How to Conduct a Neurological exam

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

1. HISTORY  

• 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:  

1. 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

2. 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

1. Abnormal gait:  
2. 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

1. 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

1. 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

1. 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.

1. 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 

1. Speech 

• Speech enables communication between  individuals.  
• Abnormalities include  
• dysphonia,  
• dysarthria, and  
• dysphasia or aphasia.

1. 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

1. Dysarthria 

• 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 

1. 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.

1. Memory 

• 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 

1. Orientation 

• 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.

iii. Intelligence 

• 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.

1. Psychological disturbances