TECHNIQUES OF EXAMINATION: THE NERVOUS SYSTEM (Cranial Nerves (V Corneal…
TECHNIQUES OF EXAMINATION: THE NERVOUS SYSTEM
Sensory System—one modality at toes—can be light touch, pain/temperature, or proprioception
finger flexors C8
knee extensors L3-4
Plantarflexion (Achilles) S1-2
polysynaptic superficial abdominal reflexes:
depend on integrity of the T8–12 spinal cord segments; elicited by gently stroking each quadrant
of abdominal wall w/ a blunt object; normal response: contraction of muscle in quadrant stimulated, w/ a brief movement of umbilicus toward stimulus
response may be depressed or lost on one side in pxs w/ an UMN disturbance from a lesion of contralateral motor cortex or its
Segmental loss of response may relate to local disease of abdominal wall or its innervation, as in a radiculopathy
cutaneous abdominal reflexes frequently absent bilaterally in elderly, in obese, in multiparous women, and in pxs who have had abdominal surgery
Stimulation of lat border of foot in normal adult--> plantar flexion of toes & dorsiflexion of ankle
Babinski response: dorsiflexion of big toe & fanning of other toes, which is part of S1 dermatome; flexion at hip & knee may also occur
extensor plantar response can also be elicited, though less reliably, by:
pricking dorsal surface of big toe w/ a pin (Bing's sign)
firmly stroking down ant border of tibia from knee to ankle (Oppenheim's maneuver)
squeezing calf muscle (Gordon's maneuver) or Achilles tendon (Schafer's maneuver)
flicking little toe (Gonda's maneuver)
stroking back of foot just below lat malleolus (Chaddock's maneuver).
● Appearance and behavior
Dress, Grooming, and Personal Hygiene
Manner, Affect, and Relationship to People and Things
Posture and Motor Behavior
Level of Consciousness
● Thoughts and perceptions
Illusions: Misinterpretations of real external stimuli
Hallucinations: Perception-like experiences that seem real but, unlike illusions, lack actual external stimulation (person may or may not recognize experiences as false)
Feelings of Unreality: A sense that the environment is strange, unreal, or remote
Anxieties: Apprehensive anticipation of future danger or misfortune accompanied by feelings of worry, distress, and/or somatic symptoms of tension
Phobias: Persistent irrational fears, accompanied by a compelling desire to avoid provoking stimulus
Obsessions: Recurrent persistent thoughts, images, or urges experienced as intrusive and unwanted that person tries to ignore, suppress, or neutralize w/ other thoughts or actions (ex, performing a compulsive behavior)
Compulsions: Repetitive behaviors that person feels driven to perform in response to an obsession, aimed at preventing or reducing anxiety or a dreaded event or situation; these behaviors are excessive and unrealistically connected to the provoking stimulus
Delusions: False fixed personal beliefs that are not amenable to change in light of conflicting evidence; types of delusions include:
● Erotomanic—the belief than another person is in love with the individual
● Somatic—involves bodily functions or sensations
● Unspecified—includes delusions of reference w/o a prominent persecutory or grandiose component, or belief that external events, objects, or people have a particular and unusual personal significance (ex, commands from the radio or television)
Feelings of Depersonalization: A sense that one’s self or identity is different, changed, unreal; lost; or detached from one’s mind or body
Variations and Abnormalities
Incoherence: Speech that is incomprehensible and illogical, w/ lack of meaningful connections, abrupt changes in topic, or disordered grammar or word use. Flight of ideas, when severe, may produce incoherence
Neologisms: Invented or distorted words, or words w/ new and highly idiosyncratic meanings.
Blocking: Sudden interruption of speech in midsentence or before idea completed, attributed to “losing the thought.” Blocking occurs in normal people
Confabulation: Fabrication of facts or events in response to questions, to fill in gaps from impaired memory
Flight of Ideas: An almost continuous flow of accelerated speech w/ abrupt changes from one topic to the next. Changes are based on understandable associations, plays on words, or distracting stimuli, but ideas are not well connected.
Perseveration: Persistent repetition of words or ideas
Derailment (loosening of associations): “Tangential” speech w/ shifting topics that are loosely connected or unrelated. Px unaware of the lack of association
Echolalia: Repetition of words and phrases of others
Circumstantiality: mildest thought disorder, consisting of speech w/ unnecessary detail, indirection, and delay in reaching point. Some topics may have a meaningful connection. Many people w/o mental disorders have circumstantial speech
Clanging: Speech w/ choice of words based on sound, rather than meaning, as in rhyming and punning. ex “Look at my eyes and nose, wise eyes and rosy nose. Two to one, the ayes have it!”
Judgment: interpret idioms
Orientation: person, time, place
: digit span,
, Spelling Backward
Remote Memory: occurences in past few days
New Learning Ability (
Higher Cognitive Functions
Information and Vocabulary
Abstract Thinking: Proverbs and Similarities
Special Techniques: Mini-Mental State Examination (MMSE) to determine high cortical function: Orientation, Registration, Attention and Calculation, Recall, Language; demenita: ACQUIRED loss of more than TWO high cortical functions;
● Speech and language
Articulation of Words
■ Hesitancies and gaps
■ Circumlocutions (ex “what you write with” for “pen”)
■ Paraphasias (ex "I write with a den" or "I write with a bar” or “I write with a dar”)
■ Disturbed inflections (ex monotone)
If lacking meaning or fluency--> test for
aphasia (problem in language zone (perisylvian region of dominant hemisphere))
(NOTE: one who can write a correct sentence does not have aphasia): Word Comprehension; Repetition; Naming;
Reading Comprehension; Writing
motor (Broca): ant
sensory (Wernicke): post
make sure each nasal passage
(compressing one side of nose & asking px to sniff through other)
ask px to
close both eyes
Occlude one nostril and test smell in other
w/ familiar nonirritating odors (
Avoid noxious odors like ammonia
that might stimulate CN V)
Ask px to identify each odor
Test smell on other side
II Visual acuity, visual fields, and ocular fundi
II, III Pupillary reactions:
and shape of pupils, and compare w/ other. Anisocoria (difference of >0.4 mm in diameter of one pupil compared to other) seen in up to 38% of healthy individuals. Test
pupillary reactions to light
Also check near response, which tests pupillary constriction (pupillary constrictor muscle), convergence (medial rectus muscles), and
of lens (ciliary muscle).
III, IV, VI Extraocular movements:
Check convergence of eyes. Identify any nystagmus (
involuntary jerking movement of eyes w/ quick and slow components
); Note direction of gaze in which it appears, plane of the nystagmus (horizontal, vertical, rotary, or mixed), and direction of the quick and slow components.
Nystagmus named for direction of quick component
. Ask px to fix his or her vision on a distant object and observe if nystagmus incr or decr
Look for ptosis (drooping of the upper eyelids). A slight difference in width of palpebral fissures is a normal variant in approximately 1/3 of pxs
V Corneal reflexes, facial sensation, and jaw movements
After explaining, test
forehead, cheeks, and chin
on each side for pain sensation. Px's eyes should be closed. Use a suitable sharp object such as a pin or cotton swab. occasionally substitute blunt end for point as a contrasting stimulus. Ask px to report whether each stimulus is “sharp” or “dull” and to compare sides
If you detect sensory loss, confirm it by testing temperature sensation.
Then test for light touch, using a fine wisp of cotton. Ask px to respond whenever you touch skin
Ask px to look up and away from you and approach from opposite side, out of px's line of vision. Avoiding eyelashes, lightly touch cornea (not just conjunctiva) w/ a fine wisp of cotton.
Inspect for blinking of both eyes, normal reaction to this stimulus.
limb of this reflex carried in CN
response in CN
on both sides.
Motor. While palpating temporal and
muscles in turn, ask px to
firmly clench teeth
. Note strength of muscle contraction. Ask px to
open and move jaw from side to side
VII Facial movements:
Inspect face both at rest and during conversation: Note any asymmetry, often visible in nasolabial folds, and observe any
tics or other abnormal
Ask px to: 1. Raise both eyebrows. 2. Frown. 3. Close both eyes tightly so that you cannot open them. Test muscular strength by trying to open them. 4. Show both upper and lower teeth. 5. Smile. 6. Puff out both cheeks
whispered voice test: Ask px to repeat numbers
into one ear while blocking or
rubbing your fingers
next to contralateral ear. If hearing loss present, determine if loss
, from impaired “air through ear” transmission, or
, from damage to cochlear branch of CN VIII
Test for air and bone conduction, using
test, and lateralization, using
Specific tests of vestibular function of CN VIII rarely included in typical neurologic examination
and rise of the palate,
Ask px to
say “ah” or to yawn
as you watch movements of soft palate & pharynx:
soft palate normally rises symmetrically, uvula remains in midline
, and each side of posterior pharynx moves medially, like a curtain. The slightly curved uvula seen occasionally as a normal variation should not be mistaken for a uvula deviated by a lesion of CN IX or X.
Warn px that you are going to test gag reflex: elevation of tongue and soft palate and constriction of pharyngeal muscles. Stimulate back of throat lightly on each side in turn and observe gag reflex. This reflex is diminished in many normally healthy people.
V, VII, X, XII Voice and speech:
px's voice: hoarse, nasal quality? difficulty in swallowing?
Shoulder and neck movements
Standing behind px: look for atrophy or fasciculations (fine flickering irregular movements in small groups of muscle fibers) in trapezius muscles, and compare one side w/ other
ask px to
shrug both shoulders upward
against your hands: Note
strength and contraction of trapezii
Ask px to
turn his or her head to each side
against your hand: Observe
contraction of opposite SCM and note force
of movement against your hand
Tongue symmetry, position, and movement
Listen to articulation of px's words (depends on CNs V, VII, IX, and X, XII)
Inspect px's tongue as it lies on floor of mouth: atrophy or fasciculations. Some coarser restless movements normal
px's tongue protruded
: asymmetry, atrophy, or deviation from midline
Ask px to
move tongue from side to side
, and note symmetry of movement
In ambiguous cases: ask px to push tongue against inside of each cheek in turn as you palpate externally for strength
tremors, tics, chorea, or fasciculations. Note location, quality, rate, rhythm, and amplitude, and relation to posture, activity, fatigue, emotion, and other factors.
muscles look flat or concave--> unilateral or bilateral? proximal or distal?
When inspecting for atrophy, pay particular attention to hands, shoulders, thighs, and legs. spaces betw metacarpals, where dorsal interosseous muscles lie, should be full or only slightly depressed. thenar and hypothenar eminences of hands should be full and convex. (Atrophy of hand muscles occurs in normal aging)
Inspect for fasciculations in atrophic muscles. If absent, tap on muscles w/ a reflex hammer, which stimulates them.
best assessed by feeling muscle’s resistance to passive stretch
Spasticity: incr in tone
that affects different muscle groups to different extents (In arms, tone incr more in flexors than extensors; in legs, tone incr more in extensors than in flexors);
R of affected muscle not the same throughout range of movement; most marked when passive movement initiated & diminishes as movement continues (clasp-knife phenomenon)
incr in tone velocity dependent: passive movement at a high velocity—but not at lower velocities—may be met w/ incr R
caused by an UMN lesion
Rigidity: incr R to passive movement
independent of direction of movement: affects agonist & antagonists equally
lead-pipe rigidity; cogwheel rigidity used when there are superimposed ratchetlike interruptions in passive movement, which probably relate to underlying tremor
generally indicates extrapyramidal dysfunction & is due to a lesion of basal ganglia (eg, Parkinson's disease)
u relates to pathologic involvement of LMN supply to affected muscles
can also occur w/ primary muscle disorders, disruption of sensory (afferent) limb of reflex arc, cerebellar disease, and certain extrapyramidal disorders such as Huntington‘ disease, as well as in acute stage of a pyramidal lesion
Some pxs give impression of being unable to relax and will move the limb being examined as physician moves it, despite instructions to contrary.
more advanced cases: rigidity when examiner moves limb rapidly but normal tone when limb moved slowly
particularly apt to occur in pxs w/ frontal lobe or diffuse cerebral disease
0 —No contraction detected
1 — contraction seen or identified w/ palpation, no movement
2 —Active movement of body part w/ gravity eliminated
3 —Active movement against gravity
4 —Active movement against gravity and some resistance
5 — Active movement against full resistance w/o evident fatigue.
4+ indicates good but not full strength, while 5− means a trace of weakness.
Test flexion (C5, C6—biceps and brachioradialis) and extension (C6, C7, C8—triceps) at elbow
Test extension at wrist (C6, C7, C8, radial nerve— extensor carpi radialis longus and brevis) by asking px to make a fist and resist as you press down Or ask px to extend forearms w/ fingers straight and palms up, then press palms downward.
Test grip (C7, C8, T1). Ask px to squeeze two of your fingers as hard as possible and not let them go. Normally it should be difficult for you to pull your fingers from px’s grip. Test both grips simultaneously w/ px’s arms extended or in lap to help compare right handgrip w/ left.
Test finger abduction (C8, T1, ulnar nerve). Position px's hand w/ palm down and fingers spread. Instruct px to prevent you from moving any fingers as you try to force them together
Test opposition of thumb (C8, T1, median nerve)
Test flexion at hip (L2, L3, L4—iliopsoas)
Test adduction at hips (L2, L3, L4—adductors)
Test abduction at hips (L4, L5, S1—gluteus medius and minimus)
Test extension at hips (S1—gluteus maximus)
Test extension at knee (L2, L3, L4—quadriceps)
Test flexion at knee (L4, L5, S1, S2—hamstrings)
Test foot dorsiflexion (mainly L4, L5—tibialis anterior) and plantar flexion (mainly S1—gastrocnemius, soleus)
Heel and toe walk also assess foot dorsiflexion and plantar flexion, respectively.*
Arms—Finger-to-Nose Test. These maneuvers test position sense and function of both labyrinth of inner ear and cerebellum.
Rapid Alternating Movements:
Arms: Repeat w/ other hand. nondominant hand may perform less well.
Show px how to tap distal joint of thumb w/ tip of index finger, again as rapidly as possible
Legs. Normally feet do not perform as well as hands
Standing in specified ways:
The Romberg Test. mainly a test of position sense. Note px's ability to maintain an upright posture. Normally any swaying minimal
Test for Pronator Drift.
occurs in some pxs w/ disturbances, u bilateral, of frontal lobe function (ex in hydrocephalus or progressive dementing disorders)
no weakness or incoordination of limbs but unable to stand unsupported or walk properly (feet seem glued to ground)
If walking possible, gait unsteady, uncertain, and short-stepped, w/ marked hesitation (“freezing”), and legs moved in a direction inappropriate to center of gravity
: selective weakness &
spasticity in UMN
--> affected leg must be circumducted to be advanced: px tilts at waist toward normal side and swings affected leg outward as well as forward;
arm on affected side u held flexed & adducted
knee cannot be bent
on affected side.
severe bilateral spasticity--> legs brought stiffly forward and adducted, often w/ compensatory movements of trunk
seen in its most extreme form in children w/ spastic diplegia from perinatally acquired static encephalopathy
mild spastic paraparesis: gait shuffling, slow, stiff, awkward, w/ feet tending to drag.
difficulty in beginning
to walk, may need to lean farther and farther forward while walking in place in order to advance;
in motion, may be
in turning & difficulty in stopping
charac by small strides, often taken at an incr rate until px almost running (
), and by loss of arm swinging that normally accompanies locomotion
gap betw legs decr
abnormal posturing of limbs or trunk; can interfere w/ locomotion or lead to a distorted and bizarre gait
irregular, unpredictable, unsteady
gait, as px dips or lurches from side to side
Choreiform movements of face & extremities u well in evidence.
orthostatic tremor: Tremor that occurs primarily on standing
may lead to an unsteady, uncertain gait
hesitancy in commencing to walk.
Cerebellar disorders: gap betw legs incr
bc of much caution walk slower and more organized:/
involvement of midline cerebellar structures, esp vermis
gait irregular, clumsy, unsteady, uncertain, and broad-based, w/ px walking w/ feet wide apart for additional support
turning and heel-to-toe walking esp difficult.
extreme cases: gross involvement of midline cerebellar structures (esp vermis): cannot stand w/o falling.
lesion of one cerebellar hemisphere--> unsteady gait in which px consistently falls or lurches toward affected side
Impaired sensation (esp
aggravated by walking in dark or w/ eyes closed
defective position sense--> many lift their feet higher than necessary when walking--> steppage gait
diseases that affect post spine (spinothalamic tract)
--> tabes dorsalis, sensory neuropathies,
vitamin B 12 deficiency, MS
Anterior horn cell, peripheral motor nerve, or striated muscle disorders
Weakness of ant tibial muscles--> foot drop
to avoid catching or scuffing foot on ground, px must lift affected leg higher than other-->
Weakness of trunk and girdle muscles, such as occurs in muscular dystrophy, other
, and Kugelberg-Welander syndrome-->
waddling gait bc pelvis tends to slump toward non-weight-bearing side.
thigh extensors weak--> pelvis slumps down)
Heel-to-knee movement: observe for a positional tremor
4- rebound test
5- rapid alternating hand movements
6- gait disterbance
Localization of Lesions
Weakness or paralysis.
Incr tendon reflexes.
An extensor plantar (Babinski) response + Loss of superficial abdominal reflexes.
Little, if any, muscle atrophy.
Weakness or paralysis.
Wasting and fasciculations of involved muscles.
Loss of tendon reflexes when neurons subserving them are affected.
Normal abdominal and plantar reflexes—unless neurons subserving them directly involved, in which case reflex responses are lost
--> hyperextensibility, pendular knee jerk, rebound phenomenon; unequal hypotonia of truncal muscle--> postural abnorm: scoliosis, elevation or depression of shoulder, pelvic tilt
Depressed or pendular tendon reflexes.
: limb, gait and speech
Gait disorder: ataxic, truncal ataxia
Imbalance of station.
Disturbances of eye movement.
Dysarthria: Scanning speech [spoken words broken up into separate syllables, often separated by a noticeable pause, and spoken with varying force]
: postural, intention, limb, trunk and head; or static type of action tremor or end-point or kinetic tremor
Normal or reduced muscle tone.
Normal or depressed tendon reflexes.
No sensory changes.
not conforming to distribution
of any single
may fluctuate in severity
periods, partic in relation to
Normal or depressed superficial reflexes.
Weakness, u most
rather than distally.
No muscle wasting until at least an advanced stage of the disorder.
Normal abdominal and plantar reflexes.
No sensory loss or sphincter disturbances.
No depression of tendon reflexes until at least an advanced stage of the disorder.