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Neurologic History and Physical Examination

SECTION X NEUROLOGY





b. Hallucinations

Legend:  subjective sensory perceptions in

Arial – OT; italicized – lecture notes the absence of relevant stimuli

Comic Sans – Handout  May occur in delirium dementia,

Times New Roman – Bates and DeMyer posttraumatic stress disorders and

alcoholism



Neurological Examination c. Delusions

- Clinical examination is of primary importance in  false, fixed, personal beliefs that

the practice of neurology even with the are not shared by other members of

availability of advanced neuroimaging the person’s culture or subculture

techniques.

 This is because it tell you whether the E. Intellectual Capacity

patient’s nervous systems working normally a. Bright

b. Dull

c. Mentally retarded

Mental Status:

A. General Behavior and Appearance F. Sensorium (Cerebral Function)

B. Stream of Talk

a. Spontaneous

I. General Cerebral Function

b. Rapid

A. Level of Consciousness

c. Slow - evaluation of wakefulness and alertness

C. Mood and Affective Responses - the patient should be conscious before

a. Euphoric proceeding with the rest if the cerebral exam

b. Agitated - measured by the Glasgow Coma Scale

c. Weeping

d. Silent Glasgow Coma Scale

Response Score

e. Angry Eye Opening Spontaneous 4

To speech 3

To pain 2

Mood VS Affect None 1

Mood Verbal Oriented 5

- a more sustained emotion that may color a person’s Confused 4

view of the world Inappropriate 3

- “climate” Incomprehensible 2

None 1

Affect

Movement Obeying 6

- An observable, usually episodic, feeling or tone Localizing 5

expressed through voice, facial expression, and Withdrawal 4

demeanor Flexion (Decorticate) 3

- “weather” Extension (Decerebrate) 2

None 1





D. Content of Thought B. Intellectual Performance

a. Illusions i. Orientation

 misinterpretations of real external o time, place and person

stimuli o remember that disorientation typically

 may occur in grief reactions, follows a sequential pattern

delirium, acute and posttraumatic  first involving the situation, then

stress disorders and schizophrenia time, place and name

o the person that is oriented to time and

place but does not know his or her

name probably has a psychiatric

problem







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June 26, 2007 Dr. Ludwig F. Damian

ii. Memory

o intermediate recall, recent memory and ii. Repetition

remote memory o The ability to repeat sentences

o In neurological patients, impaired o Intact repetition in the presence of

immediate recall is usually due to serious deficits in fluency or

attention deficits rather than to pure comprehension is diagnostic of

amnesia transcortical aphasia, which implies a

good prognosis for recovery

iii. Calculation

o depends on the patient’s educational iii. Comprehension

background o If the patient is attentive, the ability to

follow one- and two-step commands

iv. Abstract Reasoning implies auditory comprehension

o interpretation of proverbs o If the patient id fluent, he may have non-

o analogy sensical speech with impaired

comprehension

v. Insight, Judgment and Impulse control

o Insight iv. Naming

 Awareness that symptoms or o Naming familiar objects

disturbed behaviors are normal or

abnormal v. Reading

o Judgment o Inability to read is called “Alexia”

 Process of comparing and

evaluation alternatives when vi. Writing

deciding on the course of action

 Reflects on values that may or may vii. Calculation

not be based on reality and social o Maybe considered as part of language

conventions or norms



II. Specific Cerebral Function Comparison of Different Types of Aphasia

A. Language Type of Fluency Repeti Compre Lesion

Aphasia Tion hension

- Disorder in language is termed “APHASIA”, Motor/ Broca’s/ Impaired Impaired Intact Inferior

referring to the abnormal language Expressive/ Frontal

production/expression of comprehension. Affluent Gyrus

- Do not confuse aphasia with dysarthria which is Sensory/ Intact Impaired Impaired Superior

Wernicke’s/ Temporal

a problem in articulation/ pronunciation and a Receptive/ Gyrus

motor disorder Fluent

Global Impaired Impaired Impaired Inferior

Components of Language Frontal and

i. Fluency Superior

Temporal

o Patient’s ability to talk spontaneously Gyrus

(rate and flow of speech production is Conduction Intact Impaired Intact Arcuate

normal) Fasiculus

o Characteristics:

 Speaking with effort

Higher Cerebral Function

 Finding words with difficulty

 Losing normal grammar and A. Cortical Sensory (Gnosis / Sensory Agnosia)

syntax - Agnosia

 Making preservative responses o With intact primary sensory modalities

 Making spontaneous there is failure or difficulty in recognizing

paraphrasic errors or identifying or interpreting an object

o Primary sensory modalities

 Light touch

 Pain

 Temperature

 Vibration

 Position sense

- Lesion : Contralateral Parietal Cortex

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- Types: o Ideational

o Astereognosia (Tactile Agnosia)  Absence of basic plan, although

 Inability to recognize objects many spontaneous actions are

placed in the hand easily carried out

 Difficulty performing the

o Agraphesthesia sequence of movements even

 Inability to recognize numbers or though the individual

letters when written in the part of movements can be performed

body. normally



o Auditory Agnosia o Constructional

 Hearing must be intact  Failure to construct simple

 Tested by audiometry models or designs



o Visual Agnosia o Dressing Apraxia

 Vision must be intact

Mini Mental State Examination (MMSE)

o Autotopagnosia - useful in screening for cognitive dysfunction or

 Own body parts dementia and the following their course over time



o Tactile Inattention



o Astatognosia Cranial Nerves

o Anosognosia A. CN I - Olfactory (Sensory, Special Visceral

 Lack of awareness or denial of a Afferent)

neurologic defect - Receptors: Olfactory Mucosa (Superior

 May be attributable to a lesion in Tubercle)

the right parietal lobe of the - Located supratentorially (above the Tentorium

brain Cerebelli)

- Pathway: Olfactory bipolar cells  Olfactory

nerve  Passes the cribiform plate  bulb 

B. Cortical Motor (Praxis) tract  Cortex (1’ and 2’)

- Apraxia - Bilateral Anosmia: disease of the olfactory

o Failure or difficulty to perform learned mucous membrane (Colds, rhinitis)

movements which cannot be explained - Unilateral Anosmia: disease/s affecting the

by weakness, sensory loss, nerve, bulb or tract ( Fracture involving the

incoordination, inattention or other cribiform plate, compression by tumors)

perceptual disorders - A lesion of one olfactory cortex is unlikely to

produce complete anosmia because fibers from

- Types each olfactory tract travel to both cerebral

o Ideomotor hemispheres.

 Motor behavior is intact when

spontaneous executed, but B. CN II - Optic (Sensory, Special somatic Afferent)

faulty when attempted in - Tests:

response to verbal commands o Visual Acuity

 Most difficult in miming the  Using the Snellen’s chart 20 feet

action away or a Jaeger chart for near

 Less difficult in imitating the vision

examiner

 Least difficult when given the o Funduscopic or Ophthalmoscopic Exam

object to use.  Look for the optic disc

 Take note of the margin’s color,

cup-disc ratio, blood vessels









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- Parasympathetic (General Visceral Efferent)

o Pupillary reaction to convergence

Papilledema (“Choked disc”) - bilateral associated with accommodation

- A sign of increased intracranial pressure  Impulses travel thru the optic

o Any space-occupying lesions such as nerve  chiasm  tract  LGB

tumors, hemorrhage, abscess and cyst  radiation  1’ visual cortex

- Disc margins become indistinct or hazy  Visual (occipital) cortex is

- Absence of the retinal venous pulsations connected to the eye field in the

- Early papilledema may not affect visual acuity frontal cortex

 From the frontal cortex 

Optic Neuritis internal capsule  synapse with

- May be unilateral or bilateral both oculomotor (III) nuclei in

- Pale discs with indistinct disc margins the midbrain  both medial recti

- Inflammation of the optic nerve contract (convergence)

- Causes: Multiple sclerosis, infections  Synapse with the

- With involvement of the visual acuity (↓) parasympathetic nuclei of the III

 papillary constriction

Large Subhyaloid Hemorrhages  Edinger-Westphal nucleus

- Subarachnoid hemorrhage

 Parasympathetic

nucleus of III

Macula

- Examined by asking the patient to look at the

o Pupillary reaction to light

light of the ophthalmoscope

 Direct light reflex

 Indirect or consensual light

o Pupillary Reflex reflex

 Direct  Impulses travel thru the optic

 Consensual nerve  chiasm  tract 

superior colliculus (midbrain) 

synapse with both

o Visual Field parasympathetic nuclei of the III

 Bedside test: Confontation test papillary constriction

 Objective test: Perimetry  Pupillary light reflex

 Receptors: (Retina) Cones and  Afferent – optic nerve

rods  Center – midbrain

 Pathway: Optic Nerve 

 Efferent – oculomotor

Chiasm  Tract  lateral

nerve

geniculate body (nucleus of the

 Check for ptosis, defined as a

thalamus)  optic radiation

drooping eyelid that does not

(parietal or superior fibers,

clear the upper margin of the

temporal or inferior fibers)  1’

pupil. Ptosis occurs with

visual cortex (calcarine fissure)

oculomotor nerve (CN3) injury

or with Horner’s syndrome

Site of Lesion Pattern of Visual Defect

(ptosis, miosis, anhidrosis)

Prechiasmatic Ipsilateral Monocular which results from injury to the

Chiasm Bitemporal Hemianopsia sympathetic nerve pathways to

Retrochiasmatic Contralateral Homonymous Hemianopsia the pupils

 Check for shape, symmetry,

reactivity to light and

C. CNIII - Oculomotor

accommodation of the pupils

- Motor (General Somatic Efferent)

o Innervates all EOM except lateral rectus

and superior oblique

o Innervates the levator palpebrae

superioris which opens the eyes









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E. CN V - Trigeminal

Reaction Small (miotic) Large (mydriatic) - Motor (Special Visceral Efferent – mandibular

Non-reactive to Argyll Robertson Holmes-Adie division)

light pupils Pasttraumatic iridoplegia

Pontine hemorrhage Mydriatic eyedrops o Muscles of mastication (TIME)

Opiates Atropine  Temporalis

Pilocarpine drops Overdose of  Internla pterygoid

Amphetamine  Masseter

Overdose of Cocaine

Brain Death  External pterygoid

Reactive to light Old Age Childhood

Horner’s syndrome Anxiety States - Sensory (General Somatic Afferent)

Holmes-Adie in the Physiologic anxiety o Ophthalmic

constricted phase

Inflammation of the

 Extends up the interauricular

iris area of the scalp

Physiologic anisocoria  Afferent for corneal reflex

o Maxillary

Lesion Direct Indirect/ o Mandibular

Response Consensual  The angle of the jaw is not

Response

Optic Nerve Negative Negative innervated

Midbrain Negative Negative

Oculomotor Negative Positive - Blink Reflex – use cotton wisp to touch the cornea

Nerve

- Jaw Jerk

- Trigeminal Neuralgia

o A Margus-Gunn Pupil is an afferent o Paroxysms of intense lancinating pains

papillary defect that results from a lesion along the distribution of a trigeminal

in the optic nerve (e.g. optic neuritis). division

With the swinging flashlight test, the

abnormal pupil will dilate rather than

constrict when the light shines on it. F. CN VI - Abducens (Motor, General Somatic

Efferent)

- Innervates the lateral rectus

D. CN IV - Trochlear (Motor, General Somatic - The cranial nerve with the longest intracranial

Efferent) course thus, affected by increase in intracranial

- Innervates superior oblique which rotates the pressure causing bilateral lateral recti palsy

eye download and medially

- The only cranial nerve that exits posteriorly *** Patients with CNs III IV VI disease complain of

- The head tilts to the opposite side to reduce diplopia (doubling of vision)

diplopia



G. CN VII - Facial

CRANIAL NERVES III,IV,VI - Motor

- Test for Extraocular Movements o Special Visceral Efferent

1. Cardinal gaze  Muscles for facial expression

2. Check for nystagmus o General Visceral Efferent

3. Bring finger directly in towards the bridge of the  Submandibular and sublingual

patient's nose to check for convergence salivary glands

- Note:  Lacrimal glands

o III Palsy- Ptosis, Large Pupil, Eye down and

out - Sensory – Special Visceral Afferent

o IV Palsy- diplopia on looking down or in o Taste from the anterior 2/3 of the tongue

o VI Palsy- Diplopia on lateral gaze o If there is proximal facial nerve lesion

 Hyperacussis (nerve to

stapedius muscle)

Mnemonics:  Loss of taste (chorda tympani)

th

LR – 6 CN  Facial Weakness

th

SO – 4 CN o If there is distal facial nerve lesion

rd

Others – 3 CN  Facial weakness only





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Types of Facial Weakness / Palsy

1) Central Facial Palsy Vertigo and Nystagmus

o Weakness of the opposite lower Peripheral Central

quadrant of the face Unilateral nystagmus Multidirectional nystagmus

Horizontal or Rotatory Horizontal or vertical

o eg. Stroke patients Severe vertigo Less Severe

 there will be positive or brisk Positional Constant

corneal reflex because (+) Ear S/Sx (+) Brainstem, Cerebellar and

orbicularis oculi is unaffected Long Tract signs

E.g. BPV, vestibular Eg. Brainstem Stroke,

neuritis, Meniere’s Multiple Sclerosis

2) Peripheral Facial Palsy disease

o Weakeness of the ipsilateral half of the

face - Cochlear:

o eg. Bell’s Palsy o Receptor: Organ of Corti

 Corneal reflex will be sluggish o Pathway: (COLIMA) Cochlea  Olive 

because orbicularis oculi is Lateral leminiscus  Inferior leminiscus

affected.  Medial geniculate body  Auditory

cortex

The Corneal Reflex o Tests:

- Afferent – Trigeminal nerve

 Weber

- Center – Pons

 Test for Lateralization

- Efferent – Facial nerve

 Conductive hearing loss-

lateralize to the

Other ways to test CN - Ask the patient to affected ear

pronounce these words:  Sensorineural deficit-

th will lateralize to the

“Mamamama” - 7 CN normal ear

th

“Lalalalala” - 12

th th  Rinne

“Kakakakaka” – 9 & 10 CN

 Compare Air and bone

Conduction

 Normally AC>BC

H. CN VIII - Vestibulocochlear (Sensory, Special

 Schwabach

Somatic Afferent)

- Vestibular:

o Receptors: Urticle, Saccule,

Semicircular canals I. CN IX - Glossopharyngeal

o S/Sx: dizziness, nystagmus - Isolated lesions are rare, usually affected

o The nuclei of III, IV and VI have together with vagus

connections with the vestibular nuclei o Motor

thru rge medial longitudinal fasciculus  Special Visceral Efferent

(MLF)  Muscles for swallowing

o Doll’s Eye Reflex which is tested together

 Positive: head is turned to the with vagus

left, both eyes deviate to the  General Visceral Efferent

right, and vice verse  Parasympathetic –

 May be done in vertical direction parotid gland

which indicates MLF is intact’

o Caloric test: (COWS) o Sensory

 Cold water  opposite direction  Taste from the posterior 1/3 of

 Warm water  same direction the tongue

 Receptors for the carotid sinus

and body (together with vagus)









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J. CN X - Vagus

- Motor and sensory to the heart, thoracic blood Motor System

vessels, respiratory (larynx, trachea, bronchi, - Check for atrophy, fasciculations, adventitious

lungs), GIT ( pharynx to colon) liver, kidneys movements, tone and power

- Test: Gag or pharyngeal reflex - Test for bulk, tone and strength

o Afferent: IX

o Efferent: IX and X

Grading of Muscle Strength

o Testing elevation of the soft palate

0 No movement

 Uvula pulled to the left- Right

1 Minimal twitch / contraction

CNIX is affected

2 Active movement without

 Uvula pulled to the right- left CN

gravity

IX affected

3 Active movement against

- Patients with CN’s IX and X problems complain

gravity

of dysphagia, dysphonia, aspiration and

4 Active movement against

dysarthria

gravity and minimal resistance

5 Maximal Resistance / Normal



K. CN XI - Spinal Accessory (Motor, Special

Visceral Efferent) - DRIFT??

- Test: Strength of the sternocleidomastoid and - For lower extremities, use activity like standing

trapezii and walking

o Peripheral lesion - Put muscle at a disadvantage

o ipsilateral SCM weakness and - Divided into pyramidal and extrapyramidal

ipsilateral trapezius weakness systems.

o Central lesion

o ipsilateral SCM weakness and Test the following for Muscle Strength

contralateral trapezius muscle Innervation

- Movement of the head and neck Flexion Elbow C5,C6 Biceps

Extension Elbow C6,C7,C8 Triceps

Extension Wrist C6 C7 ,C8 Radial

Grip Squeeze two of C7,C8, T1

L. CN XII - Hypoglossal (Motor, General Somatic your fingers

Efferent) Abduction Finger C8 ,T1 Ulnar nerve

- innervates the intrinsic tongue muscles Opposition Thumb C8,T1 Median nerve

Flexion Hips L2,L3,L4 Iliopsoas

- LMNL: with atrophy and fasciculation; tongue Adduction Hips L2,L3,L4 Adductors

deviates towards the weak side (site of lesion) Abduction Hips L4,L5,S1 Gluteus medius

- UMNL: no atrophy and fasciculation; tongue and min

deviates opposite to the lesion Extension Hips S1 Gluteus Max

- Ask the patient to protrude their tongue straight Extension Knee L2,L3,L4 Quadriceps

Flexion Knee L4, L5,S1,S2

out of the mouth Dorsiflexion Ankle L4, L5

o Tongue deviated to the right- Flexion Plantar S1

Right CN XII affectation

o Tongue deviated to the left- Left

CN XII affectation A. Pyramidal Tract

- NB. The strong side of the tongue “pushes” the - Passes through the pyramids of the medulla

tongue toward the weak side - Corticospinal tract

- Pathway: cerebral cortex  corona radiata 

***These CN’s may be affected by lesions like traumatic internal capsule (posterior limb)  anterior

injuries, tumors compression on or arising from them, or portions of the brainstem (crus cerebri, cerebral

more generalized disease such as myasthenia gravis, peduncle, basis pontise, pyramid)  majority

GBS, hyperthyroidism, infectious and malignant crosses at the lower medullary pyramid

infiltrative disease. (pyramidal decussation)  descend the spinal

cord as the lateral corticospinal tract









-7-

Differentiation between Lower and Upper Motor Example of Disease

Neuron Lesions 1. Parkinson’s Disease

S/Sx UMN LMN

Atrophy Absent Present

- Lesion: Substantia nigra

Muscle tone Spasticity Flaccidity - Neurotransmitter: Dopamine (↓)

DTR’s Increased Normal,

decreased, 2. Drug-induced EPS (usually from anti-psychotics)

absent

- Anti-psychotics antagonize dopamine.

Pathological Present Absent

Reflexes

Fasciculations Absent Present

II. Cerebellum and its connections

- Possible sites for an UMN lesion - 2 hemispheres connected by a midline vermis

o Opposite Cerebrum - Hemisphere: ipsilateral limbs

o Opposite Brainstem - Vermis: trunk

o Ipsilateral Spinal Cord - Symptoms can be seen in the limbs, trunk, gait

- Possible sites for LMN lesion and stance, speech and eye movement as

o Anterior horn cell in the spinal cord; ataxia or incoordination

motor nuclei of the cranial nerves in the - Ataxia is the disorder in the rate, rhythm,

brainstem amplitude, and force of a voluntary movement

o Peripheral Nerve; Cranial Nerve - Dysdiadochokinesis is the slowing or

o Myoneural Junction awkwardness of performing alternating

o Muscle movements



Phylogenic Divisions of the Cerebellum

B. Extrapyramidal Tract 1) Archicerebellum

- Does not pass through the pyramids o Flocculonodular lobe

- Basal ganglia, cerebellum and its connections o Oldest; with connections with the vestibular

system

I. Basal Ganglia Components o For equilibrium and balance

1) Corpus Striatum: Caudate Nucleus + Lenticular o S/Sx: Ataxia, Broad-based gait

Nucleus 2) Paleocerebellum

2) Lenticular Nucleus: Putamen + Globus Pallidus o Anterior lobe

3) Neostriatum: Caudate Nucleus + Putamen o With connections with the spinal cord

4) Substantia Nigra (midbrain) o For maintenance of muscle tone

5) Subthalamic Nucleus o S/Sx: Hypotonia

3) Neocerebellum

Cardinal Symptoms o Posterior lobe

- Involuntary movements o With connections with the cerebrum and

o Tremors pontine nuclei

o Chorea o For coordination of fine movements

o Athetosis o S/Sx: Tremors (intention) dysmetria

o Hemiballismus

o Dystonia Cerebellar Cortex – 3 layers

- Rigidity o Molecular

o Increased resistance is present o Purkinje Cell Layer

throughout a full range of motion o Granular

o Differentiate from spasticity (UMNL) –

muscle tone and resistance is greatest Cerebellar White Matter

at the beginning of the movement and o Climbing and mossy fibers

slowly decreases until there is a sudden

loss of resistance. Cerebellar Deep Nuclei (lateral to medial)

- Poverty of Movement o Dentate

o Bradykinesia or hypokinesia o Emboliform

o Globose

o Fastigial Nuclei









-8-

Reflexes

Sensory System A. Deep Tendon Reflexes

- Dermatomes: skin areas innervated by the nerve - Striking the muscle tendon with a reflex hammer

roots normally leads to a muscle contraction mediated

- Because of its subjectivity, is the most difficult and by the lower motor neuron motor arc.

the least reliable part of the neurological - Hyperreflexia results from upper motor neuron

examination lesions as a result of release from normal

- In patients with depressed level of consciousness or descending inhibition

severe inattention, sensory testing usually provides - Hyporeflexia results from lesions f the lower

little useful information. motor neuron

- Usually test for:

o Pain and temperature Principal DTR’s and their corresponding

o Vibration and propioception Spinal Roots

Reflex Nerve Root

o Light touch

Biceps Musculocutaneous C5-C6

- Sensory loss typically occurs in specific patterns: Try

Triceps Radial C6-C7

to look for them

o Hemisensory loss: cortical/cerebral Brachioradialis Radial C5-C6

o Crossed sensory loss (ipsilateral face, Quadriceps / Femoral L2-L4

Knee

contralateral body): Brainstem

Achilles / Tibial S1

o Spinal level and Brown Sequard’s

Ankle

Syndrome: Spinal Cord

o Distal symmetrical or glovestocking sensory

loss polyneuropathy Scale of Grading Reflexes

o Dermatomal sensory loss: mononeuropathy 0 Areflexia / No

o Saddle anesthesia: Cauda Equine or Conus response

Medullatis + Hyporeflexia

- Different sensory modalities and pathways ++ Normal

o Pain and temperature: Lateral Spinothalamic +++ Hyperreflexia

Tract ++++ Hyperreflexia +

 Decussates at the spinal cord level clonus

o Propicception, vibration: Dorsal column-

medial lemniscus pathway ***MSR – Muscle Stretch Reflexes

 Decussates at the lower medulla Jendrassik Maneuver - reinforce reflexes



Different Spinal Cord Sydromes and their Clinical Manifestations B. Superficial / Cutaneous Reflexes

Brown-Sequard Below the lesion: - They do not require routine testing, but their

Syndrome (Hemisection) - Ipsilateral weakness

- Ipsilateral loss of proprioception,

testing is useful in unconscious patients or when

vibration a spinal cord or a cauda equine lesion is

- Contralateral loss of pain and suspected

temperature - They are frequently absent in otherwise normal

Central Cord Syndrome - Sacral scarring

- Sensory dissociation

elderly or obese individuals

(Eg. Syringomyelia) o Loss of pain and - Their presence implies normal function of the

temperature at the level spinal cord and corresponding sensory and

of the lesion and motor nerves

position and vibration

sense/ dorsal column - Usually tested

spared initially o Cremasteric Reflex

- Shawl-like or brachial distribution o Superficial Abdominal Reflex

of weakness and sensory loss

more than the lower extremities

Anterior Spinal Artery - Dorsal column/ proprioception and C. Frontal Release Signs

Syndrome vibration spared - These primitive reflexes are typically seen with

- anterior 2/3 of - Lateral Spinothalamic/pain and

the spinal cord temperature and lateral dementia and frontal lobe disease, but they may

corticospinal/ motor tracts affected also occur in normal individuals, especially

infants









-9-

D. Pathologic Reflexes (some occurs normally in Gait and Station (Balance)

infants) - Disturbances of gait can result from dysfunction in

a. Babinski one of the following motor cortex, corticospinal

o Dorsiflexion of the big toe with the tracts, basal ganglia, cerebellum, vestibular system,

extension and fanning of the other toes peripheral nerves, muscles and visual and

elicited by firmly stroking the lateral propioceptive afferent tracts

aspect of the sole of the foot. - Look for the posture, width of stance, length of

o If present in adults, it indicates a lesion in stride, arm swing, and balance

pyramidal tract - Test the following:

o Natural Gait

o Tandem heel to toe

b. Clonus

o Toe walking for distal leg strength

o Another way of demonstrating hyperactive

o Heel walking for distal leg strength

MSRs after an interruption of the UMNs. o Sitting to standing to assess proximal leg

o A to-and-fro, 5- to 8-cycles per seconds, strength

rhythmic oscillations of the body, elicited o Romberg’s Test / Sign

by quick stretch  A test of position sense

 The patient should first stand with feet

c. Hoffman’s together and eyes open, then close both

o Finger flexion Reflex eyes for 20-30 secs without support.

o Depression of the distal phalanx and  If the patient cannot stand with eyes

allows it to flip up, the extension of the open and feet together, suspect a

phalanx starches the flexor muscles, severe cerebellar or vestibular

causing the fingers and thumb to flex. disturbance

 If substantial instability or falling

occurs only after the patient closes

d. Palmomental

the eyes, Romberg’s test is Positive

o an abnormal neurologic sign, elicited by and indicates either propioceptive

scratching the palm of the hand at the (neuropathy or dorsal column

base of the thumb, characterized by disease) or vestibular dysfunction

contraction of the muscles of chin and in o Pull test

the corner of the mouth on the same side  Falling or retropulsion suggest

of the body stimulus impaired postural reflexes. As

o Also called a Palm-Chin Reflex occurs with parkinsonism

o Test for Pronator Drift

e. Grasp

 Patient should stand for 20-30 seconds

with both arms straight forward, palms

o A pathologic reflex in adults which is

up and with eyes closed… then tap the

induced by stroking the palm or sole with

arms briskly downward (With arms

the result that the fingers or toes flex in normally return smoothly at the

a grasping motion. horizontal position)

o Occurs in the diseases of the premotor  (+) Pronator Drift

cortex.  Pronation of one arm (suggest

contralateral lesion in the

f. Snout / Rooting corticospinal tract)

o Snout: An abnormal sign elicited by  Downward drift of the arm

tapping the nose, resulting in a marked with flexion of the fingers and

facial grimace elbows

o Indicates bilateral corticopontine lesion

Types of Gait

o Rooting: A normal response of the

1) Hemiparesis

newborns when the cheek is touched or

o Weakness of one half of the body

stroked along the slide of the mouth to o Spastic Hemiparesis: Associated with lesion in

turn the head toward the stimulated side corticospinal tract, such as stroke.

and begins to suck.



g. Glabellar Tap



- 10 -

2) Ataxic (Cerebellar)

o A gait that lacks coordination with reeling and Cerebellum

instability

- Coordination

o Associated with disease of the cerebellum or

associated tracts o Coordination of muscle movement requires

o Gait is staggering, unsteady and wide-based, 4 areas of nervous system function in a

with exaggerated difficulty on the turns integrated way

 Motor System

3) Parkinsonian  For muscle strength

o Associated with basal ganglia defects of  Sensory System

Parkinson’s Disease  For rhythmic movement

o Posture is stooped, with head and neck forward and steady posture

and hips and knees slightly flexed  Vestibular System

o Arms are flexed at elbows and wrist  For balance

o Steps are short and shuffling

 Cerebellar System

o Arm swings are decreased

o Patient turns around stiffly “ all in one piece”  For position sense

o The following are used to assess

4) Steppage coordination:

o Associated with foot drop, usually secondary to  Finger-to-nose test

LMNL  Dysmetria and intention

o Patients tend to drag their feet or lift them high tremor

with knees flexed  Heel-to-shin test

 Point-to-point movements

5) Scissors  Rapid alternating movements

o Associated with bilateral spastic paresis of the  Overshoots

legs

o Gait is stiff

o Each leg is advanced slowly and the thighs tend Dysmetria

to cross forward on each other at each step. - inability to perform point-to-point movements due

to over or under projections of one’s fingers

6) Wadding Dysdiadokinesia

7) Apraxic - inability to perform rapidly alternating movements

8) Hysterical - Nystagmus

o Involuntary, rhythmic movements of the

Meningeal Signs eyes

- Brudzinski’s Sign

o As you flex the neck, watch the hips and knees Autonomics

in reaction to your maneuver. - Continence

o (-) hips and knees are relaxed and motionless - Sweat Pattern

o (+) Flexion of knees and knees ( which suggest - Horner’s syndrome

meningeal inflammation) o Ipsilateral ptosis

- Kernig’s Sign

o Pupilloconstriction

o Flex the patient’s leg at both the hip and the

o Anhidrosis

knee, and then straighten the knee.

o Flushing

o Note that discomfort behind the knee during full

extentionoccurs in many normal people but it o Sometimes Exopthalmos

should not produce pain

o (+) Pain and increased resistance to extending

the knee. When bilateral it suggest meningeal

irritation

- Meningeal Irritation

o Anything that is not normally found in the

CSF space like infection, blood, therapeutic

or radiologic chemicals, or abnormal

malignant cells can cause meningeal

irritation or meningismus

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Level Of Consciousness : Technique and Response

Level Technique Response

Special Examinations

Alertness Speak to the Opens the eyes, looks at

- Straight-Leg Test (Laseague’s Test)

patient in a you and responds fully

o Test for nerve root compression which

normal tone and appropriately to

stretches the sciatic nerve.

of voice stimuli

o The examiner elevates he leg, then

Lethargy Speak to the Appears drowsy but opens

dorsiflexes the foot

patient in a the eyes and looks at you,

o (+) Pain due to inflamed, compressed and

loud voice responds to questions,

imprisoned by mechanical lesion

then falls asleep

Obtuntation Shake the Opens the eyes, responds

- Reverse straight leg raising test

patient gently to questions but seems

- Crossed straight leg raising test

as if confused.

- Tinel’s Sign

awakening a

o An indication of irritability of a nerve

sleeper

resulting to distal tingling sensation or

Stupor Apply painful Arouses only after an

percussion of a damaged nerve

stimuls painful stimuli. Verbal

o Often present in carpal tunnel syndrome

responses are slow or

o Done by tapping over the medial nerve on

even absent. The patient

the volar aspect of the wrist

lapses into an

unresponsive state when

- Phalen’s Maneuver

the stimulus ceases.

o Hyperflexion of the wrist for 60 secs.

Coma Apply No response to inner need

Produces pain in the median nerve

repeated and external stimuli

distribution

painful stimuli

o Relived by extension of the wrist.



III. Neurologic Evaluation

Neurologic Examination in a Comatose - Respirations

Patient - Pupils

- Ocular Movement

I. Asses the ABC’s - Oculocephalic Reflex (Doll’s Eye Movement)

- Check the patient’s Airway, Breathing and - Oculovestibular Reflex (Caloric Stimulation)

Circulation - Posture and Muscle Tone

- Assess the remaining vital signs: - Cheese (052507)

o Pulse

o Blood Pressure

o Rectal Temperature

II. Establish the patient’s level of consciousness

- determined by the level of activity that the

patient can be aroused to perform in response to

escalating stimuli from the examiner









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