NEUROLOGICAL EXAMINATION

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Dr. Sema Saltık

Ass. Prof of Child Neurology

Neurological Examınatıon

Consciousness level assessment, cooperation Disorders of speech and language Neck stiffness and evidences of meningeal irritation Cranial nerves Motor system Muscle power Muscle tone Sensation Reflexes Posture-gait disorders Cerebellar tests Higher cerebral function Movement disorders Other….

Consciousness

is the quality or state of being aware of an external object or something within oneself.

Consciousness is assessed by observing a patient's arousal and responsiveness.

The abnormal state of consciousness ;

Clouding of consciousness is a very mild form of altered mental status in which the patient has inattention and reduced wakefulness.

Confusional state is a more profound deficit that includes disorientation, bewilderment, and difficulty following commands.

Abnormal state of consciousness

Lethargy consists of severe drowsiness in which the patient can be aroused by moderate stimuli and then drift back to sleep.

Obtundation is a state similar to lethargy in which the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states.

Stupor means that only vigorous and repeated stimuli will arouse the individual, and when left undisturbed, the patient will immediately lapse back to the unresponsive state.

Coma is a state of unarousable unresponsiveness.

Glasgow Coma Scale

Motor response Obeys commands 6 Localizing to pain 5 Withdraws to pain 4 Flexing to pain 3 Extending to pain 2 None 1

Verbal response Orientated 5 Confused 4 Words 3 Sounds 2 None 1

Eye opening Spontaneous 4 To speech 3 To pain 2 None 1

< 7 coma

<5 deep coma

Modified Pediatric Glasgow Coma Scale

Verbal response

Smiles, orients to sounds, follows objects, interacts 5

Cries but consolable, inappropriate interactions 4

Inconsistently inconsolable, moaning 3

Inconsolable, agitated 2

No verbal response 1

Language and speech disorders

Anarthria-Dysarthria; Loss of the ability to vocalize words

as a result of an injury to the part of the brain that is responsible for controlling the larynx or "voice box." (Cerebellar, Extrapyramidal,

IX. X. Cranial nerve palsies)

Aphasia, Dysphasia; a disorder caused by damage to the

parts of the brain that control language. It can make it hard for you to read, write, and say what you mean to say.

Broca’s aphasia (Motor aphasia) (+right hemiparesis)

Wernicke aphasia (Sensorieal aphasia)

Meningeal Irritation Evidences

Neck stiffness

Kerning’s sign

Brudzinski’s sign

Meningeal Irritation Evidences

I. Cranial Nerve- Olfactory Nerve

Smell is tested in each nostril

separately by placing stimuli under

one nostril and occluding the opposing

nostril. The stimuli used should be

non-irritating and identifiable.

II. Cranial Nerve- Optic Nerve

Visual acuity; is tested in each eye separately.

The patient is asked to read progressively smaller lines

on the near card or Snellen chart.

Visual fields; are assessed by asking the patient to cover one eye while the examiner tests the opposite eye. The examiner wiggles the finger in each of the four quadrants and asks the patient to state when the finger is seen in the periphery. (Confrontation)

Fundoscopy;

Pupills; size, shape, equality, reaction to light, accommodation and convergence.

Oculomotor (III), Trochlear (IV), Abducens (VI) Cranial Nerves

Extraocular muscle movement

♦ Upward movement, looking out - superior rectus (Oculomotor nerve)

♦ Upward movement, looking in – inferior oblique (Oculomotor nerve)

♦ Downward movement, looking out - inferior rectus (Oculomotor nerve)

♦ Medial movement– medial rectus (Oculomotor nerve)

♦ Lateral movement – lateral rectus ( Abducens nerve)

♦ Downward movement, looking in – superior oblique (Trochlear nerve)

Oculomotor (III), Trochlear (IV), Abducens (VI) Cranial Nerves

Diplopia; ask patient about diplopia and if present note the direction of maximum displacement of the images and determine the pair of muscles involved.

Conjugate movements; is the ability of the eyes to act together to the horizontal or vertical direction

Nystagmus; upset in the normal balance of eye control.

Horizontal-vertikal

Direction (e.g. Nystagmus to the right)

Gaze direction where nystagmus is maximal (e.g. max. to

lateral gaze)

Ptosis;

V. Cranial Nerve-Trigeminal Nerve

Motor fibres: innervate the muscles of

mastication (Temporalis, masseter and pterygoid muscles)

(Jaw jerk)

Sensory fibres: subserves facial sensation

Ophthalmic division

Maxillary division

Mandibular division

CORNEAL REFLEX

VII. Cranial Nerve- Facial Nerve

Motor fibres: supply the muscles of facial

expression

Visceral afferent fibres: convey sensations of

taste from the anterior two-thirds of the tongue.

Visceral efferent (parasympathetic) fibres:

Salivation (sublingual, submaxillary, tears)

VIII. Cranial Nerve-Statoacustic Nerve

Cochlear nerve: hearing

Vestibular nerve: balance

IX. Glossopharyngeal nerve X. Vagus nerve

These nerves are considered jointly since they are examinated together and their actions are seldom individually impaired.

Swallowing difficulty, nasal regurgitation of fluids?

Ask patient to open mouth and say ‘aa’, note any asymmetry of palatal movements.

Note the patient’s voice

Taste in the posterior 1/3 of the tounge is impractical to test (IX)

GAG REFLEX

XI. Cranial Nerve-Accessory nerve

Sternocleidomastoid : ask the patient to rotate head against resistance. Compare power and muscle bulk on each side.

Trapezius; ask the patient to ‘shrug’ shoulders and to hold them in this position against resistance. Compare power on each side.

XII. Hypoglossal Nerve

Motor nerve of the tongue

Inspect tongue (atrophy, fasciculation)

Ask the patient to protrude the tongue, note any difficulty or deviation. Tongue deviates towards side of the weakness.

Motor System Examination

any asymmetry or deformity

muscle wasting

muscle hypertrophy

muscle fasciculation

power

tone

Motor System Examination

Upper Limbs

Shoulder abduction- m.deltoideus

Shoulder adduction- m. pectoralis major, latissimus dorsi

Elbow flexion- m. biceps, brachioradialis

Elbow extension- m. triceps

Wrist Extension- ext.carpi radialis longus, ext. carpi ulnaris

Finger extension

Finger flexion

Interosseous muscles

Motor System Examination

Lower Limbs

Hip flexion - Iliopsoas

Hip extension- Glutei

Hip abduction- Glutei and tensor fascia lata

Hip adduction- Adductors

Knee flexion- Hamstrings

Knee extension- Quadriceps

Plantar flexion- Gastrocnemius, tibialis posterior

Plantar dorsiflexion- tibialis anterior,extensor hallucis longus,ext. Digitorum longus

Strength of Muscle Groups

0/5: no contraction

1/5: muscle flicker, but no movement

2/5: movement possible, but not against gravity (test the joint in its horizontal plane)

3/5: movement possible against gravity, but not against resistance by the examiner

4/5: movement possible against some resistance by the examiner

5/5: normal strength

Tone

Ensure that the patient is relaxed, and assess tone by alternately flexing and extending the muscles.

Normal tone

İncrease in tone

Spastisity

Rigidity

Decrease in tone

Posture and Gait

Posture (decerebration, decortication, hemiplegic…)

Gait

Spastic

Ataxia Cerebellar ataxia

Sensory ataxia (Romberg’s test)

Steppage

Parkinsonian

Waddling gait - a duck-like walk

Sensory Exam

I. SUPERFICIAL SENSATION

Light touch

Pain

Temperature

Sensory Exam

II. PROPRIOCEPTIVE SENSATION

Position Sense Ask the patient close the eyes and report if their large toe is "up" or "down" when the examiner manually moves the patient's toe in the respective direction.

Vibratory Sense

A positive Romberg test suggests that the ataxia is sensory in nature, that is, depending on loss of proprioception.

Sensory exam

III. CORTICAL SENSATION: (Parietal lobe)

Stereognosia: Ask the patient to close their eyes and identify the object you place in their hand. Place a coin or pen in their hand.

Two-point discrimination is the ability to discern that two nearby objects touching the skin are truly two distinct points, not one.

Graphesthesia: Ask the patient to close their eyes and identify the number or letter you will write with the back of a pen on their palm.

Touch localization (topognosis): ability to localize stimuli to parts of the body. Topagnosia is the absence of this ability.

Reflexes

I- Deep Tendon Reflexes

0 No response, absent

± A reflex that is only elicited with reinforcement

+ Diminished

++ Normal

+++ Hyperactive

++++ Hyperactive with clonus

Jaw Reflex

N. trigeminus (V. CN)

Pons

The lower jaw—is tapped at a downward angle just

below the lips at the chin while the mouth is held slightly open. In response, the masseter muscles will jerk the mandible upwards.

Normal response; this reflex is absent or very slight.

Upper motor neuron lesions; the jaw jerk reflex can be quite pronounced

Biceps Reflex

Normal response; forearm flexion

Peripherial nerve: N. musculocutaneous

Spinal segment: C5, C6

Palpate the biceps

tendon

Triceps Reflex

Normal response; forearm extension

Peripherial nerve : N. radialis

Spinal segment: C6, C7

Strike the patient’s elbow a

few inches above the

olecranon process.

Brachioradial Reflex

Normal response; flexion and slight supination of elbow, slight flexion of fingers

Peripherial nerve : N. radialis

Spinal segment: C5, C6

Strike the lower end of the

radius

Patellar Reflex (Knee jerk)

Normal response; sudden extension of the leg.

Peripherial nerve : N. Femoralis

Spinal segment: L2 - L4

Achille Rejlex (Ankle jerk)

Normal response; plantar flexion

Peripherial nerve : N. Tibialis

Spinal segment: S1-S2

Externally rotate the leg

Hold the foot in slight dorsiflexion

Palpate the tendon of tibialis anterior

(ensure the foot is relaxed)

Tap the achille tendon

Superficial Neurological Reflexes

Abdominal reflex

Stroke or lightly scratch the skin towards the umblicus in each

quadrant in turn.

Look for abdominal muscle contraction and note if absent or impaired.

Spinal segment: T7-T12

Cremasteric reflex

Scratch inner thigh.

Observe contraction of cremasteric muscle causing testicular elevation.

Spinal segment: L1

Anal reflex

Scratch on the skin beside the anus.

Observe a reflex contraction of the anal sphincter.

Spinal segment: S4, S5

Superficial Neurological Reflexes

Plantar Reflex

Stroke the lateral aspect of the sole and across the ball of the foot. Watch for the first movement of the big toe.

Clonus

Series of involuntary, rhythmic, muscular contractions and relaxations

Clonus is most commonly found at the ankle specifically with a dorsiflexion/plantarflexion movement (up and down).

Clonus at the ankle is tested by rapidly flexing the foot into dorsiflexion (upward), inducing a stretch to the gastrocnemius muscle.

Cerebellar tests

Dysmetria

Finger-to-nose test

Ankle-over-tibia test

Dysdiadochokinesis

Rapid pronation-supination

Ataxia

Assessment of gait

Nystagmus

Intention tremor

Staccato speech

Movement disorders

Chorea

Athetosis

Hemiballismus

Dystonia

Tremor

Tic

Myoclonus

Fasciculation