Neurological Examination by Emmanuel.pptx

I. Introduction & Purpose

A neurological exam assesses the nervous system (brain, spinal cord, nerves).

Purpose: find if there is neurological dysfunction, localize lesion, guide diagnosis.

It is done by history + physical tests (not imaging).
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Key principles: symmetry, localization, side comparison, pattern recognition.
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Always begin with consent, exposure, and positioning.
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Keywords: nervous system, localization, symmetry, consent, exposure

II. Preparation & General Approach

Wash hands, introduce self, explain the exam, obtain permission.
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Confirm patient identity (name, age) and key info (dominant hand, comorbidities).

Ask about history: onset, duration, progression, associated symptoms (pain, sensory changes, weakness, seizures).

Inspect patient at rest: posture, general appearance, facial symmetry, involuntary movements.

Ensure good lighting, proper exposure (arms, legs accessible).
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Use a systematic sequence so nothing is forgotten (e.g. mental status → cranial nerves → motor → reflexes → sensation → coordination → gait).
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Keywords: history, inspection, systematic sequence

III. Mental Status & Higher Functions
A. Level of Consciousness & Orientation

Assess alertness, wakefulness.

Ask orientation: Person, Place, Time (A & O × 3).

Use Glasgow Coma Scale if altered consciousness (Eye, Verbal, Motor) (scores 3–15).
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Keywords: consciousness, orientation, GCS

B. Attention, Memory & Cognition

Test attention (e.g. digit span forwards/backwards).

Test immediate recall, short-term memory (e.g. 3 objects).

Test remote memory, general knowledge.

Test language: naming, repetition, comprehension, fluency.

Ask patient to read or write (if possible).

Test praxis, calculation, abstract thinking.

Keywords: attention, memory, language, praxis

C. Speech

Observe fluency, volume, articulation.

Note dysarthria (slurred speech) or aphasia (language disorder).

Check naming, repetition, comprehension.

Keywords: dysarthria, aphasia, articulation

D. Other Higher Functions

Visuospatial: drawing, copying figures.

Neglect / extinction: bilateral stimulation, visual neglect tests.

Calculation, writing, reading comprehension.

Keywords: visuospatial, neglect, abstraction

IV. Cranial Nerve Examination (I to XII)
Cranial Nerve Function / Test Key Points / Observations
I (Olfactory) Smell Test nonirritant scents, one nostril at a time
II (Optic) Vision, visual fields, pupil reflex, fundus Snellen chart, confrontational fields, fundoscopy, pupil reactions
III, IV, VI (Oculomotor / Trochlear / Abducens) Eye movements, pupil size, accommodation Test extraocular movements, check for ptosis, diplopia, pupil constriction
V (Trigeminal) Facial sensation, muscles of mastication Light touch, pinprick on 3 branches; ask patient to clench jaw; corneal reflex (afferent V_1)
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1. Neurological Examination Focus: Cranial Nerves, Motor, Sensory, and Cerebellar Functions Presented by: AFOLABI EMMANUEL O.

2. Outline Introduction Component of neurological Examination Cranial Nerve Examination Motor & sensory System examination Cerebellar Examination Features of common Neurological Disorders Diagnostic Tools Conclusion

3. Introduction Neurological examination is a systematic process to assess the function of the nervous system. It evaluates various domains such as cranial nerves, motor system, sensory system, and cerebellar functions.

4. Purpose of Neurological Examination 1. Identify abnormalities in the nervous system. 2. Localize the lesion to the central or peripheral nervous system. 3. Guide further diagnostic testing.

5. Components of Neurological Examination The examination includes: 1. Mental status and higher cortical functions. 2. Cranial nerves. 3. Motor system. 4. Reflexes. 5. Sensory system. 6. Coordination and gait.

6. Mental Status Examination This assesses: 1. Level of consciousness (alertness). 2. Orientation (time, place, person). 3. Memory (short- and long-term). 4. Attention and concentration. 5. Language and speech.

7. Cranial Nerve Examination Cranial nerves are tested systematically: - CN I (Olfactory): Smell identification. - CN II (Optic): Visual acuity, fields, and fundus. - CN III, IV, VI: Pupillary reflexes and extraocular movements. - CN V: Facial sensation and mastication. - CN VII: Facial expressions and taste. - CN VIII: Hearing and balance. - CN IX, X: Palate elevation and gag reflex. - CN XI: Shoulder shrug and head rotation. - CN XII: Tongue movements.

8. cranial nerve Sensory Nerves: CN I (Olfactory), CN II (Optic), CN VIII (Vestibulocochlear) Motor Nerves: CN III (Oculomotor), CN IV (Trochlear), CN VI (Abducent), CN XI (Accessory), CN XII (Hypoglossal) Both Sensory and Motor: CN V (Trigeminal), CN VII (Facial), CN IX (Glossopharyngeal), CN X (Vagus) CN 1& 2 Cerebrum CN 3 & 4 midbrain CN 5, 6, 7 & 8 pons CN 9, 10, 11, 12 medulla NOTE YOUR GENERAL INSPECTION

9. Cranial Nerve I: Olfactory Nerve Test sense of smell by using familiar odors (coffee, vanilla). Loss of smell can indicate damage to the olfactory nerve or brain conditions like Parkinson's.

10. Cranial Nerve II: Optic Nerve Pupil-Size, shape, Symmetry, Reflex Assess: 1. Visual acuity using a Snellen chart. 2. Color vision using ishihara chart 3 . Visual fields via confrontation test ., Blindspot 4 . Fundoscopy to examine the optic disc and retina.

11. Optic Nerve

12. Cranial Nerves III, IV, and VI: Oculomotor, Trochlear, and Abducens Test eye movements: - Extraocular muscle function. (H pattern, Nysgamus) - corneal light reflex (direct and consensual). - Accommodation reflex. (strabismus)

13. Cranial Nerve V: Trigeminal Nerve Assess: 1. Sensation in ophthalmic, maxillary, and mandibular areas. (light touch wool, Pin Prick) 2. Muscles of mastication (clench jaw, move side-to-side , opening against resistance ) , jaw reflex,

14. Cranial Nerve VII: Facial Nerve Assess facial movements: - Raise eyebrows, close eyes tightly, smile, puff cheeks. (muscles of facial expression) - Test anterior two-thirds taste with sugar or salt.

15. Cranial Nerve VIII: Vestibulocochlear Nerve Assess hearing using: 1. Whispered voice test. 2. Rinne and Weber tuning fork tests. 3. Balance with Romberg test ( 30 sec, vestibular function).

16. Cranial Nerves IX and X: Glossopharyngeal and Vagus Nerves Assess: 1. Palate elevation when saying 'Ah.' 2. Gag reflex. 3. Voice quality and swallowing.

17. Cranial Nerve XI: Accessory Nerve Test: 1. Shoulder shrug (trapezius). 2. Head rotation against resistance (sternocleidomastoid).

18. Cranial Nerve XII: Hypoglossal Nerve Test tongue movements: - Protrude tongue, move side-to-side. - Check for fasciculations , wasting or asymmetry.

19. Motor System Examination Assessment includes: 1. Muscle bulk, tone, and strength. (R/L) 2. Involuntary movements like tremors or fasciculations. 3. Reflexes (deep tendon, plantar reflex). 4. Coordination (finger-to-nose, heel-to-shin tests). Posture and gait abnormalities.

20. Motor System Examination: Tone Assess muscle tone by passive movement of joints. Look for: - Hypertonia (spasticity or rigidity). -(cogwheel, lead pipe) Ashworth Scale - Hypotonia (flaccidity). Brunnstrom stages

21. Motor System Examination: Strength Test strength in major muscle groups using the Medical Research Council (MRC) grading scale (0-5). MRC system Gr. 0 – no contraction Gr. 1 – detectable contraction Gr. 2 – weak contraction insufficient to overcome gravity Gr. 3 – weak contraction that overcome gravity Gr. 4 – moderately strong contraction still demonstrating some weakness Gr. 5 – full strength

22. Motor System Examination: Reflexes Assess deep tendon reflexes. Jaw reflex Biceps reflex Brachioradialis reflex Triceps reflex Finger reflexes Hoffmann’s sign Patellar reflex (knee jerk) Achilles reflex (ankle jerk) Babinski sign Superficial reflexes Abdominal reflexes (CSTL) Cremaster reflexes Superficial anal (anal wink) reflex

23. Sensory System Examination: Superficial Sensation Test: 1. Light touch with cotton. (Across Dermatomes 2. Pain using a pinprick. 3. Temperature with a cold or warm object.

24. Sensory System Examination: Deep Sensation Test: 1. Vibration sense with a tuning fork. (over distal Bony Points) 2. Proprioception (joint position sense).

25. Sensory System Examination: Cortical Sensation Assess higher-order sensations: 1. Stereognosis (identify objects by touch). 2. Graphesthesia (recognize numbers traced on the skin). 3. Two-point discrimination. (discriminator, caliper)

26. Cerebellar Examination: Gait Assess gait patterns: 1. Normal walking. 2. Heel-to-toe walking (tandem gait). 3. Walking on heels and toes.

27. Cerebellar Examination: Coordination Tests include: 1. Finger-to-nose test. 2. Heel-to-shin test. 3. Rapid alternating movements (dysdiadochokinesia).

28. Cerebellar Examination: Balance Perform the Romberg test: - Stand with feet together, eyes closed. - Swaying or falling indicates cerebellar or sensory ataxia. Rebound phenomena //Tone, Speech(slurred),Nystagmus

29. Special Neurological Tests Additional tests may include: - Lhermitte’s sign for cervical spinal cord Pathology(myelin) . - Hoffmann’s reflex for upper motor neuron lesions. Spurling Sign-nerve root compression

30. Common Neurological Disorders: Stroke Stroke symptoms include: - Cranial nerve deficits. - Hemiparesis. - Speech impairment (dysarthria, aphasia).

31. Common Neurological Disorders: Parkinson’s Disease Features include: - Resting tremor. - Bradykinesia. - Rigidity and postural instability.

32. Common Neurological Disorders: Multiple Sclerosis Symptoms include: - Visual disturbances (optic neuritis). - Weakness and spasticity. - Sensory deficits and ataxia.

33. Common Neurological Disorders: Peripheral Neuropathy Symptoms include: - Numbness and tingling (glove-and-stocking distribution). - Loss of reflexes. - Muscle weakness.

34. Diagnostic Tools Techniques include: 1. Neuroimaging (MRI, CT). 2. Electrophysiological studies (EMG, nerve conduction tests). 3. Lumbar puncture (CSF analysis).

35. Conclusion Neurological examination is a comprehensive approach to assess nervous system health. It provides crucial insights for diagnosis, management, and prognosis of neurological conditions.

36. References falase Bradley's Neurology in Clinical Practice National insititute of neurological Disorders and stroke(NINDS)-Guildline uptodate youtube-geeky medics