The Neurological Examination
- 1. History
- 2. Higher functions
- 3. Examination of cranial nerves
- 4. Sensory system
- 5. Motor system
- 6. Reflexes
- 7. Cerebellar signs
- 8. Meningeal signs
- 9. Autonomic nervous system
- 10. Neurovascular system
- 11. Neurocutaneous system
- 12. Skeletal system. Cranium, spine, bones, joints
- Onset of symptoms (acute, subacute, chronic, insidious). Duration. Course (static, progressive, or relapsing and remitting). Pain ( location, radiation, severity, precipitating factors, relieving factor).
Past medical history.
- Examination: Aim to localise lesion, determine aetiology and plan treatment
- Steps in the neurologic examination:
- higher functions, 2. cranial nerves (CNs). 3. Sensory system, 4. motor system, 5. reflexes, 6. cerebellar function.
- Tools required
- Gloves, tongue depressors, ophthalmoscope, a reflex hammer, tuning fork, sterile safety pins
- HIGHER FUNCTIONS
Gait, speech, mental status
Abnormal gait: hemiparetic, ataxic, shuffling, steppage, spastic/scissor, antalgic
- Speech: dysphonia/aphonia, dysarthria, dysphasia/aphasia
- Mental status: memory, orientation, intelligence, psychological disturbances
- Abnormal gait:
- Hemiparetic gait
- (a) lesion in cortical, subcortical, capsular region (above brainstem). Paralysis of one side, upper motor neuron type, contralateral to the lesion.
- (b) lesion in midbrain (Weber syndrome). Lower motor neuron paralysis of oculomotor nerve on side of lesion and hemiparesis on opposite side (crossed paralysis).
- (c) lesion in pons (Millard-Gubler syndrome). Lower motor neuron facial nerve paralysis on side of lesion and hemiparesis on opposite side (crossed paralysis).
- (d) lower medullary lesion (Jackson’s syndrome): cranial nerve XII paralysis with crossed hemiplegia
- Ataxic gait
- In ataxia, the patient spreads his or her legs apart to widen the base of support to compensate for the imbalance while standing or walking. In severe cases, patients stagger as they walk. The heel-to-toe or tandem walking maneuvers and standing on one leg uncover subtle forms of ataxia.
- Ataxia results from midline lesions of the cerebellum When the lesion is unilateral, the patient may veer to the side of the lesion.
With bilateral cerebellar involvement, the patient may fall to either side.
iii. Shuffling gait
- The individual takes short steps to the point of practically not moving forward or making little progress. In other words, the patient appears to shuffle his or her legs rather than put them forward. The steps and pace may vary with a tendency for the patient to accelerate (festinating gait) as he or she walks. Both types are seen in Parkinson disease and may be associated with other extrapyramidal signs
- Steppage gait
- High-stepping, slapping. The individual takes high steps as if climbing a flight of stairs while walking on a level surface. This peculiar gait pattern results from the patient trying to avoid injury to the feet (from dragging them) by stepping high. However, as the patient puts the feet down one by one, they slap the ground, hence the description of a foot-slapping gait. The condition that can be diagnosed even before the patient enters the room because the sound is very characteristic.
- Steppage gait is seen in chronic peripheral neuropathies and can be the result of the functional elongation of the legs due to bilateral drop foot
- Spastic or scissor gait
- In this condition, the legs are held in adduction at the hip and the thighs rub against each other as the patient walks. Spasm of the inner thigh muscles also occurs. If the spasm is severe, with each advancing step the knees tend to slide over each other like the blades of a pair of scissors. This is typically seen in cerebral palsy.
- Antalgic gait
• Patient favors the affected painful (usually lower) extremity and walks, putting weight on the normal leg. The hand held over hip on the
- Speech enables communication between individuals.
- Abnormalities include
- dysarthria, and
- dysphasia or aphasia.
- Dysphonia or aphonia
- Dysphonia is the impairment or inability to phonate. As a result, the voice becomes hoarse. In extreme cases, it is absent, and the patient is mute.
• The most frequent cause of this problem is the common cold, which results in dysphonia due to inflammation of the larynx. Dysphonia may also occur in patients with hypothyroidism, as a result of thickening of the vocal cords from amyloid deposits. Neurologic causes include unilateral recurrent laryngeal nerve paralysis and lesions of the vagus nerve. Intermittent hoarseness may affect patients with vagus nerve stimulator implants, which are used for the treatment of certain medically intractable forms of epilepsy
- Dysarthria is the inability to articulate spoken words. The quality of oration is impaired, but the content remains intact (eg, slurred speech). The patient’s ability to understand and synthesize speech remains intact. It results from paralysis of pharyngeal, palatal, lingual, or facial musculature.
It also is observed with cerebellar lesions and/or disease.
iii. Dysphasia or aphasia
- In dysphasia, the ability to process language is impaired, resulting in an inability to understand (ie, receptive or sensory or Wernicke aphasia), transfer signals from the Wernicke to the Broca area (ie, conduction aphasia), or properly execute speech (ie, expressive, motor, or Broca aphasia). The combination of Broca and Wernicke aphasias is referred to as global aphasia.
Essential Features of Common
- Mental status
- Mental status evaluation includes testing of memory, orientation, intelligence, and the other aspects of the patient’s psychic state. When overt symptoms or signs of a psychic disturbance are present, psychiatric evaluation should be considered.
• Memory is the ability to register and recall prior sensory input. Recent and remote memory functions are differently affected depending on the disease process. Remote memory is relatively preserved in chronic dementing processes, with major disturbances in the attention span and recent memory. On
- Orientation is an individual’s cognitive sense of his status in time, place, and person. These functions are affected in the same order as they are in organic disease. In other words, the sense of time is first to be impaired in organic dysfunction, and the sense of person is the last to be lost.
- A patient who does not know who he or she is, but at the same time can tell the time and is oriented in place, is more likely to have a psychological disturbance than to have an organic etiology for the condition.
- Intelligence is the ability to quickly and successfully apply previous knowledge to a new situation and to use reason in solving problems. Vocabulary, fund of knowledge, calculations (eg, serial-7 calculations), abstraction (eg, use of proverbs), and judgment (eg, what to do with a found wallet) are good indicators of intelligence.
- Psychological disturbances