dizziness and what relieves the dizziness

7. sensation

• complaints of numbness, tingling, burning
• increased or decreased

8. weakness

• paresis vs paralysis
• location
• duration
• precipitating factors

9. pain

• location
• description of pain (sharp, dull)
• continuous vs intermittent

10. gait

• broad-based
• staggering
• off-balance
• festinating-Parkinson’s

IV. Cerebral Function (Mental Status Exam)

Usually tested while obtaining the medical history, while the rest of the neurologic exam is done as the last part of the physical exam. The mental status exam consists of a variety of at least 20 different psychic characteristics including behavior, appearance, emotional state, personality, level of consciousness, attention span, memory and speech. Many neurologic syndromes include problems with memory, therefore it is important to address this issue during the exam. The patient’s educational level and socioeconomic background must also be considered.

General or diffuse functions

orientation, insight, judgement, mood, fund of knowledge, attentiveness

Focal or specific functions

frontal lobes-motivation, inhibition, planning, judgement

dominant parietal lobe-speech and language, calculations, agnosia, alexia, agraphia

nondominant parietal lobe-inattention, denial, extinction, neglect

temporal lobe-memory

Assessment Techniques

1. Level of Consciousness

1. awake-eyes open spontaneously and immediately to minimal stimuli
2. alert-responds quickly and appropriately
3. drowsy-appears sleepy even when awake, responds to minimal stimuli and responses are appropriate
4. lethargic-sleeps on and off, easily aroused with minimal stimuli, but may drift back to sleep when stimuli withdrawn, may be disoriented or slightly confused
5. stuporous-able to arouse with persistent application of more intense stimuli, falls asleep when withdrawn, usually disoriented even when fully aroused
6. comatose-absence of purposeful responses to painful stimuli (pressure to nailbeds, sternal rub), reflex motor activity may be only response observed

2. Mental Status

a. attention span-test the ability to repeat a series of five or six digits backward and forward

b. orientation-ask the patient to state his or her name, the date including the month, year, and time of day, and the name of the health facility or clinic

c. memory-immediate, recent, and remote

• immediate: state 3 objects, ask the patient to repeat them back to you in 5 minutes
• recent: ask the patient world event questions
• remote: ask the patient his or her age, date of birth, questions about their first job, where he or she grew up

d. general knowledge-ask the patient the names of the last 3 presidents, ask about current events

e. mood and behavior-observe the patient for anxiousness, depression

V. Cranial Nerves

Assessment Techniques

(I) Olfactory Nerve-smell, not usually tested

1. patient should close both eyes and occlude one nostril
2. identify the odor of a common object placed under each nostril
3. objects frequently used include coffee, cloves, lemon or soap (avoid ammonia or harsh soaps)

(II) Optic Nerve-visual acuity and visual fields

a. Visual Acuity

1. Snellen eye chart at 14"
2. counting fingers covering one eye at a time

b. Visual Fields

1. patient covers one eye
2. examiner moves fingers of left hand and then right into patient view
3. patient identifies when fingers can be seen
4. repeat with patient covering the opposite eye

(III) Oculomotor, (IV) Trochlear, and (VI) Abducens

• CN III controls pupillary reactions (pupillary light reflex and accommodation), eyelid elevation, eye movements up, down, and medially
• CN IV controls eye movement down and in toward nose
• CN VI controls eye movement laterally toward temporal field
• (CN III, IV, and VI function together to control eye movement)

a. Pupillary reaction (CN III)

1. instruct the patient to fix both eyes on an object
2. shine the beam of a light directly into each pupil
3. note the size, shape, and reaction of the pupils

(may see "PERRLA" in chart notations)

b. Ocular movement (CN III, IV, and VI)

1. instruct the patient to follow your finger without moving head
2. examiner moves finger up, down, left, right
3. note the presence of nystagmus, limited eye movement

(V) Trigeminal Nerve-sensation of face, corneal reflex, muscles of mastication (jaw movement) (has both motor and sensory functions)

a. Motor function testing

1. ask the patient to open mouth as wide as possible
2. observer attempts to close mouth by placing one hand under chin and the other on top of head

(VII) Facial Nerve-controls facial muscles, supplies taste fibers to the anterior 2/3 of tongue, controls eyelid closure (has both motor and sensory functions)

a. Motor function testing

1. have patient wrinkle forehead, smile showing teeth, and wink eyes
2. note any asymmetrical movement or facial drooping

(VIII) Auditory or Acoustic Nerve-controls hearing and sense of balance

1. test using Rinne and Weber tests with tuning fork
2. test gross hearing by holding a watch or rubbing fingers together close to ears

(IX) Glossopharyngeal Nerve and (X) Vagus Nerve-control cough, gag, swallow, articulation, and phonation

• CN IX also controls posterior 1/3 of tongue
• CN X also controls autonomic function
• (have both motor and sensory functions)

1. instruct patient to open mouth and say "ahhh"
2. look for elevation of soft palate and uvula in the midline
3. assess gag reflex by stimulating back of pharynx with tongue depressor
4. note any difficulties in articulation and/or speech

(XI) Spinal Accessory Nerve-controls trapezius and sternocleidomastoid muscles, movement of shoulder and head, shoulder shrugging

a. Trapezius testing

1. patient raises both shoulders while examiner applies resistance

b. Sternocleidomastoid testing

1. patient turns head to left and then to right while examiner applies resistance

(XII) Hypoglossal Nerve-controls tongue movement and strength

a. patient protrudes tongue

b. normally should be midline, note deviation to the right or left

VI. Motor Function

Abnormalities of the motor system are assessed by evaluating the patient’s muscle size, tone, tenderness, strength and involuntary or abnormal muscle movements (chorea, athetosis). Both primary muscle diseases and diseases of nerves innervating muscles can cause weakness and atrophy. Muscle tone can be decreased (flaccid) or increased (spasticity).

Assessment Techniques

When performing the motor exam, look for symmetry between the sides of the body. Also, both the proximal and distal muscles of the upper and lower extremities should be tested. To test muscle strength, the examiner applies maximum force to the extremity while the patient pushes against that force. Muscle strength is graded on a scale of 0 to 5.

5/5 .............full range of motion against gravity with extreme resistance

4/5 .............full range of motion against gravity with some resistance

3/5 .............full range of motion against gravity, but not against added resistance

2/5 .............full range of motion with gravity eliminated

1/5 .............slight contraction visible

0/5 .............no movement

VII. Sensory Function

The primary sensations include pain, touch, vibration, joint position sense (JPS) and thermal. Pain is conveyed by small unmyelinated fibers and is tested with a pinprick (PP). Light touch (LT) is mediated by a combination of small and larger nerve fibers and is tested with a wisp of cotton. Vibration and JPS are mediated by large myelinated fibers. Vibration is tested with a tuning fork.

Assessment Techniques

Sensation is tested by evaluating the patient’s ability to perceive a LT, superficial pain (PP), differences in temperature, vibration, position sense and motion. If any abnormality is found, it is important to identify the area of deficit clearly and find the point where the abnormal sensation becomes normal again. This point is referred to as a sensory level.

a. touch the patient in various areas with cotton (LT) and with the tip of a pin (PP)

b. typically begin with the face and move down the body noting any asymmetry between the right and left sides

VIII. Cerebellar Function

The cerebellum is responsible for balance and coordination. Coordination of movement is a complex process involving both sensory afferent information regarding proprioception and muscle efferent stimuli. The Romberg test evaluates proprioception and cerebellar function. Ataxia can be assessed using the finger-to-nose (FTN) test, while coordination in the lower extremities is assessed using the heel-to-shin (HTS) test.

Assessment Techniques

a. Romberg test

1. ask the patient to stand, feet together with eyes closed and arms at sides

2. (+) Romberg-only positive if loss of balance occurs

b. FTN test

1. ask the patient to alternately point from his or her nose to the examiner’s finger

2. the examiner will typically move his or her finger to different locations

c. HTS test

1. ask the patient to run the heel of one foot along the shin of the opposite leg

2. the patient then does the same procedure on the opposite side

IX. Reflex Function

Evaluation of deep tendon reflexes (DTRs) examines the spinal reflex arc. DTRs are usually tested by tapping on a tendon with fingers or a reflex hammer. This causes a stretching of certain muscles and results in contraction. When damage occurs to higher centers (upper motor neurons), the spinal reflex arc is uninhibited and the DTRs are hyperactive.

When damage occurs to the peripheral nerve or dorsal roots (lower motor neurons), the reflex arc is interrupted and the DTRs are decreased. The rapidity and strength of the reflexes should be symmetrical when comparing one side with the other. The reflexes most often tested are the biceps, brachioradialis (wrist), triceps, patellar (knee), and Achilles (ankle).

The plantar reflexes refer to the reflex motion of the great toe after a noxious stimuli is applied to the bottom of the foot. An upgoing great toe and fanning of the other toes is a positive response. This is called Babinski’s Sign and is suggestive of an upper motor neuron lesion. A normal response is a downgoing toe.

Assessment Techniques

Reflexes are graded on a scale of 0 to 4. A stick figure typically appears in the chart to designate the elicited reflexes.

0 ............Not present

1+ ..........Present but diminished

2+.......... Normal

3+ ..........Hyperactive, may have clonus but not sustained

4+...........Hyperactive with sustained clonus

X. Gait and Stance

The act of walking requires the integration of the peripheral and central nervous systems. Look at the rate, rhythm, and character of the movements. This may aid in the diagnosis of specific neurologic disorders. For example, a shuffling gait is seen in Parkinson’s disease and ataxia is frequently seen in cerebellar disorders.

Assessment Techniques

Stance is tested by asking the patient to stand with his or her feet together, head erect, eyes open, and arms outstretched. When stable, the patient is asked to close his or her eyes and any tendency to sway or fall is noted.

XI. Other Diagnostic Tests

Lumbar puncture (LP) and cerebrospinal fluid (CSF) evaluation are used in the diagnosis of meningitis, subarachnoid hemorrhage, multiple sclerosis, and dementia.

Electroencephalography (EEG) is used to record the electrical activity of the brain and is used in the assessment of seizure disorders.

Computed tomography (CT) scanning allows clinicians a noninvasive view of the brain. The area is scanned in layers or "slices" by narrow x-ray beams that pass through that area. Useful in differentiating cerebral infarction from hemorrhage and to identify tumors and cerebral edema. May be used with intravenous contrast medium to enhance the image in certain situations.

Magnetic resonance imaging (MRI) uses the magnetic properties of the hydrogen atom nucleus and proton to produce computer-processed scans having a high degree of anatomic accuracy. MRI does not use radiation to produce the image, therefore the risks of radiation exposure are eliminated. It is less available and more costly than CT scanning, but has a proven advantage over CT scans in certain situations.

Newer imaging techniques include positron emission tomography (PET) and single photon emission computed tomography (SPECT). These are tests of brain functioning as they assess chemical activity and rates of biologic processes within the brain. They are primarily investigational at this time, but are being studied in epilepsy, cerebral tumors, cerebrovascular disorders, dementia, and movement disorders.

Previous	Next	Syllabus
The College of Pharmacy		UICPHARM@uic.edu
The University of Illinois at Chicago		Last modified: Dec 30, 1997