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Neurological

 exam  

By    
H.Khorrami  Ph.D.  
 
h1p://www.scribd.com/khorrami4  
h1p://khorrami1962.spaces.live.com    
khorrami4@yahoo.com    

 
Instruments    
•  RecepFve  field(two  point  discriminaFon  test)  
•  VibraFon  test  
Sensory  system  
•  Fine  touch  
•  Temperature  
•  Shape  
•  Deep  sense  
•  VibraFon  
•  Name  objects  
Deep  sense  of  vibraFon  
TacFle  sense  
Olfactory  nerve  
OpFc  nerve    
Trochlear  nerve  
Corneal  reflex  
•  DesensiFzaFon    
Facial  nerve  
Glossopharyngeal  nerve(IX)  
Accessory  nerve(XI)  
Accessory  nerve    
Hypoglossal  nerve(XII)  
Cranial Nerve    Number   Innervation(s)   Primary Function(s)    Test(s)  
Olfactory   I   Sensory   Smell   Identify odors  
Visual acuity, fields,
Optic   II   Sensory   Vision  
color, nerve head  
Upper lid elevation,
extraocular eye
Physiologic "H" and near
Oculomotor   III   Motor   movement, pupil
point response  
constriction,
accommodation  
Trochlear   IV   Motor   Superior oblique muscle   Physiologic "H"  
Trigeminal   V   Motor   Muscles of mastication   Corneal reflex  

Scalp, conjunctiva, Clench jaw/palpate,


Trigeminal   V   Sensory  
teeth   light touch comparison  
Abduction, physiologic
Abducens   VI   Motor   Lateral rectus muscle  
"H"  
Smile, puff cheeks,
Muscles of facial
Facial   VII   Motor   wrinkle forehead, pry
expression  
open closed lids  
Taste-anterior two
Facial   VII   Sensory      
thirds of tongue  
Rinne test for hearing,
Vestibulocochlear    VIII   Sensory   Hearing and balance  
Weber test for balance  
Glossopharyngeal    IX   Motor   Tongue and pharynx   Gag reflex  
Taste-posterior one
Glossopharyngeal   IX   Sensory      
third of tongue  

Pharynx, tongue, larynx,


Vagus   X   Motor   thoracic and abdominal Gag reflex  
viscera  
Larynx, trachea,
Vagus   X   Sensory      
esophagus  
Sternomastoid and Shrug, head turn against
Accessory   XI    Motor  
trapezius muscles   resistance  
 Hypoglossal   XII   Motor   Muscles of tongue   Tongue deviation  
Signs  of  UMN  and  LMN  lesions  

Sign     UMN  lesions   LMN  lesions  


Weakness   Yes     Yes  
Atrophy   Mild/No   Yes  
FasciculaFon   No     Yes  
Reflexes     Increased   Decreased    
Tone   Increased   Decreased    
Grading  Motor  Strength  
Grade   Descrip5on  
0/5   No  muscle  contracFon  
Visible  muscle  movement,  but  
1/5  
no  movement  at  the  joint  
Movement  at  the  joint,  but  not  
2/5  
against  gravity  
Movement  against  gravity,  but  
3/5  
not  against  added  resistance  
Movement  against  resistance,  
4/5  
but  less  than  normal  
5/5   Normal  strength  
RaFng  of  muscle  strength  
MyotaFc  reflexes  
•  Response    
–  Amplitude  
–  Speed  
–  Pa1ern  
•  Descending  pathway  effects  
•  A1enFon    
•  Calcium  status    
–  Chvostek’s  sign  
–  Trousseau’s  sign  
Chvostek’s  sign  
Trousseau’s sign
Tendon  Reflex  Grading  Scale  

Grade   Descrip5on  
0   Absent  
1+  or  +   HypoacFve  
2+  or  ++   "Normal"  
3+  or  +++   HyperacFve  without  clonus  
4+  or  ++++   HyperacFve  with  clonus  
Clasp-­‐knife  reflex  
Peripheral  myotaFc  reflexes    
•  Biceps    
•  Triceps  
•  Brachioradialis  
•  Tromner  
•  Mayer  
•  Adductor  
•  Quadriceps  
•  Achill(ankle  jerk)  
Biceps  reflex  
Triceps  reflex  
Brachioradialis  reflex  
Adductor  reflex  
Knee  jerk  reflex  
Achill  reflex  
Reinforcement    
•  Jendrassick  maneuvers  
–     
CorFcospinal  tract  
•  Wartenberg  
•  Babinski’s  sign(1857-­‐1932)  Plantar  reflex  
•  Oppenheim’s  sign  
•  Gordon’s  sign  
Cerebellar  tests  

(Archi-­‐cerebellum  )  

(Neo-­‐cerebellum  )  
Cerebellar  tests  
•  Finger  to  nose  
•  Rapid  alternaFng  finger  movements    
•  Rapid  alternaFng  hand  movements  
•  Romberg  test  
•  Heel  to  shin  tesFng  
•  Rebound  phenomenon      
Cerebellar  tests    
Finger  to  nose  
Romberg    
Posture
Gait – Ataxia
Tremor
a b c
Cerebellar
Ataxia

Ataxic gait and


position:
Left cerebellar tumor
d

a. Sways to the right in


standing position
b. Steady on the
right leg
c. Unsteady on the
left leg
d. ataxic gait
Heel-­‐to-­‐shin  
Auditory  &  VesFbular  system  
Nystagmus    
•  Pandular    
•  Jerk    
–  Slow  phase  
–  Fast  phase  
VesFbulo-­‐cerebellum    
•  Real  rotaFon  
•  Barany’s  chair  
•  Caloric  test  
Auditory  system  
•  ConducFve  
•  Neural  

ü Rinne  test,  use  a  512Hz  tuning  fork  


ü AC>BC  
ü Weber  test,  use  a  256/512Hz  tuning  fork  
ü R=L  
ü Shwabach  
ü Ex=Pt    
Auditory  &  VesFbular  system  
Rinne      
Weber  test  
Auditory  system  

Test     Expecta5on     Based  on   Diagnose  


 
Rinne     AC>=BC   Air  conducFon   ConducFve  
deafness  
Weber   No  lateralizaFon     Bone  conducFon   Neural/conducFve/
both  
Schwabach     EX=Pt   Bone  conducFon   Neural/conducFve,  
bilateral    
NEUROLOGIC  
DESCRIPTION  OF  
MEDICAL  CONDITION   STRUCTURES  
PROBLEM  
AFFECTED  


 Decreased  Level  of  


Coma   Nonlocalizing  
Consciousness  

Lack  of  OrientaFon  


DisorientaFon   Temporal  Lobe  
to  Time  and  Place  

Amnesia   Memory  Loss   Temporal  Lobe  


Frontal,  
Aphasia   Speech  Problems   Temporoparietal  
Lobe  

Inappropirate   Bilateral  Cerebral  


Inappropriate  Affect  
EmoFonal  Display   Damage  

Inability  to   Nondominate  


Agnosia  
recognize  Objects   Parietal  Lobe  

Inability  to  Follow  


Apraxia   Frontal  Lobe  
Orders