Neuro Exam 2020

The Neurological Examination
By
Dr Nkouonlack Cyrille
09/06/2020 MED 426 CLINICAL SEMIOLOGY 3 1

Learning Objectives:
• Demonstrate assessment of cranial nerves I – XII.
• Demonstrate technique for assessing the motor system,
including tone, muscle bulk, and strength.
• Demonstrate testing of muscle stretch reflexes and plantar
reflex.
• Demonstrate assessment of sensory system for light touch, pain,
vibration, and position sense (including Romberg testing).
• Demonstrate techniques for testing coordination.
• Demonstrate techniques for testing gait and stance.
Introduction
• Clinical method in neurology is a three-stage process
• Aims at formulating a plan of investigation and
management.
• Take a careful and comprehensive history.
• Perform a physical examination, focusing on the relevant
nervous system function as determined by the history.
• Basic screening examination of the nervous system and
a brief general examination.
The Goals of the Neurological Examination.
• Determine, on the basis of an organized and thorough
examination, whether in fact neurological dysfunction exists.
• Identify which component(s) of the neurological system are
affected (e.g. motor, sensory, cranial nerves etc).
• On the basis of these findings, generate a list of possible etiologies.
• Unlikely diagnoses can be excluded and appropriate testing (e.g.
brain and spinal cord imaging) applied in an orderly and logical
fashion.
• Screening for the presence of abnormalities in patients at risk for
the development of neurological disorders.
The Neurological History
• The history sets the scene.
• Identifies the region or neurological subsystem involved.
• Assesses the temporal development of the complaint in the
context of age, past history and family history.
• Reveals the nature of the pathology localized by
examination.
• It may be important to talk to an observer or family member
to find out more.

Key Points in Neurological History
• Cognitive disturbance, change in mood, concentration or sleep.
• Episodes of loss of consciousness or dizzy spells
• Loss of Vision or double vision
• Loss of Hearing or balance
• Difficulty with Speech, swallowing
• Arms, handwriting
• Difficulty walking or weakness or heaviness in limbs.
• Involuntary movements
• Bladder, bowel function, sexual function
• Pain, headache
Scheme of Neurological History-taking
Aspect of history Examples
1. Region(s) or subsystem(s) involved Vision, swallowing, limbs, gait and stance.
2. Temporal aspects Onset, duration, improving or progressing?, periodicity
3. Character, severity Negative symptoms (e.g. numbness, paralysis) or positive
symptoms (e.g. pain, jerking), a pulsing or tight headache
4. Causative and relieving factors Headache on coughing, leg pain relieved by rest
5. Associated factors Symptoms that occur together in attacks, e.g. nausea,
sweating, diarrhoea
6. Disability resulting from symptom Unable to work, unable to feed oneself
7. General health, past history Other symptoms, weight change, mood
8. Medication history, substance Medication side effects, alcohol, cigarette smoking
abuse, social history

Various Pathologies Suggested by Clinical Pattern
Pattern of onset and development Suspected Pathology
Sudden Traumatic, vascular, psychogenic

Acute on chronic Exacerbation of pre-existing pathology (e.g. cervical
spondylosis and disc prolapse)
Subacute Infective, inflammatory
Chronic and steadily progressive Malignant tumours
Chronic and indolent Benign tumours, degenerative (e.g. spondylotic,
neurodegenerative), genetic
Relapsing-remitting Inflammatory, rarely infective
Stepwise Vasculitic, inflammatory, multiple strokes
Previous episodes in other Vasculitic, inflammatory, multiple strokes
neurological systems
The Neurological Examination
• Done to support your hypothesis, but also to refute it.
• Approach the exam systematically and establish a
routine.
• Experience guides the full examination and result in
focusing more on the most pertinent signs and
symptoms.
• Simple observation can reveal much about the
patient’s neurological function.
Major Areas of the Neurological Exam Include:
• Mental Status Examination
• Cranial Nerves Examination
• Motor System: Muscle strength, tone and bulk
• Reflexes
• Coordination
• Sensory Function
• Station and Gait
Tools used for the Neurological Exmaination.
• Reflex hammer.
• 128-Hz tuning fork.
• Ophthalmoscope.
• Pocket eye chart (for near
vision testing)
• Cotton swabs
• Tongue blades, and safety
pins
Mental Status Examination
• In addition to its value in localization, mental status testing is
used to establish the reliability of the rest of the neuro exam.
• You can assess much of patients’ mental status via simple
observation and through their answers to your questions
during history taking.
• For a screening exam, you are done if the patient makes
appropriate eye contact and does not drift off or need things
repeated, is able to converse normally with you, and answers
questions about medical history and recent events in a
consistent manner.
Mental Status Examination
1. Level of awareness.
2. Attentiveness: Is the patient paying attention to you and your
questions or is he distractible and requiring re-focusing?
3. Orientation: to self, place, time
4. Speech & language: includes fluency, repetition, comprehension,
reading, writing, naming.
5. Memory: includes registration and retention.
6. Higher intellectual function: includes general knowledge,
abstraction, judgment, insight, reasoning.
7. Mood and affect: To determine if psychiatric disease may be
interfering with the neurological assessment.
Mental Status Examination: Orientation
• Orientation is tested in three dimensions: Self, Place,
And Time.
• Time: Ask the patient about (day, date, month, year),
what time of the day is it?
• Place: Ask where he is now (room, building, town,
country), what floor is it on?
• Person: Ask the patient about his (name, age, work,
address) also ask him about the relative’s names who
are around his bed?
Mental Status Examination: Memory
• Memory is the ability to register, store, and finally retrieve information.
• Immediate recall, recent memory and remote memory correspond to
registration, storage and retrieval, respectively.
• Immediate recall (registration):
• Digit number: ask the patient to repeat a random series of numbers
• Ask the patient to register three words now; then ask them after a few minutes to
recall.
• Recent memory (short term memory):
• Repetition of three short words, events that occurred minutes to hours.
• Remote memory (long term memory):
• Date of birth/marriage, birthplace, presidents, where did you grow up?
Mental Status Examination: Judgment and Reasoning
Testing of Abstraction, calculation and general behavior.
1. Abstraction and calculation
• I. Proverb interpretation: Ask the patient to explain proverb or fable.
• II. Similarities and dissimilarities. Describe similarities and
differences between groups of object (e.g. orange and a ball, child
and dwarf)
• III. 100-7 test: subtraction of serials 3’s or 7’s from l00 is a good test
of calculation and concentration.
2. General behavior: It includes mood, hallucinations, delusions and
other abnormalities of behavior like attitude, manner of dress.
Testing for Defects of Higher Cortical Function

Categories of Cognition Tested in Mental
Status Examination

Cranial Nerves Examination
• The cranial nerve exam part of
the neurological examination.
• It is used to identify problems
with the cranial nerves.
• Each test is designed to assess
the status of one or more of the
twelve cranial nerves (I-XII).

The Components of the Cranial Nerve System

Cranial Nerve 1 (Olfactory):
• Check to make sure that the patient is able to
inhale and exhale through the open nostril.
• Have the patient close their eyes.
• Present a small test tube filled with
something that has a distinct, common odor
(e.g. ground coffee) to the open nostrils.
• The patient should be able to correctly
identify the odor at approximately 10 cm.

Cranial Nerve 2 (Optic):
• This nerve carries visual impulses from the eye to the
optical cortex of the brain by means of the optic
tracts.
• Testing involves 3 phases.
1. Acuity:
2. Visual Field Testing:
3. Pupils:

Cranial Nerve 2 (Optic): Acuity.
• Each eye is tested separately.
• A Snellen Chart is the standard, wall
mounted device used for this assessment.
• Patients are asked to read the letters or
numbers on successively lower lines (each
with smaller images) until you identify the
last line which can be read with 100%
accuracy.
• Each line has a fraction written next to it.
20/20 indicates normal vision.
Cranial Nerve 2 (Optic): Acuity.
• There are hand held cards that look like
Snellen Charts but are positioned 14
inches from the patient.
• These are used simply for convenience.
• Testing and interpretation are as
described for the Snellen.
• Cover one eye and have the patient
read the chart.
• For each eye record the smallest line a
patient can read.
Hand held visual acuity card

Cranial Nerve 2 (Optic): Visual Field Testing.
• Specific areas of the retina receive
input from precise areas of the
visual field.
• This information is carried to the
brain along well defined anatomic
pathways.
• Holes in vision are caused by a
disruption along any point in the
path from the eyeball to the visual
cortex of the brain.

Nomenclature for the visual fields and visual
field defects

• The examiner should be nose to nose with the patient.
• Each eye is checked separately.
• The examiner closes one eye and the patient closes the one
opposite.
• The open eyes should then be staring directly at one another.
• The examiner should move their hand out towards the
periphery of his/her visual field on the side where the eyes are
open.
• The finger should be equidistant from both persons.
• The examiner should then move the wiggling finger in towards them,
along an imaginary line drawn between the two persons.
• The patient and examiner should detect the finger at more or less the
same time.
• The finger is then moved out to the diagonal corners of the field and
moved inwards from each of these directions.
• Testing is then done starting at a point in front of the closed eyes.
• The wiggling finger is moved towards the open eyes. The other eye is
then tested.

Cranial Nerve 2 (Optic): Visual Field Testing:
Confrontation test.
• Stand infront of patient at one feet and
have patient look at your nose.
• Ask patient to indicate on which side the
finger is moving.
• Repeat in the upper and lower temporal
quadrants.
• If abnormality is suspected, test all
quadrants of each eye individually.

Positioning of examiner and patient

Cranial Nerve 2 (Optic): Pupils.
• The pupil has afferent (sensory)
nerves that travel with CN2.
• These nerves carry the impulse
generated by the light back
towards the brain.
• They function in concert with
efferent (motor) nerves that
travel with CN 3 and cause
pupillary constriction.
• Seen under CN 3 for specifics of
testing.
Technique of ophthalmoscopy

Cranial Nerve Examination: CN II Optic Nerve
Fundoscopy
• Have patient focus on a distant wall
• View the optic disc using the
ophthalmoscope
• Note the disc color and presence
of venous pulsations, papillaedema
(disc hyperemia, blurred margins,
absent venous pulsations) or
hemorrhages.

Cranial Nerves 3, 4 and 6: Extra Ocular Movements
• The eye normally moves in a concert.
• This coordinated movement depends on 6 extra ocular muscles that
insert around the eye balls and allow them to move in all directions.
• Each muscle is innervated by one of 3 Cranial Nerves: CNs 3, 4 and 6.
• Movements are described as:
• Elevation (pupil directed upwards),
• Depression (pupil directed downwards),
• Adbduction (pupil directed laterally),
• Adduction (pupil directed medially),
• Extorsion (top of eye rotating away from the nose), and
• Intorsion (top of eye rotating towards the nose).
Testing Extraocular Movements
• Stand in front of the patient.
• Ask them to follow your finger with their eyes while keeping their head
in one position
• Using your finger, trace an imaginary "H" or rectangular shape in front
of them, making sure that your finger moves far enough out and up so
that you're able to see all appropriate eye movements.
• At the end, bring your finger directly in towards the patient's nose.
• This will cause the patient to look cross-eyed and the pupils should
constrict, a response referred to as accommodation.

Cranial Nerve III, IV, VI: Oculomotor, Trochlear, Abducens

Afferent and Efferent Innervation of the Eye by Its Six Nerves

Oculomotor (Third nerve) palsy
1-Drooping of eyelids (ptosis).

2- Divergent squint.
3- Diplopia.
4- Dilated pupil.
CN 5 (Trigeminal):
• This nerve has both motor and sensory
components.
• Assessment of CN 5 Sensory Function:
• The sensory limb has 3 major branches,
each covering roughly 1/3 of the face.
• They are: the Ophthlamic, Maxillary, and
Mandibular.

Assessment of CN 5 Sensory Function:
• Use a sharp implement (e.g. broken wooden
handle of a cotton tipped applicator).
• Ask the patient to close their eyes so that
they receive no visual cues.
• Touch the sharp tip of the stick to the right
and left side of the forehead, assessing the
Ophthalmic branch.
• Touch the tip to the right and left side of the
cheek area, assessing the Maxillary branch.
• Touch the tip to the right and left side of the
jaw area, assessing the Mandibular branch

Assessment of CN 5 Sensory Function:
• The Ophthalmic branch of CN 5 also
receives sensory input from the
surface of the eye.
• To assess this component:
1. Pull out a wisp of cotton.
2. While the patient is looking straight
ahead, gently brush the wisp against
the lateral aspect of the sclera
(outer white area of the eye ball).
3. This should cause the patient to
blink.
Blinking also requires that CN 7
function normally, as it controls
eye lid closure.
Assessment of CN 5 Motor Function:
• The motor limb of CN 5 innervates the Temporalis and
Masseter muscles.
Assessment is performed as follows:
• Place your hand on both Temporalis muscles, located
on the lateral aspects of the forehead.
• Ask the patient to tightly close their jaw, causing the
muscles beneath your fingers to become taught.
• Then place your hands on both Masseter muscles,
located just in from of the Tempero-Mandibular joints.
• Ask the patient to tightly close their jaw, which should
again cause the muscles beneath your fingers to
become taught. Then ask them to move their jaw from
side to side, another function of the Massester.

Cranial Nerve VII (Facial Nerve) Examination
• First look at the patient's face. It should appear symmetric.
• Ask the patient to wrinkle their eyebrows and then close
their eyes tightly.
• Ask the patient to smile. The corners of the mouth should
rise to the same height and equal amounts of teeth should
be visible on either side.
• Ask the patient to puff out their cheeks. Both sides should
puff equally and air should not leak from the mouth.


• Observe for any facial asymmetry at rest
in forehead wrinkles, palpebral fissure
width, nasolabial folds, or corner of
mouth
• Examines both sponataneous facial
movements and to command.
• Raising eyebrows
• Closing both eyes and resist attempt to open
them
• Closing both lips and resist attempt to open them
• Smiling
• Puff off cheeks
• Taste on the anterior 2/3 of the tongue:
• Salt, sugar, lemon
Left peripheral CN7 dysfunction:
• Note loss of forehead wrinkle,
ability to close eye, ability to
raise corner of mouth, and
decreased naso-labial fold
prominence on left.
• This clinical distinction is very
important, as central vs
peripheral dysfunction carry
different prognostic and
treatment implications.

Summary of Tests of the Facial Muscles
Innervated by Cranial Nerve VII

Cranial Nerve VIII (Acoustic) Examination
Screen hearing:
• With eyes closed, the patient should be instructed
to acknowledge hearing the gentle rubbing of the
examiner's fingers approximately 3-4 inches away
from his right and left ear.
• A watch, which the examiner can hear at a specific
distance from his ear, is placed next to the patient's
ear.
• Ask him to note when the watch sound disappears.
• Rub your fingers together on one side
• Ask the patient to tell you when and on which side
the rubbing is.
• Note any asymmetry.
Cranial Nerve VIII (Acoustic) Examination
• The cause of subjective hearing loss can be assessed with bedside
testing.
• Hearing is broken into 2 phases: conductive and sensorineural.
• The conductive phase refers to the passage of sound from the outside
to the level of CN 8.
• This includes the transmission of sound through the external canal
and middle ear.
• Sensorineural refers to the transmission of sound via CN 8 to the
brain.

Weber Test:
• Grasp the 512 Hz tuning fork by the stem and
strike it against the bony edge of your palm,
generating a continuous tone.
• Hold the stem against the patient's skull,
along an imaginary line that is equidistant
from either ear.
• The bones of the skull will carry the sound
equally to both the right and left CN 8. Both
CN 8s, in turn, will transmit the impulse to
the brain.
• The patient should report whether the sound
was heard equally in both ears or better on
one side then the other (referred to as
lateralizing to a side).

Rinne Test:
• Grasp the 512 Hz tuning fork by the stem and strike it against
the bony edge of your palm, generating a continuous tone.
• Place the stem of the tuning fork on the mastoid bone, the
bony prominence located immediately behind the lower part
of the ear.
• The vibrations travel via the bones of the skull to CN 8,
allowing the patient to hear the sound.
• Ask the patient to inform you when they can no longer
appreciate the sound.
• When this occurs, move the tuning fork such that the tines
are placed right next to (but not touching) the opening of the
ear.
• At this point, the patient should be able to again hear the
sound.
• This is because air is a better conducting medium then bone
Auditory Nerve Testing: Weber and Rinne Testing.

Cranial Nerve VIII (Acoustic) Examination: Interpretation.
• First determine by history and crude acuity testing which ear
has the hearing problem.
• Perform the Webber test.
• If there is a conductive hearing deficit, the Webber will lateralize to the affected
ear.
• If there is a sensorineural deficit, the Webber will lateralize to the normal ear.
• Perform the Rinne test.
• If there is a conductive hearing deficit, BC will be greater then or equal to AC in
the affected ear.
• If there is a sensorineural hearing deficit, AC will be greater then BC in the
affected ear.

Cranial Nerves IX and X Examination
(Glossopharyngeal and vagus nerves)
• Listen to the patient’s voice.
• Note any hoarseness, nasal, or
breathy quality.
• Ask the patient to say « Ah » and
watch movement of soft palate
and pharynx.
• Note any asymmetry of the palate.
• Test gag reflex in the unconscious patient.

Cranial Nerve XI (Accessory nerve)
Examination
• Functions:
• Motor power to the trapezii and to the sternomastoids
• Posture and movements of the head and shoulder girdles
• Inspection: look for: Wasting, atrophy, Fasciculation, Abnormal head
posture and scapula
• Palpation: Palpate the bulk of these muscles and compare the two
sides.
• Have patient turn the head forcefully against examiner hand and
shrugging both shoulders against resistance.

Cranial Nerve XII (Hypoglossal Nerve) Exam
• Note tongue position at rest in the
mouth and on protrusion.
• Does tongue deviate in either
position?
• Ask the patient to stick out the tongue
and move it quickly from side to side.
• Note strength and rapidity of
movements
• Have patient push tongue into each
cheek while you push from side the
outside.
• Note the strenght.
Examination of the Motor System
• Examination of motor functions includes the determination
of muscle power, evaluation of muscle tone and bulk, and
observation for abnormal movements.
• Examination of coordination and gait are closely related to
the motor examination.
• Coordination is often viewed as a cerebellar function, but
integrity of the entire motor system is essential for normal
coordination and control of fine motor movements.

Components of the Motor Examination
• Inspection : Posture and abnormal movements
• Palpation
• Tone
• Muscle strength or Power

Motor Examination: Visual Inspection
• Note the muscle bulk.
• Look for generalized or focal muscle wasting or hypertrophy
• Muscle wasting occurs in a distribution characteristic of
particular conditions
• Look for involuntary movements, e.g. tremor (at rest?, with
action?), fasciculations (muscle twitching)
• Note speed of movement, e.g. slow to initiate (bradykinesia)
• Muscle symmetry and whether distal or proximal pattern on
inspection.
Motor Examination: Muscle Tone
• Muscle tone is the muscle tension at rest.
• Ask patient to relax
• Flex and extend patient’s wrists, elbows, shoulders, ankles and
knees.
• Look for resistance that is decreased (hypotonia) or increased
( throughtout the range of motion = rigididty or
hypertonia).
• Rigidity could be spring-like = spasticity or it could be a
cogwheel rigidity.
Motor Examination: Muscle Tone
• Flaccid = limb feels like (over) – cooked spaghetti
• Normal = like spagheti al dente
• Rigid = (lead – pipe rigidity) constantly increased resistance at all speeds
and in all directions. e.g. parkinsonism
• Spastic = (clasp-knife rigidity) resistance that varies with speed and/or
direction.
• Usually constant for a given speed e.g. weeks after a stroke.
• Cogwheel rigidity = feel like you are turning a ratchet.
• Contracture = Joint’s excursion range is truly reduced.

Disorders Of Muscle Tone: Hypertonia And Hypotonia
• Muscle tone is the muscular
resistance that the Examiner feels
when manipulating a Patient’s resting
joint (apart from gravity or joint
disease).
• Hypotonia is a decreased resistance
the Ex feels when manipulating a Pt’s
resting joint.
• The two most common hypertonic
states are spasticity and rigidity.

Clinical Differentiation of Spasticity and Rigidity

Muscle strength
• Muscle strength is tested by having the patient move against
the examiner’s resistance.
• One side is always compared with the other and strength is
graded on a scale from 0–5/5
• The strength of individual muscle groups is tested by comparing
them with the examiner's own strength.
• Most muscles are tested with the patient supine on an
examination couch, although the proximal shoulder girdle
muscles are usually more conveniently examined with the
patient sitting up.
Medical Research Council Scale of Muscle Power

Technique for testing for pronator drift.
Barré's sign
• The patient is asked to stand for 20–30 seconds
with both arms straight forward, palms up, and eyes
closed
• keeping the arms still while the examiner gently
taps downwards.
• In normals, the palms will remain flat, the elbows
straight, and the limbs horizontal.
• In pronator drift, the patient fails to maintain
extension and supination (and the limb ‘drifts’ into
pronation).
Testing for a corticospinal tract lesion using arm roll.
• The involved extremity tends to have a
lesser excursion as the forearms roll
about each other.
• The normal extremity tends to rotate
around the abnormal extremity, which
tends to remain relatively fixed.
• Patients with mild corticospinal tract
lesions may have an abnormal arm roll
test in the absence of clinically
detectable weakness to formal strength
testing.
Mingazzini sign

Muscle strength
• Muscle strength is tested by having the patient move against
the examiner’s resistance.
• One side is always compared with the other and strength is
graded on a scale from 0–5/5
• The strength of individual muscle groups is tested by comparing
them with the examiner's own strength.
• Most muscles are tested with the patient supine on an
examination couch, although the proximal shoulder girdle
muscles are usually more conveniently examined with the
patient sitting up.
Medical Research Council Scale of Muscle Power

Examination of flexion of the neck.
• The patient attempts to flex his neck
against resistance; the
sternocleidomastoid, platysma, and
other flexor muscles can be seen and
palpated.
• Examination of extension of the neck.
• The patient attempts to extend his
neck against resistance; contraction of
the trapezius and other extensor
muscles can be seen and felt, and
strength of movement can be judged.

Examination of The Scapular Muscles
• The rhomboids can be tested by having the
patient, with hand on hip, retract the shoulder,
against the examiner's attempt to push the
elbow forward
• Examination of the rhomboids.
• With hand on hip, the patient retracts the
shoulder against the examiner's effort to push
the elbow forward; the contracting muscles can
be seen and palpated.
• Examination of the trapezius.
• On retraction of the shoulder against
resistance, the middle fibers of the muscle can

Examination of the serratus anterior of Scapula
• The serratus anterior is primarily a
protractor of the scapula and functions
during forward arm elevation.
• When the serratus is weak, the inferior
angle is shifted medially and the entire
vertebral border rides up from the chest
wall.
• The patient pushes against a wall with his
arms extended horizontally in front of
him; normally, the medial border of the
scapula remains close to the thoracic wall.

The deltoid muscle is innervated by the C5
nerve root via the axillary nerve.
• The deltoid is the most prominent
muscle in the shoulder region.
• It is supplied by C5 and C6 through
the axillary nerve, a branch of the
posterior cord of the brachial
plexus..
• Examination of the deltoid.
• The patient attempts to abduct his
arm against resistance; the
contracting deltoid can be seen and
palpated.
Examination of the biceps brachii
• The biceps muscle is innervated
by the C5 and C6 nerve roots
via the musculocutaneous
nerve.
• On attempts to flex the forearm
against resistance, the
contracting biceps muscle can
be seen and palpated

Examination of the Triceps Muscle
• The triceps muscle is innervated
by the C6 and C7 nerve roots via
the radial nerve.
• Extension of the forearm.
• On attempts to extend the
partially flexed forearm against
resistance, contraction of the
triceps can be seen and palpated.

Flexion at the wrist.
• Flexion of the wrist is carried out principally
by the flexor carpi radialis (FCR) and flexor
carpi ulnaris (FCU) muscles.
• On flexion of the hand at the wrist against
resistance, the tendon of the flexor carpi
radialis can be seen and palpated on the
radial side of the wrist, and that of the flexor
carpi ulnaris on the ulnar side; the tendon of
the palmaris longus can also be seen and
palpated.

Extension at the wrist.
• Extension (dorsiflexion) of the wrist is
executed primarily by the extensor carpi
radialis longus (ECRL), extensor carpi
radialis brevis (ECRB), and extensor carpi
ulnaris (ECU)
• On attempts to extend the hand at the
wrist against resistance, the bellies of the
extensors carpi radialis longus, carpi
ulnaris, and digitorum communis can be
seen and palpated.

Examination of the Hand and Fingers:
Flexion of the Fingers
• Possible movements include flexion, extension,
adduction, abduction, and opposition.
• The muscles that power the hand can be divided into
extrinsics and intrinsics.
• The extrinsic muscles originate in the forearm and insert
on hand structures; the intrinsics originate and insert
within the hand.
• Examination of the flexor digitorum profundus.
• The patient resists attempts to extend the distal
phalanges while the middle phalanges are fixed

Flexion of the Fingers
• Examination of the flexor
digitorum sublimis.
• The patient resists attempts to
straighten the fingers at the first
interphalangeal joint

Extension of the Fingers
• Examination of the extensor
digitorum communis.
• With hand outstretched and
interphalangeal joints held in
extension, the patient resists the
examiner's attempt to flex the
fingers at the
metacarpophalangeal joints.

The Thumb and Its Muscles
• It is capable of movement in many
directions.
• Examination of the flexor pollicis
longus.
• The patient resists attempts to
extend the distal phalanx of the
thumb while the proximal phalanx is
fixed.

• Palmar abduction of the thumb.
• The patient attempts, against
resistance, to bring the thumb to
a point vertically above its
original position.
• Examination of the opponens
pollicis.
• The patient attempts, against
resistance, to touch the tip of
the little finger with the thumb.
• Opposition of the thumb and little
finger.
• Thumb opposition is innervated by the
C8 and T1 nerve roots via the median
nerve.
• Palmar adduction of the thumb.
• The patient, against resistance,
attempts to approximate the thumb to
the palmar aspect of the index finger;
the thumbnail is kept at a right angle to
the nails of the other fingers.

• Ulnar adduction of the thumb.
• The patient attempts to grasp a piece
of paper between the thumb and the
radial border of the index finger while
the thumbnail is parallel to the nails of
the other fingers.
• Examination of the abduction of the
fingers.
• The patient resists the examiner's
attempt to bring the fingers together.
Examination of the Movements and Muscles
of the Lower Extremities
The movements of the
lower extremities are
less complex than those
of the upper
extremities, and there
are fewer substitution
movements.

The Hip Joint:
Examination of the flexors of the thigh.
• The movements that take place at the
hip are flexion, extension, abduction,
adduction, and internal and external
rotation.
• Hip flexion is innervated by the L2 and
L3 nerve roots via the femoral nerve.
• The patient attempts to flex the thigh
against resistance; the knee is flexed
and the leg rests on the examiner's
arm.

The Hip Joint:
Examination of the extensors of the thigh at the hip.
• Hip extension is innervated by
the L4 and L5 nerve roots via
the gluteal nerve.
• The patient, lying prone with
the leg flexed at the knee,
attempts to extend the thigh
against resistance; contraction
of the gluteus maximus and
other extensors can be seen
and palpated.
Abduction of the thigh at the hip.
• Abduction of the hip is mediated

by the L4, L5 and S1 nerve roots.
• The recumbent patient attempts
to move the extended leg
outward against resistance;
contraction of the gluteus medius
and tensor fasciae latae can be
palpated.

Examination of adduction of the thigh at the
hip.
• Adduction of the hip is
mediated by the L2, L3 and L4
nerve roots.
• The recumbent patient attempts
to adduct the extended leg
against resistance; contraction
of the adductor muscles can be
seen and palpated

Examination of internal rotation of the thigh
The patient, lying prone with
the leg flexed at the knee,
attempts to carry the foot
laterally against resistance,
thus rotating the thigh
medially.

The Knee Joint
• The major movements that take place at the knee joint
are flexion and extension.
• The movement of internal and external rotation of the
lower leg at the knee is not clinically relevant.

Examination of flexion at the knee.
• This tests the hamstrings.
• The hamstrings are innervated by the
L5 and S1 nerve roots via the sciatic
nerve.
• The prone patient attempts to
maintain flexion of the leg while the
examiner attempts to extend it; the
tendon of the biceps femoris can be
palpated laterally and the tendons of
the semimembranosus and
semitendinosus, medially.

Examination of extension of the leg at the knee.
• Knee extension by the quadriceps

muscle is innervated by the L3 and
L4 nerve roots via the femoral
nerve.
• The supine patient attempts to
extend the leg at the knee against
resistance; contraction of the
quadriceps femoris can be seen
and palpated.
Examination of plantar flexion of the foot.
• Ankle plantar flexion is innervated by
the S1 and S2 nerve roots via the tibial
nerve.
• The patient attempts to plantar flex
the foot at the ankle joint against
resistance; contraction of the
gastrocnemius and associated muscles
can be seen and palpated.

Examination of dorsiflexion (extension) of the
foot.
• Ankle dorsiflexion is innervated by the
L4 and L5 nerve roots via the peroneal
nerve
• The patient attempts to dorsiflex the
foot against resistance; contraction of
the tibialis anterior can be seen and
palpated.

Examination of inversion of the foot.
• The patient attempts to raise the
inner border of the foot against
resistance; the tendon of the
tibialis posterior can be seen and
palpated just behind the medial
malleolus.

Examination of eversion of the foot.
The patient attempts to raise the
outer border of the foot against
resistance; the tendons of the
peronei longus and brevis can be
seen and palpated just above and
behind the lateral malleolus.

Examination of dorsiflexion (extension) of the
toes.
On attempts to dorsiflex the toes
against resistance, the tendons of
the extensors digitorum and
hallucis longus and the belly of
the extensor digitorum brevis can

Examination of flexion of the toes.
• The patient attempts to flex the
toes against resistance.
• The extensor halucis longus
muscle is almost completely
innervated by the L5 nerve root.

The Motor System Examination
• When testing, the following should be
considered:
• The overall distribution (proximal versus
distal),
• The pattern (flexor versus extensor), and
• The grouping:
• single root
• multiple roots
• plexus
• single nerve
• multiple nerves.

The Motor System: Patterns of muscle weakness
• Pyramidal weakness:
• It affects particular movement rather than particular muscles, and is most marked in the
abductors and extensors of the upper limbs, and flexors of the lower limbs
• Distribution is more distal than proximal, particularly in the upper limb, where hand
movements are affected earliest.
• Proximal weakness:
• This pattern is commonly encountered in myopathies.
• Distal weakness:
• Encountered in peripheral neuropathies and radiculopathies that involve the distal parts
• Radicular weakness:
• Weakness is limited to the muscles having that segmental supply e.g. disc prolapse at L5,
S1 level lead to weakness which respect S1 root.
• Isolated peripheral nerve weakness:
• It means loss of the function of that nerve (mononeuropathy).
Examination Of Muscle Stretch Reflexes
• Have the Patient sit or recline.
• The Patient places the part to be tested at rest, with the
muscles relaxed.
• Usually the best position is intermediate between full extension and
full flexion.
• The response of the muscle and the mechanics of the tap with the
hammer will depend on the joint angle.
• About 90 degrees for the elbow, knee, and ankle joints is a standard
angle.

Examination of Reflexes
• Reflex testing is important because it is the most objective part
of the neurological examination.
• Does not depend much on the cooperation and it may provide
an early indication of neurologic dysfucntion.
• Reflexes are under voluntary control to a lesser extent than
most other parts of the neurologic examination, and reflex
abnormalities are difficult to simulate.
• The muscle stretch reflexes are elicited by tapping the tendon
of a lightly stretched muscle with a reflex hammer.

The Deep Tendon or Muscle Stretch Reflexes
• The muscle strecth reflexes or deep tendon reflexes localize
to various segments in the spinal cord.
• Commonly tested Deep tendon reflexes
• The biceps jerk (C5, C6/ musculo-cutaneouse nerve).
• The supinator jerk (C5, C6/ radial nerve).
• The triceps jerk(C7/ radial nerve).
• The knee jerk (L3, L4/femoral nerve).
• The ankle jerk. (S1)

Grading of Muscle Stretch Reflexes

Examination of Reflexes
• Pay attention to symmetry of the reflexes between right
and left.
• If the reflexes are brisk, try to bring out subtle asymmetry
by using the lightest tap that will elicit the reflex.
• If reflexes are absent or diminished, try to reinforce the
reflex by distraction or having the patient contract other
muscles (e.g. clentch teeth).

Method of obtaining the biceps reflex.
• With the arm relaxed and the forearm
slight pronated and midway between
flexion and extension.
• The examiner places the palmar
surface of her extended thumb or
finger on the patient's biceps tendon
• Then strikes the extensor surface with
the reflex hammer
• The major response is a contraction of
the biceps muscle with flexion of the
elbow.

Biceps reflex.
• The examiner’s thumb places slight
tension on the patient’s biceps
tendon and the bicipital aponeurosis.
• The examiner strikes his thumbnail a
crisp blow.

Method of obtaining the triceps reflex.
• This reflex is elicited by tapping the
triceps tendon just above its insertion
on the olecranon process of the ulna.
• The arm is placed midway between
flexion and extension, and may be
rested in the patient's lap, on her thigh
or hip, or on the examiner's hand
• The response is contraction of the
triceps muscle with extension of the
elbow.

Triceps reflex.
• (A) Dangle the patient’s forearm
over your hand and strike the
triceps tendon.
• (B) Cradle the patient’s forearm
in your hand and strike the
triceps tendon.

Method of obtaining the brachioradialis reflex.
• The Brachioradialis
(Radial Periosteal or Supinator) Reflex.
• Tapping just above the styloid
process of the radius with the
forearm in semiflexion and
semipronation causes flexion of
the elbow, with variable
supination

Brachioradialis reflex.
• Cradle the patient’s forearm in one
hand, placing the thumb on top of
the radius.
• (A) The hammer strikes the
examiner’s thumbnail rather than
the patient’s radius.
• (B) Don’t whack away on the
patient’s unprotected bone.
• The examiner may cradle both
forearms side by side for accurate
comparison of the responses of the
two arms.
Method of obtaining the pectoralis reflex.
• With the patient's arm in midposition
between abduction and adduction.
• The examiner places her finger as nearly as
possible on the tendon of the pectoralis
major muscle near its insertion on the
greater tuberosity of the humerus
• Tapping the finger causes adduction and
slight internal rotation of the arm at the
shoulder.
• A hyperactive pectoralis reflex indicates
spinal cord compression at the C2-C3
and/or C3-C4 levels.
Method of obtaining the patellar (quadriceps)
reflex with the patient seated.
• The patellar reflex is contraction
of the quadriceps femoris
muscle, with resulting extension
of the knee, in response to
percussion of the patellar
tendon.
• If the reflex is brisk, the
contraction is strong and the
amplitude of the movement is
large.

Method of obtaining the patellar (quadriceps)
reflex with the patient recumbent.
• If the patient is lying in
bed, the examiner should
partially flex the knee by
placing one hand beneath
it and then tap the
tendon

Method of reinforcing the patellar reflex.
Jendrissick Maneouver
• Pull method (of Jendrassik) for
reinforcing the quadriceps
reflex.
• The patient locks the hands
and pulls apart hard while the
examiner strikes the tendon.

Achilles (triceps surae) reflex with the patient recumbent.
• The ankle jerk is obtained by

striking the Achilles tendon just
above its insertion on the
calcaneus.
• The resulting contraction of the
posterior crural muscles, the
gastrocnemius, soleus, and
plantaris, causes plantar flexion
of the foot at the ankle.
Achilles (triceps surae) reflex with the patient kneeling.
• The ankle jerk is by far the most
difficult reflex to master.
• The reflex may also be elicited by
having the patient kneel on a chair
or similar surface, with the feet
projecting at right angles; the
Achilles tendons are percussed
while the patient is in this position.
• This method is particularly useful
for comparing reflex activity on the
two sides.

Method for eliciting ankle clonus.
• Marked exaggeration of the patellar
reflex may be accompanied by
patellar clonus .
• The examiner jerks upward and a
little outward on the patient’s foot
(thin arrow).
• The thick arrow represents the
downward response.

Hyperactive Reflexes: Clonus
• Test clonus if any of the reflexes
appeared hyperactive.
• Hold the relaxed lower leg in your
hand, and sharply dorsiflex the
foot and hold it dorsiflexed.
• Feel for oscillations between
flexion and extension of the foot
indicating clonus.

Examination Of The Superficial Reflexes
(Skin-muscle Reflexes)
• Because stimulation of receptors deep to the skin elicits the MSRs, the
MSRs are classed with the deep reflexes.
• Stimulation of receptors in skin and mucous membranes elicits
superficial or skin-muscle reflexes.
• The superficial skin-muscle reflexes commonly elicited in the NE
consist of:
a. Corneal reflex
b. Gag reflex
c. Abdominal skin-muscle reflexes
d. Anal wink and bulbocavernosus reflexes
e. Plantar reflex (the most important of all reflexes)

Standard technique for eliciting the plantar reflex
• Place the Patient supine with the limbs
completely relaxed and symmetrically
arranged, and with the knees straight
or slightly flexed, with knees slightly
turned out.
• The feet should be warm.
• Using the serrated, broken end of a
tongue blade, a key, or the butt of a
reflex hammer, stroke the lateral side
of the sole.

Abnormal responses to a plantar stimulus.
• (A) Extension (dorsiflexion) of the
great toe in response to a plantar
stimulus in a patient with an
upper motoneuron lesion.
• (B) Flexor withdrawal reflex (triple
flexion reflex) consisting of
dorsiflexion of the ankle and
flexion of the knee and hip in
response to plantar stimulus.

Methods for eliciting the extensor toe sign.

Methods for eliciting the extensor toe sign.

Technique for eliciting the superficial abdominal
and cremasteric reflexes
• Stroking the skin of the abdominal quadrants or
inner thighs elicits the superficial abdominal
and cremasteric reflexes.
• The thin arrows represent the direction of the
examiner’s stroke.
• The thick arrows indicate the direction of the
response.
• The umbilicus twitches in the direction of the
quadrant stimulated.

The Superficial (Cutaneous) Reflexes.
The Cremasteric Reflex
• This reflex is elicited by stroking or lightly scratching or pinching the skin on the
upper, inner aspect of the thigh.
• The response consists of a contraction of the cremasteric muscle with a quick
elevation of the homolateral testicle.
• The innervation is through the ilioinguinal and genitofemoral nerves (L1-L2).
The Superficial Anal Reflex.
• The cutaneous anal reflex (anal wink) consists of contraction of the external
sphincter in response to stroking or pricking the skin or mucous membrane in
the perianal region.
• The reflex is mediated by the inferior hemorrhoidal nerve (S2-S5).

The Hoffmann sign
• To elicit the Hoffmann sign the patient's relaxed
hand is held with the wrist dorsiflexed and
fingers partially flexed.
• With one hand, the examiner holds the partially
extended middle finger between her index finger
and thumb or between her index and middle
fingers.
• With a sharp, forcible flick of the other thumb,
the examiner nips or snaps the nail of the
patient's middle finger, forcing the distal finger
into sharp, sudden flexion followed by sudden
release

Finger flexion reflex (Hoffman’s method).
• The examiner depresses the distal
phalanx and allows it to flip up.
• The extension of the phalanx
stretches the flexor muscles,
causing the fingers and thumb to
flex.
• This method is effective only with
very brisk muscle stretch reflexes.

Finger flexion reflex (Tromner’s method).
• The examiner supports the patient’s
completely relaxed hand and briskly flips
the patient’s distal phalanx upward, as
though to flip a handful of water high
into the air.
• The patient’s fingers and thumb flex in
response to the stretch of the finger
flexor muscles.

Sensory System Examination
• The sensory exam is subjetive and relies on cooperation.
• Explain to the patient what you are going to do and what you
expect them to do, then have them close their eyes for the
testing.
• Both superfical and deep sensation should be tested in all
four limbs.
• Always compare side-to-side, asking, « are this about the
same » rather than « is this sharp », or « which is stronger? »

General Clinical Principles In Testing All Somatic Sensations
• Demonstrate and describe the tests.

• Ask for yes or no responses, or “Is [stimulus] one different from
[stimulus] two?” a procedure called forced-choice testing.
• Have the Patient close the eyes to avoid visual cues.
• Compare homologous areas of the right and left sides and compare
normal areas to any suspected abnormal areas.
• Determine whether sensory deficits match a central pathway, segmental
(dermatomal), plexus, or peripheral nerve pattern or match a
nonorganic distribution.

There are five categories of sensation to test:
• Superficial sensory modalites
• Light touch
• Pain
• Temperature
• Deep sensory modalies
• Vibration
• Position Sense


Technique For Testing Temperature Discrimination
• Randomly touch the

tuning fork shaft and your
little finger to test
temperature
discrimination.
•

Sensory Exam: Superficial Sensation
• Pain and Temperature is
mediated by unmyelinated and
small myelinated nerve fibers via
the spinothakamic tract.
• Pain sensation can be tested
with a sharp object
• Temperature sensation can be
tested with a cool metal object
(like a tuning fork).

Sensory Exam: Deep Sensation
• Pressure, position sense, and
vibration are mediated by large fibers
via the dorsal and lateral columns.
• Vibration and position sense
(proprioception) should be tested at
the most distal joint of the limb.
• The appropriate tuning fork to use in
testing vibration is 128Hz.

Cerebral Sensory Functions
• Cerebral sensory functions are those which involve the primary
sensory areas of the cortex to perceive the stimulus, and the sensory
association areas to interpret the meaning of the stimulus and place
it in context.
• These functions are also referred to as secondary or cortical
modalities.
• The cortical modalities of greatest clinical relevance include
stereognosis, graphesthesia, two-point discrimination, sensory
attention, and other gnostic or recognition functions.
• Extinction is the loss of the ability to perceive sensation on one side
of the body when both sides of the body are stimulated
simultaneously.
Cerebral Sensory Functions
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graphesthesia, MED 426 CLINICAL SEMIOLOGY 3
two-point discrimination 145
Test Station (Equilibratory Coordination)
• Ask the patient to stand comfortably with the
hands at the sides.
• Observe the position of the feet.
• Normally, the feet will be just a few
centimeters apart and the knees opposed.
• A wide stance suggests an accommodation to
instability of stance.
• Note swaying of the trunk or elevation of the
arms to maintain balance.
• Now, have the patient close her eyes while
again observing for loss of balance.
Falling during the test is the Romberg
•09/06/2020 sign.
MED 426 CLINICAL SEMIOLOGY 3 146
Coordination
• These tests assess cerebellar function and
require relatively intact motor power.
• The patient is asked to slap rapidly the
palmar and dorsal surface of the hand
alternately on the thigh.
• In the lower limbs, the patient taps the
examiner’s hand with the sole of each foot.
• Dysdiadochokinesis is the clinical term for

an inability to perform rapidly alternating
movements

Coordination
• Observe the patient at rest and note the presence of abnormal postures,
tremor, chorea, athetosis or dystonia.
• Have the patient hold both arms outstretched with eyes closed and note
any abnormal movement such as tremor, weakness or posturing.
• Have the patient perform a simple functional task such as buttoning a
shirt or writing and observe the smoothness and rhythm of the
movement.
• Have the patient move from sit to stand without use of the hands and
observe for postural instability and loss of balance.

Coordination
Point-to-Point Test Heel-Shin Test
If motor and sensory systems are intact, an abnormal,

Past-pointing And Dysmetria asymmetric heel to shin test is highly suggestive of an
09/06/2020
ipsilateral cerebellar lesion.
MED 426 CLINICAL SEMIOLOGY 3 149
Gait and Station
• Station is the patient's attitude, posture, or manner of standing.
• The healthy individual stands erect with her head up, chest out,
and abdomen in.
• Gait is the single most important part of the motor exam because
it allows the examiner to assess muscle strength, coordination,
balance and timing - all vital higher cortical functions.
• The first step in analyzing gait is to check the width of the base.
• The wider the base the better the balance, and spreading the feet
farther apart is the first compensatory effort in most gait
disorders.
Gait and Station
• Tandem walking stresses the gait and balance mechanisms
even further.
• Ask the patient to walk down a hallway.
• Observe for symmetry, rhythm and speed while walking.
• Look for limping, scissoring, staggering, weight bearing and
foot clearance during the swing phase.
• Ask the patient to walk on the heels and then on the toes.
• Observe the person walking toe to heel and note any
abnormalities with balance and coordination during this task.
Gait Disorder Characteristics and Etiology

Gait and Station

Signs of Meningeal Irritation
• Nuchal Rigidity:
• The patient cannot place the chin on the chest.
• Passive flexion of the neck is limited by involuntary muscle spasm.
• Kernig Sign:
• With the patient supine, passively flex the hip to 90 degrees while the knee is flexed at
about 90 degrees.
• With the hip kept in flexion, attempts to extend the knee produce pain in the hamstrings
and resistance to further extension.
• This is a reliable sign of meningeal irritation, which may occur with meningitis, herniated
disk, or tumors of the cauda equina.
• Brudzinski Sign:
• With the patient supine and the limbs extended, passively flex the neck.
• Flexion of the hips, a sign of meningeal irritation, is a positive Brudzinski sign.

Two Signs of Meningeal Irritation
A. Kernig sign:
• With the patient supine, flex the hip and
knee, each to about 90 degrees.
• With the hip immobile, attempt to
extend the knee.
• In meningeal irritation, this attempt is
resisted and causes pain in the hamstring
muscles.
B. Brudzinski sign:
• Place the patient supine and hold the
thorax down on the bed.
• Attempt to flex the neck.
• With meningeal irritation this causes
involuntary flexion of the hips.

Conclusion
• Completion of a neurological evaluation will give you a picture
of the extent and possible location of the nervous system
damage.
• With practice you gain more skills and are able to complete the
neurological exam quickly and efficiently.
• This is important with sudden onset or life-threatening diseases
in which the outcome is dependent on an accurate referral or
timely management.

Bibliography

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The Neurological Examination

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Sudden Traumatic, vascular, psychogenic

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1-Drooping of eyelids (ptosis).

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• Muscle strength or Power

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• Abduction of the hip is mediated

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