Neurological examination

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The neurological examination is the physical examination of the nervous system. The assessment of sensory neuron and motor responses, especially reflexes is undertaken to determine whether the nervous system is impaired.

This typically includes a physical examination and a review of the patient's medical history and attempts to identify or exclude signs of nervous system disease, and - if these signs are present - to produce a likely anatomical or physiological explanation that can be tested through further, deeper investigation usingmedical imaging andneuroimaging, neurophysiology tests, blood tests, lumbar puncture or a combination of these

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.

Patient's history

A patient's history is the most important part of a neurological examination and must be performed before any other procedures unless impossible (i.e. the patient is unconscious Certain aspects of a patient's history will become more important depending upon the complaint issued). Important factors to be taken in the medical history include:

• Time of onset, duration and associated symptoms (e.g. is the complaint chronic or acute)
• Age, gender, and occupation of the patient
• Handedness (right- or left-handed)
• Past medical history
• Drug history
• Family and social history

Handedness is important in establishing the area of the brain important for language (as almost all right-handed people have a left hemisphere which is responsible for language). As patients answer questions, it is important to gain an idea of the complaint thoroughly and understand its time course. Understanding the patient's neurological state at the time of questioning is important, and an idea should be obtained of how competent the patient is with various tasks and their level of impairment in carrying out these tasks. The interval of a complaint is important as it can help aid the diagnosis. For example, vascular disorders (such as strokes) occur very frequently over minutes or hours, whereas chronic disorders (such as Alzheimer's disease) occur over a matter of years.

Carrying out a 'general' examination is just as important as the neurological exam as it may lead to clues to the etiology of the complaint. This is shown by cases of cerebral metastases where the initial complaint was of a mass in the breast.

Areas assessed

The Neurological Examination is directed primarily towards the localization of lesions within the nervous system and is traditionally split into an examination of the cognitive state, cranial nerves, motor system, sensory system, cerebellar system, walking and gait and the extrapyramidal system.

Central nervous system

• Assessment of consciousness, often using the Glasgow Coma Scale (EMV)
• Mental status examination, often including the abbreviated mental test score (AMTS) or mini mental state examination (MMSE)
• Global assessment of higher functions
• Intracranial pressure is roughly estimated by fundoscopy; this also enables assessment for microvascular disease

Peripheral nervous system

• Cranial nerves (I-XII): sense of smell (I), visual fields and acuity (II), eye movements (III, IV, VI) and pupils (III, sympathetic and parasympathetic), sensory function of face (V), strength of facial (VII) and shoulder girdle muscles (XI), hearing (VII, VIII), taste (VII, IX, X), pharyngeal movement and reflex (IX), tongue movements (XII)
• Reflexes: masseter, biceps and triceps tendon, knee tendon, ankle jerk and plantar (i.e. Babinski sign). Globally, brisk reflexes suggest an abnormality of the UMN or pyramidal tract, while decreased reflexes suggest abnormality in the anterior horn, LMN, peripheral nerve or motor end plate. A reflex hammer is used for this testing.
• Muscle strength (typically graded on the MRC scale I-V)
• Sensory system (to fine touch, pain, temperature)
• Muscle tone and signs of rigidity

Specific tests

Specific tests in a neurological examination include:

Category	Tests	Example of writeup
Mental status examination	The assessment of consciousness, often using the Glasgow Coma Scale (EMV) Mental status examination, often including the abbreviated mental test score (AMTS) or mini mental state examination (MMSE) Global assessment of higher functions Intracranial pressure is roughly estimated by fundoscopy; this also enables assessment for microvascular disease.	"A&O x 3, short and long-term memory intact"
Cranial nerve examination	Cranial nerves (I-XII): sense of smell (I), visual fields and acuity (II), eye movements (III, IV, VI) and pupils (III, sympathetic and parasympathetic), sensory function of face (V), strength of facial (VII) and shoulder girdle muscles (XI), hearing (VII, VIII), taste (VII, IX, X), pharyngeal movement and reflex (IX), tongue movements (XII). These are tested by their individual purposes (e.g. the visual acuity can be tested by a Snellen chart).	"CNII-XII grossly intact"
Motor system	Muscle strength, often graded on the MRC scale 0 to 5 (i.e. 0 = Complete Paralysis to 5 = Normal Power). grades 4 -, 4 and 4+ maybe used to indicate movement against slight, moderate and strong resistance respectively. Muscle tone and signs of rigidity. Examination of posture Decerebrate Decorticate Hemiparetic Resting tremors Abnormal movements Seizure Fasciculations Tone Spasticity Pronator drift Rigidity Cogwheeling (abnormal tone suggestive of Parkinson's disease) Gegenhalten - is resistance to passive change, where the strength of antagonist muscles increases with increasing examiner force. More common in dementia.	"strength 5/5 throughout, tone WNL"
Deep tendon reflexes	Reflexes: masseter, biceps and triceps tendon, knee tendon, ankle jerk and plantar (i.e. Babinski sign). Globally, brisk reflexes suggest an abnormality of the UMN or pyramidal tract, while decreased reflexes suggest abnormality in the anterior horn, LMN, nerve or motor end plate. A reflex hammer is used for this testing.	"2+ symmetric, downgoing plantar reflex"
Sensation	Sensory system testing involves provoking sensations of fine touch, pain and temperature. Fine touch can be evaluated with a monofilament test, touching various dermatomes with a nylon monofilament to detect any subjective absence of touch perception. Sensory Light touch Pain Temperature Vibration Position sense Graphesthesia Stereognosis, and Two-point discrimination (for discriminative sense) Extinction Romberg test - 2 out of the following 3 must be intact to maintain balance: i. vision ii. vestibulocochlear system iii. epicritic sensation	"intact to sharp and dull throughout"
Cerebellum	Cerebellar testing Dysmetria Finger-to-nose test Ankle-over-tibia test Dysdiadochokinesis Rapid pronation-supination Ataxia Assessment of gait Nystagmus Intention tremor Staccato speech	"intact finger-to-nose, gait WNL"

• Finger-to-nose and ankle-over-tibia tests for ataxia
• Various tests for dysdiadochokinesis
• Tests for cogwheeling (abnormal tone suggestive of Parkinson's disease) or gegenhalten (more common in dementia). Gegenhalten is resistance to passive change, where the strength of antagonist muscles increases with increasing examiner force.
• Closer examination of any tremors
• Assessment of gait
• Romberg test to examine proprioception or cerebellar function
• Graphesthesia, stereognosis, and two-point discrimination for discriminative sense

Interpretation

The results of the examination are taken together to anatomically identify the lesion. This may be diffuse (e.g. neuromuscular diseases, encephalopathy) or highly specific (e.g. abnormal sensation in one dermatome due to compression of a specific spinal nerve by a tumor deposit). A differential diagnosis may then be constructed that takes into account the patient's background (e.g. previous cancer, autoimmune diathesis) and present findings to include the most likely causes. Examinations are aimed at ruling out the most clinically significant causes (even if relatively rare, e.g. brain tumor in a patient with subtle word finding abnormalities but no increased intracranial pressure) and ruling in the most likely causes.

External links

• Neuroexam.com - an interactive online guide to the neurologic examination
• Overview at University of Florida
• Overview at University of California, San Diego
• Overview at University of Toronto
• Overview at University of Virginia
• eMedicine neuro/632 - "Neurological History and Physical Examination"