A Comprehensive Neurological Examination

Guide and Approach to Localization

Edition 1

Dr. Jasmyn De Leon

Copyright ©2020 by Dr. Jasmyn Angon-De Leon

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any electronic or mechanical
means, including photocopying, recording, or by any information storage and retrieval system, without permission in writing
from the copyright owner.

2
 CONTENTS
Page

Introduction 5

History Taking 7

Physical Examination 11

Neurological Examination 12
I. Cerebrum 13
Mini-Mental State Examination 16

II. Cranial nerves 17

III. Upper limbs 32

a) General Inspection
b) Tone
c) Reflex and pathological reflex
d) Motor
e) Cerebellum
f) Sensory

IV. Lower limbs 37

a) General Inspection
b) Tone
c) Reflex and pathological reflex
d) Motor
e) Cerebellum
f) Sensory

V. Gait 41

VI. Meninges 43

VI. Pathological Reflexes 43

Approach to Localization 45

3
4
 INTRODUCTION

“The Art of Medicine was to be properly learned only from its practice and its exercise”,
according to Thomas Sydenham, founder of Clinical Medicine and Epidemiology. It was
proven from previous research that physicians make a diagnosis from the patient’s history in
70 – 90% of cases. The series of directed examination and investigations were heavily based
on the chief complaint or presenting symptoms.

At this time of advanced technology, several studies showed a decline in history taking and
physical examination skills among physicians and other medical practitioners. It was
postulated that improvement of medical technology increased the reliance of doctors to
laboratory and imaging investigations.

The author aims to encourage not only medical students, junior doctors but also the nurses
and allied health professionals to continue to develop their precise history taking skills and
upgrade their physical examination skills especially emphasizing on neurological examination
skills. The second part of the book is a simple approach on neurological localization. It
highlights the importance of understanding neuroanatomy in a clinical context.

There was a quote by Vince Lombardi saying " Practice does not make perfect. Perfect practice
makes perfect." We are challenged to improve our skills everyday for the benefit of our
patients.

5
6
HISTORY TAKING
GENERAL DATA
• Patient’s name
• Address
• Contact person

DEMOGRAPHICS:
• Age
• Gender
• Civil Status
• Handedness - helps to identify the dominant hemisphere of the patient
• Occupation – helps to identify occupation related hazards/ injury / exposure
• Stays with whom – to understand the family dynamics

CHIEF COMPLAINT IN NEUROLOGY

Example:
1. symptoms of increased intracranial pressure - headache, altered level of sensorium,
vomiting

2. focal neurologic deficit - hemiparesis, numbness, slurring of speech, visual disturbance

(blurred vision/ double vision)

3. seizures

4. symptoms of meningeal irritation - neck stiffness, photophobia

Others:
• Giddiness
• Paresthesias
• Memory disturbance

7
HISTORY OF PRESENT ILLNESS

Organize the history taking based on the presenting symptom and build up the temporal
profile

• Symptom onset (e.g. acute, subacute, chronic, insidious)

• Duration
• Course of the condition (e.g. static, progressive, or relapsing and remitting)
• Associated symptoms such as pain, headache, nausea, vomiting, weakness and
seizures

Develop the story from onset of symptoms until the current admission or consult

The history of present illness may help an individual to consider the following etiology in
Neurology:

Acute onset: vascular, trauma

Subacute onset: inflammatory, autoimmune, metabolic/ toxic, infectious

Chronic progression: infectious, neoplastic, paraneoplastic, neurodegenerative

8
REVIEW OF SYSTEMS
• Constitutional symptoms: Loss of appetite, weight loss
• Head: no head injury
• Ears: no deafness, no tinnitus
• Nose & Sinuses: no colds, no epistaxis
• Mouth & Throat: no gum bleeding, no sore throat
• Neck: no mass
• Respiratory: no cough, no wheezing, no dyspnea, no hemoptysis
• Cardiac: no chest pain, no easy fatigability, no orthopnea, no PND, no palpitations
• Gastrointestinal: no nausea, no vomiting, no dysphagia, indigestion, bowel movement
no hematemesis, hematochezia, melena, no abdominal pain, no diarrhea,
constipation, no jaundice
• Urinary: no dysuria, frequency, urgency, hesitancy, no hematuria, no urethral
discharge, no nocturia, no history of passage of sandy urine, no flank pain, no passage
of bubbly urine
• Genital: No active lesions, no abnormal bleeding
• Musculoskeletal: no back pain, no joint stiffness, no limitation of motion on both
extremities
• Peripheral Vascular: no varicosities, no history of phlebitis, or leg pain
• Hematologic: No easy bruisability, no pallor
• Endocrine: no heat-cold intolerance, no thyroid problems, no polyuria, polydipsia,
polyphagia, no nocturia (x/night)

PAST MEDICAL HISTORY

• Hypertension (Known HPN for # of years, medications, control)
Highest BP, Usual BP
• Diabetes mellitus (known diabetic for # of years, medications, control)
• Cardiovascular Disease
• Asthma, PTB
• Others: Thyroid Dysfunction, Malaria, Typhoid, Pneumonia, Bronchitis, Emphysema,
PUD, Kidney Disease, Allergies, adverse drug reaction, surgical operations,
transfusions, injuries

FAMILY HISTORY
• Hypertension
• Diabetes Mellitus
• Heredo - familial disease
• Stroke

PERSONAL AND SOCIAL HISTORY

• Diet: prefers salty or fatty foods
• Smoking: #of sticks/20 x years smoking
• Alcohol: bottle/day what kind
• Substance Use/Abuse:
• Hobbies:

9
ENVIRONMENTAL EXPOSURE
• Living condition
• Workplace/Occupation
• Disease Prevention Measures
• Raising livestock/pigeons/fighting cocks
• Recent travel to endemic areas

IMMUNIZATIONS

OB – GYNE HISTORY
• Menarche regularity/frequency
• Duration pads consumed
• menopause
OB HISTORY
• Gravida-Para (FPAL)
• Last menstrual period:
• Oral contraceptive pill (OCP) Use

10
PHYSICAL EXAMINATION
• General Inspection: Conscious, coherent, ambulatory, not in respiratory distress,
oriented to time, place, person
Weight (kg): Height (cm): BMI:
Vital signs: BP (mmHg) PR: 60-100 bpm regular RR: 14-20/min regular
Temperature:
• Skin: Warm, moist skin, no active skin lesions
• Head and Neck: Palpate head, temporal arteries for tenderness
• Pink palpebral conjunctivae, anicteric sclera,
• No nasal discharge, mucosa pink, not congested,
• Dry/moist lips/buccal mucosa, mucosa pink, teeth in good repair
• posterior pharynx non-hyperemic, tonsils not enlarged, no gum bleeding
• Supple neck, neck veins not distended, Auscultate Carotid, vertebral, mastoid,
temporal and oculars for bruits
No palpable cervical lymph nodes, thyroid not enlarged
• Lungs: Inspection: Symmetrical chest expansion, no retractions
Palpation (tactile & vocal fremitus)
Auscultation: adventitious breath sounds – crackles, wheezes
• Heart: Inspection: Point of maximal impulse (PMI) 5th Intercostal space (ICS),
midclavicular (MCL)
Palpation: Adynamic precordium, heaves, thrills
Auscultation: rate, rhythm, murmurs
Mitral – 5th ICS, Left, MCL
Tricuspid – 5th ICS, Right, parasternal
Aortic – 2nd ICS, Right parasternal
Pulmonic - 2nd ICS Left parasternal
• Abdomen: Inspection: Flat, globular
Auscultation: use the bell for normoactive bowel sounds at left lower quadrant
Palpation: organomegaly; direct or indirect pain
Percussion: ascites
• Extremities: Inspection: no edema, cyanosis, pallor
• Pulses: Full and equal in radial, brachial, femoral, popliteal, dorsalis pedis
• Rectal Exam: no fissures, no skin tag, tight sphincter tone, no pararectal tenderness,
no palpable mass, smooth mucosa, brown stool on examining finger, no saddle
anaesthesia

11
NEUROLOGIC EXAMINATION

12
I. CEREBRUM
• Patient’s ability to relate history is already a gauge of his current mental status:
a.) Orientation
b.) Fluency of speech
c.) Ability to recognize objects
d.) Recall

ASSESS LEVEL OF CONSIOUSNESS: (Alert) (Drowsy) (Stupor) (Coma)

The Glasgow Coma Scale provides a practical method for assessment of impairment of
conscious level in response to defined stimuli.

Glasgow Coma Scale: ( E4 V5 M6 )

4
Spontaneous
3
To speech
2
To pain
Eye Opening
1
None
5
Oriented
4
Confused
3
Verbal Response Words
2
Sounds
1
None
6
Obeys
5
Localizes
4
Withdraws
Motor Response
3
Decorticate
2
Decerebrate
None 1

13
 ASSESS FOR HIGHER CORTICAL FUNCTION
Higher function include speech, and mental status

SPEECH
a.) Dysphonia or aphonia
- Impairment or inability to phonate
- Hoarse to mute
b.) Dysarthria or anarthria
- Inability to articulate spoken words
- Oration is impaired but content is intact
c.) Dysphasia or aphasia
- impaired ability to process language

Type of aphasia Naming Fluency Comprehension Repetition Localization

Broca X Non Fluent ✓ x Posterior inferior frontal lobe

Area,(suprasylvian)
Area 44, 45

Wernicke X Fluent x x Posterior superior temporal lobe

(Temporal, infrasylvian including
angular & supramarginal gyrus or
insula)
Area 22 plus 39, 40

Global X Non Fluent x x Posterior inferior frontal lobe and

posterior superior temporal lobe
Areas, 44,45, 22

Transcortical X Non Fluent ✓ ✓ (a)Frotal lobe watershed between

motor MCA and ACA terriotries

White matter lesions in (a)

Transcortical X Fluent x ✓ Subcortical temporoparietal

sensory
Temporoparietal watershed between
MCA and PCA territories

Conduction X Fluent ✓ x Arcuate fasciculus

(arcuate fasciculus, supramarginal
gyrus or insula)
Area 40,41,42

Nominal X Fluent ✓ ✓ Numerous possible locations

14
Abulia: diminished will power
Acalculia: difficulty with calculations
Agnosia: "ignorance or altered knowledge”; lack of sensory ability to recognize objects
• Auditory agnosia: central auditory imperception of sound with intact cochlea and
peripheral nerve
• Finger agnosia: no recognition of digit
• Ideational agnosia: failure to conceptualize (use everyday objects correctly)
• Optic agnosia: failure to recognize visual images
• Positional agnosia: failure to recognize the posture of extremities
• Tactile agnosia: failure to recognize objects by touch

Apraxia: disorder of voluntary movement with difficulty executing purposeful movements,

with preservation of strength, sensibility and coordination

• Ideational apraxia: misuse of objects due to disturbance of identification

• Ideokinetic (Ideomotor) apraxia: disconnection between limb center and ideational center;
Simple movements are retained, and complicated movements fail

• Limb-kinetic apraxia: motor issues

Anosognosia: denial of disease or paralysis

Astereognosis: poor judgement of objects by touch

Gerstmann’s Syndrome
Characterized by:
a.) Agraphia
b.) Acalculia
c.) Right-left disorientation
d.) Finger agnosia

• Any one of these deficits in isolation could be caused by lesions in a number of

locations, but in combination, they are very localizing to the dominant (usually left) inferior
parietal lobe in the region of the angular gyrus
• Often associated with contralateral visual field cut, alexia, anomia, or more severe
aphasia

15
MINI MENTAL STATE EXAMINATION

Years of Education Language

MMSE Items Maximum Score Patient Score

ORIENTATION
What is the Year? Season/ festival? Date? Day? Month? 5

Where are we: Country? Part of the country? Town? Hospital? Level? 5
REGISTRATION:
Name 3 objects: 1 second to say each then ask patient all 3 after you mention them. 1 3
point for each correct answer (pen, red, cat)
Trials:
ATTENTION AND CALCULATION:
Serial 7’s (Subtract 7 serially from 100). 5
1 point for each correct answer.
Stop after 5 answers. (100, 93, 86, 79, 72)
Alternatively, spell “WORLD” backwards
RECALL:
Ask for the 3 objects repeated above. Give 1 point for each correct answer. 3
(pen, red, cat)
LANGUAGE
Name 2 items Pen, watch 2

Repeat the following: “NO IFS, AND OR BUTS” 1

Follow 3 step commands: 3

“Take a paper in your hand, fold it in half, and put on table”

Read and obey the following: CLOSE YOUR EYES 1

Write a SENTENCE 1

1
Copy the DESIGN shown:

Total Score 30

Date

Interpretation of MMSE
Method Score Interpretation
Single cut off <24 Abnormal
Range <21 Increased odds of dementia
>25 Decreased odds of dementia

Education 21 Abnormal for 8th grade education

<23 Abnormal for high school education
>24 Abnormal for college education
Severity 24-30 No cognitive impairment
18-23 Mild cognitive impairment
0-17 Severe cognitive impairment

16
II. CRANIAL NERVES
It is not necessary to examine the cranial nerves in order. Here is a simple systematic approach
to perform a complete cranial nerves examination.

Inspection: Use the acronym

S Scar (back of the ear for any acoustic neuroma surgery scar or parotid surgery scar)/
Squint
Speech
W Wasting of facial muscles
I Involuntary movements (dyskinesia)
F Fasciculation
Facial asymmetry
T Twitches
Tracheostomy and aids (glasses, hearing aids)

Eyes: AFRO-C (II, III, IV, VI)

Corneal reflex

Face: Sensation (V)

Facial expression / muscles (VII)
Jaw muscles

Ears: Hearing
Weber / Rinne test

Tongue and Throat (IX, X, XII)

Tongue movement
Gag
Taste
Cough
Voice

Shoulder and neck (XI)

Power

17
 Cranial Nerves (CN) CNS Nucleus Function Foramen where the CN
exits
I Olfactory Olfactory bulb Smell Cribriform plate of
ethmoid bone
II Optic Retina Vision Superior orbital fissure
Lateral geniculate nucleus

III Oculomotor Oculomotor nucleus Levator palpebral muscle Superior orbital fissure
(Somatic nucleus) EOMs (Superior rectus, Inferior rectus,
Medial rectus, inferior oblique) except
Superior oblique (SO) and Lateral rectus (LR)

Edinger Westphal Nucleus Pupillary constriction

(Parasympathetic Nucleus)

IV Trochlear Trochlear nucleus Superior oblique muscle Superior orbital fissure

V Trigeminal

V1 Ophthalmic division Spinal and main sensory nucleus Sensory from face, dura, tympani Superior orbital fissure

V2 Maxillary division Mesencephalic nucleus Mechanoreceptors of face and mouth Foramen rotundum

V3 Mandibular division Trigeminal motor nucleus Muscles of mastication, tensor tympani Foramen ovale

VI Abducens Abducens nucleus Lateral rectus muscle Superior orbital fissure

VII Facial Facial motor nucleus Muscles of facial expression and stapedius Stylomastoid foramen

Spinal trigeminal nucleus Ear and tympanic membrane sensation

Solitary nucleus Taste from Anterior 2/3 of tongue

Superior salivatory nucleus Salivation and lacrimation

VIII Vestibulocochlear Cochlear nucleus Hearing Internal acoustic meatus

Vestibular nucleus Balance

IX Glossopharyngeal Nucleus ambiguous Pharyngeal muscles Jugular foramen

Spinal trigeminal nucleus Sensation of ear posterior 1/3 of tongue

Solitary nucleus Taste from posterior 1/3 of tongue

Solitary and spinal trigeminal Carotid, oropharynx sensation

Inferior salivatory nucleus Parotid gland secretion

X Vagus Nucleus ambiguous Larynx/pharyngeal muscles Jugular foramen

Spinal trigeminal nucleus Sensory from external ear

Solitary nucleus Taste buds of epiglottis

Solitary and spinal trigeminal Larynx/pharynx sensation; Parasympathetic

nervous system from chest and abdomen

Dorsal motor nucleus Parasympathetic nervous system to chest and

abdomen

XI Spinal accessory Nucleus ambiguous Larynx and pharyngeal muscles Jugular foramen

Accessory nucleus Sternocleidomastoid and trapezius

XII Hypoglossal Hypoglossal nucleus Intrinsic muscles Hypoglossal canal

18
CRANIAL NERVE I – unmyelinated special visceral afferent (SVA)
• use cigarette and coffee to one nostril at a time (use aromatic non-irritant material)

CRANIAL NERVE II – special somatic afferent (SSA)

Use AFRO-C
An Acuity
Test for visual acuity
Jaeger type card or Snellen Chart:
Counting fingers → Hand wave → Light perception

F Field
Test for Visual fields
a. Confrontation test – wiggle or ask how many fingers
i. 1 eye at a time
ii. Midline to left or midline to right
iii. if patient is Stuporous, may use visual threat

19
Visual pathway

R Reflex
Test for Pupillary reflex
• Comments on whether the pupils are the same size, look for Horner’s
syndrome
• Direct and Consensual
• Accommodation (pupils constrict on convergence)
• Considers testing for relative afferent pupillary defect (RAPD): damage to optic
nerve on one side results in a delay in constriction when swinging a light
between the eyes. Pupils appear to dilate when the light is swung to the eye
with the damaged optic nerve

20
Pupillary Size

Large pupil Small Pupil

Cranial Nerve III palsy Horner’s Syndrome
Holmie – Adie syndrome (young women, Argyll Robertson pupil (neurosyphilis,
absent ankle and knee reflexes) accommodates on convergence but does
not react to light)

Traumatic (may be irregular) Age-related miosis

Drugs (dilating eye drops-tropicamide, Drugs (opiates)

atropine) illicit drugs (cocaine, ecstasy)
Anisocoria (difference in pupil sizes)

O Ophthalmoscopy
Examine the Optic fundus
Fundoscopy: (+) ROR, Clear media, Distinct disc borders, (-) haemorrhages,
(-) papilledema

C Color vision
Use Ishihara chart

21
Pupillary Light reflex

Pupillary light reflex: Pupillary constriction to light

AFFERENT LIMB: optic nerve
EFFERENT LIMB: oculomotor nerve (parasympathetic)

Accommodation
- stimulating smooth muscle of ciliary body in the eye to contract
- Parasympathetic

22
CRANIAL NERVE III, IV, VI
• Look for: Ptosis, lid lag, proptosis, enophthalmos
• Doll’s eye if not awake
• test eye muscles individually to all quadrants: voluntarily or with finger
• convergence

a.) Oculomotor nerve- general somatic efferent (GSE) and general visceral efferent (GVE)
• pupillary sphincter muscle (constricts eye)
• Levator palpebra (opens eye)
• EOMs except SO, LR

GSE: EOM
Levator palpebral conjunctiva
GVE: preganglionic parasympathetic
Cell bodies at Edinger Westphal nucleus → ciliary ganglion → postganglionic fibers
→ Short ciliary nerves
= sphincter pupillae (MIOSIS) and ciliary muscles (ACCOMMODATION)

b.) Trochlear nerve- GSE to superior oblique muscle (SO4)

- Smallest cranial nerve
- The only cranial nerve that exits from the
Dorsal aspect of the brainstem and crosses midline

c.) Abducens nerve- GSE to lateral rectus (LR6)

- pierces the dura or dorsum sellae of sphenoid bone
- passes thru the cavernous sinus

Extraocular movements and their innervation: SO4, LR6 and the rest is 3

23
CRANIAL V
• Sensory – corneal reflex bilateral
o Light touch – cotton
o pain – pinprick sensation
o Temp –tuning fork and 5th digit (hot or cold)
Distribution: root pattern/ brainstem “onion skin” pattern
✓ Greater auricular nerve (C2, C3)
✓ Anterior Cutaneous nerve of neck (C2, C3)
✓ Great occipital nerve (C2)
✓ Lesser occipital nerve (C2, C3, C4, C5)
• Motor – ‘hollowing out’ the temporalis muscle
Check temporalis, masseter and pterygoid muscles

Note:
Trigeminal nerve – nerve of first branchial arch
SVE:
1.) Muscles of mastication – medial and lateral pterygoids, temporalis, masseter
2.) Mylohyoid
3.) Anterior belly of digastric
4.) Tensor tympani
5.) Tensor veli palatini
GSA: face, scalp, auricle, external auditory meatus, nose, paranasal sinuses, mouth
(Except posterior 1/3 of tongue), parts of nasopharynx, auditory tube, cranial dura mater
Divisions:
• Ophthalmic division(V1)
• Maxillary division(V2)
• Mandibular division(V3)

24
1. Ophthalmic
-lateral wall of cavernous sinus
-sensory inner: eyeball, tip of nose, skin of face above the eye

Corneal reflex: most sensitive indicator of trigeminal damage

AFFERENT LIMB: V 1 via nasociliary branch (light touch-main sensory nucleus)
EFFERENT LIMB: facial nerve

2. Maxillary
-lateral wall of cavernous sinus
-midface (below eye but above upper lip), palate, paranasal sinuses, maxillary teeth

Sneeze reflex:
AFFERENT LIMB: irritation of nasal mucosa via V 2
EFFERENT LIMB: vagus nerve

3. Mandibular
SVE: tensor veli, palatine, tensor tympani, muscles of mastication, anterior belly of digastric,
mylohyoid
GSA: lower part of face (below lower lip), scalp, jaw, mandibular teeth, anterior 2/3 of the
tongue

Jaw jerk reflex:

AFFERENT LIMB: V 3
EFFERENT LIMB: V 3

25
CRANIAL VII
• Motor – raise eyebrows, smile, whistle, candy on the R/L cheek
o Eye closure
o Asymmetrical elevation of one corner of mouth
o Flattening of nasolabial fold
o Check- frontalis, orbicularis oculi, buccinator, orbicularis oris

• Sensory – taste ant2/3 using sugar and salt

Note:
Facial nerve (VII) – derived from the second branchial arch
SVE: larger root- facial muscles of expression
SVA: smaller root – nervus intermedius – taste fibers from anterior 2/3 of tongue
GVE: preganglionic parasympathetic – lacrimal, submandibular, sublingual, nasal, palatine
glands
GSA: external acoustic meatus, auricle
Sensory ganglion: geniculate ganglion

26
CRANIAL NERVE VIII
• gross hearing using index and thumb
• Otoscopy: No aural discharge (+) cone of light, tympanic membrane intact
• Weber’s and Rinne test

AC – air conduction
BC – bone conduction

Note:
Vestibulocochlear/Auditory nerve (VIII)
SSA: organ of Corti, ampullae of semicircular ducts, utricle, saccule

27
CRANIAL NERVE IX, X
• Say aaaahhhh: check for palatal / tonsillar pillar
• Gag reflex

Note:
Glossopharyngeal nerve (IX) - derived from the third branchial arch
SVE, SVA (taste), GVE, GVA, GSA

Branches:
1. Tympanic nerve
Tympanic plexus on the medial wall of middle ear with sympathetic fibers from internal
carotid plexus (caroticotympanic nerves) + branch from geniculate ganglia of CN VII

GVA: tympanic cavity, mastoid antrum, air cells, auditory tube

Lesser petrosal nerve – preganglionic parasympathetic → otic ganglion

28
2.Communicating branch – joins auricular branch of vagus nerve GSA fibers
3. Pharyngeal branch
GVA: pharynx
Pharyngeal plexus on the middle constrictor muscle: pharyngeal branch of vagus (SVE) +
branches from sympathetic trunk

Gag reflex:
AFFERENT LIMB: glossopharyngeal nerve
EFFERENT LIMB: vagus nerve

4. Carotid sinus branch

GVA: carotid sinus and body
5. Motor branch
SVE: stylopharyngeus
6. Lingual branch
GVA
SVA (taste): posterior 1/3 of tongue and vallate papillae
7. Tonsillar branch
GVA: palatine tonsil and soft palate

Vagus(X) – derived from 4th and 6th branchial arches

SVE: muscles of larynx, pharynx (ext. stylopharyngeus), palate (except tensor veli palatini)
GVE: SM and cardiac muscles, glands
GVA: AFFERENT: mucous membrane, lower pharynx, larynx, trachea, bronchus, and
oesophagus, thoracic, abdominal visceral organs (except descending colon, sigmoid, rectum,
and pelvic organ)

Cough reflex:
AFFERENT LIMB: vagus nerve
EFFERENT LIMB: vagus nerve

Gag reflex:
AFFERENT LIMB: glossopharyngeal nerve
EFFERENT LIMB: vagus nerve

29
Branches:
1. Meningeal branch
> From superior ganglion
> Dura mater of posterior cranial fossa

2. Auricular branch
GSA: external acoustic meatus
> joined by a branch from VII and IX

3. Pharyngeal branch
SVE: all muscles of pharynx except stylopharyngeus (pharyngeal plexus);
All muscles of palate except tensor veli palatine
GVA: nerve to carotid body

4. Superior, middle, inferior cardiac

> Cardiac plexus

5. Superior laryngeal nerve

a. Internal laryngeal nerve
GVA: larynx above vocal cord, lower pharynx, epiglottis
SVA: taste buds or the root of tongue near and on the epiglottis
B. external laryngeal nerve
SVE: cricothyroid and inferior pharyngeal constrictor muscles

6. Recurrent laryngeal nerve

> Hooks around subclavian, right arch of aorta lateral to ligamentum arteriosum, left
> ascend bet. Trachea and oesophagus
GVA: larynx below vocal cord
SVE: all muscles of larynx except cricothyroid
Becomes inferior laryngeal nerve at lower border of cricoid cartilage

30
CRANIAL NERVE XI
• Sternomastoid (turn head right or left against resistance)
• Trapezius (shrug shoulders against resistance)
Note:
Accessory nerve (XI)
SVE: SCM and trapezius

CRANIAL NERVE XII

• tongue protrusion

Note:
Hypoglossal nerve (XII)
> Loops around occipital artery
> Between external carotid artery and internal jugular vein
> Deep to digastric post. Belly and stylohyoid
> Above hyoid bone on lateral surface of hyoglossus deep to mylohyoid
GSE: intrinsic and extrinsic muscle of tongue except palatoglossus
GSA: from C1 – dura
GSE: from C1 – thyrohyoid and geniohyoid

31
III. EXAMINATION OF UPPER LIMBS
• General Inspection
• Tone
• Reflex and pathological reflex
• Motor (Manual Muscle Testing)
• Cerebellum / Coordination
• Sensory

General Inspection

❑ Scars
❑ Wasting of muscles (atrophy vs hypertrophy)
❑ Involuntary movements
❑ Fasciculations
❑ Tremor

✓ Check for pronator drift (UMN Pyramidal pathology)

TONE
✓ Cogwheeling and rigidity (Parkinson’s disease)
✓ Increased tone (UMN lesion e.g. stroke)

REFLEXES
✓ Biceps reflex (C5/C6)
✓ Triceps reflex (C6/C7)
✓ Brachioradialis reflex (C5/C6)
✓ Finger jerk

32
UPPER EXTREMITY
ACTION MUSCLES NERVES NERVE ROOTS
Arm Abduction at Deltoid Axillary nerve C5, C6
shoulder
Elbow flexion Biceps Musculocutaneous C5, C6
(with forearm Brachioradialis
supinated)
Elbow extension Triceps Radial C6, C7
C8
Wrist extension and Extensor carpi radialis Radial C5, C6
hand abduction
Wrist flexion and hand Flexor carpi ulnaris Ulnar nerve C7, C8
adduction T1
Wrist flexion and hand Flexor carpi radialis Median nerve C6, C7
abduction
Flexion at distal Flexor digitorum Ulnar nerve C7, C8
interphalangeal joints profundus to digit 4,5
digit 4,5
Flexion at distal Flexor digitorum Median nerve C7, C8
interphalangeal joints profundus to digit 2,3
digit 2,3
Finger abduction Dorsal interossei Ulnar nerve C8, T1
Abductor digiti minimi
Finger and thumb Adductor pollicis Ulnar nerve C8, T1
adduction in plane of Palmar interossei
palm
Finger extension Extensor digitorum Radial nerve C7, C8
Extensor indicis (Posterior interosseus
Extensor digiti minimi nerve)
Thumb abduction in Abductor pollicis longus Radial nerve C7, C8
plane of palm (Posterior interosseus
nerve)
Thumb abduction Abductor pollicis brevis Median nerve C8, T1
perpendicular to plane
of palm
Thumb opposition Opponens pollicis Median nerve C8, T1

33
Brachial plexus

COORDINATION
Finger to nose test
Observe for Intention tremor and Past pointing (cerebellar disease)

Dysmetria is a condition in which there is improper measuring of distance in muscular acts

Hypermetria is overreaching (overstepping)
Hypometria is underreaching (understepping)

Rapid alternating movement test

Dysdiadochokinesia is impairment of the ability to perform rapidly alternating movements.

• Successive pronation or supination of the hands

• Rapid tapping of fingers
• Rapid opening and closing of fist

34
SENSATION
• Pain – pinprick (dull or sharp)
- Alternate touching the patient with 2 ends randomly
- 3 pricks for each stimulus with same pressure
• Temperature – finger and tuning fork (forehead is the most sensitive area)
• Light touch – cotton (hairy skin perceives tickling and touch better)
- Test over the rest of the body: dorsum of hand and face
• Quantitative tests of touch and pressure done with graded monofilament or hair of
different strength
• Vibration – 128 tuning fork, toenail and fingernails then distal to proximal bony
prominence
- Ulnar, styloid, distal radius, internal malleolus
• Position – 4th digit: wiggle then up, down or straight/middle
• 2-point discriminative sensation
2-4mm fingertips
4-8mm dorsum of finger
8-12mm palm
20-30mm dorsum of hand

1.) Light touch (cotton wool) provide an example of sensation at a central point (e.g. sternal
angle/ forehead)

2.) Pinprick sensation (using a neurotip)

Assessment each of the dermatomes (comparing right with left)
• C5
• C6
• C7
• C8
• T1

35
Vibration sensation (128 Hz tuning fork)
-place tuning fork on a distal bony prominence (e.g. DIP joint)
If patient is unable to sense vibration, assess at a more proximal bony point

Proprioception (joint position sense)

Hold distal phalanx by its sides (otherwise pressure on the nail bed may provide clues as to
the direction of movement)

36
IV. EXAMINATION OF LOWER LIMBS
• General Inspection
• Tone
• Reflex and pathological reflex
• Motor
• Cerebellum
• Sensory

General Inspection

❑ Scars
❑ Wasting of muscles (atrophy vs hypertrophy)
❑ Involuntary movements
❑ Fasciculations
❑ Tremor

TONE
Cogwheeling and rigidity (Parkinson’s disease)
Increased tone (UMN lesion e.g. stroke)
look for ankle clonus

REFLEXES
✓ Knee jerk - patellar tendon (L2 L3 L4)
✓ Ankle jerk - Achilles tendon (S1)
✓ Plantar reflex (S1)

37
LOWER EXTREMITY
ACTION MUSCLES NERVES NERVE ROOTS
Hip flexion Iliopsoas Femoral nerve L1, L2
L1-L3 nerve roots L3, L4

Knee extension Quadriceps Femoral nerve L2, L3, L4

Knee flexion Hamstring Sciatic nerve L5, S1, S2

(semitendinosus,
semimembranosus,
biceps femoris)

Leg abduction Gluteus medius Superior Gluteal L4, L5, S1

Gluteus minimus nerve
Tensor Fasciae latae

Leg adduction Obturator externus Obturator nerve L2, L3, L4

Adductor longus,
magnus, brevis,
gracilis

Toe dorsiflexion Extensor hallucis Deep peroneal L5, S1

longus nerve
Extensor digitorum
longus

Foot dorsiflexion Tibialis anterior Deep peroneal L4, L5

nerve
Foot plantar flexion Triceps surae Tibial nerve S1, S2
( gastrocnemius,
soleus)

Foot eversion Peroneus Superficial peroneal L5, S1

longus/brevis nerve

Foot inversion Tibialis posterior Tibial nerve L4, L5

38
SENSATION
• Pain – pinprick (dull or sharp)
- Alternate touching the patient with 2 ends randomly
- 3 pricks for each stimulus with same pressure
• Delayed pain: pinch dorsum of foot
• Deep pain: squeeze Achilles tendon
• Temperature
• Light touch – cotton (hairy skin perceives tickling and touch better)
- Test over the rest of the body: feet
• Quantitative tests of touch and pressure done with graded monofilament or hair of
different strength
• Vibration – 128 tuning fork, toenail then distal to proximal bony prominence
Position – 4th digit: wiggle then up, down or straight/middle

1.) Light touch (cotton wool) →provide an example of sensation at a central point (e.g sternal
angle/ forehead)

2.) Pinprick sensation (using a neurotip)

Assessment each of the dermatomes (comparing right with left)
L2
L3
L4
L5
S1
If sensation is reduced peripherally. Assess from distal point and move proximally to identify
"stocking " sensory loss

39
Vibration sensation (128 Hz tuning fork)
-place tuning fork on a distal bony prominence (e.g. DIP joint)
If patient is unable to sense vibration, assess at a more proximal bony point

Proprioception (joint position sense)

Hold distal phalanx by its sides (otherwise pressure on the nail bed may provide clues as to
the direction of movement)

COORDINATION
Heel to Shin test

Abnormal heel - shin test can be due to:

• lower limb weakness
• impaired joint proprioception
• cerebellar disorder

Check for Truncal Ataxia

40
STANCE AND GAIT
Romberg's test
• Assessment of proprioception

Positive test = loss of balance

• this suggest ataxia is sensory in nature

Assess proximal muscle weakness

Assess the following:

• Speed
• Symmetry
• Balance
• Arm swing

Tandem gait
Tiptoes walking (power test of plantar flexion)
Heel walking (power test of dorsiflexion)

41
Type of Gait Description
Hemiparetic gait - Shoulder is adducted
- Elbow is flexed
- Forearm is pronated
- Wrist and fingers are flexed
- Knee is held in extension
- Ankle is plantar flexed
- Has to circumduct the affected leg to ambulate
- Usually post strok e

Broad – based Ataxic gait - Wide based

- Cerebellar dysfunction
Shuffling gait - Short steps
- Parkinsonism

High Steppage gait - High stepping, slapping (as if climbing a flight of stairs)
- Sensory neuropathy and in foot drop

Spastic or scissor gait - Legs adducted at hip

- Thigh rub against each other
- Cerebral palsy and multiple sclerosis

Antalgic gait - Handheld over hip on affected side

- Joint or back pain in which the patient takes their
weight off the affected side

Waddling gait - Proximal myopathy

Stamping gait - Sensory neuropathy
Apraxic gait - Diffuse cerebral disease and dementia

42
V. MENINGES
• Nuchal rigidity
• Kernig
• Brudzinski
• Laseque / straight leg testing

VI. PATHOLOGIC REFLEXES/PRIMITIVE REFLEXES

Abnormal reflex:
The plantar reflex can be elicited in a number of ways, which were described in the late 19th
and early 20th century.
These have their own eponyms.
• Bing sign – multiple pinpricks on the dorsum of the foot
• Cornell sign – scratching along the inner side of the extensor hallucis longus tendon
• Chaddock sign – stroking the lateral malleolus
• Gonda sign – flexing and suddenly releasing the 4th toe
• Gordon sign – squeezing the calf muscle
• Moniz sign – forceful passive plantar flexion of the ankle
• Oppenheim sign – applying pressure to the medial side of the tibia
• Schaeffer sign – squeezing the Achilles tendon
• Silva sign – pinching the rectus femoris muscle
• Stransky sign – vigorously abducting and suddenly releasing the little toe
• Strümpell sign – patient attempts to flex the knee against resistance
• Throckmorton reflex – percussion over the metatarsophalangeal joint of the big toe

43
Primitive reflexes:
Grasp reflex: When an object is brushed against the palm, the patient’s fingers will close on
it. This frontal release sign is the one most clearly associated with frontal lobe dysfunction in
conditions such as dementia.

Palmo-mental reflex: When the palm is stroked, there may be contraction of the ipsilateral
mental muscle (in the chin). The stroking can be done with a thumbnail and in my experience
is most effective when done over the thenar eminence with enough pressure to blanch the
skin.

Rooting: when the cheek or lips are stroked, the head will turn towards the stimulus. This is
usually only present in people with severe dementia.

Snout: When gentle pressure is applied to the philtrum, a positive response is upward
movement of the chin or lips into a pouting or pursing appearance.

Glabellar tap: The glabella is the area immediately above the nose on the forehead. In most
people, when this area is tapped repetitively at one second intervals, the blink response
extinguishes after a short number of taps. In patients with frontal lobe injury and particularly
with Parkinson’s disease, the response does not extinguish for more than 3-7 repetitions.

44
Approach to Localization
Arriving at a Diagnosis in Neurology requires:
1. Localization of the lesion
2. Processing the Etiology of the lesion
❖ Localization is not equal to Etiology

I. NEUROLOGICAL LOCALIZATION
= “where” is the lesion responsible for a patient’s symptoms and signs

Must know:
1. anatomy and physiology of the nervous system, its blood supply
2. the disease processes that affect it

Process:
History taking → General and Neurological Examination → Relevant diagnostic studies

STEPS:

45
1. LEVELIZE
• Topographical localization involves determining the anatomical level within the
nervous system that accounts for all the patient’s findings
• Central vs Peripheral Nervous system

46
CENTRAL NERVOUS SYSTEM
The main structures of the CNS
- Cortex
- Subcortical structures: thalamus, basal ganglia
- Brainstem: midbrain, pons, medulla
- Cerebellum
- Spinal cord

Cortex
Cortical subcortical lesions may cause hemiparesis or hemisensory loss
How to differentiate? Look for cortical signs

47
48
49
50
 The rule of 4 of the brainstem

In the rule of 4 there are 4 rules:

1) There are 4 structures in the ‘midline’ beginning with M

2) There are 4 structures to the side beginning with S
3) There are 4 cranial nerves in the medulla, 4 in the pons and 4 above the pons (2 in
the midbrain)
4) The 4 motor nuclei that are in the midline are those that divide equally into 12
except for 1 and 2, that is 3, 4, 6 and 12 (5, 7, 9 and 11 are in the lateral brainstem)

The 4 medial structures and the associated deficit are:

1.) The Motor pathway (or corticospinal tract): contra lateral weakness of the arm and
leg.
2.) The Medial Lemniscus: contra lateral loss of vibration and proprioception in the arm
and leg.
3.) The Medial longitudinal fasciculus: ipsilateral internuclear ophthalmoplegia (failure
of adduction of the ipsilateral eye towards the nose and nystagmus in the opposite
eye as it looks laterally).
4.) The Motor nucleus and nerve: ipsilateral loss of the cranial nerve that is affected (3,
4, 6 or 12).

The 4 lateral structures and the associated deficit are:

1.) The Spinocerebellar pathways: ipsilateral ataxia of the arm and leg.
2.) The Spinothalamic pathway: contra lateral alteration of pain and temperature
affecting the arm, leg and rarely the trunk.
3.) The Sensory nucleus of the 5th: ipsilateral alteration of pain and temperature on the
face in the distribution of the 5th cranial nerve (this nucleus is a long vertical
structure that extends in the lateral aspect of the pons down into the medulla).
4.) The Sympathetic pathway: ipsilateral Horner’s syndrome, that is partial ptosis and a
small pupil (miosis).

The 4 cranial nerves in the medulla are:

9 Glossopharyngeal: ipsilateral loss of pharyngeal sensation.
10 Vagus: ipsilateral palatal weakness.
11 Spinal accessory: ipsilateral weakness of the trapezius and sternocleidomastoid
muscles.
12 Hypoglossal: ipsilateral weakness of the tongue. The 12th cranial nerve is the motor
nerve in the midline of the medulla.

Although the 9th, 10th and 11th cranial nerves have motor components, they do not
divide evenly into 12 (using our rule) and are thus not the medial motor nerves.

51
The 4 cranial nerves in the pons are:
5 Trigeminal: ipsilateral alteration of pain, temperature and light touch on the face
back as far as the anterior two-thirds of the scalp and sparing the angle of the jaw.
6 Abducent: ipsilateral weakness of abduction (lateral movement) of the eye.
7 Facial: ipsilateral facial weakness.
8 Auditory: ipsilateral deafness.

The 4 cranial nerves above the pons are:

Olfactory: not in midbrain.
Optic: not in midbrain.
Oculomotor: impaired adduction, supraduction and infraduction of the ipsilateral
eye with or without a dilated pupil. The eye is turned out and slightly down.
Trochlear: eye unable to look down when the eye is looking in towards the nose.

Principles in Cranial nerve localization:

Cranial nerve mimics

Lastly, don’t forget that muscle and neuromuscular junction disorders can mimic CN lesions:

e.g. bilateral facial weakness in myopathies

e.g. ophthalmoplegia in thyroid eye disease
e.g. ophthalmoplegia in myasthenia gravis

52
53
Cerebellum is connected to the brainstem by:

3 pairs of “bridges”:
superior cerebellar peduncles →midbrain
middle cerebellar peduncles →pons
inferior cerebellar peduncles → medulla

Through which run

3 circuits or loops:
1.) cortical loop: for coordination of articulation, fine movements
2.) vestibular loop: for equilibrium and oculomotor control
3.) spinal loop: for tone, posture, gait

54
Because of the cross-sectional anatomy of the spinal cord, there are unique features:
• Sensory level
• Dissociated sensory loss (in combination with sensory level)

55
MOTOR PATHWAY

Upper motor neuron

Upper motor starts from the Betz cells at Primary Motor Cortex (precentral gyrus) and ends
in the spinal cord

Lower Motor Neuron

Lower Motor start from the anterior horn cell and ends in the muscle

56
Differentiating Upper motor neuron from Lower Motor Neuron lesion

Lower Motor Neuron

57
 2. LATERALIZE
-determine whether left or right side

3. LOCALIZE
Type of lesions:
a.) Focal
→is one in which a single, discrete neuroanatomical locus can account for all the patient’s
symptoms and signs.
Example:
(a)Aphasia, right sided hemiplegia: Left cerebral hemisphere
(b)Weakness of the right abductor pollicis brevis and numbness of the first 3½ digits on the
right hand: Right median nerve

b.) Multifocal
→ involves more than one locus, but the loci remain discrete.
Example:
(a)Multiple cardiac - origin emboli
➢ Acute onset of right hemiplegia and aphasia (left cerebral hemisphere) and
➢ left superior quadrant visual field cut (right posterior temporal hemisphere)
(b)Metastases
➢ smoker with chronic cough, papilledema &
➢ subacute onset left arm and leg dysmetria (left cerebellar hemisphere) & left
homonymous hemianopia (right optic tract)

c.) Diffuse
→indicates widespread dysfunction of a part of the nervous system.
Examples:
(a)encephalopathy due to a variety of metabolic or toxic causes
(b)Dementia
(c)numbness and pain in a stocking and glove distribution due to diabetic small fiber
peripheral neuropathy.

❖ Note that in both a multifocal and a diffuse process, there is involvement of more
than one physical location.
❖ But in multifocal, the lesions remain discrete, whereas in diffuse, the dysfunction is
generalized.

58
 i.) specific system is a subset of diffuse localization
In specific system processes, there is diffuse dysfunction of a particular pathway or
neurotransmitter system
Example:
(a)The progressive diffuse weakness, atrophy, fasciculation, and spasticity in
amyotrophic lateral sclerosis (Lou Gehrig’s disease) = loss of the anterior horn cells and
degeneration of the corticospinal tracts.

(b)The progressive loss of vibration and proprioception is a manifestation of posterior

column dysfunction = vitamin B12 deficiency

CHECKPOINTS:
During the process of localization, ask yourself three questions:

1.) What is the necessary minimal amount of neuroanatomy that must be damaged in
order to produce the patient’s symptoms/signs?

❑ A patient with monocular blindness must have a lesion on the same side somewhere
between the cornea and optic chiasm.
❑ A patient with aphasia must have a lesion of the dominant (95% left) cerebral
hemisphere

2.) If the lesion is here, does it explain all the findings?

❑ If the answer is no, you should carefully re-examine the data and your conclusions.
❑ Either the localization is wrong, or the disease process is multi-focal or diffuse.

3.) If the lesion is here, what else should be present?

❑ That’s another way of saying, does the patient have the expected neighborhood
signs to go along with your proposed localization?

59
 II. ETIOLOGY OF THE LESION

How to come up with Diagnosis / Differential Diagnosis:

1.) What is the Time-intensity Profile?

a) Acute: minutes to hours.
This implies acute metabolic dysfunction as occurs with ischemia, seizure, trauma,
etc.

b) Subacute: days to weeks. May be smooth, stair-step, or crescendo.

This suggests an expanding lesion, as occurs with tumors, abscess, etc.

c) Recurrent-remittent: episodic attacks of symptoms with rapid recovery to normal

health.
This implies repeating episodes of a single process as occurs with transient ischemic
attacks (TIA), seizures, migraine, and multiple sclerosis.
• In the case of seizures, migraine, and often TIAs, the symptoms are highly
stereotypical.
• In the case of multiple sclerosis, symptoms vary depending on the lesion site,
and the process may evolve to a secondarily progressive one in which there is
only partial recovery from each attack.

d) Chronic-progressive: months to years.

This implies gradual deterioration as occurs with degenerative diseases like Alzheimer’s
dementia, Huntington’s chorea, etc.

Possible etiology in NEUROLOGY:

60
Other principles:

Examples:
• Degenerative: MSA (autonomic + cerebellar + parkinsonism + pyramidal)
• Hereditary: Friedrich ataxia (cerebellar + pyramidal + posterior column + peripheral
neuropathy)
• Metabolic: B12 deficiency (posterior column + peripheral neuropathy)
• Infective: tabes dorsalis (posterior column + pyramidal tracts + peripheral
neuropathy)
• Autoimmune: Multiple sclerosis (anywhere in the CNS e.g. cortex, cerebellum, spinal
cord)

Note: patient profile must fit the diagnosis! Do not diagnose multiple sclerosis in 90-year-old
man!

61
Examples:
• In a 60-year-old diabetic man, cervical myelopathy + peripheral neuropathy >> tabes
dorsalis
• In a 50-year-old man hypertensive smoker, cerebellar stroke + lacunar stroke >>
multiple sclerosis

62
 jasmynangondeleon
by: Dr. Jasmyn Angon-De Leon
Images and Guidelines are adopted from several sources.
All for the Glory of God: 1 Corinthians 10:31

63