Neurologic Examination

Neurologic examination
Review of the anatomy of the CNS:

A. The Motor System
• The corticospinal System
• motor fibers connecting the pyramidal cells in the fifth layer
of the motor cortex with the motor neurons in the brainstem
and anterior horn of spinal cord
• The motor area in the cerebral cortex is located in the gyrus
anterior to the central sulcus.
• The body is represented in the opposite precentral gyrus
motor cortex.
• The motor fibers descend form the cortex in to the internal
capsule to occupy the anterior 2/3 of the posterior limb of the
internal capsule.
The corticospinal system
• from the IC, they pass along the cerebral peduncle in the mid-
brain to the upper part of the medulla
• In the medulla, the corticospinal fibers decussate to the
opposite side and descend posteriorly to form the lateral
corticospinal tract in the spinal cord.
• These corticospinal fibers are concerned with initiation of
voluntary and skilled motor activities by stimulating selected
muscle actions and inhibiting others.
THE EXTRAPYRAMIDAL SYSTEM
• Motor functions concerned with movemtn and coordination

• The basal ganglia, subthalamic ganglia, suabstantia negria
mediate the extrapyramidal activites
• Involved in sitting, walking, running, complex volitional
activities
The Lower motor neuron
• The lower motor neuron consist of the anterior horn cells in
the spinal cord (peripheral nerves) or motor neurons in the
brain stem (cranial nerves).
• the nerve fibers originating from the motor neurons and
innervating muscles.
Common motor symptoms
weakness
• Weakness is reduction of normal power of one or more
muscles
• Paralysis or suffix “plegia” : indicate complete or near
complete weakeness
• Paresis : partial weakness
• Hemiplegia/hemiparesis: half body paralysis/partial weakness
• Parplegia/parapareis: paralysis/weakness of both lower
extremities
• Monoplegia/monoparesis: paralysis/weakness of one
extremity
Abnormal movements
• Hyperkinetic movements disorder: excess

amount of spontaneous motor activity is seen
or abnormal movement occurs
– Tremor, astrexis, dystonia, myoclonus
• Hypokinetic movement disorder: purposeful

movement is reduced or absent ( bradykinesia
or akinesia)
Imbalance and disorders of gait
• Imbalance is inability to maintain intended

orientation of body in space
(ataxia)
• Can occur in standing, walking
• Patients with disequilibrium have vertigo

Distinguishing patterns of weaknesses (paresis
or paralysis )
Character UMNL LMNL Myopathy

Atrophy None Sever mild
Tone increased decreased Normal/decreased
Fasciculation absent common absent
DTR hyperactive hypoactive/ Normal/hypoactive

absent
Plantar reflex Up going Down going Down going
The Sensory system
• Positive phenomena: sensory sx resulting from impulses

generated at a sight of lower threshold or heightened
excitability in the sensory pathway
• It includes: pins –and-needles, tingling, band like, burning,
lancinations, knife-like, searing, tightening
• They are not necessary associated with abnormal finding in
examination
• Negative phenomenon: represent loss of
sensory function and are characterized by
decreased or absent feeling
• Numbness is principal sx
• Sensory examination is accompanied by
abnormal finding
• Paresthesia: tingling or pin-and-needles sensations
• Dysthesias: all abnormal sensations even painful in the
presence or absence of stimuli
• Hypesthesia:reduced sensation to cutaneous stimuli
• Anesthesia: complete absence of skin sensation to stimuli and
pinprick
• Hyperesthesia: pain to in response to touch
Leminiscal and spinothalamic pathways
EXAMINATION OF HIGHER MENTAL
FUNCTIONS
• Level of consciousness
– Alert
– Drowsy
– Stuporos
– Coma (Glasgow Coma Scale)
• Awareness to the environment
– Do they know where he/she is ? Data? Year?
Persons ?
Appearance
• How is the patient dressed ? Is clothing clean,

pressed, and properly fastened ?
• Note the patient’s nail, hair,, skin, teeth?
How are they groomed ?
– Grooming and personal hygiene may deteriorate
in depression, Schizophrenia, dementia.
– Excessive fastidiousness may be seen in neurotics
Mood
• Moods include sadness and deep melancholy;
elation ; anger; indifference
• How do the patient feel ?
– You may ask do you feel sad, happy, angry ?
– Is it appropriate for the situation ?
– Ask about suicidal thoughts

Speech and language
• Through out the interview note the speech of the patient with
respect to
• Rate
• Loudness
• Articulation of words
– dysarthria: defective articulation
• Fluency
Testing for Aphasis
• Assess for
– Word comprehension
– Repetition
– Naming
– Reading comprehension
– Writing
Assess: Broca’s Aphasia Wernick’s Aphasia
Fluency Nonfluent fluent; noncoherenet
Comprehension good Impaired
Repetition Impaired Impaired
Naming Impaired Impaired
Reading Good Impaired
Writing Impaired Impaired
Location of
Lesion Inferior F. lobe Superior T. lobe
Higher cognitive functions
• Assess
– Information and vocabulary
– Calculating ability
– Abstract thinking
– Constructional ability
• Mini-Mental Test
Mini-Mental Status Examination
• 1. Orientation
– What is the: year, season, month, date, day ( One pt each=5)
– Where are we: State, County, town, hospital, floor (one point each=5)
• 2. Registration
– Name three objects then ask patient all the three after you ( three
points, one for each repetition)
• 3. Attention and Calculation
– Serial sevens, start subtracting form 100: One point for each correct
response. Stop after five answers
Mini-Mental Status Examination
• 4. Recall
– Ask for the three objects named in registration: give one point for each correct
answer
• 5. Language
– Name a pencil and watch ( one point each)
– Repeat the following “ No ifs, ands, or buts” ( one pt)
– Follow three-stage command : “ take a paper in your tight hand, fold in half,
and put it on the floor “ ( 3pts)
– Read and obey the following: “ close your eyes” (1 pt)
– Write a sentence. (1 point)
– Copy a design. ( 1 point )
• Examination of the cranial nerves
Cranial Nerve 1 (Olfactory)
• Each nostril should be checked separately. Push

on the outside of the nares, occluding the side
that is not to be tested.
• Have the patient close their eyes. Make sure
that the patient is able to inhale and exhale
through the open nostril.
• Present a small test tube filled with something
that has a distinct, common odor (e.g. ground
coffee) to the open nostril. The patient should
be able to correctly identify the smell.
Cranial nerve II: Optic nerve
• Visual Acuity
• Color Perception
Visual Field Testing
• Specific areas of the retina receive input from precise areas of the visual
field. This information is carried to the brain along well defined anatomic
pathways. Holes in vision (referred to as visual field cuts) are caused by a
disruption along any point in the path from the eyeball to the visual
cortex of the brain. Visual fields can be crudely assessed as follows:
• The examiner should be nose to nose with the patient, separated by
approximately 8 to 12 inches.
• Each eye is checked separately. The examiner closes one eye and the
patient closes the one opposite. The open eyes should then be staring
directly at one another.
– The examiner should move their hand out towards
the periphery of his/her visual field on the side where
the eyes are open. The finger should be equidistant
from both persons.
– The examiner should then move the wiggling finger in
towards them, along an imaginary line drawn
between the two persons.The patient and examiner
should detect the finger at more or less the same
time.
– The finger is then moved out to the diagonal corners
of the field and moved inwards from each of these
directions. Testing is then done starting at a point in
front of the closed eyes. The wiggling finger is moved
towards the open eyes.
– The other eye is then tested.
Examination of the pupils
• Inspect for : size, symmetry
• Direct light reaction
• Consensual reaction
• Near sight reaction ( Accommodation)

CN: III, IV, VI
• CN III: Oculomotor nerve
» Suprior levator palpebrae
» Sphinctor pupillae
» All extra-ocular muscles except lateral rectus
and superior oblique
• CN IV: Trochlear nerve
» Superior oblique muscle
• CN VI: Abducent nerve
» Lateral rectus muscle
CN III, IV, VI
• 1. Ocular movements
Inferior Superior
Oblique rectus
Right eye Left eye

Lateral
Medial
rectus
Rectus
Superior Inferior
oblique Rectus
Examination of the pupils
• Size
• Shape
• Reaction to light: Direct and consensual
• Accommodation
– PERRLA
– Argill Roberston pupils
CN V
• Motor function:
– Assess the temporal and masseter muscles: clinching of
teeth
– Movement of lower jaw: opening, protrusion, lateral mvt
• Sensory function:
– assess ophthalmic, maxillary and mandibular distributions
• Corneal reflex
– Afferent CN V and efferent by CN VII
CN VII
• Inspect for facial asymmetry
• Motor function assessment
– Closing eyes
– Wrinkling forehead, frowning
– Whistling, blowing
• Sensory test
– Examine taste sense in anterior 2/3 of tongue
CN VIII
• Cochlear and Vestibular functions
• Cochlear
– Conversational voice at about 3.5m
– Whispering, watch tickling
– Tuning fork
• Rinne Test : air –bone conduction test
• Weber Test: Test of Lateralization
CN IX and X
• CN IX: taste sensation to posterior third of
tongue and motor function of Pharynx
• CN X: motor to the soft palate, pharynx and
larynx
• Position of uvula and soft palate

• “gag” reflex
CN XI
• Shoulder shrugging
• Lateral and rotational movement of the neck

CN XII
• Inspect the tongue for size
• Atrophy, tremor or fasiculation
• Assess strength of the tongue
Motor examination
– Bulk
– Tone
– Power
– Reflex
– Coordination
– Gait
– Abnormal movements
Motor examination: BULK
• Inspect for volume of muscle

– Atrophy: lower motor lesion, peripheral
– Atrophy proximal: myopathy
– Pseudohypertrophy: Duchen dystrophy
– Hypertrophy: body builders and sport person

Motor examination: TONE
• Tone: the resistance of muscle to passive stretch

• Upper limb:
– assess tone by repetitive pronation and supination of
the forearm, and by rolling the had at the wrist join
• Lower limb
– Roll the foot around the ankle joint
– Place hands behind the thigh to raise the leg rapidly.
Normally the foot will be dragged before lifting . in
hypertonia foot will be raised briskly
Motor examination: TONE
• Hypertonia
– Spasticity: clasp-knife type, pyramidal
– Rigidity: lead-pipe type ( plastic) in EPD
Cogwheel type in PD
– Paratonia/gegenhalten: falactuating, in frontal lobe
disease
• Hypotonia
– Flaccid or floppy muscles
– LMNL, cerebellar diseases
Motor examination: POWER or STRENGTH
• Observe patients when walking, dressing and

undressing, sitting up from bed….
• Passive /active assessment of power of muscle
group for major movement around each joint
• Ex: extension , flexion, adduction, abduction,
rotation
•
Motor examination: POWER
• Grading of the strength

– Grade 0= no movement
– Grade 1: flickering or side to side movement
– Grade 2: movement with gravity eliminated
– Grade 3: movement against gravity but not against
resistance
– Grade 4: movement against resistance but with
some weakness
– Grade 5. full power
Motor examination: Reflexes
• 1. Deep Tendon reflex

– Biceps reflexes: C5, C6
– Triceps Reflex: C7, C8
– Brachioradial reflex: C5, C6
– Knee reflex: L3, L4
– Ankle Reflex: S1, S2
• Jenderassik Maneuver: Clinching, finger

hooking.
• Grading DTR:
– Grade 0: Absent DTR
– Grade 1: Present ( like in ankle reflex)
– Grade 2: brisk ( like in knee reflex)
– Grade 3: very brisk ( with non sustained clonus)
– Grade 4: Sustained Clonus
• Superficial Reflexes
– Plantar reflex
– Abdominal reflex
– Cremasteric reflex
– Anal reflex
– Corneal reflex
– Ciliospinal reflex
Motor examination: COORDINATION
• Finger to nose
• Rapid alternating movement of hands
• Heel to shine test
• Romberg’s Test ( assess sensory ataxia)

Motor examination: GAIT
• Inspection
– Spastic gait
– Sensory ataxia
– Cerebellar ataxia
– Fesinant gait
– Waddling gait
– High-stepping gait
Motor examination: abnormal movement
• Focal seizure in comatous patient

• Myoclonus
• Tremor:
– Rest tremor : in PD
– Postural tremor: familial essential tremor, toxcity
– Intentional Tremor: enhanced when reaching to target
ex in cerebellar ataxia
• Asterixis: flapping tremor
• Tetany: Chevostek’s and Trousseau’s Sign
SENSORY EXAMINATION
• Examination of primary sensory modalities
– Vibration
– Position
– Light touch
– Pain
– Temprature
SENSORY EXAMINATION
• Cortical sensation
– Two point discrimination
– Touch localization
– Steriognosis
– Graphestesia
Special examination
• Meningeal signs
– Neck rigidity
– Brudzinski’s Sign
– Kernig’s Sign
• Straight leg raising Test: entrapment of sciatic

nerve
The spinal cord and its tracts
Spinal cord
• White Matter
– Anterior Funiculus (Anterior White Column)
– Posterior Funiculus (Posterior White Column)
Fasciculus Gracilis & Fasciculus Cuneatus
– Lateral Funiculus (Lateral White Column)
• Gray Matter
– Anterior Horn -------------- motor
– Posterior Horn -------------- sensory
– Lateral Horn ----------------- autonomic
(sympathetic)
– Gray Commissure -------- anterior and posterior
Ascending Tracts
• Modality: Touch, Pain, Temperature, Kinesthesia

• Receptor: Exteroceptor, Interoceptor, Proprioceptor
• Primary Neuron: Dorsal Root Ganglion (Spinal
Ganglion)
• Secondary Neuron: Spinal Cord or Brain Stem
• Tertiary Neuron: Thalamus (Ventrobasal Nuclear
Complex)
• Termination: Cerebral Cortex, Cerebellar Cortex, or
Brain Stem
Lumbar puncture :
Needle inserted between
L3-L4
Spinal cord
• Somatotopically organized with 31 spinal segments
• 8 cervical, 12 Thoracic, 5 Lumbar, 5 sacral and 1
coccygeal
• Spinal cord extends from the foramen magnum to
body of first lumbar vertebrae
• Seven of C-nerves exit above respective C-
vertebrae,
C-8 above T 1 vertebera. All other spinal nerves exit
above respective vertebral bodies.
Spinal Cord levels relative to vertebral bodies
Spinal cord levels Corresponding Vetebral body

1. Upper Cervical segments 1. Same as cord level
2. Lower Cervical Segment 2. One level higher
3. Upper thoracic segment 3. 2 levels higher
4. Lower thoracic segment 4. 2 levels higher
5. Lumbar segment 5. T10- T12 Vertebrae
6. Sacral segment 6. T 12 – L1 Vertebrae
7. Coccygeal 7. L 1 Vertebrae
Example: Localization of spinal lesion at T10 segment corresponds to compression

Of the spinal cord at thoracic 7-8 vertebral bodies
Dermatomal landmarks
• C 5 deltoid area
• C 8 thumb
• C 6 little finger
• T4 nipple
• T 6 xyphi sterni
• T 10 umblicus
• T 12 inguinal ligament
• L5 big toe
• S1 small toe

Neurologic Examination

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Neurologic examination

Review of the anatomy of the CNS:

• Motor functions concerned with movemtn and coordination

• Hyperkinetic movements disorder: excess

• Hypokinetic movement disorder: purposeful

• Imbalance is inability to maintain intended

• Patients with disequilibrium have vertigo

Character UMNL LMNL Myopathy

Tone increased decreased Normal/decreased

Fasciculation absent common absent

DTR hyperactive hypoactive/ Normal/hypoactive

• Positive phenomena: sensory sx resulting from impulses

• How is the patient dressed ? Is clothing clean,

– Ask about suicidal thoughts

Fluency Nonfluent fluent; noncoherenet

Comprehension good Impaired

Repetition Impaired Impaired

Naming Impaired Impaired

Reading Good Impaired

Writing Impaired Impaired

• Each nostril should be checked separately. Push

• Direct light reaction

• Near sight reaction ( Accommodation)

Right eye Left eye

• Position of uvula and soft palate

• Lateral and rotational movement of the neck

• Inspect for volume of muscle

– Hypertrophy: body builders and sport person

• Tone: the resistance of muscle to passive stretch

• Observe patients when walking, dressing and

• Grading of the strength

• 1. Deep Tendon reflex

• Jenderassik Maneuver: Clinching, finger

• Rapid alternating movement of hands

• Heel to shine test

• Romberg’s Test ( assess sensory ataxia)

• Focal seizure in comatous patient

• Straight leg raising Test: entrapment of sciatic

• Modality: Touch, Pain, Temperature, Kinesthesia

Spinal cord levels Corresponding Vetebral body

Example: Localization of spinal lesion at T10 segment corresponds to compression

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