NEUROLOGICAL EXAMINATION

KABILAN.A… (MSC.,(N),PGDHM,PGDPH)

LECTURER., MANIPAL COLLEGE OF MEDICAL SCIENCES

INTRODUCTION:A neurological examination is the

assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired.[1] This typically includes a physical examination and a review of the patient's medical history but not deeper investigation such as neuroimaging. It can be used both as a screening tool and as an investigative tool.

Examples of Definitions • Alert: o awake, looks about o responds in a meaningful manner to verbal instructions or gestures • Drowsy:o oriented when awake but if left alone will sleep• Confused: o disoriented to time, place, or person o memory difficulty is common o has difficulty with commands o exhibits alteration in perception of stimuli, may be agitated

• Stuporous:o generally unresponsive except to vigorous stimulation o may make attempt at verbalization to vigorous/repeated stimuli o Opens eyes to deep pain • Comatose:o unarousable and unresponsive o some localization or movement may be acceptable within the comatose category depending on the coma definitions e.g. light coma to deep coma o Does not open eyes to deep pain

The difference between Coma and Sleep:

• sleeping persons respond to unaccustomed stimuli• sleeping persons are capable of mental activity

(dreams)• sleeping persons can be roused to normal

consciousness• cerebral oxygen uptake does not decrease during

sleep as it often does in coma

Special States of Altered Levels of Consciousness

• Brain Death: An irreversible loss of cortical and brain stem activity.

• Persistent Vegetative State: A condition that follows severe cerebral injury in

which the altered state becomes chronic or persistent. • Locked-in Syndrome:

A state of muscle paralysis, involving voluntary muscles, while there is preservation of full consciousness and cognition.

Indications:

A neurological examination is indicated whenever a physician suspects that a patient may have a neurological disorder. Any new symptom of any neurological order may be an indication for performing a neurological examination.

Organic Disease ?

Signs &/or symptoms that cannot be faked must be examined closely.

Examples include, asymmetry in pupils, abnormal retinal exams, nystagmus, muscle atrophy, and muscle fasciculation.

Where are the Connections

Upper Motor Neurons (UMN) are defined as the connections of motor nerves before they leave the spinal cord

Lower Motor Neurons (LMN) are defined as after the synapse (connection) into the peripheral nerve cell bodies.

Objectives

Organize Exam into the 6 Subsets of Function Concept of Screening Examination Understand Afferent and Efferent Pathways for Brainstem

Reflexes Differentiate Between Upper and Lower

Motor Neuron Findings

Six Subsets of the Neuro Exam

Here’s what you need to examine. Mental Status Cranial Nerves Motor Sensory Coordination Reflexes

Concept of a Screening Exam

Screening each of the subsets allows one to check on the entire neuroaxis (Cortex, Subcortical White Matter, Basal Ganglia/Thalamus, Brainstem, Cerebellum, Spinal Cord, Peripheral Nerves, NMJ, and Muscles)

Expand evaluation of a given subset to either• Answer questions generated from the History• Confirm or refute expected or unexpected findings on Exam

Neurological ExaminationMental Status Exam

“FOGS” Family story of memory loss Orientation General Information Spelling &/or numbers Recognition of objects

1. INTERVIEW

The patient/family interview will allow the nurse to: • gather data: both subjective and objective about the �

patient's previous/present health state • provide information to patient/family �• clarify information �• make appropriate referrals �• develop a good working relationship with both the patient �

and the family • initiate the development of a written plan of care which is �

patient specific

Interview to identify presence of: • headache • difficulty with speech • inability to read or write • alteration in memory • altered consciousness • confusion or change in thinking • disorientation • decrease in sensation, tingling or pain • motor weakness or decreased strength • decreased sense of smell or taste • change in vision or diplopia • difficulty with swallowing • decreased hearing • altered gait or balance • dizziness • tremors, twitches or increased tone

Physical Examination Considerations

• Level of Consciousness – Most important aspect of neurologic examination– Level of consciousness first to deteriorate; changes often subtle,

therefore requiring careful monitoring. • Consciousness:

– Composed of Two Components:• Arousal (Alertness)• Awareness (Content)

– Assessment: Orientation vs. Disorientation » Person, Place & Time » Varying sequence of questions is important !!

Assessing LOC

• Glasgow Coma Scale (GCS)– Three Categories:

• Eye opening• Best motor response• Best verbal response

– Scoring• Highest or best possible score 15 • A score of < 8 indicates coma • Lowest or worst possible score 3

Glasgow Coma Scale

Pupillary Examination• The pupillary examination can be quickly and easily

performed in the unconscious or minimally responsive patient when a TBI is suspected, and can provide valuable information about the degree of initial or progressing brain injury. Several types of TBI’s may cause pupillary changes, which indicate the need for rapid interventions to decrease ICP caused by cerebral bleeding and/or edema. Nurses are in a key position to detect early changes in a patient's condition and administer or advocate for immediate interventions.

Check pupil size in lighted room, and reactivity to light in a darkened room.

Unequal pupil size can be a sign of a serious brain injury.

Brain Injury with bleedingor swelling

Rapid interventionsare needed to preventdeath or permanent brain damage – TBI’scan progress rapidly!

Mental Status

Level of Alertness• Subjective view of Examiner• Definition of Consciousness• Terminology for Depressed Level of Consciousness• Concept of Coma• Delerium

Degree of Orientation• To what?

Mental Status

Concentration• Serial 7’s or 3’s• “WORLD” backwards• Months of the Year Backwards• Try to quantify degree of impairment

* A and O and Concentration need to be intact for other aspects of the Mental Status Exam to have localizing value!

Mental StatusMemory

Immediate Recall• A task of concentration

Short-Term Memory• “3/3 objects after 5 minutes”

Long-Term Memory• Last thing to go

Mental StatusLanguage

Aphasia vs Dysarthria Receptive Language

• Command Following Expressive Language

• Fluency• Word Finding

Repetition• Screens for Receptive, Expressive, and Conductive

Aphasias

Language

Mental Status Calculations, R-L confusion, finger agnosia,

agraphia• Gerstmann’s Syndrome (Dominant Parietal Lobe)

Hemineglect• Non-Dominant Parietal Lobe

Delusional Thinking, Abstract Reasoning, Mood, Judgement, Fund of Knowledge, etc• Important for Psychiatry• Does not localize well to one region of the cortex• Neurocognitive Testing required to get at more specific deficits

The Neurological ExaminationCranial Nerves

Olfactory Nerve - I

The Neurological ExaminationCranial Nerves

Olfactory Nerve Distinguish Coffee from Cinnamon Smelling Salts irritate nasal mucosa and test V2

Trigemminal Sense Disorders of Smell result from closed head injuries

The Neurological ExaminationCranial Nerves

Optic Nerve

Cranial nerve II

The Neurological ExaminationCranial Nerves

Optic Nerve Visual Acuity Visual Fields Afferent input to Pupillary Light

Reflex• APD

Look at the Nerve (Fundoscopic Exam)“VA equals 20/20 OU at near”“PERRLA”

The Neurological ExaminationCranial Nerves

Trochlear Nerve

c.n. IV

Oculomotor NerveCn III

Abducens NerveCn VI

CN III Oculomotor: moves eyes in all directions except outward and down & in; opens eyelid; constricts pupil

CN IV Trochlear:moves eyes down and in…..

CN VI Abducens: moves eyes outward

EOM’s: (extraoccular movement) assessment of eye movement in all directions ( III, IV VI)

The Neurological ExaminationCranial Nerves

Trigeminal Nerve - V

CN V Trigeminal: 3 branches; sensation to the face, cornea and scalp; opens jaw against resistance

The Neurological ExaminationCranial NervesFacial Nerve-VII

CN VII Facial: moves the face; taste.

CN VII paralysis

The Neurological ExaminationCranial Nerves

Vestibulocochlear Nerve-VIII

Vestibulocochlear Nerve Hearing and Balance

• Patients will complain of tinnitis, hearing loss, and/or vertigo Weber and Renee Test

• Differentiates Conductive vs Sensorineural hearing loss Afferent input to the Oculocephalic Reflex

• Doll’s Eye Maneuver• Cold Calorics• Not “COWS”“Hearing grossly intact AU”

The Neurological ExaminationCranial Nerves

Glossopharyngeal and Vagus Nervesc.n.’s IX and X

CN IX Glossopharyngeal: moves the pharynx (swallow, speech & gag)

CN X Vagus: voice quality

The Neurological ExaminationCranial Nerves

Spinal Accessory Nervec.n. XI

Trapezius strength

Sternocleido-Mastoid strength

CN XI Spinal Accessory:

turns head and elevates

shoulders

ShoulderShrug

The Neurological ExaminationCranial Nerves

Hypoglossal Nervec.n. XII

Hypoglossal Nerve

Protrudes the tongue to the opposite sideTongue in cheek (strength)Hemi-atrophy and fasiculations (LMN)

The Neurological ExaminationMotor Examination

Strength Tone DTR’s Plantar Responses Involuntary Movements

The Neurological ExaminationMotor Examination

StrengthMedical Research Council Scale

5/5 = Full Strength 4/5 = Weakness with Resistance 3/5 = Can Overcome Gravity Only 2/5 = Can Move Limb without Gravity 1/5 = Can Activate Muscle without

Moving Limb 0/5 = Cannot Activate Muscle

The Neurological ExaminationMotor Examination

Weakness Describe the Distribution of Weakness

• Upper Motor Neuron Pattern• Peripheral neuropathy Pattern• Myopathic Pattern

The Neurological ExaminationMotor Examination

The Neurological ExaminationMotor Examination

Tone Tone is the resistance appreciated when moving a limb

passively “Normal Tone” Hypotonia

• “Central Hypotonia”• “Peripheral Hypotonia”

Increased Tone• Spasticity (Corticospinal Tract)• Rigidity (Basal Ganglia, Parkinson’s Disease)• Dystonia (Basal Ganglia)

The Neurological ExaminationMotor Examination

DTR’s 0/4 = Absent 1-2/4 = Normal Range 3/4 = Pathologically Brisk 4/4 = Clonus

The Neurological ExaminationMotor Examination

Involuntary Movements Hyperkinetic Movements

• Chorea• Athetosis• Tics• Myoclonus

Bradykinetic Movements• Parkinsonism (Bradykinesia, Rigidity, Postural Instability,

Resting Tremor)• Dystonia

Drift Assessment

Drift Assessment: test for motor weakness

Arm: hold arms out with palms up; eyes closed • Pronator drift: hands pronate (roll over); • Motor drift: arm “drifts” downward • Cerebellar drift: arm “drifts” back toward head or out to side

Leg: no need to close eyesmotor: leg “drifts”toward bed

Movement Assessment

Movements are purposeful or non-purposeful purposeful: picking at tubings or bed linens, scratching noselocalizing: moving toward or removing a painful stimulus; must cross the midline; occurs in the cortexwithdrawal: pulling away from pain; occurs in the hypothalamus

non-purposeful: do not cross the midlineabnormal flexion: (decorticate) rigidly flexed arms and wrists; fisted hands; occurs in upper brainstemabnormal extension: (decerebrate) rigidly, rotated inward extended arms with flexed wrists and fisted hands; occurs in midbrain or pons.

Decorticate

Decerebrate

The Neurological ExaminationSensory Examination

The Neurological ExaminationSensory Examination

Primary Sensory Modalities Light Touch (Multiple Pathways) Pain/Temperature Sensation (Spinothalamic Tract) Vibration/Position Sensation (Posterior Columns)

Cortical Sensory Modalities Stereognosis Graphesthesia Two-Point Discrimination Double Simultaneous Extinction

The Neurological ExaminationSensory Examination

Pain and Temperature• Pinprick (One pin per patient!)• Sensation of Cold• Look for Sensory Nerve or Dermatomal Distribution

Vibration Sensation• C-128 Hz Tuning Fork (check great toe)

Joint Position Sensation• Check great toe• Romberg Sign

The Neurological ExaminationSensory Examination

Higher Cortical Sensory Function Graphesthesia Stereognosis Two-Point Discrimination Double Simultaneous Extinction Gerstmann’s Syndrome (acalculia, right-left

confusion, finger agnosia, agraphia)• Usually seen in Dominant Parietal Lobe lesions

The Neurological ExaminationCoordination

Hemisphere Dysfunction Dysmetria on Finger-Nose-Finger Testing* Irregularly-Irregular Tapping Rhythm* Dysdiadochokinesis* Impaired Check* Hypotonia* Impaired Heel-Knee-Shin* Falls to Side of Lesion* Nystagmus (Variable Directions)

* All Deficits are Ipsilateral to the side of the lesion

The Neurological ExaminationCoordination

Midline Dysfunction Truncal Ataxia Titubation Ataxic Speech Gait Ataxia

• Acute Ataxia (unsteady Gait)• Chronic Ataxia (wide-based, steady Gait)

REFLEXES

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

MSR / DTR

• BICEPS• BRACHIORADIALIS• TRICEPS• KNEE• ANKLE

OTHER REFLEXES• Upper motor neuron dysfunction

– BABINSKI • present or absent• toes downgoing/ flexor plantar response

– HOFMAN’S– JAW JERK

• Frontal release signs– GRASP– SNOUT– SUCK– PALMOMENTAL

Abmornal Reflexes

Abnormal Reflexes: Babinski: initial inflection of great toe in response

stroking of sole; upgoing toe is abnormal Grasp: involuntary grasp in response to stimulation

of palm; abnormal in an adult Doll’s eyes: impairment of eye movement to opposite

side when head is turned = damage to brainstem; no movement = loss of

brainstem

Neuro Aessessment Quiz• 1. Peripheral Nervous System (PNS)

is made up of the following except::a) Cranial nerves (12) b) Ventriclesc) Axons and Neuronsd) Spinal nerves (31)e) Cerrebellar nerves• 2. The Autonomic Nervous System

contains both the Sympathetic Division of nerves and the Parasympathetic Division of nerves. True or False________________.

• 3. Intracranial Hemorrhage can occur in the following places except:

a) Epidural spaceb) Subdural spacec) Subarachnoid spaced) Ethmoid space

• .4. A Coup Contracoup injury is defined as: When the head strikes a fixed object, the coup injury occurs at the site of impact and the contrecoup injury occurs at the opposite side. True or False____________________

• 5. The Facial nerve controls:a) Movement of the chin, tongue and parotid

glands.b) Movement of the tongue, soft palete and

eyebrows.c) Movement of the chin and cheeks

muscles.d) Movement of all the facial expression

muscles.• 6. Which nerve controls movement on the

neck and shoulders?a) Abducensb) Accousticc) Spinal Assesoryd) Occulomotor

• 7. A serious injury to the cervical spine and spinal cord most likely will result in the following condition:

a) Hemiplegiab) Quadraplegiac) Paraplegiad) Contralateral paralysis• 8. Any suspected head, neck or spine

injured victim should immediately be given spinal immobilization precautions, except:

a) When the victim complains of pain only upon turning his head to one side.

b) When the victim refuses to allow spinal immobilization even after listening carefully to multiple attempts to explain the dangers and risk involved.

c) When the victim is intoxicated on alcohol and cannot speak clearly.

d) When the victim was never unconscious and denies any pain.

• 9. When assessing a patient with altered LOC, you feel his state of awareness/arousal is best described as “Obtunded”, this means:

a) Very drowsy, when not stimulated, but can follow simple commands when stimulated (i.e. shaking or shouting); verbal responses include one or two words, but will drift back to sleep without stimulation.

b) A state of drowsiness; client needs increased external stimuli to be awakened but, remains easily arousable; verbal, mental & motor responses are slow or sluggish.

c) Awakens only to vigorous and continuous noxious (painful) stimulation; minimal spontaneous movement; motor responses to pain are appropriate but, verbal responses are minimal and incomprehensible (i.e. moaning).

d) Vigorous external stimulation fails to produce any verbal response; both arousal and awareness are lacking; no spontaneous movements but, motor responses to noxious stimuli maybe be purposeful

• 10. The Glasgow Coma scale tests for three kinds of responses, they are:

a) Eye Openingb) Motor Responsec) Verbal Responsed) Auditory Response• 11. The best and worst possible score on

the GCS is:a) 15 and 0b) 13 and 3c) 15 and 3d) 18 and 5• 12. When assessing pupillary response,

you are looking for the following conditions except:

a) Coordinated eye movement and bilateral blinking.

b) Reactivity to and accommodation to light.c) Symmetry of pupils and accommodation

to light.d) Abnormal pupil shape.

• 13. A constricted “pin point” pupil indicates: (best answer)

a) Brain Stem herniationb) Cardiac Arrestc) Cerebral Infarction of the parietal lobed) Cerebral Infarction of the occipital lobee) A wide variety of conditions, some being

extremely life threatening. • 14. What Cranial nerve(s) controls the

movement of the eyes down and in?a) CN VI Abducensb) CN III Oculomotorc) CN IV Trochleard) CN II Optic• 15. The Motor strength scale goes from 0/5 to

5/5, 0 being no strength at all and 5 being normal strength. A person with a motor strength of 4/5 would be:

a) overcomes gravity; offers no resistanceb) strong against resistancec) weak against resistanced) no muscle movement

• 16. Match the following postures with its definition:

• Decerebrate_____________• Decorticate______________

a) Abnormal flexion: rigidly flexed arms and

wrists; fisted hands; occurs in upper brainstem

b) Abnormal extension: rigidly, rotated inward, extended arms with flexed wrists and fisted hands; occurs in midbrain or pons.

• 17. The Babinski reflex is the initial inflection (extension) of great toe in response stroking of the sole of the foot, select the correct answer:

a) An upgoing great toe is abnormal.b) An upgoing great toe is normal.c) An upgoing great toe is abnornal in adults.d) An upgoing great toe is normal in infants.

• Answers• 1 e• 2 True• 3 d• 4 True• 5 d• 6 c• 7 b• 8 b• 9 a• 10 d• 11 c• 12 a• 13 e• 14 c• 15 c• 16 Decer = b. Decor = a• 17 c&d