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THE NEUROLOGICAL EXAMINATION. NEUROLOGICAL EXAM. MENTAL STATUS CRANIAL NERVES MOTOR EXAM STRENGTH GAIT CEREBELLAR REFLEXES SENSATION. MENTAL STATUS. Level of Consciousness. Awake and alert Agitated Lethargic Arousable with Voice Gentle stimulation Painful/vigorous stimulation

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neurological exam
NEUROLOGICAL EXAM
  • MENTAL STATUS
  • CRANIAL NERVES
  • MOTOR EXAM
    • STRENGTH
    • GAIT
    • CEREBELLAR
  • REFLEXES
  • SENSATION
level of consciousness
Level of Consciousness
  • Awake and alert
  • Agitated
  • Lethargic
    • Arousable with
      • Voice
      • Gentle stimulation
      • Painful/vigorous stimulation
  • Comatose
language
LANGUAGE
  • FLUENCY
  • NAMING
  • REPETITION
  • READING
  • WRITING
  • COMPREHENSION

Aphasia vs. dysarthria

memory
MEMORY
  • IMMEDIATE
    • REALLY A MEASURE OF ATTENTION RATHER THAN MEMORY
  • REMOTE
  • 3 OBJECTS AT 0/3/5 MINUTES
  • HISTORICAL EVENTS
  • PERSONAL EVENTS
orientation
ORIENTATION
  • PERSON
    • NOT WHO THEY ARE BUT WHO YOU ARE
  • PLACE
  • TIME
other cognitive functions
OTHER COGNITIVE FUNCTIONS
  • CALCULATION
  • ABSTRACTION
  • SIMILARITIES/DIFFERENCES
  • JUDGEMENT
  • PERSONALITY/BEHAVIOR
cranial nerve exam
CRANIAL NERVE EXAM
  • I - OLFACTORY
    • DON’T USE A NOXIOUS STIMULUS
    • COFFEE, LEMON EXTRACT
  • II - OPTIC
    • VISUAL ACUITY
    • VISUAL FIELDS
    • FUNDOSCOPIC EXAM
cranial nerve exam11
CRANIAL NERVE EXAM
  • III/IV/VI OCULMOTOR, TROCHLEAR, ABDUCENS
    • PUPILLARY RESPONSE
    • EYE MOVEMENTS
      • 9 CARDINAL POSITIONS
    • OBSERVE LIDS FOR PTOSIS
  • V - TRIGEMINAL
    • MOTOR - JAW STRENGTH
    • SENS - ALL 3 DIVISIONS
cranial nerves12
CRANIAL NERVES
  • VII - FACIAL
    • OBSERVE FOR FACIAL ASYMMETRY
    • FOREHEAD WRINKLING, EYELID CLOSURE, WHISTLE/PUCKER
  • VIII - VESTIBULAR
    • ACUITY
    • RINNE, WEBER
cranial nerves13
CRANIAL NERVES
  • IX/X - GLOSSOPHARYNGEAL, VAGUS
    • GAG
  • XI - SPINAL ACCESSORY
    • STERNOCLEIDOMASTOID M.
    • TRAPEZIUS MUSCLE
  • XII - HYPOGLOSSAL
    • TONGUE STRENGTH
    • RIGHT XII THRUSTS TONGUE TO LEFT
strength
STRENGTH
  • STRENGTH
    • GRADED 0 - 5
    • 0 - NO MOVEMENT
    • 1 - FLICKER
    • 2 - MOVEMENT WITH GRAVITY REMOVED
    • 3 - MOVEMENT AGAINST GRAVITY
    • 4 - MOVEMENT AGAINST RESISTANCE
    • 5 - NORMAL STRENGTH
strength exam
STRENGTH EXAM
  • UPPER AND LOWER EXTREMITIES
  • DISTAL AND PROXIMAL MUSCLES
  • GRIP STRENGTH IS A POOR SCREENING TOOL FOR STRENGTH
  • SUBTLE WEAKNESS
    • TOE WALK, HEEL WALK
    • OUT OF CHAIR
    • DEEP KNEE BEND
motor exam cont
Motor exam, cont
  • Subtle signs of weakness on a cortical/subcortical basis
    • Pronator drift
    • Orbiting
gait evaluation
Gait evaluation
  • Include walking and turning
  • Examples of abnormal gait
    • High steppage
    • Waddling
    • Hemiparetic
    • Shuffling
    • Turns en bloc
muscle observation
MUSCLE OBSERVATION
  • ATROPHY
  • FASCIULATIONS
abnormal movements
ABNORMAL MOVEMENTS
  • TREMOR
    • REST
    • WITH ARMS OUTSTRETCHED
    • INTENTION
  • CHOREA
  • ATHETOSIS
  • ABNORMAL POSTURES
cerebellar function
CEREBELLAR FUNCTION
  • RAPID ALTERNATING MOVEMENTS
  • FINGER TO FINGER TO NOSE TESTING
  • HEEL TO SHIN
  • GAIT
    • TANDEM
romberg sign
Romberg Sign
  • Stand with feet together - assure patient stable - have them close eyes
  • Romberg is positive if they do worse with eyes closed
  • Measures
    • Cerebellar function
        • Frequently poor balance with eyes open and closed
    • Proprioception
        • Frequently do worse with eyes closed
    • Vestibular system
muscle stretch reflexes deep tendon reflexes
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
msr dtr
MSR / DTR
  • BICEPS
  • BRACHIORADIALIS
  • TRICEPS
  • KNEE
  • ANKLE
other reflexes
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
slide27
TONE
  • INCREASED, DECREASED, NORMAL
  • COGWHEELING
  • CLASP KNIFE
sensory exam29
SENSORY EXAM
  • VIBRATION
    • 128 hz tuning fork
  • JOINT POSITION SENSE
  • PIN PRICK
  • TEMPERATURE

Start distally and move proximally

higher cortical sensations
HIGHER CORTICAL SENSATIONS
  • GRAPHESTHESIA
  • STEREOGNOSIS
  • DOUBLE SIMULTANEOUS STIMULATION
  • BAROSTHESIA
  • TEXTURES