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The Neurologic Exam

Topic updated on 07/02/17 11:58am

Snapshot
  • A 44-year-old man presents with "numbness" affecting his bilateral upper extremity. The patient reports that this has never happened before and that his symptoms are associated with mild upper extremity weakness. The patient says that a few years prior to presentation he was in a motor vehicle accident that lead to a fracture in his C2 and C3 vertebrae. On physical exam, there is increased tone in his upper and lower extremity. He has 4-/5 strength in his bilateral upper extremity and decreased pinprick sensation there as well. His biceps and triceps tendon reflex is 3+ and his vibration sense is intact. An MRI of the spine shows a fluid filled collection between C2-C4 and plans are made for decompressive surgery. (Post-traumatic syringomyelia)
Mental Status
  • Attention
    • can be tested by asking the patient to spell "world" or reciting the months of the year forwards and backwards
  • Orientation
    • ask the patient what is their full name, location, and the date
      • this mainly tests the patient's recent and long term memory
  • Memory
    • recent memory is tested by asking the patient to remember 3 items after a 3-5 minute delay
    • remote memory is tested by asking historical events or events that has happened to them
    • clinical correlate
      • impairment can suggest a lesion in the memory limbic structures and medial diencephalon
        • anterograde amnesia
          • memory impairment of events after lesion onset
        • retrograde amnesia
          • memory impairment immediately before lesion onset
  • Language
    • assess a patient's
      • spontaneous speech
      • naming
      • comprehension
      • repetition
      • reading
      • writing
    • clinical correlate
      • aphasia
  • Sequencing
    • assesses a patient's ability to do a sequence of tasks
      • inability to do this is suggestive of frontal lobe dysfunction
        • patients will have difficulty changing from one task to the next
    • clinical correlate
      • perseveration
        • repetitive or prolonged action
          • e.g., if asking the patient to draw alternating triangles and squares they may stick to drawing triangles
  • Clinical correlate
    • Gerstmann's syndrome
      • results from a lesion in the dominant parietal lobe
      • presents as acalculia, right-to-left confusion, finger agnosia, and agraphia
    • apraxia
      • an inability to follow a movement command due to an impairment in motor planning or conceptualization
    • anosognosia
      • unaware of their own deficits
Cranial Nerves
  • Please refer to the cranial nerve topics  
Motor Exam
  • Observation
    • to determine the presence of
      • tremors or involuntary movements
      • twitching
      • atrophy
  • Inspection
    • to determine the presence of
      • atrophy
      • hypertrophy
      • fasciculations
  • Palpation
    • to determine if there is tenderness
      • tenderness can be seen in cases of myositis
  • Muscle tone
    • passive movement of the limb to see if there is any resistance or rigidity
  • Functional testing
    • determine the presence of pronator drift
      • this is suggestive of an upper motor neuron lesion
    • fine movements such as rapid finger tapping and pronation-supination tests cerebellar function
  • Strength testing
    • 0/5
      • no muscle contraction
    • 1/5
      • muscle flicker but no movement
    • 2/5
      • anti-gravity muscle movement
    • 3/5
      • muscle contraction against gravity but not resistance
    • 4/5
      • muscle contraction against some resistance
    • 5/5
      • normal strength
Reflexes
  • Deep tendon reflexes
    • 0+
      • areflexic
    • 1+
      • trace reflex
    • 2+
      • normal reflex
    • 3+
      • brisk reflex
    • 4+
      • clonus (nonsustained)
    • 5+
      • clonus (sustained)
  • Hoffman's sign
    • flick the patient's middle finger at the nail and observe for contraction of the thumb 
      • this is suggestive of an upper motor neuron lesion 
  • Babinski's sign
    • an object scrapes (e.g., the end of a reflex hammer) the sole of the foot from the heal towards the toes and then medially
      • upgoing big toe and fanning of the toes is a positive Babinski's sign
        • this is suggestive of an upper motor neuron lesion
Coordination and Gait
  • Finger-to-nose test
    • the patient touches their nose and then the examiner's finger
  • Heel-to-shin test
    • the patient's heel touches the knee of the opposite leg and then drags it to the shin and back to the knee
  • Romberg test
    • the patient is standing with their feet together and eyes closed
  • Gait
    • ask the patient to walk towards and away from you
      • it is important to pay close attention to things such as
        • rising from a chair
        • stance
        • leg swing
        • turning
Sensory Exam
  • Light touch
    • can be performed by placing a cotton swab or finger to the skin
  • Pain sensation
    • can use the sharp and dull end of a safety pin
  • Temperature
    • can place a cool piece of metal to the skin
  • Vibration sense
    • place a vibrating tuning fork to the large toe or finger and ask the patient when the vibration stops
  • Proprioception
    • position the patient's toe or finger up or down and ask them at which position it's in
 


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This video shows a positive Hoffman's and Babinski reflex.
7/1/2017
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