Neurological examination PDF manual

Neurological examination PDF manual

9. ‘Table 1 -The Glasgow Coma Score (GCS)

10. ‘Table 2 - Mental Status Examination (MSE)

11. able 3 - Aphasia

15. Table 4

26. MAC Seale

‘Table 6 - Norve Roots and Peripheral Nerves Supplying Arm / Leg Muscles

32. xtensor Carpi Ulnaris C7}
ke (Posterior

33. . Hallucis Longus LSjExtensor Digitorum Brevislexiensor Digitorum Longust
Deep Peronea N. [LS Deep Peroncal N. ILS Deep Peroncal N.

on of Deep Tendon Retlexo

43. in

44. Table 1: Glascow Coma Scale
Parameter Score Response
Eye opening Spontaneous 4
To voice 3
To pain 2
No response
Best verbal response Orient, converses
Disorented, converses
Inapproprate words
Incomprehensil sounds
No response orintubated
Best motor response Folows commands
Localzos response
Wibdraws
‘Abnormal exon
‘Abnormal extension
No response
Highest score = 15 Lowest score = 3
‘Table 2: Glascow Outcome Scale

— No Carora era lui at can be ed by
Severe disabilty Conscious but dependent
Moderate csabilty Independent but disabled

‘Able 1o paripat in normal social fe and abe to return

Good recovery See

Table 3: Glascow Coma Scale Scores vs. lascow Outcome Seale

Glascow coma scale at 24 Good recovery or moderate
hours satity by %

1115 91% 6%

Vegetative or dead by %

810 ES
57 28%
34

46. ss

52. Use the fotowing scale trate strength

No movement, no contraction ofthe muscle

Trace, evidence of muscle contraction but no joint movement

wth gray olminated

006, complete range of maton against gravity wih moderate resistance

53. ‘Scoring of Deep Tendon Retloxe

6 respon:

‘Sluggish or diminished

Acive or expected respons
More brisk than expected, sighty hyperactive

56. Minimal Distances for Two Paint Diserminaton by Location

Minimal distance (mm)
mm
40 1 70mm

59. Neurologic Examinati

INDEX. COCA MSWMY VISORES www yassermewwally nto
"Beinen Noos Gear

+ General Considerations
1 Menu Sat
1 Cranial Nes
* Obseration

lacio

M-Opie

ML Gealomotor
IV Trost
V-Tnigeminal
VI-Abducens
VAL Facial
VII Acoustic
IX-Glossopharyngcal
X- Vagus
SI Accessory
XIL-Hypoglossal

+ Moor
> Observation
S Missle Tons
© Made Strength
© Ponator Dit
+ Coordination and Gait
"> Rapid Altsmating Movements
Poiio-Point Movements
© Romberg
> Gait
Reflexes
‘© Deep Tendon Reflexes
> Clonus
© Maar Response Babinski)
Senor
© General
Vibaion
9 Subst Light Touch
‘Pion Sense
© Desmstomal Testing
5 Bin
© Temperature
© Ligh Touch
5 Discrimination

+ Meningeal signs

Decerebrte & Daconticate posturing
Nos

60. Equipment Needed

Equipment Needed
«Reflex Hammer

+ 128 and $12 (or 1024) Hz Tuning Forks
+ A Stellen Eye Chart ox Pocket Vision Cant
Pen Light or Otoscope

‘Wooden Handled Coton Swabs

‘Paper Clips

General Considerations
‘+ Always consider lft orght symmetry

‘+ Consider central vs. peripheral dics

Organo your thinking ino seven categories:
‘Mental Stats

Cranial Nerves

Motor

Coonination and Gait

Sonny

Special Tests

Mental Status

“The Mini Me

tal Staus Examination ia useful seoening too

Cranial Nerves
Observation

+ Poss ct

+ Facial Droop or Asymmetry (VI

1 Hoarse Voice 00),
Articulation of Words (Y VI X, XID)

{Abnormal Eye Position (I, IV, VD

À Abnorma or Asymmetrical Pups (I)

1- Olfactory [1]

value he patency ofthe nasal passages bilateral by asking th atento beat in hough
thor nose while the examiner cles one nor a à tne. Once patency is established, ak
the patient to los their eyes Occldo one nose, and place à small ur sap near the patent
mi and ck ie paint o smell the object and opor what it. Making certain the pits
‘yes rem closed. Switch nos and repeat Futhemor, ask he patient to compare the
Strength ofthe sel in ach not

61. Oise rives CET
mon)

a
‘The olfactory nerve is part of our ability to smell. Loss o th sense of smell i all
“anomia. Most patients with anosmia can still smell harsher smells (eet and our)
bot have dificult with flavors like cinnamon and peppermint. Patents with
{anosmia often complain that they've lst thei sense of taste. Much of the pleasure
(derived from cating Is due to smell, not taste (think of sing glass of fine wine
before drinking 10. There are many causes for ames:

1. Trauma,
2 Surgery
3. Masses affecting the orbitofrontal region or erbiform plate

4. Destruction of the neuroepitheliam due to inflammation, as in chronic

‘nko al fc
1-Opic

+ amine Opti Fond

Tea Vinal sy E:

1. An the pi oe gls or cont ns avala. Yo ae man paie corrected PP:

Man Fons

2. Tone ao 2 cn rant ofthe Sal eye ha or Rosnhuum can a a Minch wading” EERE

ames, a

pr
Pe Sn

ot

1

Have the patent cover one eye aa
ASK patent 1 rad

Record the small inet
Repeat with the other xe

me witha cad.
gressively smaller lts ul they can go o fae.
paient ral succesfully (20720, 2030, te) (2)

a Visual Fields by Confrontation

‘Stand fe in font ofthe patient and have them look nt our yes.
Hol your hands about one foot away from he patient ars, and wiggle finger on one hand. [3

Ask

patient to indicate which sie they se the finger move

Repeat wo oe hr times tots bot temporal feds
Wa abnormality is suspected test the four quadrants of each eye while aking the patient to cover the opposite eye with an,

+18)

à Pupilary Reations to Light

Din room ight as necessary
ASK he patient ook nto the distance,

Shine a right ight obiquely into each pupil in tum.

Look for bot dhe tet same eye) and consensual (other eye) 4
Im and any symmetry or ep.

abnormal prod with th tet for accommoda

‘Tes Papillary Reactions to Accommodation [3] +

Record pupil siz

Hol our finger about 10cm fom the patent nos.
2. Asksthem to kemate looking ino the distance and at your Finger
3. Observe the pupillary response in each ee

Figure 1. Examination of the light reflex

II -Oculomotor (oxctoranoninewaso i) (Gara so)
{Observe for Prosis

62. + Tex Exaocalar Movements 2
1. Sand or 3106 ein front ofthe parent
2. Ask the aient 0 follow your finger Wh thee eyes without moving hei ca
3. Check gaze inthe sx cardinal ston sing across or Hatte
&. ane during upwar and lateral are to check for ysagmu. 16
5. Check convergence by moving our ings ward the ee of he pens noe
+ Test Papy Reactions u Light (See Aie)

IV - Trochlear

‘Test Exraocular Movements (Inward and Down Movement, See Aborc)
Ve Trigeminal (Cs

+ Test Temporal and Masseer Muscle Strength
1. Ask patient to both open her mouth and clench hi ch.
2, Palpate the temporal and muster muscles as they do tis
+ Tesihe Teo Divisions fr Pain Sensation
1. Explain what you inten 0 do.
2. Un suitable shar objet to tet the rc, check, andj on bath sis 17)
3. Soit à blunt objet ocesioally and ask the patient 10 por “sharp” or ll”
{tf yu find and abnormalis the:
1. Test thee divisions fr temperature sensation ia tuning fork heated or cold by water ++.
2. Teste thee division for sensation to ight touch using a Wisp of cotton +
+ Teste Comeal Reflex ++
AK the paint to look up and away.
From the ther side touch the come eh witha ine wis o coton,
Look forche norma link action of both eyes
Repeat on the ater sie
Use of contact ens may decrease his response

samination of ihe motor part ofthe trigeminal nerve
1. ‘Tos Temporal and Maseer Muscle Strength
2. Askthe patient to pen their mouth and clench hir eth,
3. Palpate the temporal and master muscle a hey do this.

63. Figure 2. Examination ofthe sensory part ofthe trkeminal nerve

‘Table 1. Examination af the sensory part ofthe trigeminal nerve

I 1
+ Test the Three Divisions for Pain Sensation

Explain what ont do thn a the paint os theres
«© Usea clean slightly sharp disposa objeto et the forehead checks and jaw on bth de.
+ Suite a lat objet (ten sab) ccsionaly and ak he paint por “tap” or “ll”
© The opin mail, and mandibular divisions ai caia nerve se ually ented VI, V2, and V3.
o Test for Temperate and Light Touch
© Han abnormality ssp, proceed with more detailed testing
«© Taste he divisions for tempertire sensato with ning ork estado cooked by water
«© Teste de divisions fr sensation igh tach using a wisp of ton.
+ Test the Cornea Reflex
0 The Corneal Ree isnt necessary uns an anormal ofthe igeminal(V) rca (VD nerves suspected,
© Remove contact lenses, if present, stos may decrease this response
«© Ask he pation took yp and ana
«Frm the oer side touch he comea igh with ine wisp coton,
6 Lock forthe nonna Mink reaction ofboth eyes.

Repeat on the oher side

Yan Glick for online video

Tos

Extrocular Movements (Lateral Movement, Ses Above)

+ Ask Patent to do the following, note any lg, weakness, or assymety
1. Raise eyebrows (8)
2, Cine both ees to resistance
3. Smile

64. 4. Frown
5. Show teeth
6. Patos cocks

+ Teste Corneal Reflex (See Above) ++

Figure 4 Intracranial facial nerve connection

“Table 2, Principle of facial nerve examination

“Observe for any Facial droop or asymmetry.
Ask the patent todo afew of the following (It snot necessary todo them all):
+ Raise eyebrows
+ Clase both eyes to resistance
+ Smile
+ Frown

+ Show toi

65. + Pat out chooks 2
+ Note any lag, weakness oF asymmetry.
Test the Cornea Reflex

‘The Corneal Reflex is not necessary unless an abnormality of the trigeminal (V) oF facial (VI) nerve ls suspected. Tease out a fine
vip from the end of cotton bal or swab. Warn the conscious patient what you are about odo. If necessary, hold the patents eyelid
‘pen to expose the cornea, Touch the cornea with the wisp by approaching from the side and avoiding the area of central vision. The
patient should spontaneously shut both eyes in response 10 corneal stimulation. This isa monosynaptie reflex between the sensation to
the cornea provided bythe ophthalmic nerve (VI) and the muscles ofthe eyelids, innervated by the facial nerve (VID.

With CN VIE recall thatthe type of finding relates to the presence of a central versus a peripheral nervous system lesion. With a
unilateral central nervous system lesion (eg stroke) rca this would involve the orticobulbar pathway, Function is preserved over

the upper part ofthe face forehead, eyebrow, eyelid) If the lesion involves the peripheral seventh nerve (Beil palsy, the entire face
involved,

VII - Acoustic

“Soren Hearing 191
1. Face the patient and holdout your arms wit our finger nca cach ea
2. Rub your fingers together on one side while moving the finger noisslesly onthe other.
3. As the pain to tl you when and on which id they hear the AN.
Increase intensity a needed and not ny a
5. Wahnorml, pocend with the Weber and Rin

tapping ton your opposite hand
3. Place the tase ofthe tuning fork Amy on tp ofthe patents ha.

4, ASK e patient where the sound appears 10 be coming from (nol in ihe midline),
‘Compare Airand Bone Condition (Rinne) ++

1. Uso 512 Hor 1028 He tuning fork.

2 Start the fork vibrating by tapping ton you apposite and
3. Place the bse ofthe tuning For agains he mastoid bone Behind theca.

Wen the pation no longer har the sound hold he end ofthe or near the pat ar air conduction i ormall greater han

bone condition).

+ Vesibular Funcion: Use the past poining test

Figure 5. Examination ofthe acoustic nerve

66. ‘Table 3. Principle of Rinne test and Weber tests

“Compare Air and Bone Conduction (Rinne)

1. Str with a 512 Hz tuning for vibrating by tapping iton your hand

2. Place the bas ofthe tuning fork aginst the mastoid process on oe side.

3. Ask patent 1 tell you when the sound goes away.

4. When the patent no longer hears he sound. bring the end ofthe tuning fork near the patients ca.

5. Airconducton is normally greater than bone conduction so they should hear the sound again fr several more seconds
Test or Lateralization (Weber)

1. Str with a $12 Hz tuning fork vibrating by taping ton your hand

2. Place the has ofthe tuning fork my inthe ner on top ofthe patient’ heat.

3. Ask patent where they ear he sound

44. They shuld hear he sound “in the center” if hey have normal hearing

bearing los
Conductive
+ Cond

e Hearing Loss (Middle Ear Deafness)

‘The Weber and Rinne tests are used to differentiate conductive from sensorineural

| bane conduction better than air on that side: The sound f transmite to the cachlea

a ‘The finger rubbing test is abnormal on the affected side. The Rinne tst wi

lnteraliz to the affected car. This is because sounds arriving vi
appear louder when ar conduction ls decreased (masking effec).

tology: Usually due to a structural defect (blocked can

scared and immobile inhibidg the transfer of sound vibrators.

+ Sensorincural Hearing Loss

that alr conduction better than bone (normal if heard

‘affected (beter) ear.

ay meningiomas), stroke, trauma, children born to mothers who had Rubel
pregnancy, aminoglycoside toxic
gene cases

IX - Glossopharyngeal

Soe Vagus None

+ Lien to the patients voice is it hoarse or nasal?

‘through bone rather than through the middle ear. Paradoxically the Weber test will
bone conduction

trauma, scarred or tom
tympanic membrane, Otoseross occurs when the stapes bone in the middle car i

‘The finger rubbing test Is abnormal onthe affected sde. The Rinne test would indicate

À Te Weber test would
Tateralize o the unaffected car. Due to the damage to the auditory neural pathway
cher bone or air will conduct well and for this reason the sound lateralizs o the

Etiology: Caused by damage tothe nerve transmitting the sound (VI) or its associated
‘neurons and reesptors (hai calls). This can be caned by tumors (acoustic neuromas,

trophy of the cochlea seen in aging and various

67. + Ask Pant to Swallow
{Ask Pao to Say "Ahr

à Watch the movement ofthe soft palate andthe pharma.
‘+ Test Gag Reflex (Unconscius/Uncoperative Patient) ++

1. Stimulate the back of he throat om cach sde

2. M normal ag after ch malos

(Principle o vagus nerve examination

«+ Listen othe patients voce is it hoarse oF nasa
+ Ask the patient to sallow.

‘Ask the patient to say

© Do the soft palate and the other pharyngeal structures move? Is the movement
symmetrial?

Gag Retex

+ Ati usually not necessary to perform this test on a conscious, cooperative patient [is
very weil in cases of coma,

+ Stimulate the back ofthe throat on cach side,
+ Its normal o gag after each stimulus,

+ This re protects the unas rom food and liquid
reflex greatly increases the risk a aspiration.

tamination. À dim

ished ang

XL: Accessory
«+ From behind, look for trophy or assymetry ofthe tapers muscles

+ Ask patient to shrug souls gain resistance
‘Ask ation 1 tim ther had against resistance, Watch and palpate the stemomastoid muscle onthe opposite sie,

amination of the accesory nerve
‘+ From behind, look for atrophy o asymmetry ofthe trapezius muslo.
‘Ask the pation o drug hir shoulders against resistance.

+ Aske patient tour cir had against resistance, Watch and palpate the
Stemocleidomastid musee onthe opposite sid,

XII-Hypoglosal Glick for'anvonline video

+ Lion tthe articulation ofthe patent's ons

+ Observe the tongue as it es inthe mouth
1 Ask patent
1. Prtrdo tongue 110)

2. Move tongue rom sie 1 side

amination of the hypoglossal nerve

1. Listen 1 the articulation of words as the patient speaks.

68. 2. Observe the tongue tien the mouth,
3 AS the ain to:

1. Sick uti tongue

2. Move her tongue from side 0 ie

4. nan infant, pinching the nosis eases he mouth to open and tb tongue to se, Observe for
‘symmetry.

Motor
Observation

+ Involuntary Movements

+ Muscle Symmetry

Leto Right

& Proximal vs. Distal
+ Au

à Pay paula attention to the Hands shoulder, ad high
+ Gait

Muscle Ton

1. ke patient to la,

Flex and extend the patient fingers, wis, and elbow
Flex and extend pants ankle and knee

“There is nomally «small, continuous resistance o passe movement
Owen for deeresel (aces) or increased paie ons

Muscle Strength
+ Teststengt by having the patient move against your resistance.

© Always comparo one side othe er.
* Gnade strength cn scale fom 0105 “out of Five

Grade

(05 [No muscle movement
US _ Visible muscle movement, but no movement athe joint
25 [Movement athe jim but not again gravity

35 _ Movement agains gravity, but not against added resistance
CAT

nt gaint resistance, ht less han normal

iS [Normal rn

+ Testhe following:
1. Flexion atthe elbow (CS, C6, biceps)
2. Extension at the elbow (C6, C7, CB, weeps)
3. Extension atthe west (C6,C7, CS, rail nerve)
3. Squvere two of your fingen a hard as possible Cerin” C7, C8, TI) 10)
5. Finger abduction (CS, TI, ular neve)
6. Oppostion ofthe thumb (CH, TI, median nerve)
7. Recon at he ip (2.13, LA psoas)
8. Adluetonatthe hips (12.13.14, ductos)
9. Abduction atthe hips (LA. LS, SI luteus mes nd minimus)

69. 40, Extension atthe hips (1, sluts maximus) (12)
Extension athe ke (3 13,14, quadrices) [10)

Flexion atthe ke (4.5, SI, 82 hamstrings)

Dorsiflexion atthe ankle (LA, LS

14, Platarexion (SI) [12],

Tables.
Hip exion iopsoas 1214
Hip extension Giuteus maximos si
Hip auction Autos
Hip auction ‘Gute matias and minimos
Kae extension Quadriceps 1214
oe Mexion Hamsrings UALS, 1,82,
Ankle dorsiexion| Anterior and lateral eg muscles 14.15
Pronator Drift

1. Ask the pinto stand for 20-30 seconds with both arms straight forward, palms up nd yes closed

2. Inseuc the pates to Keep the arm till wile you tp them briskly downward
3 The patent will ot beable fo maintain extension and supination (and “drift ino pronation) with upper moor neuro disease

Coordination and G:

Rapid Alternating Movements
1. Ask the patient o strike one hand on he thigh rise dh han, tum it over, and then strike it hack down as fast as possible,

2. Askthe patient to a he distal thumb with the ip ofthe index Finger as astas posible.
3. As patient to tp your hand with the ball ofeach fot as fasta posi

Point-to-Point Movements Glick forthe video:enriched online topio”Cassiication of tremors”

1. Ask he patent to touch your inde Finger and thei ose altemuely several times. Move your finger about as the patent performs
task

2. Hold your finger sl so that he patient can touch it with one arm and finger outstetche. Ask the patient to move tirar and retum
tw your finger with thei eyes clone
3. Askthe patent place one hes on he opposite ke and rn it down he shin to the big Lo Repeat with the patients eyes closed,

Howto Nos ide for online video Giekforonin video
+ Ae patin th or inex finger and ire aerate is,
arc notre
ee
Yi rye ct pal es lr mn mn Io Tage

pa

70. ra

‘Ask the pation 0 place one hos just Below the opposite knoe and un it down th shin tothe
big toe

‘Repeat with th patents ees close.
“Repeat onthe ater side

[Rapid alternating movement used vo ases cerebellar funcion in the upper and lower
extremities

+ Ask the patient to sie one hand on the thigh, alse dhe hand, ur it ver and then sit
back down as fast x posible.

© Ask the patient 0 ap their hum with the tip o the index finger a fast as possible.
“Ask the patient 1 ap yourhand withthe al of each foot as fast as posite

+ Slow or uncoordinated altemating movement i known as dysindochakinsis,

Romberg
1. Be prepared to cach the patent if they are unstable

2. Askthe patent to stand with the feet together and ees elsa for 5-10 seconds without support.
3. ‘The test al 10 be pose if th patent bocames unstable indicating a velar or proprioceptive problem).

{Rombers Test
+ Be prepared 1 catch the paint if they ar unstable

‘+ Fis test when he paint yes a open to get a general sense of balance and
ropricepion,

© Askthe patient stand with ther ec together and eyes close for five to ten seconds without
‘suppor.

2 The testis sid 10 be postive i the patent becomes unstable indicating a vestibular or
proprioceptive problem)

(Gia oran onine io ds) (ik ar an mano ide (Oe toran nio video ao)
Ask he patient to
1. Walk across the oom, tum and comeback

Walk hoc in a straight in
Walk on thir tos ln straight no
Walk on thi oes ina stag ine
Hopin place on each foot.

Do a salon ke bend

Rise from siting position

Reflexes
Deep Tendon Reflexes

‘+ The paient mst be lane and positioned property bore starting,

71. 13

“+ ele response depends on he ore of our stimulus. Use no more force than you need to provoke a definite response.
Reflexes can be rinorcd by having the patient perform ¡someta contrction ol ode muscle (clonchal teat),
© eens should he graded on a 0194 plus” scale

“Tendon Reis Grading Sea
Ge | Denon
CT
[tears [Hyper
(2+or++ Normal

Se oress. [Hyperactive without conos
[it ot Hyperactive with conus

+ Biens (CS, C6
12° The patents arm shouldbe partly flexed atthe elbow with he palm down,
2. Place your thumb or finge lyon the biceps tenon
3. Str your finger with he alex hummer.
4. Youshoul feel the response even if you can't seit
+ Biceps (C6. C7)
1." Support upper arm and let the patient forearm hang fos
2. Sink the triceps tendon above the elbow with the bra side of the hammer
3. the patients siting or ying down, ex the patient arm a the elbow and lit else to Meche
+ Brachiordiais (CS. CH)
1. Has to patient est forearm on the abdomen o lp.
2 Strike ads about 1.2 ches above the wes
3. Wach for exi and supination of the fre.
+ Abdominal (FS. 79, TIO, TH,

1. Use lun object such as a Key or tongue blade
2. Suoke he abdomen light on cach side in an inward and downwanl diction above (TS, O, TIO) and below the umbilicus IO,

THT
3. Not the contraction of the abdominal mosses and devi
3

n ofthe umbilics towards the simula,

3. Not conracion of the qualraceps and extensión ofthe knee
+ Ankle ST

1. Doris the foot at he ankle
2. ‘Suk the Achilles tendon,
3. Watch and feo for planta exon atthe ankle

Clasica tendon jerk refers inthe upper

Biceps reflex C3, CO
+ The patients arm should be para Med at the elbow with he palin down resting on their
tap.

+ Place our thumb or finge rly on the biceps tendon

+ Strike you

finger with he reflex hammer.

© You should feel the response even i you can seit

Ischioradiais reflex (C5,C6)

“The Biceps tendons reflex

+ Haveihe aten rest the forearm on the abdomen o lap.

1 Strike the brachiraisis tendon where i passes over the radis about two 1 four
‘entemeters above the wri

72. bé
Watch for flexion and supination of the forearm

(Triceps reflex (C6, C7)

+ The patient's arm shold be paral Need at he elbow with the palm down resting on their
lap. Atemaively support the upper arm and lt he patient’ forearm hang fe.

+ Strike the weeps tendon above the elbow with he brad side of he hammer.

= Wach for extension ofthe forearm

The Triceps tendons reflex

Classical tendon jerk refer inthe lower tb

[Knee reflex (12, 13,14)
+ Havethe patient sit or lie down with the ke flexed
+ Strike the pull tendon just below the patella
+ Note contraction ofthe quadraeps and extension ofthe knee.
[Ankle rex (S1, $2)

+ Dorsilx the foot tthe ane

+ Strike the Achille tendon

The ko reflex

each and fel for platas flexion at the ankle

toms. li for an nine video

the reflexes som hyp

rive test for ankle cons: ++
1. Suppor the ne in partly Nese poston,

2. Withthe patent relaxed, quickly dors the foot.
3. Observe loriytlmic oil.

iting lonas
+ Clomas occurs when there is a lack of normal comical inhibition ofa deep tendon reflex,
resuling in rapid. song, escilaing muscular contrctons This occurs when sustained
tension placed on one ofthe muscles controling jon, sch asthe wis or ankle
+ Ari efes scem hyperactive ts fo ankle clans
+ Support the ace ina pay Med position.
+ With the patent relaxed, quickly dors the foo.

+ Observe fr ythmic oscillations,
citing onus

Up 108-10 contractions of ankle clus is considered normal in newborns, but cotrctions|
sisting beyond this ae evidence of «central nervous system defi.

Plantar Response (Babinski)

73. 1. Suoke the lateral aspect ofthe ole of ach foot withthe end of reflex hammer or key

15

2. Note movement ofthe toes, nomnally flexion witha)
3. Extension ofthe big toe wi fanning of the ther os I bor This is fered o asa positive Bab.

ic

Sensory

General

+ Explain each ext before you do it

y abdominal reflex

France eons QI NE geo

1 This test se to assess upper motor neuron sons,
“+ Stroke the lateral aspect ofthe sol ofeach fot with he Blunt end ofa els hammer oF ey.
+ Note movement ofthe tes, normally flexion (ida)

+ Extension ofthe big te wih faning ofthe other toes is sbnormal. This i refered 1 a a
positive planar response.

‘Symmetry is pacularly important for interpretation. A postive Babinski on onesie and not
the other isan important lue 16 the cation of lesion.

2 The or plantar texts are equivalent,

‘+ Te term "Babinski reflex" isthe abnormal response to plantar stimulation, Therefore itis
income to make the statement theta paient has a “normal? or "down.going Babin
Rather ithe response is normal, ne should simply stat thatthe “plantar reflex oral or
‘hat the “oss ae down going.”

+ The presence of a Babinski response in infants may be normal (sometimes up to 2 years of
age) and should not be taken as conclusive evidence of neurological disease.

[Abdominal rex 18,19, 110, TIL, T12)
+ Usea blunt object such as a key or tongue blade

+ Stoke the abdomen lightly on ach side in an inward and downward distion above (T8, TO,
0) and below he umbilicus (TIO, TIA, 12),

+ Note the contraction ofthe abdominal muscles and deviation of the umbilicus towards the
simul.

‘+ Babies do nt exhibit the abdominal flex until bout 6 months, but if spinal cord lesions are
suspected the anal flexi present at bh and can be tested

Unless otherwise specific, he patients eyes should be closed during the acts testing,
Compare symmetcl reason the two sides of he body.

Also compare distal and proxi

‘When you dit an aca of sensory os map cutis Boundaries in deta

asso the extremis,

‘Use ow püched toning ok (1281

3

‘Tea'with non
Place the m ofthe fork over
Ask the pit o tll you i they fel the Vibration.

ating tuning fork iso ensure thal epa

lens responding to the comet sims
e patios index age and big oe

he dial inerphalangeal joint o

+ Afin seme is impaired proceed proximal: +

74. Examination of vibration sense

16

Miss
Bows
Media malt
Pass
Anterior superior lic spines
6. Spinous press

Caicos

FEsamination of bration sense
+ Use low pliched (128 Ha) tuning fork.

+ Test with a non-vibrating tuning fork first to ensure that the patent is responding to the
corrects.

+ Place the stem o the fork over the distal interphalangeal joint ofthe patients index
Finger and great toes.

+ Ask the patient tol you If they fel the vibration.

inact,
+ Lfvibration sense is impaired proceed proximally:

© Wrists, Ethows, Metal maliol Patella, Anterior superior ic spines, Spinows
processes, Claves

‘+ Vibratory sensation uses the same receptors as proprloceptlon. These receptors are only
sensitive o lower fequencies. Your exam will be inaccurate ou use a tuning fork

| 41 pat ent eects vibra tthe or pls Ir ratory eo
inh pth higher han 28 He

‘Subjective Light Touch

‘+ Use your fingers to touch the skin lightly on both sides simultancousl. [13],

1 Tes several aras om oth the upper and lower extremis.
Ask patin tol you thee ls difference from side o side or oter “strange” sensations.

Position Sense

Grasp the patients big te and hol it away rom the eter test void ction. ++

Show the paint "yp" and “down”
‘With th patients oyes closed ask the pen to entity the direction you move the toe.
I posivon senses impaired move proximally o ts ankle ont +
Test be fingers in a similar fashion:

indicated mone proximally to the metacarpophalang

cal joins, wrists, and elbows, +

Examination of sense of position

+ Use this tet when an abormality is suspected for insane if patent hasan uncoordinated
gal or positive Romberg Tes.

“Grasp the patients big toe on the sds and hold it away fom the her os to avo friction.

+ Move the distal join with your other hand.

+ Demonstrat "up" and “down while the patent watches.

+ With the patient eyes closed ask the patent t identify he diecin you move the te.

position sens is impaired move proximally o test he ankl joint

75. ‘ 13
Examination of sense of position + Teste index finger in a similar fashion

+ Ifindcated move proximally tothe metacrpophalangea joints, wrists, and cows,

Dermatomal Testing

IF vibracion, position sense, and subjective ight touch are normal inthe fingers and

cs You may assume the est of his exam will e normal

Pain
+ Use a suitable sharp object to es "sharp" or “ul” sensation. 17)

+ Tesihe following areas
‘Shoulders (C8)
Innerand outer aspects of the forearms (C6 and TI)
“Thumbs and litle iger (CG and CS)
Frot ofboth highs (12)
and lateral spt ofboth calves (LA and LS)
wes 1)

‘Temperature

‘Often omitd if pan sensation is normal. ++

‘+ Use ating fork heated or cooled by water and ask the patient o iden “ht” o cok.”
* Tesihe following areas

1. Shoulders (C8)

2 Inner and our aspects of he forearms (C6 and TI)

3 Thumbs and litle fingers (C6 and CS)

3, From of both thighs (L2)

5. Media and lateral aspect of both calves (Lt and LS)

6. Lie wes 61)

Light Touch
+ Use a fine hip of con o our fingers to touch the skin ight.

“Ask the patent 1 rspond whenever touch so
1 Tesihe following sree

1. Shoulders (C2)

Inner and outer aspects ofthe forearms (C6 and TI)

Thumbs and ite fingers (C6 and CB)
Front ofboth thighs (12)
Media and lateral aspect of both calves (LA and LS)
Lite tes ($1)

76. 18

Discrimination:

Since these tes ae dependen on touch and positon sense, hey canna e performed when he tests above ar lcary shor. ++
+ Grapheshesia

1° Wa the bu end ofa pen or pencil draw a age number inthe patents palm

2. Aske patent to deny the nome,
+ Surcognosie

1. Une as an aemaive to grphestesia. ++

2. Pla a familia obj inthe patient hand (coin, paper clip pencil, te.)

3. Askine patent tll you wha itis
‘+ Two Point Discriminación

‘Use in situations where more quantitative data are nocdd, such as following the progression fa col leon. ++

Use an opened pape lip to ouch patient iger pad into places simultaneous
Alternate ireplily with one pot ouch
‘As the patient identify “one” oro”
Find the minimal stant at which the patent can discriminate

(Graphesthesia

‘+ With the lan end open e pencl,daw a large number in the patents palm.
“Ask the patient 10 identify th number.

Stercognons

+ Uscasanakematve to grapheshesia,

pene ‘+ Ask te patient to tll you what it is.

(Tactile localization

+ Use in situations where more quantitative de
‘of acortcal lesion.

are needed, such as following the progression

‘+ Use an opened paper clip fou he paint finger pads in two places simultaneously.
‘Alia iregulaly with one point ouch.

“Ask the pation to identify “one” on wo.”

act localizacion «+ Find the minimal distance at which the paient can discriminate

Meningeal signs
Signs of meningeal initation indicate inflammation of he dur; these ins are follows:

1. Nach iii or neck súlinss i tested by placing the examiners hand under th pins had and geil
Unive resistance implies dis ination of the cervical nerve rots rom meningeal inflammation,

eying w flex

Brudzinsk sign is exon of Bah knces during the maneuver 0 test nuchal igdiy. Tis indicates diffuse meningeal iii inthe

spinal nerve roots

3. Kemig sig i elicit by Mexing the hip and knse on ono side while the patient i spine then extending the Kn withthe hip si
ed. Hamsting spasm results in pain inthe posterior thigh muscle and dieu wath knoe extension. With severe meningeal
inflammation, the opposite ce may Nex during he test

44 Laseque or straight eg rain (SLR) sign seit by passively flexing the hip with the Knce stright while the patent i in the supi
pasion. Limitation of flexion due to hamsting spasm andor pin indicates oca tation ofthe lower lumbar nerve rors. Reverse
SUR is listed by passively hyperextending the hip wih the knce straight while the patent is in the prone poston Limitation of
extension due to span andr pan nthe anterior high muscles indicates local ion othe upper lumbar noni rot.

77. 19

[Sirah aim test
2 This isa test for nerve root compression in the lower back
© Askthe patient i supine on he exam table with knees right
“Grasp the eg nar the hoo and a he lg slowly towards the ceiling.
+ Pun in an LS o St disiution suggests nerve root compression or tension (radicular pan}
+ Dore the foot while maintaining the rise position othe le
+ Inerssed pin srengens the likelihood of nerve oo! problem.
“Repeat the process with he opposite leg

+ Increase pai on the opposi ide (a postive crossed righ le rase) indicates high
probably of nerve ro compresion on tht ide.

Brudzinski's Sign
1 Flex the patients neck and observe the ips and knees
rudainsk’s Sign
‘Het hips and knees flex in response, this suggess meningeal ration.
Kern’ Sign
+ With the patient supine, Nex the eg 90 degrees a the hip and nee
+ Keeping the hip xed, sten the lg slowly atthe kee.

+ Some discomforts normal, but bilateral pan and increased resistance o extension suggest
moines tation.

Kerns Sign

Decerebrate & Decorticate postu

WR (Gia toranninevieo ip

These are often assessed in patents who present comatose and non-esponsive, often requiring respiratory support. There are two classic

reflexive postures: deconicte and decerhre

Decerebrate posturing

+ Decerebrte posturing is sen in parents with lesions ofthe brainstem itself: These patient
= Will exhibit extension of the arms, flexion ofthe wri, jaw-clnchig, back arching, plantar |
exi, and neck extension, cr spontancously or in sponse oa sera ub

+ A way to remember the difference between the two postures that in he decorate posture
the patients arms wll poi he cate.

Decerebrate posturing

Decorticate posturing

‘+ Decorate posturing is sen when there i a lesion ofthe comicospnal tract superior to the
level of the ranstem. This ls indicate inthe comatore paint who respond o tral rb
by ful exon of the elbows, wists, and Fingers, as wel as plantar flexion ofthe fet with

78. a inerte "I

Decotieate posturing

Notes

1. For more information refer to A Guide 10 Physical Examination and History Taking, Sich Elion by Barbara Bates, published by
Lippincou in 1995.

2. Visual cuit reporte sa pair of numbers (2020) where the ist number show fr he patents fom the chart and he second
numbers the distance frm which the “normal” eye can rad a ine of eters. For example, 20/40 means that at 20 Fst the ptt can
‘nly read ler a “aoa” person can red rom twice that distance

3. You may. instead of wiggling a finger, rane one or wo Fingers fumier or Dilaterally) and have the patent ste how many fingers
(otal boi sides) they se. To test or neglect, on some tals wiggle your Fight ad ft Fingers simalkanousy. The patient shoul ce

‘movement in both hands

Additional Testing - Tests marke with (++) muy be skipped unes an abormaiy i suspected.

PERRLA is acommon abbreviation that stands for "Pupils Equal Round Reactive to Ligh and Accommodation.” The se ofthis termi

so routine that ts fen sed income. I you did nt specifically check the accommodation section ne the tem PERRL- Pops

‘ih a diminished response to ight but normal response o accommodation (Ar l-Roberion Pupils) ar a sign of neurosyphilis.

6. Nostagnus is ahythnicosilation of he eyes Horizontal nystagmus is described as bein eher "evar o “rightward” based on

the diction ofthe fast component

7. Testing Pain Sensation - Usa now objetor cach patient. Break a wooden cotton swab to creat a sharp end. The cotton end cun be

used fora dll stimulus. Do not go fom patient to patent with a safety pin. Do ot use non-«dispoxble instruments such as those found
in cena reflex hammers. Do nat use very har items suchas lypodermic nee

8. Cental vs Peripheral «Wil a wat central nervous stem lesion (stoke), functions preserved ove the upper par ofthe face

{reheat eyebrow, ey), With a peripheral nerve lesion (Bells Palsy), he entre ace involv,

9. Te hearing screening procedure presented by Bateson page 181 I more complex than necessary. Te technique presented inthis

ssl is prefered.

10, Deviation of the tongue or ja is toward he sde ofthe sion

11: Altough itis often tested, rip strength is ot a pariculary good test inthis context. Grip strength may be omite if finger abdution

and thumb opposition have ben ested

12. The anti-gay” muscles ae dificult to asses adequately with manual testing. Useful altes include: walk on tes

(plantaron ise from a hair without sing the arms (hip extensors and knee extensors): step upon a ep, once with ech
tensors and ke extensos.

13. Subjective light touch sa quick survey for “range” or asymmetica sensations only, no formal es of demstomes.

ex hip

82. Special Top

Idiopathic Seizures ‘Clear CSF with normal protein, normal glucose, no
WC, no RBC’, normal opening pressure and normal
& Gamma globulin,
Bacterial Meningitis: Milky CSF si in, decreased. glucos
WBCs a BCs, mildly
increased opening pressure and normal % Gamma
globulin.

Guillain-B: Yellow CSF with very high protein (up to a gram
normal glucose, no WBCS, no RBCS, normal opening
pressure and normal % Gamma globulin,

Yellow CSF with increased protein, normal glucose, few
WBCS, inumerable mildly increased opening

J normal & Gamma globulin,
Herpes Simplex Encephalitis: Cloudy CSF with increased protein, normal glucose
WBCS (lymphocyte predominate), few RBCS,
in opening pressure and normal % Gamma

WBCS (lymphocyte predominate), no RBC

83. pressure and normal % Gamma globulin
ar CSF with mild increase in protein, normal

few WBCS (lymphocytic predominate), no RBCs,

normal opening pressure, increased % Gamma globulin

n Intracranial Hypertension: Clear CSF with normal protein, normal glucose, no
WBCS, no RBCs, increased opening pressure and
mal % Gamma el

84. The 256 hertz tuning fork.

he ophthalmoscope.

Visual acuity card

91. action is noted in the muse
while the patent attempts to contract it

The patient is able to actively move the muscle when gravity
Jiminated

The patient may move the muscle group against s
the examine

The patient moves the muscle group an
the examiner. This is normal muscle tren

102. most common site of disc hemiation. The following are the characteristic "lower back
syndromes" associated with nerve root compression. Note that disc hemiations are mostly inthe
posterolateral direction, thus compression ofthe nerve root exiting from the vertebral foramen at
‘one level below is affected. (The nerve root at the same nation is already within
the vertebral foramen and therefore not compressed)

SI Disc Prolapse

Pain along postr
‘Weakness on plantar flexion (may be absent)
Sensory loss in the lateral foot

Absent ankle jerk refle

Dise Prolapse

Pain along the posterior or posterolateral thigh with radiation ot
the top ofthe foot

‘Weakness of dorsiflexion ofthe great toe and foot

Paraesthesia and numbness of top of foo

No reflex changes noted

L3/LA Dise Prot

Pain in front of thigh
of quadriceps muscles may be present

Diminished sensation on the front of the thigh and medial lower leg

Reduced knee jerk reflex

112. 2

115. Note swelling of the

(Optic Atrophy. Note the chalky white|
dise with discrete margins. Optic atrophy
is a late finding with increas
intracranial pressure

116. [Central Retinal Artery Occlusion. Note the
ldiffusely pale retina and prominent central
fovea which is usually blended in with the
Inormal, pink retina,

al Vein Occlusion. The disc
is massively swollen with diffuse
hemorrhages and cotton-wool spots.

Proliferative Diabetic Retinopathy. Note
Ihe multiple hemorrhages, exudates and
Ineovascularization throughout the retina,
[Chorioretinal striae extend towards the are:
lof fibrovascular proliferation in the lowe
[portion of the photograph.

the lower portion of the photograph,
Common in patines with
immunodeficie AIDS.

119. 1. Motor Response
6- Obeys commands fully
5 - Localizes to noxious stimuli
Withdraws from noxious stimuli

4
3- Abnormal flexion, ie. deconicte p

Extensor response, ie. decerebrate
1 No response
11. Verbal Response
Alert and Oriented
Confused,
Inappropriate words,
Incomprehensible sounds
I, Bye Ops
4 - Spontancous eye opening
3 Eyes open to speech
2- Eyes open to pain
1 No eye open
GGlascow Coma Seale = 1+ 114 IIL
score indicts a deeper coma ana poorer prognosis

122. Feature | Optic Neuritis Papilloedema

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Side
Pain on eye movement
Onset of visual loss

Degree of visual loss as
compared to degree of disc
swelling

Color vision

Field defect

Pupillary reaction
Degree of disc swelling
Venous engorgement
Venous pulsation
Hemorrhages

Slit lamp examination for
cells in vitreous

Unilateral
Usually present
Sudden

Gloss

Impaired (especially red
and green)

Central or centrocecal
scotoma

Ill sustained

Less than 3 Dioptres
Less marked
Present

Uncommon

Positive
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Bilateral (rare exceptions)
No pain (rare exceptions)
Gradual

Slight (except PPOA)

Defective only at late stage

Enlarged blind spot,
Peripheral constriction

Normal

More than 3 Dioptres
More marked
Absent

May be present

Negative

125. BLOOD
VESSELS
= 4

Normal fundus
= © A

128. rmal fundus

130. vascullitis

131. Dot. Flame. Boat Retinal Hemorrhages

136. Optic neuritis

139. papilledema

140. y
4

ss papilledema

141. papilledema

143. papilledema

145. Postpapilledemic atrophy

146. >

Primary optic atrophy

150. Primary optic atrophy

152. "2

primary and Optic Disc Cupping

154. Retinal phakoma

157. Retinitis pigmentosa