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PG Y III Resident
Family and Community Medicine
National University of Rwanda
October 2010
Initial approach
Mental Status
Cranial Nerves
Motor Exam
Reflexes
Coordination and Gait
Sensory Exam
References
The Neurologic History
AVPU-GCS
Awake and alert
Agitated
Lethargic
Comatose
Test attention by seeing if the patient can remain focused on a simple
task, such as spelling a short word forward and backward (R-W-A-N-D-A
/A-D-N-A-W-R) is a standard.
Comprehension: Can the patient understand simple questions and
commands? Comprehension of grammatical structure should be tested
as well
2.Speech and Language
II - Optic
Visual Acuity (test with hand card)
Color Vision (loss of color vision especially red is an important symptom
of optic neuritis)
Visual Fields (can be tested at the bedside by counting fingers in each
quadrant)
Visual Extinction (to detect visual neglect)
Funduscopic Examination
II and III –Optic/Oculomotor
The size and shape of the pupil should be recorded at rest. Under normal
conditions, the pupil constricts in response to light.
Note the direct response, meaning constriction of the illuminated pupil,
as well as the consensual response, meaning constriction of the opposite
pupil.
Test the pupillary response to accommodation. Normally, the pupils
constrict while fixating on an object being moved from far away to near
the eyes.
III/IV/VI-Oculomotor/Trochlear/Abducens
Observe the eyes at rest to see if there are any abnormalities such as
spontaneous nystagmus or dysconjugate gaze (eyes not both fixated on
the same point) resulting in diplopia (double vision).
Test smooth pursuit by having the patient follow an object moved across
their full range of horizontal and vertical eye movements.
Test convergence movements by having the patient fixate on an object
as it is moved slowly towards a point right between the patient's eyes.
In comatose or severely lethargic patients, the vestibulo-ocular reflex can
be used to test whether brainstem eye movement pathways are intact.
The oculocephalic reflex, a form of the vestibulo-ocular reflex, is tested
by holding the eyes open and rotating the head from side to side or up
and down.
Pupillary response, eye movements,9 cardinal positions, observe lids for
ptosis.
V – Trigeminal
the stem of a vibrating tuning fork is placed on the midline of the head
and the patient indicates in which ear the tone is heard louder.
A patient with a unilateral conductive hearing loss hears the tone louder
in the ear with the conductive hearing loss, or reasons that are unclear.
In contrast, a patient with a unilateral sensorineural hearing loss hears
the tone louder in the normal ear because the tuning fork stimulates
both inner ears equally and the patient perceives the stimulus with the
more sensitive, unaffected end organ and nerve.
Rinne's test
Ask the patient to shrug their shoulders, turn their head in both
directions, and raise their head from the bed, flexing forward against the
force of your hands.
Sternocleidomastoid muscle, Trapezius muscle.
XII – Hypoglossal
0 No contraction
1 Flicker or trace contraction
2 Active movement with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity and resistance
5 Normal power
Romberg test
With the eyes open, three sensory systems provide input to the
cerebellum to maintain truncal stability. These are vision, proprioception,
and vestibular sense.
0 : absent reflex
1+ : trace, or seen only with reinforcement
2+ : normal
3+ : brisk
4+ : no sustained clonus (i.e., repetitive vibratory movements)
5+ : sustained clonus
Muscle Stretch Reflexes
Pectoral C5
Jaw Jerk Trigeminal, Facial
Biceps C5,C6
Triceps C6,C7
Brachioradialis C7
Patellar L3,L4
Achilles Tendon S1
Cutaneous Reflexes
Abdominal reflexes T9-T12
Cremasteric L1-L2
Anal S1-S3-S4
Extensor plantar response or Babinski sign
Primitive Reflexes
Grasp, suck, palmomental
Primary sensation
Light Touch
Pinprick
Vibration
Joint Position
Temperature
Two point discrimination
The pattern of sensory loss can provide important information that helps
localize lesions to particular nerves, nerve roots, and regions of the spinal
cord, brainstem, thalamus, or cortex.
Cortical sensation