a guide for students....

1. NEUROLOGICAL
EXAMINATION

2. INTRODUCTION:
A neurological examination is the
assessment of sensory neuron and motor
responses, especially reflexes, to determine
whether the nervous system is impaired. This
typically includes a physical examination and a
review of the patient's medical history but not
deeper investigation such as neuroimaging. It
can be used both as a screening tool and as an
investigative tool.

3. Examples of Definitions
• Alert:
o awake, looks about
o responds in a meaningful manner to verbal instructions or
gestures
• Drowsy:
o oriented when awake but if left alone will sleep
• Confused:
o disoriented to time, place, or person
o memory difficulty is common
o has difficulty with commands
o exhibits alteration in perception of stimuli, may be agitated

4. • Stuporous:
o generally unresponsive except to vigorous stimulation
o may make attempt at verbalization to vigorous/repeated
stimuli
o Opens eyes to deep pain
• Comatose:
o unarousable and unresponsive
o some localization or movement may be acceptable within
the comatose category
depending on the coma definitions e.g. light coma to deep
coma
o Does not open eyes to deep pain

5. The difference between Coma and Sleep:
• sleeping persons respond to unaccustomed stimuli
• sleeping persons are capable of mental activity
(dreams)
• sleeping persons can be roused to normal
consciousness
• cerebral oxygen uptake does not decrease during
sleep as it often does in coma

6. Special States of Altered Levels of Consciousness
• Brain Death:
An irreversible loss of cortical and brain stem activity.
• Persistent Vegetative State:
A condition that follows severe cerebral injury in
which the altered state becomes
chronic or persistent.
• Locked-in Syndrome:
A state of muscle paralysis, involving voluntary
muscles, while there is preservation of full
consciousness and cognition.

7. Indications:
A neurological examination is indicated
whenever a physician suspects that a patient
may have a neurological disorder. Any new
symptom of any neurological order may be
an indication for performing a neurological
examination.

8. Organic Disease ?
 Signs &/or symptoms that cannot be faked must
be examined closely.
 Examples include, asymmetry in pupils, abnormal
retinal exams, nystagmus, muscle atrophy, and
muscle fasciculation.

9. Where are the Connections
 Upper Motor Neurons (UMN) are defined as the
connections of motor nerves before they leave
the spinal cord
 Lower Motor Neurons (LMN) are defined as after
the synapse (connection) into the peripheral
nerve cell bodies.

10. Objectives
 Organize Exam into the 6 Subsets of Function
 Concept of Screening Examination
 Understand Afferent and Efferent Pathways for
Brainstem Reflexes
 Differentiate Between Upper and Lower
Motor Neuron Findings

11. Six Subsets of the Neuro Exam
 Here’s what you need to examine.
 Mental Status
 Cranial Nerves
 Motor
 Sensory
 Coordination
 Reflexes

12. Concept of a Screening Exam
 Screening each of the subsets allows one to check on
the entire neuroaxis (Cortex, Subcortical White
Matter, Basal
Ganglia/Thalamus, Brainstem, Cerebellum, Spinal
Cord, Peripheral Nerves, NMJ, and Muscles)
 Expand evaluation of a given subset to either
• Answer questions generated from the History
• Confirm or refute expected or unexpected findings on Exam

13. Neurological Examination
Mental Status Exam
 “FOGS”
 Family story of memory loss
 Orientation
 General Information
 Spelling &/or numbers
 Recognition of objects

14. 1. INTERVIEW
The patient/family interview will allow the nurse to:
• ƒgather data: both subjective and objective about the
patient's previous/present health state
• ƒprovide information to patient/family
• ƒclarify information
• ƒmake appropriate referrals
• ƒdevelop a good working relationship with both the patient
and the family
• ƒinitiate the development of a written plan of care which is
patient specific

15. Interview to identify presence of:
• headache
• difficulty with speech
• inability to read or write
• alteration in memory
• altered consciousness
• confusion or change in thinking
• disorientation
• decrease in sensation, tingling or pain
• motor weakness or decreased strength
• decreased sense of smell or taste
• change in vision or diplopia
• difficulty with swallowing
• decreased hearing
• altered gait or balance
• dizziness
• tremors, twitches or increased tone

16. Physical Examination Considerations
• Level of Consciousness
– Most important aspect of neurologic examination
– Level of consciousness first to deteriorate; changes often
subtle, therefore requiring careful monitoring.
• Consciousness:
– Composed of Two Components:
• Arousal (Alertness)
• Awareness (Content)
– Assessment: Orientation vs. Disorientation
» Person, Place & Time
» Varying sequence of questions is important !!

17. Assessing LOC
• Glasgow Coma Scale (GCS)
– Three Categories:
• Eye opening
• Best motor response
• Best verbal response
– Scoring
• Highest or best possible score 15
• A score of < 8 indicates coma
• Lowest or worst possible score 3

18. Glasgow Coma Scale

19. Pupillary Examination
• The pupillary examination can be quickly and easily
performed in the unconscious or minimally responsive
patient when a TBI is suspected, and can provide valuable
information about the degree of initial or progressing brain
injury. Several types of TBI’s may cause pupillary
changes, which indicate the need for rapid interventions to
decrease ICP caused by cerebral bleeding and/or edema.
Nurses are in a key position to detect early changes in a
patient's condition and administer or advocate for
immediate interventions.

20. Check pupil size in lighted room, and
reactivity to light in a darkened room.

21. Unequal
pupil size
can be a sign
of a serious
brain injury.

22. Brain
Injury with
bleeding
or swelling
Rapid interventions
are needed to prevent
death or permanent
brain damage – TBI’s
can progress rapidly!

23. Mental Status
Level of Alertness
• Subjective view of Examiner
• Definition of Consciousness
• Terminology for Depressed Level of Consciousness
• Concept of Coma
• Delerium
Degree of Orientation
• To what?

24. Mental Status
Concentration
• Serial 7’s or 3’s
• “WORLD” backwards
• Months of the Year Backwards
• Try to quantify degree of impairment
* A and O and Concentration need to be intact for other
aspects of the Mental Status Exam to have localizing
value!

25. Mental Status
Memory
Immediate Recall
• A task of concentration
Short-Term Memory
• “3/3 objects after 5 minutes”
Long-Term Memory
• Last thing to go

26. Mental Status
Language
Aphasia vs Dysarthria
Receptive Language
• Command Following
Expressive Language
• Fluency
• Word Finding
Repetition
• Screens for Receptive, Expressive, and Conductive
Aphasias

27. Language

28. Mental Status
 Calculations,
R-L confusion, finger
agnosia, agraphia
• Gerstmann’s Syndrome (Dominant Parietal Lobe)
 Hemineglect
• Non-Dominant Parietal Lobe
 Delusional Thinking, Abstract
Reasoning, Mood, Judgement, Fund of
Knowledge, etc
• Important for Psychiatry
• Does not localize well to one region of the cortex
• Neurocognitive Testing required to get at more specific deficits

29. Olfactory Nerve - I

30. Olfactory Nerve
 DistinguishCoffee from Cinnamon
 Smelling Salts irritate nasal mucosa and test V2
Trigemminal Sense
 Disorders of Smell result from closed head injuries

31. Optic Nerve
Cranial nerve II

32. Optic Nerve
 Visual Acuity
 Visual Fields
 Afferent input to Pupillary Light
Reflex
• APD
 Lookat the Nerve (Fundoscopic
Exam)
“VA equals 20/20 OU at near”
“PERRLA”

33. Abducens Nerve
Cn VI
Oculomotor Nerve
Cn III
Trochlear Nerve
c.n. IV

34. CN III Oculomotor: moves
eyes in all directions except
outward and down & in; opens
eyelid; constricts pupil
CN IV Trochlear:
moves eyes
down and in…..

35. CN VI Abducens: moves eyes outward
EOM’s:
(extraoccular movement)
assessment of eye
movement in all
directions ( III, IV VI)

36. Trigeminal Nerve - V

37. CN V Trigeminal:
3 branches;
sensation to the face,
cornea and scalp;
opens jaw against resistance

38. Facial Nerve-VII

39. CN VII Facial:
moves the face;
taste.
CN VII paralysis

40. Vestibulocochlear Nerve-VIII

41. Vestibulocochlear Nerve
 Hearing and Balance
• Patients will complain of tinnitis, hearing loss, and/or vertigo
 Weber and Renee Test
• Differentiates Conductive vs Sensorineural hearing loss
 Afferent input to the Oculocephalic Reflex
• Doll’s Eye Maneuver
• Cold Calorics
• Not “COWS”
“Hearing grossly intact AU”

42. Glossopharyngeal and Vagus Nerves
c.n.’s IX and X

43. CN IX Glossopharyngeal:
moves the pharynx (swallow,
speech & gag)
CN X Vagus:
voice quality

44. Spinal Accessory Nerve
c.n. XI
Sternocleido-
Mastoid Trapezius
strength strength

45. CN XI Spinal Accessory:
turns head and elevates
shoulders
Shoulder
Shrug

46. Hypoglossal Nerve
c.n. XII

47. Hypoglossal Nerve
Protrudes the tongue to the
opposite side
Tongue in cheek (strength)
Hemi-atrophy and fasiculations
(LMN)

48. Strength
Tone
DTR’s
Plantar Responses
Involuntary Movements

49. Strength
Medical Research Council Scale
 5/5 = Full Strength
 4/5 = Weakness with Resistance
 3/5 = Can Overcome Gravity Only
 2/5 = Can Move Limb without Gravity
 1/5 = Can Activate Muscle without Moving
Limb
 0/5 = Cannot Activate Muscle

50. Weakness
Describe the Distribution of Weakness
• Upper Motor Neuron Pattern
• Peripheral neuropathy Pattern
• Myopathic Pattern

52. Tone
 Tone is the resistance appreciated when moving a limb
passively
 “Normal Tone”
 Hypotonia
• “Central Hypotonia”
• “Peripheral Hypotonia”
 Increased Tone
• Spasticity (Corticospinal Tract)
• Rigidity (Basal Ganglia, Parkinson’s Disease)
• Dystonia (Basal Ganglia)

53. DTR’s
 0/4 = Absent
 1-2/4 = Normal Range
 3/4 = Pathologically Brisk
 4/4 = Clonus

54. Involuntary Movements
 Hyperkinetic Movements
• Chorea
• Athetosis
• Tics
• Myoclonus
 Bradykinetic Movements
• Parkinsonism (Bradykinesia, Rigidity, Postural
Instability, Resting Tremor)
• Dystonia

55. Drift Assessment
Drift Assessment: test for motor weakness
Arm: hold arms out with palms up; eyes closed
• Pronator drift: hands pronate (roll over);
• Motor drift: arm “drifts” downward
• Cerebellar drift: arm “drifts” back
toward head or out to side
Leg: no need to close eyes
motor: leg “drifts”toward bed

56. Movement Assessment
Movements are purposeful or non-purposeful purposeful: picking at
tubings or bed linens, scratching nose
localizing: moving toward or removing a painful stimulus; must cross the midline; occurs in
the cortex
withdrawal: pulling away from pain; occurs in the hypothalamus
non-purposeful: do not cross the midline
abnormal flexion: (decorticate)
rigidly flexed arms and wrists; fisted
hands; occurs in upper brainstem
abnormal extension: (decerebrate)
Decorticate
rigidly, rotated inward extended arms
with flexed wrists and fisted
hands; occurs in midbrain or pons.
Decerebrate

58. Primary Sensory Modalities
 Light Touch (Multiple Pathways)
 Pain/Temperature Sensation (Spinothalamic Tract)
 Vibration/Position Sensation (Posterior Columns)
Cortical Sensory Modalities
 Stereognosis
 Graphesthesia
 Two-Point Discrimination
 Double Simultaneous Extinction

59.  Pain and Temperature
• Pinprick (One pin per patient!)
• Sensation of Cold
• Look for Sensory Nerve or
Dermatomal Distribution
 Vibration Sensation
• C-128 Hz Tuning Fork (check great toe)
 Joint Position Sensation
• Check great toe
• Romberg Sign

60. Higher Cortical Sensory Function
 Graphesthesia
 Stereognosis
 Two-Point Discrimination
 Double Simultaneous Extinction
 Gerstmann’s Syndrome (acalculia, right-left
confusion, finger agnosia, agraphia)
• Usually seen in Dominant Parietal Lobe lesions

61. Hemisphere Dysfunction
 Dysmetria on Finger-Nose-Finger Testing*
 Irregularly-Irregular Tapping Rhythm*
 Dysdiadochokinesis*
 Impaired Check*
 Hypotonia*
 Impaired Heel-Knee-Shin*
 Falls to Side of Lesion*
 Nystagmus (Variable Directions)
* All Deficits are Ipsilateral to the side of the lesion

62. Midline Dysfunction
 Truncal Ataxia
 Titubation
 Ataxic Speech
 Gait Ataxia
• Acute Ataxia (unsteady Gait)
• Chronic Ataxia (wide-based, steady Gait)

63. REFLEXES

64. MUSCLE STRETCH REFLEXES (DEEP TENDON
REFLEXES)
• GRADED 0 - 5
– 0 - ABSENT
– 1 - PRESENT WITH REINFORCEMENT
– 2 - NORMAL
– 3 - ENHANCED
– 4 - UNSUSTAINED CLONUS
– 5 - SUSTAINED CLONUS

65. MSR / DTR
• BICEPS
• BRACHIORADIALIS
• TRICEPS
• KNEE
• ANKLE

66. OTHER REFLEXES
• Upper motor neuron dysfunction
– BABINSKI
• present or absent
• toes downgoing/ flexor plantar response
– HOFMAN’S
– JAW JERK
• Frontal release signs
– GRASP
– SNOUT
– SUCK
– PALMOMENTAL

67. Abmornal Reflexes
Abnormal Reflexes:
Babinski: initial inflection of great toe in response
stroking of sole; upgoing toe is abnormal
Grasp: involuntary grasp in response to stimulation
of palm; abnormal in an adult
Doll’s eyes: impairment of eye movement to opposite
side when head is turned = damage to brainstem; no
movement = loss of
brainstem

68. Neuro Aessessment Quiz
• 1. Peripheral Nervous System (PNS) • .4. A Coup Contracoup injury is defined
as: When the head strikes a fixed
is made up of the following except:: object, the coup injury occurs at the site of
a) Cranial nerves (12) impact and the contrecoup injury occurs
b) Ventricles at the opposite side. True or
False____________________
c) Axons and Neurons • 5. The Facial nerve controls:
d) Spinal nerves (31) a) Movement of the chin, tongue and parotid
e) Cerrebellar nerves glands.
• 2. The Autonomic Nervous System b) Movement of the tongue, soft palete and
contains both the Sympathetic eyebrows.
Division of nerves and the c) Movement of the chin and cheeks
Parasympathetic Division of nerves. muscles.
True or False________________. d) Movement of all the facial expression
• 3. Intracranial Hemorrhage can occur muscles.
in the following places except: • 6. Which nerve controls movement on the
neck and shoulders?
a) Epidural space a) Abducens
b) Subdural space b) Accoustic
c) Subarachnoid space c) Spinal Assesory
d) Ethmoid space d) Occulomotor

69. • 7. A serious injury to the cervical spine • 9. When assessing a patient with altered
and spinal cord most likely will result in LOC, you feel his state of awareness/arousal is
the following condition: best described as “Obtunded”, this means:
a) Hemiplegia a) Very drowsy, when not stimulated, but can
b) Quadraplegia follow simple commands when stimulated (i.e.
c) Paraplegia shaking or shouting); verbal responses include
one or two words, but will drift back to sleep
d) Contralateral paralysis without stimulation.
• 8. Any suspected head, neck or spine b) A state of drowsiness; client needs increased
injured victim should immediately be external stimuli to be awakened but, remains
given spinal immobilization easily arousable; verbal, mental & motor
precautions, except: responses are slow or sluggish.
a) When the victim complains of pain only c) Awakens only to vigorous and continuous
upon turning his head to one side. noxious (painful) stimulation; minimal
b) When the victim refuses to allow spinal spontaneous movement; motor responses to
immobilization even after listening pain are appropriate but, verbal responses are
carefully to multiple attempts to explain minimal and incomprehensible (i.e. moaning).
the dangers and risk involved. d) Vigorous external stimulation fails to produce
c) When the victim is intoxicated on alcohol any verbal response; both arousal and
and cannot speak clearly. awareness are lacking; no spontaneous
d) When the victim was never unconscious movements but, motor responses to noxious
and denies any pain. stimuli maybe be purposeful

70. • 10. The Glasgow Coma scale tests for • 13. A constricted “pin point” pupil indicates:
three kinds of responses, they are: (best answer)
a) Eye Opening a) Brain Stem herniation
b) Motor Response b) Cardiac Arrest
c) Verbal Response c) Cerebral Infarction of the parietal lobe
d) Auditory Response d) Cerebral Infarction of the occipital lobe
• 11. The best and worst possible score on e) A wide variety of conditions, some being
the GCS is: extremely life threatening.
a) 15 and 0 • 14. What Cranial nerve(s) controls the
b) 13 and 3 movement of the eyes down and in?
c) 15 and 3 a) CN VI Abducens
d) 18 and 5 b) CN III Oculomotor
• 12. When assessing pupillary c) CN IV Trochlear
response, you are looking for the d) CN II Optic
following conditions except: • 15. The Motor strength scale goes from 0/5 to
a) Coordinated eye movement and bilateral 5/5, 0 being no strength at all and 5 being
blinking. normal strength. A person with a motor strength
b) Reactivity to and accommodation to light. of 4/5 would be:
c) Symmetry of pupils and accommodation a) overcomes gravity; offers no resistance
to light. b) strong against resistance
d) Abnormal pupil shape. c) weak against resistance
d) no muscle movement

71. • 16. Match the following postures with its
definition: • Answers
• Decerebrate_____________ • 1 e
• Decorticate______________ • 2 True
• 3 d
a) Abnormal flexion: rigidly flexed arms and • 4 True
wrists; fisted hands; occurs in upper • 5 d
brainstem
• 6 c
b) Abnormal extension: rigidly, rotated
inward, extended arms with flexed wrists • 7 b
and fisted hands; occurs in midbrain or • 8 b
pons. • 9 a
• 17. The Babinski reflex is the initial • 10 d
inflection (extension) of great toe in • 11 c
response stroking of the sole of the
foot, select the correct answer: • 12 a
a) An upgoing great toe is abnormal. • 13 e
b) An upgoing great toe is normal. • 14 c
c) An upgoing great toe is abnornal in • 15 c
adults. • 16 Decer = b. Decor = a
d) An upgoing great toe is normal in infants. • 17 c&d