Facilitator Manual: HDPE Neurological Exam

Unit 6: Brain, Mind and Behavior

Session #: 127
January 23/26, 2017
Session Title: CS PE LAB: HDPE Neurological Exam

Description
Learn the focused physical examinations of all body systems in the context of
chief complaints, limited differential diagnoses, and discriminating features.
Coaching and practicing the skill of performing the neurological exam properly, including
proper use of the reflex hammer.

Readings
Bates Guide to Physical Examination and History Taking, 11th edition:
Chapter 5 : pp. 141-169
Chapter 17: pp 681-762
Medscape « Neurological History and Physical Exam
http://emedicine.medscape.com/article/1147993-overview#aw2aab6b2

View: http://depmedicina.med.up.pt/opeta/neuro/NE_main.html
Alternate Video source:
http://library.med.utah.edu/neurologicexam/html/home_exam.html

Learning Objectives:
1. Wash/sanitize hands before and after encounter
2. Utilize universal precautions when indicated
3. Touch patient in a gentle manner accommodating to cultural variation
4. Appropriately explain examination to the patient
5. Describe and demonstrate a neurological exam properly
Mental Status Exam:
6. Describe and demonstrate a comprehensive mental status exam including
appearance and behavior, speech and language, mood, thoughts and
perceptions, cognitive functions and higher cortical functions
7. Localize the deficits founds on mental status exam if possible; interpret the
findings of the mental status exam in the context of the patient and/or disease.
Cranial Nerve Exam:
8. Describe and demonstrate proper performance of a comprehensive cranial nerve
exam
9. Localize the deficits founds on cranial nerve exam; interpret the findings of the
cranial nerve exam in the context of the patient and/or disease
Sensation:
10. Demonstrate proper technique to assess sensation: pinprick (with sterile broken
wooden q-tip), temperature (cool metal tuning fork), vibration, proprioception,
double simultaneous stimulation, graphesthesia, and stereognosis
11. Interpret the findings of the sensation neurologic exam in the context of the
patient and/or disease
 Motor Function:
12. Assess muscle bulk; observe for involuntary movements; assess tone; assess
strength and document by properly using the grading scale (0-5)
13. Perform testing for gait/station [casual gait; toe, heel, and tandem walking,
Romberg]
14. Assess coordination [fine finger movements, rapid alternating movements, finger-
to-nose, heel-to-shin, involuntary movements]
15. Examine for pronator drift
16. Interpret the findings of the motor neurologic exam in the context of the patient
and/or disease
Reflexes:
17. Examine reflexes: deep tendon reflexes, plantar responses, clonus
18. Localize findings; interpret the findings of the reflex exam in the context of the
patient and/or disease
Specialized Maneuvers:
19. Describe and demonstrate neurologic specialized maneuvers including Kernigs,
Bruzinski’s
20. Interpret the finding of neurologic specialized maneuvers in the context of the
patient and/or disease

Equipment: : 2 penlights, eye chart, ophthalmoscope, tuning fork, reflex hammer

(Queen square is easiest to use) , and paper and pen, otoscope.
Wooden Q-tips and test tubes with coffee grounds will be provided.

Attire: Your students will be assigned to a lab with colleagues of their gender
where they will be asked to pair off to practice the techniques of the neurological
exam. They are asked to wear a tank top or tee shirt. Woman may wear sports
bras.

Pre-session assignments: Students are required to complete the Hypothesis

Driven Physical Exam table (HDPE) below prior to the session. The shoulder and
elbow HDPE tables should be submitted to the CS SG assignment dropbox into the
HDPE folder. The assignment must be submitted by 8am Monday January 23rd at
8am.
During the lab session, please confirm that they have completed the
assignment.
PHYSICAL EXAM SESSION FORMAT:
Your students will have 90 minutes to learn and practice the technique of
performing a complete neurological exam based on one clinical vignette. They
will also need to review the HDPE tables for 2 complaints (15 minutes). Allow
approximately 60 minutes for the physical exam, as outlined below. The session
concludes with a debrief of the session and question and answer period.

INTRODUCTION TO SESSION: (5 minutes)

This session begins with a review of three key concepts of the physical
exam. Begin the session by asking the students each of the following 3
open ended questions. Facilitate a discussion about each question.
1. Brief introduction of group and facilitator
2. What are important components of the history and physical of a neuro
complaint? What demographics should you obtain from the patient? What
risk factors? What are the components of the review of systems, including
pertinent positives and negatives?
Lead a discussion about the important historical data that needs to be
obtained from a patient with a neurological complaint. Reinforce that all
data gathering should include 1) Signs and sx 2) Chronology 3) Risk
Factors 4) Demographics
Review of the neuro history and physical:
 Signs and sx
 Nausea/Vomiting
 Vertigo (make sure you have patient describe
sensation)
 Dizziness
 Seizure
 Weakness
 Numbness (again have patient describe what is
meant, pay attention to dermatomal distribution)
 Weakness (global versus a spinal level)

 Chronology
o Duration
 Acute
 Subacute
 Chronic
 Insidious
o Course of condition
o Static
o Progressive
o Relapsing and remitting

 Risk factors
o Family History
 o Precipitating factors (sleep deprivation, stress,
 Demographics
REVIEW OF HDPE TABLE: (15 minutes)
 This should be an interactive session led by the students. Different students should
come up to the smart board to complete the table.

Complaint:

Differential diagnosis:
1. Bell’s Palsy (isolated CN VII palsy)
2. Stroke (either facial weakness due to stroke hitting the UMN or
brainstem stroke hitting CN VII)

Example of a scenario

Judy, 40 years old, sees you because the right side of her face feels funny. She
realized it this morning when she woke up. You are thinking of a possible isolated
facial nerve palsy (Bell’s palsy) or a stroke (central facial palsy). In anticipation of
your focused physical exam list the positive sign(s) associated with each
diagnostic hypothesis.

Bell’s Palsy Stroke

Wash Hands

Inspect the face (D) Flattening of the forehead Flattened nasolabial

and nasolabial fold on the fold but intact upper
side of the palsy forehead muscles if
UMN

Test cranial nerve XII Intact motor function ±

Test cranial nerve V Intact motor function ±

(motor: masseter,
temporalis, pterygoids)

Test cranial nerve V Normal ±

sensory

Test cranial nerve VII Weakness and inability to Weakness and inability
(motor: show teeth) show teeth on the right to show teeth on the
side right side

Test cranial nerve VII Unable to raise eyebrow Able to raise eyebrows
(motor: raise eyebrow) on affected side. bilaterally (UPPER
(D) HALF OF THE FACE
HAS BILATERAL
 INNERVATION)

Test cranial nerve XI Intact motor function Intact motor function

(motor:
sternocleidomastoids)

Test cranial nerve XI Intact motor function Intact motor function

(motor trapezius)

Test motor strength of Intact motor function May be decreased on

extremities contralateral side

Test sensation Intact Loss of sensation on

same side of cva

Test Discriminative Intact Loss of stereognosis.

Sensations Loss of Graphesthesia

Auscultate Carotids No abnormal bruits Bruit possibly present

if thrombus present

Auscultate heart Normal Possible murmur if

embolic stroke is
valvular in origin.
Possible atrial
fibrillation if stroke is
embolic

Palpate upper extremity Normal Possible irregularly

pulses(D) irregular pulse of atrial
fibrillation

Skin exam Possible hx erythema normal

marginatum of lyme
disease or vesicular rash
of herpes (should also
look for vesicles in the
ear canal)

* D=DISTINGUISHING FEATURES
Please read the PE findings below, following the students’ review of the
HDPE table:

Following your physical examination of the above patient, you find that the
patient is well appearing but in mild distress. Her vitals are 210/112, 110
irregular, 20, Saturation 96%. Cranial nerve exam reveals intact upper forehead
muscles. She is able to show her teeth on the right side but her lower face is
clearly weaker on the right than on the left, resulting in facial asymmetry, even at
rest. The rest of the cranial nerve exam is within normal limits. Remainder of the
neurologic exam is normal except for a pronator drift, clumsy fine finger
movement with the right hand, and right and reflexes that are slightly brisker on
the right than on the left. Cardiac and pulse exam reveals an irregularly irregular
rhythm. Cardiac exam reveals no thrills or abnormal pulsations. Her PMI is not
displaced. S1 is normal. There are no rubs, clicks or gallops. No S3/S4. There
are no murmurs. The lungs are clear to auscultation. There are no rashes

Given the results of the physical exam, which diagnosis is most likely?
Diagnosis: Stroke (central cranial nerve palsy)

References:
McGee, S. Facial Nerve. Evidence-Based Physical Diagnosis. Philadelphia: W.B.
Saunders Company. 2001, p. 708-711.
www.uptodate.com (v15.2) Bell’s palsy.
 This should be an interactive session led by the students. Different students should
come up to the smart board to complete the table

Complaint:

Differential diagnosis:
1. Central Vertigo
2. Peripheral Vertigo

Example of a scenario

Pat, 50 years old with diabetes and hypertension, came to the Emergency Room
because she has felt “dizzy” since this morning. She describes the dizziness as
the “room spinning.” She said the vertigo started after she woke up and was
severe at onset. It is associated with severe nausea and vomiting. Her daughter
noticed that when the patient moves her head, her eye dart back and forth but
then stop. She has no associated weakness. There is no associated hearing
loss. You are trying to distinguish a central from a peripheral cause of the
patient’s vertigo.

In anticipation of your physical exam of the Central Nervous System, list the
positive sign(s) associated with each diagnostic hypothesis.

Central Vertigo Peripheral Vertigo

Wash Hands

Evaluate speech pattern Scanning-enunciates Normal

individual syllables

Evaluate for nystagmus Fast phase towards side Unidirectional

of lesion horizontal nystagmus
toward good ear.
Fatigable.

Auscultate carotid artery Normal or bruit may be Normal

bilaterally auscultated

Palpate the carotid pulse, Normal or diminished Normal

bilaterally

Rinne and Weber Normal Sensorineural hearing

loss may be present.

Test Tone Hypotonia Normal

Perform Romberg test NOT normal Positive or difficult to
perform

Observe gait while Ataxic-Clumsy, Normal or possibly

patient walks staggering and wide- decreased
based. May fall to side of
the lesion

Observe heel to toe gait Abnormal, unsteady May be unsteady.

(Tandem gait)

Perform pronator drift test Upperward drift may be Normal

present

Perform upper extremity Normal Normal

strength testing

Perform Lower extremity Normal Normal

strength testing

Perform upper extremity Normal Normal

reflex testing

Perform lower extremity Normal Normal

reflex testing

Perform Babinski test Absent Absent

bilaterally

Test finger to nose Presence of dysmetria Normal

coordination bilaterally

Test heel to shin Abnormal-Patient will not Normal

coordination bilaterally be able to keep heel on
shin

Test rapid alternating Presence of Normal

movements dysdiadochokinesia

Test sharp and dull Normal Normal

Test position sense Normal Normal

bilaterally

Test vibratory sense Normal Normal

bilaterally

Perform Dix-Hallpike Normal Positive

maneuver

Perform Kernig’s and Normal Normal

Brudzinski

Please read the PE findings below, following the students’ review of the
HDPE table:

Following your physical examination of the above patient, you find that the
patient is well appearing but in distress due to severe vertigo and nausea. Her
vitals are 210/112, 110 irregular, 20, Saturation 96%. Cranial nerve exam
demonstrates a Rinne and Weber positive for a sensorineural hearing loss on the
left. She has fatigable nystagmus towards the left side. Speech is normal. The
Dix-Hallpike Test is positive. The rest of the cranial nerve exam is within normal
limits. The patient is unable to perform the Romberg test or tandem walk.
However, there is no dysdiadochokinesia or dysmetria. Speech is normal. The
patient has some clear rhinorrhea from a recent URI. Cardiac and pulse exam
are normal. Cardiac exam reveals no thrills or abnormal pulsations. Her PMI is
not displaced. S1 is normal. There are no rubs, clicks or gallops. No S3/S4.
There are no murmurs. The lungs are clear to auscultation. There are no
rashes. There are no meningeal signs.

Given the results of the physical exam, which diagnosis is most likely?
Diagnosis: Peripheral Vertigo

References:
McGee, S. Facial Nerve. Evidence-Based Physical Diagnosis. Philadelphia: W.B.
Saunders Company. 2001, p. 708-711.
www.uptodate.com (v15.2) Bell’s palsy.
PHYSICAL EXAM PRACTICE: (60 minutes)

Complaint:
This portion of the lab requires the students to perform a focused physical exam
based the HDPE case. Before starting the exam, have the students discuss with
their partner the components of the focused exam for the case.

Stress to the students to vocalize the reasoning for each exam component and
what they expect to find for either Bell’s palsy or cva.

Remember, this physical exam table is focused for this specific clinical
case. For other presentations, the exam may be adjusted for the clinical
setting. The focused physical exam is a problem-oriented approach.

Differential diagnosis:
1. Bell’s Palsy (isolated CN VII palsy)
2. Stroke (either facial weakness due to stroke hitting the UMN or
brainstem stroke hitting CN VII)

Example of a scenario

Judy, 40 years old, sees you because the right side of her face feels funny. She
realized it this morning when she woke up. You are thinking of a possible isolated
facial nerve palsy (Bell’s palsy) or a stroke (central facial palsy). In anticipation of
your focused physical exam list the positive sign(s) associated with each
diagnostic hypothesis.
 Student Name: Rater Initials: Date:
Check each item done correctly. Facilitator must directly observe items that are highlighted.

NEUROLOGICAL EXAMINATION CHECKLIST

Properly
Setting the stage for the Physical Exam
Performed
1. Assemble all your tools in easy reach of where you will be examining the
patient.
2. Wash hands in view of patient
3. Introduce self to patient, greet the patient by making a welcoming remark,
ensure patient readiness, comfort and put the patient at ease.
4. Ask the patient to sit on the examination table. Examiner stands in front of the
patient.
5. Describe what is being done while examining the patient.
6. Summarize the findings to the patient.
1MENTAL STATUS EXAM
APPEARANCE AND BEHAVIOR
Level of Consciousness- Is the patient awake? Do they fall silent or asleep?
If patient does not respond speak more loudly or shake gently. If patient does
not respond assess for stupor or coma..
Posture and Motor Behavior-Does patient lie in bed or prefer to walk around?
Note posture and ability to relax. Observe character of movements.
Dress, Grooming, and Personal Hygiene-How is patient dress? How is their
grooming? How does patient’s grooming compare with those of other people of
comparable age, lifestyle, and socioeconomic group?
Facial Expression-Observe face and expression when patient interacts with
others. Does expression vary depending on topics under discussion? Are
expressions appropriate? Is the face relatively immobile throughout?
Manner, Affect, and Relationship to People and Things-Assess affect based
on facial expressions, voice, and body movements. Does affect change
appropriately depending on topics under discussion or is it blunted, labile, or
flat? Is patient able to hear or see things that you do not or seem to be
conversing with someone who is not there?
SPEECH AND ARTICULATION
Quantity-Is patient talkative or relatively silent? Are comments spontaneous or
only in direct response to questions?
Rate- Is speech fast or slow?
Volume-Is speech loud or soft?
Articulation of Words- Assessment for dysarthria. Are words clear and
distinct?
Fluency-Assess for aphasia. Assess rate, flow and melody of speech. Notice
hesitancies and gaps in flow and rhythm of words. Is patient monotone? Are
there circumlocutions? Are there paraphasias?
 Word Comprehension-Ask the patient to follow a one-stage command,
such as “point to your nose.” Try a two-stage command: “Point to your
mouth, then to your knee.”
 Repetition-Ask the patient to repeat a phrase of one-syllable words: “no
ifs, ands, or buts.”
  Naming-Ask the patient to name the parts of a watch
 Reading Comprehension-Ask the patient to read a paragraph aloud
 Writing-Ask the patient to write a sentence.
MOOD
Assess Mood-How does the patient feel? Are there any variations from
baseline? Assess risk of suicidality. Has mood been labile (periods of
depression followed by elevated mood)?
THOUGHTS AND PERCEPTIONS
Thought Processes-Assess logic, relevance, organization, and coherence of
patient’s thoughts process. Does speech progress logically toward a goal?
Thought Content- Assess content of information gathered during the interview.
Perceptions-Inquire about false perceptions such as hallucinations or illusions.
Insight and Judgment: Does patient understand why they came to the
hospital? Assess how patient would respond to certain situations. Are these
responses appropriate? Are decisions and actions based on reality? Do they
compare with a comparable mature adult?
COGNITIVE FUNTIONS
Orientation-Determine patient’s orientation to person, time and place. Include
self and relatives and professional personal
Attention:
Digit Span-Recite a series of digits starting two at a time at rate of 1 per second
and have patient repeat the numbers to you. Keep track of speed and accuracy
of responses. If accurate repeat with series of 3 then 4 numbers as long as
patient answers accurately. Stop after a second failure in a series. Start again
but have the patient repeat the numbers backwards.
Serial 7s- Instruct patient “starting from 100, subtract 7, and keep subtracting
7s. Usually can complete in 1.5 minutes with fewer than four errors.
Spelling Backward- Say a five letter word- W-O-R-L-D, and ask patient to spell it
backward.
Recall: Inquire about birthdays, anniversaries, jobs held or other events
relevant to patient’s past.
Short Term Memory: Involves events of the day that you can confirm to see if
the patient is confabulating. 1) Ask about the weather, time of today’s
appointment, etc. 2) Give the patient 3 objects to remember -for example "car,
ball, red" - ask the pt to repeat the words, and tell them you will ask them again
in 5 minutes. Then in 5 minutes - ask the patient what the 3 words were.
HIGHER COGNITIVE FUNCTIONS
Information and Vocabulary: Gives rough estimate of intelligence. Note
vocabulary, grasp of information. Some questions-“Who is the president?”
“Name 5 large cities in the country”
Calculating Ability: Test ability to do simple arithmetic either by rote simple
addition or word problems.
Abstract Thinking: Test capacity to think abstractly by asking meaning of
proverbs-For example, “Don’t count your chickens before they hatch.”
Constructional Ability: Have patient copy circle, cube, and diamond on a
blank piece of paper. Have patient draw a clock face.
CRANIAL NERVES
CN I (Olfactory nv/ smell): Test one nostril at a time by using a nonirritating
smell (such as orange, vanilla, or coffee). Ask patient to block the nostril that is
 not being examined. Ask patient to A. detect the presence of a scent and then
B. identify the scent
CN II (Optic nv/Visual Acuity, visual fields, ocular fundi) 1. Test visual acuity
in each eye separately, holding chart 14” from patient’s face. 2. Test visual
fields by confrontation, using own visual field as reference. Stand 12” away; be
sure to start with visual target outside of both patient’s and your visual field.
Test 4 quadrants. 3. Perform fundoscopy to assess the optic disc, health of the
retinal vessels, macula, and retina
CN II, III (Optic and oculomotor nerve/pupillary reactions) 1. Inspect
pupillary size and shape bilaterally. 2. Observe direct and consensual pupillary
response in each eye, while patient looks in distance. 3. Check for
convergence by asking patient to visually track your finger as you move it
towards patient’s nose.
CN III, IV, VI (Oculomotor/trochlear/abducens nv-extraocular movements)
Test extra-ocular movements by asking patient to follow your finger in an “H”
pattern (arms length distance). You may stabilize patient’s head with other
hand, if necessary.
Demonstrate “sharp” and “dull” on patient’s face broken stick of Q-tip in contrast
to cotton swab.
CN V (Trigeminal nv/ corneal reflexes, facial sensation, and jaw
movements) 1. Corneal reflex tested by touch piece of cotton to cornea not just
conjunctiva. Blinking is normal response. Do not practice corneal reflex on
partner. 2. Test patient’s ability to discriminate “sharp” vs. “dull” on forehead,
middle cheek, jaw, on each side of face, with eyes closed. Place your hands on
both sides of patient’s face over masseter muscles. 3. Ask patient to bite down
while palpating contraction of muscles.
CN VII (Facial nv/facial movements) 1. Inspect face at rest and during
conversation. Note asymmetry. Observe for any abnormal movements. 2. Ask
patient to hold eyelid closed while examiner puts upward traction on superior
orbital ridge. 3. Ask patient to frown 4. Show both teeth 5. Smile 6. Puff out
cheeks
CN VIII (Vestibulocochlear n. /Hearing) 1. Test auditory acuity by whispering
in each ear at a distance of 2 feet; ask patient to repeat what you said. 2.
Perform Rinne test 3. Perform Weber test
CN IX, X (Glossopharyngeal and Vagus nerve-Swallowing and rise of
palate, gag reflex) 1. Instruct patient to say “ah” and watch for palate
elevation. 2. After warning patient, test gag reflex
CN XI- (spinal accessory nv/shoulder and neck movement- 1. Ask patient
to keep head in midline while you try to push chin to one side, then the other. 2.
Place your hands on patient’s shoulders; ask patient to shrug shoulders up
against your resistance.
CN XII-Hypoglossal nv/tongue symmetry and position- 1. Inspect tongue as
it lies on floor of mouth. 2. Ask patient to protrude tongue and move it from side
to side.
MOTOR FUNCTION
1. Test tone. Observe for involuntary movements and muscle bulk. Ask the
patient to relax the limb being tested. Passively move the limb
(flexion/extension, pronation/supination); compare right to left sides looking for
any asymmetry of tone. There are several ways to assess tone, here are some
 examples: 1. Passively flex and extend the patients elbows. 2. Support the leg
under the popliteal fossa with one hand and the ankle with the other hand, ask
patient to relax the leg, let the ankle go letting the lower leg drop while
continuing to give support at the knee.
2. Pronator Drift Test: Ask patient to hold arms out in front of him/her with palms
up (as if holding up a tray) with the eyes closed. Observe for at least 15
seconds for signs of pronation of one hand and forearm or one of the arms
dropping below the other. There must be pronation for the test to be a positive
sign. Sometimes there is drift downward along with the pronation. If there is only
a drift downward without pronation, then this is an abnormality in proprioception
and the pronator drift sign is negative.
Test the upper extremity muscle strength bilaterally, separately, and
symmetrically.
3. Test the deltoid muscle strength (axillary nerve, C5/C6) bilaterally by
pushing downward on the patient’s fully abducted arms at the same time.
4. Test the biceps muscle strength (musculocutaneous nerve, C5/C6)
bilaterally and symmetrically by positioning patient’s elbow to a 90-degree bend,
palm up. Push downward on the wrist or forearm while the patient resists your
pressure.
5. Test the triceps muscle strength (radial nerve, C6/C7/C8) bilaterally and
symmetrically by positioning patient’s elbow to a 90-degree bend, palm up.
Push upward on the wrist or forearm while the patient resists your pressure.
5. Finger Strength: Thumb Opposition (median nerve C8, T1) Ask patient to
touch the thumb to the middle finger, place your finger within the circle of his/her
fingers and try to break the opposition (examiner should not be able to break it).
Finger abduction (ulnar nerve C8, T1) Ask the patient to spread fingers of
each hand stiffly out and keep them that way while you try to push them inward.
6. Test grip strength: (C7/C8/T1) bilaterally by asking patient to squeeze your
index finger as you try to pull it out of patient’s grip.
Test the lower leg muscle strength bilaterally, separately, and symmetrically.
Hip flexion/iliopsoas: (L2/L3/L4) Place your hand on the patient’s thigh and
ask the patient to raise the leg against your hand.
Hip adduction/adductor muscles: (L2/L3/L/4) Place your hands firmly on the
bed between the patient’s knees. Ask the patient to bring both legs together.
Hip abduction/gluteus medius and minimus: (L4/L5/S1) Place your hands
firmly on the bed outside the patient’s knees. Ask the patient to spread both
legs against your hands.
Hip Extension/gluteus maxiumus: (S1) Have the patient push the posterior
thigh down against your hand.
7. Knee extension/Quadriceps muscles: (femoral nerve L2/L3/L4) In seated
position with knees bent at 90 degrees place your hand over the patient's distal
tibia and ask patient to extend the leg against your resistance.
8. Knee Flexion/Hamstrings muscles: (Sciatic nerve (Tibial division)
L4/L4/S1/S2) In seated position with knees bent at 90 degrees ask patient to
extend the leg to about 30 degrees. Then place your hand under the distal calf
and ask patient to bend their knee against your resistance.
9. Dorsiflexion/tibialis anterior (deep peroneal nerve, L4/L5) In seated position
ask the patient to straighten the leg. Push on dorsal aspect of the foot while
patient flexes the ankle. Plantarflexion/gastrocnemius/soleus (tibial nerve
S1): Then push on the plantar aspect of the foot while the patient extends the
 ankle.
COORDINATION
1.Rapid Alternating Movements: Have patient strike one hand on the thigh,
raise the hand, turn it over, and strike back of hand down on the same place as
rapidly as possible. Observe speed, rhythm, and smoothness of movement.
2.Ask
3 patient to quickly touch each finger with his/her thumb. Observe speed,
rhythm,
. and smoothness of movement. The non-dominant hand often performs
less well.
3.Test
1 finger-to-nose coordination: position your index finger to allow the
patient
. to fully extend his/her arm to reach it. Ask the patient to hold his/her
head still, and first touch the index finger to his nose, then to your finger, then to
the nose, alternating back and forth as you reposition your finger several times,
in different directions.
4.Test
2 heel-to-shin coordination bilaterally by asking the patient to place the
heel
. of one foot just below the opposite knee and then slide the heel straight
down the anterior surface of the leg to the ankle.
STANCE/PROPRIOCEPTION
1. Romberg Test: Instruct patient to stand with his/her feet together and arms
down at the sides with eyes open. Watch for obvious unsteadiness. If she
remains steady, continue with the test. Move closer to the patient. Place your
hands near her shoulders (ready to catch the patient if needed). Ask her to
close eyes and then reassure the patient that you will not let her fall. Observe
the patient for signs of swaying or signs of unsteadiness for at least 15 seconds.
GAIT
1. Ask patient to rise from a sitting position without arm support or hop in place if
not too ill.
2. Ask patient to perform a shallow knee bend or step up on a stool
3. Ask patient to walk away from you while you observe the way he/she walks
(form and steadiness).
4. Ask patient to walk towards or away from you on his/her toes.
5. Ask patient to walk towards or away from you on his/her heels.
6. Ask patient to walk towards you heel-to-toe (one foot tightly in front of the other,
i.e. tandem gait).
REFLEXES
Assess Reflex Technique: The movement of the hammer should be a rapid
downward snap of the wrist. The hammer should not be held too firmly. Always
compare one side to the other before moving to the next deep tendon reflex.
The patient’s muscles should not be actively contracted; relaxation or just slight
passive contraction is ideal and allows just small tension on the muscle spindle.
Note speed and intensity of each response.
1. Test the biceps reflex (C5/C6) bilaterally. With the elbow slightly flexed and
forearm resting in the patient’s lap, palm down, palpate the biceps tendon with
your thumb and press in to produce moderate tension. Then strike your
thumbnail with the reflex hammer.
2. Test the brachioradialis reflex (C5/C6) bilaterally. Let patient’s arm rest in her
lap, elbow bent, forearm halfway between supination and pronation. Palpate the
radial styloid (at the wrist by the base of the thumb) and move 2 inches
 proximally. Palpate the tendon over the radius. Stretch the tendon by striking
your finger (or thumb). Watch for flexion and supination of the forearm.
3. Test the triceps reflex (C6/C7) bilaterally. Position yourself posterior to the
patient, his/her arms are still in his/her lap or you can lift the upper arm with
your arm near 90 degrees, instructing patient to let the arm be limp. Palpate the
triceps tendon just above the olecranon. If you have trouble finding the tendon,
press on the tendon as he/she extends her arm against your resistance. The
tendon will tighten and bulge. Strike the tendon directly. (Stay clear of the ulnar
groove, just medial to the tendon). Watch for extension of the forearm or
contraction of the muscle.
4. Test the patellar (knee) reflex (L2/L3/L4) bilaterally. Position the patient with
legs dangling freely. If the patient is sitting on a surface where his/her legs
reach the ground ask, him/her to cross the leg you wish to examine over the
other so that it is dangling (relaxed). Locate the tendon just inferior to the
patella. Tap briskly and observe extension of the knee and/or contraction of the
quadriceps muscle.
5. Test the Achilles (ankle) reflex bilaterally. The Achilles tendon should be
stretched by the examiner when eliciting its’ reflex. With the legs dangling, or in
the crossed legged position (examining the front leg), grasp the plantar surface
of the foot, and hold it in a slightly dorsiflexed position. Strike the tendon briskly.
Watch for the intensity of the plantar flexion and also how quickly it relaxes
afterward.
6. Clonus: Support the knee in a partly flexed position. With your other hand
dorsiflex and plantar flex the foot a few times to relax. Then sharply dorsiflex
the foot and maintain in dorsiflexion. Look and feel rhythmic oscillations
between dorsiflexion and plantarflexion.
7. Plantar Response/Babinski (L5/S1): With an object such as the handle of the
reflex hammer, stroke the lateral aspect of the sole from heel to the ball of the
foot, curving medially across the ball. Normal movement is plantar flexion of the
big toe. Dorsiflexion is a positive Babinski from a central nervous system lesion
in the corticospinal tract.
SENSORY FUNCTIONS
1. Test spinothalamic sensory functions: Pain and temperature. Touch the
patient with dull and sharp (dull cotton end of Q-tip versus broken sharp end of
wooden Q-tip) OR warm and cold objects (for temperature testing, a cool tuning
fork will do.). Patient’s eyes must be closed; patient identifies what is felt
(sharp/dull, cold/warm). Always compare right verses left and proximal verses
distal.
2. Position Sense Demonstration and Test: Grasp the large toe or finger by the
sides at the distal phalanx (the ring finger is sometimes recommended as
preferred, as it has the least cortical representation). Move the digit upwards or
downwards and ask patient to identify in which direction it is moving, while
his/her eyes are closed. To avoid confusion, first demonstrate to the patient,
while patient is watching. The joint must be completely relaxed; you should
move only the distal phalanx; do not rub against other digits when doing so.
Position sense must be checked on all 4 extremities.
3. Vibratory Sense Demonstration and Test: Demonstrate to patient, while
patient is watching you. Hold tuning fork near its base and activate it by tapping
it on the heel of your hand or by striking it with a reflex hammer. Always press it
to a bony prominence. Ask patient if he/she can feel the “vibration” or “buzz”
(and when the vibration stops). Next, ask patient to close eyes, and test the
vibration sense on all four distal limbs. Ask patient if he/she feels a vibration,
and have them tell you when the vibration stops (you should make it stop by
touching it; otherwise you’ll be waiting a long time). Vibratory sense must be
checked on all 4 extremities.
Discriminative Sensations
Stereognosis: Identify an object by feeling it. With eyes closed place a familiar
object such as a coin, safety pin or key in a patient’s hand. They should be able
to identify it within 5 seconds
Graphesthesia: With eyes closed, use the blunt end of a pen to write a large
number on the patient’s palm. Normal patient’s should be able to identify the
number
FOCUSED MANEUVERS
Inspect Skin for rashes, vesicles. Lyme disease and reactivation of herpes
zoster are risk factors for Bell’s Palsy
Auscultate carotid arteries for bruits. Instruct patient to hold breath while
auscultating with the bell. Can be done with patient in sitting or supine position.
Bruit may indicate carotid artery thrombosis leading to plaque rupture and
stroke
CN VIII (Vestibulocochlear n. /Hearing Test auditory acuity by whispering in
each ear at a distance of 2 feet; ask patient to repeat what you said. Hearing
loss may indicate a tumor compressing facial nerve especially if symptoms are
long standing
Examine each ear with a clean speculum with the otoscope. Hold otoscope like
a pencil so you can brace that hand against patient’s face; insert carefully into
ear canal until tympanic membrane is visualized. Bell’s palsy may be a
complication of chronic otitis media
Inspect lips, gums, tongue, floor of mouth, inside of cheeks, and teeth with help
of tongue blade and light. Ascertain for parotid swelling since mumps is a rare
cause of Bell’s palsy
Cardiac Auscultation: Utilize the 4 standard auscultation positions
Auscultate each of the 4 areas of the heart using the diaphragm in the supine
position
1. Auscultate the aortic area:
(2nd intercostal space at the right sternal border)
2. Auscultate the pulmonic area:
(2nd intercostal spaces at the left sternal border)
3. Auscultate the tricuspid area:
(4th to 5th intercostal space at left lower sternal border)
4. Auscultate the mitral (cardiac apex) area:
(5th intercostal space, mid-clavicular line, PMI)
Auscultate for irregularly irregular rhythm of atrial fibrillation as a risk
factor for stroke. Auscultate for murmurs indicating valvular heart
disease as a risk factor for stroke
Thought provoking comments during exam:
1. Always perform the Romberg first with eyes open. If the patient can not
stand with the eyes open then they surely will not be able to perform the
Romberg with eyes closed.
2. For initial screening, one cerebellar test (such as finger-to-nose) is
sufficient. If positive or clinical suspicion is high for cerebellar disease,
additional tests are required to assure that the results are durable. That is,
if the abnormality on one test is truly due to cerebellar dysfunction, other
tests should identify the same problem.
3. Gait testing is a very important component of any neurological exam
4. Always test upper and lower extremity strength testing together.
(Separated for this lab so not to replicate exam and allow you to practice
each component.)
5. Understand the diagnostic significance of the Dix-Hallpike maneuver. You
will not be required to perform the maneuver in class.
6. If patient presents with fever,vertigo, assess for meningeal exam to rule
out meningitis as cause.
7. As you are performing the cranial nerve and motor testing verbalize which
nerves are being tested.