General Neurological Examination
Jetty 21M058
Joanna 21M059
Joseph 21M060
INTELLECTUAL EXAMINATION
• Handedness
• Memory
• Immediate memory
• Give the patient three unrelated words (e.g. carrot, ankle, honesty ). Ask
him to repeat.
• Short-term memory
• Ask the patient to recall the three words you previously asked him to
remember. Test the patient's ability to remember the events of that day.
Ask what actions he has recently carried out, what he has eaten for
breakfast, who have met him today, how he came to the present building
• Long-term (remote) memory
• Ask the patient to recall personal and historic events. Ask where
was he born, where did he go to school or college, where has he
worked, what is his wife's or children's names and how old are
they. For historical events, ask him to name four people who have
been presidents or prime ministers
• Level of consciousness
• Speech
• Fluency, comprehension, repetition, naming objects, reading, calculation
• Speech defects fall into four main types: aphasia, dysarthria (anarthria), dysphonia
(aphonia) and mutism.
• If the patient is conscious, but making no attempt to speak or make sound, this is
mutism.
• If the patient, though speaking, fails to produce any volume of sound, or merely
whispers, this is aphonia. It is due to disorders of the larynx and vocal cords.
• If the volume of sound and the content of the speech are normal, but the articulation
arid enunciation of the individual words and phrases are distorted, this is dysarthria.
• If the patient is failing to put into properly constructed words or phrases the thoughts
he wishes to express, even if articulation is adequate, this then is aphasia.
CRANIAL NERVE EXAMINATION
• I. Olfactory nerve
• Close eyes, close one nostril and repeat on both sides. Use
smelling Coffee, salt, asafoetida
• II. Optic nerve
• Visual acuity; Snellen chart test each eye separately, test at
distance of 20 feet. Note the number of line which the patient can
clearly see.
• Visual field ; confrontation
• Colour vision; Ishihara chart
• Light reflexes
• CN III, IV,VI
• Ocular movements
• V. Trigeminal nerve
• Sensory: over face
• Corneal reflex
• Motor ; muscles of mastication ;
pterygoids, temporalis; ask to clench teeth
• VII. Facial nerve
• To test motor function of facial muscles, deviation of mouth,
frowning, closure of eyes against resistance, blowing, whistling,
smiling
• Taste anterior 2/3rd of tongue
• VIII. Vestibulocochlear nerve
• Vestibule ocular reflex ;with patients eye fixed rotate head by 20°
and take back to mid line rapidly. Look for movement of eyes
• Weber test
• Rinne test
• IX, X Glossopharyngeal and vagus nerves
• Gag reflex and position of uvula
• XI. Spinal accessory nerve
• Trapezius muscle; shrugging of shoulder
• Sternocleidomastoid muscle; movement of head to one side
against resistance
• XII. Hypoglossal nerve
• Ask patient to protrude tongue and move side to side
• Normal findings, deviation of tongue, fasciculations
Motor System Examintion
Motor system examination consists of
1. Attitude of the limbs
2. Bulk/nutrition
3. Tone
4. Power
5. Reflexes
6. Coordination
7. Gait
Attitude
It is the position of the limbs that is adopted when the patient is
in resting positon.
Bulk / Nutrition
• In some areas, just inspection is adequate (thenar eminence,
hypothenar eminence, shoulder) whereas in other areas (thighs,
legs, arms and forearms) measurement is required.
• Bony landmarks:
• 10 cm below the olecranon
• 10 cm above the medial humeral epicondyle
• 18 cm above the patella
• 10 cm below the tibial tuberosity.
• Wasting is considered if there is >1 cm reduction on the dominant
extremity and >2 cm in the nondominant extremity.
Muscle Tone
• Tone is defined as partial state of contraction of the muscle at
rest which is demonstrated by resistance offered by the muscle
to passive movement across the joint.
• Tone is examined in the upper limb (wrist and elbow joint) and
the lower limb (knee and ankle joint).
Clonus
• Clonus is a rhythmic series of contractions evoked by a sudden
stretch of the muscle & tendon.
• Insustained (< 6 beats) maybe physiological
• Sustained - indicates UMN damage & is accompanied by
spasticity.
• Best elicited at ankle.
Mucle Power
Medical Research Council Grading:
Grade 0—no contraction
Grade 1—Flicker or trace of contraction
Grade 2—active movement, with gravity eliminated
Grade 3—active movement against gravity
Grade 4—active movement against gravity and resistance
Grade 5—normal power
Grades 4-, 4, and 4+ may be used to indicate movement against
slight, moderate, and strong resistance, respectively.
Reflexes
A reflex is an involuntary response to a sensory stimulus.
Deep Tendon Reflexes
Superficial Reflexes
• These are the responses to stimulation of either the skin or
mucous membrane.
• Superficial reflexes are abolished by pyramidal tract lesions.
Plantar Reflex - stroking the plantar surface of foot from the heel
forward is normally followed by plantar flexion of foot and toes.
Babinski Sign - it is the pathologic variation of plantar reflex (i.e.
extensor plantar response).
Coordination and gait
• Finger nose test : Ask the patient their nose with the tip of the index
finger and then touch your fingertip. Do this as quickly as possible
• Knee heel test : With the patient lying supine ask them to lift the heel
into the air and place it on their opposite knee then slide their heel up
and down their shin between knee and ankle
• Gait
• Rhombergs test
Sensory system
• Fine touch : When patient is looking away or closes eyes use a wisp of cotton wool and
ask patient to say yes to each touch
• Temperature : Touch the patient with a cold metallic object and ask if he feels cold.
More sensitive assessment need tubes of hot and cold water at controlled temperature.
• Pain : Use a fresh neurological pin such a neurotip not a hypodermic needle dispose the
pin after use.
• Vibration : place a vibrating 128hz tuning fork on the patients big toe if vibration not
felt then move proximally to the medial malleolus if not perceived move to patella then
anterior iliac spine lower chest wall or patella.
• Repeat the process in the upper limb start at distal interphalangeal joint of the fore
finger if sensation impaired proceed approximately to metacarpophalangeal joints wrist
elbow then to clavicle.
Sensory system(CONTD)
• Joint position sense: Lightly hold the distal phalynx of the patients great toe
at the sides. Tell the patient you are going to move the toe up or down
demonstrating as you do. Ask the patient to close their eyes and to identify
the direction of small movements in random order.
• Stereognosis : Ask the patient to close eyes , place a familiar object in their
hands and ask them to identify
• Graphaesthesia : Use the blunt end of a pencil and trace letter or number in
patients palm and ask to identify..
• Sensory inattention : Touch their arms/legs in turn and ask which side has
been touched. Now touch both sides simultaneously and ask whether the
left side right side or both sides were touched.
Cerebellum
• In cerebellum check for speech , nystagmus , pendular knee jerk ,
ataxia , Tremors and released reflexes.
References
• Macleod’s Clinical Examination 15th Edition
• Hutshison‘s Clinical Methods 23rd Edition
Thank You
