Common Neurologic Problems

The Neurologic Exam

Attention: are they awake, asleep but arousable, drowsy, somnolent, sedated, etc. Can they participate in the exam? Can test attention by spelling “world” backwards or by asking for days of the week or months of the year backwards
Orientation: to person, place, time, and/or situation
Memory/Fund of knowledge: do not need to formally assess unless part of complaint. For memory, can be bedside testing of 3 or 5 word recall after 5 minutes
Language: look for aphasia by testing for fluency (can test by naming objects), comprehension (can test by complex commands, eg “touch your right shoulder with your left hand and stick out your tongue”), and repetition

CN1: smell, typically do not test this
2: vision, check with pupillary light response, visual field testing, or visual acuity if part of complaint
3, 4, 6:: extraocular movements. 6 abducts, 4 raises in and up and helps with intorsion, 3 does rest and is in pupillary light reflex (constricts pupil)
5: facial sensation in V1, V2, and V3, compare left and right
7: facial movements/strength, compared left and right, upper (eyebrow raise/eye closure) and lower (mouth such as smile or puffing out cheeks)
8: hearing. Can do finger rub or just assess grossly when talking during interview
9, 10: palate elevation symmetry, cough/gag if intubated
11: shoulder shrug from trapezius and head turn from sternocleidomastoid
12: tongue protrusion: should be midline. If abnormal, deviates to side of injury

Strength: manual muscle testing (MMT) scale ranging from 0 to 5
- 0 = No muscle activation
- 1 = trace muscle activation (eg muscle twitch) but unable to move across ROM of joint
- 2 = muscle action with gravity eliminated (eg in plane of bed), with full ROM in that plane
- 3 = action against gravity only and not against resistance
- 4 = action against some resistance
- 5 = full strength against resistance
Other aspect of motor: muscle tone (decreased, normal, increased), tremor (at rest, with action, or postural), pronator drift, any other abnormal movements (if not sure what it is, just describe what you see), rapid alternating movements (eg bradykinesia, dysdiadochokinesia)
If altered or sedated – look for spontaneous movement, compare left and right sides, assess response to noxious stimuli (eg centrally with trapezius squeeze or sternal rub vs peripherally with nailbed pressure)

Light touch is simplest -- is it the same left and right and in uppers and lowers, can also assess for a sensory level (eg compare torso to extremities)
Unless sensation loss or changes is part of chief complaint, typically do not assess other modalities which include pinprick, temperature (hot or cold), vibration, proprioception

Grading scale: 0 = areflexia, 1+ = decreased but present, 2+ = normal, 3+ increased without clonus but often with spread to adjacent joints, 4+ = increased with clonus (sustained response to one tap)
Increased reflexes often indicate central etiology, but 3+ can be normal in young adults
Decreased reflexes often indicate lower motor neuron or peripheral etiology, can be normal in older adults
Biceps: C5-C6, musculocutaneous nerve
Brachioradialis: C5-C6, radial nerve
Triceps: C7-C8, radial nerve
Patellar: L2-L4, femoral nerve
Achilles: S1, tibial nerve
Babinski – scrape along lateral edge of foot then across top in a hockey stick motion. Often easier to describe by direction big toes moves – up or down, can also be mute (no motion of the big toe)

Finger-nose-finger and heel-knee-shin testing, looking for smooth movements vs ataxia or dysmetria, and can also pick up on tremor with FNF

Station: can stand still with feet with feet less than shoulder width apart, assess posture
Natural gait: Smooth coordinated with normal arm swing
- Symmetric? Stride length? Narrow or wide based? Speed?
- Lateralizing findings (ie circumduction, shoulder droop)?
Toe walk: tests balance, strength of distal lower extremities
Tandem walk (heel to toe): should be able to balance without falling or stepping to the side, can help detect ataxia