THENEUROLOGICEXAMINATION

20142015
I.

Introduction
Thenervoussystemislessaccessibletoinspection,palpation,percussion,and
auscultationthanmostotherorgansystems.Instead,thenervoussystemistreatedasa
blackboxthatisanalyzedbyexaminingwhatgoesinandwhatgoesout,andfrom
thisdeterminingwhethertheboxisperformingitsfunctionscorrectly.Fortunately,the
nervoussystemhasmanykindsofinputandoutput,becauseitistheprincipalorgan
systemresponsibleforregulatingananimalsinteractionswiththeenvironment.The
neurologicexaminationisasystematicassessmentofthenervoussystemsoutputin
responsetovariousformsofinput.
Inthebroadestterms,allinputtothenervoussystementersviasensorynerves,andall
outputismediatedbymuscles.Theprocessingthatoccursbetweeninputandoutput
canbeextremelycomplicated.Forexample,considerwhatisinvolvedinresponding
tothequestion,Whattimeisit?Apersonmust(1)hearthequestion(2)identifythe
noisesasrecognizablewords(3)interpretthewords(4)generateamotorprogram
designedtobringaclockorwatchintoview(5)transmittheprogramtothecorrect
muscles(6)activatethemuscleswiththecorrecttimingandforcesothatthe
movementdoesnotundershootorovershootthetarget(7)seethefaceofthewatchor
clock(8)analyzetheshapesintoacoherentvisualpicture(9)interpretthepicture(10)
translatethetimeintowords(11)generateamotorprogramdesignedtoactivatethe
oralandlaryngealmusclesinvolvedinproducingthosewords(12)transmitthe
programtothecorrectmuscles(13)activatethemuscleswiththecorrecttimingand
force.Furthermore,eachofthesestepsinvolvesmanycomponentprocesses.A
malfunctionatanystepalongthewaycouldresultinanincorrectorabsentresponse.
Thetypeoferrormayhelptoidentifythespecificsiteofmalfunction,butusually
moreinformationisnecessary.Thisisprovidedbypresentingavarietyofdifferent
tasksthatinvolvedifferentcombinationsofsensoryinputs,centralprocessing,and
motoroutputs,identifyingthetasksthatareperformedincorrectly,anddetermining
whetherthosetasksshareacommoninputpathway,outputpathway,orcentral
processingstep.
Itisconvenienttoclassifythenervoussystemfunctionsintothegeneralcategories
listedinthetable.Thementalstatusportionoftheexaminationinvolvestasksthat
requiresophisticatedcentralprocessingbythebrain.Thetwelvecranialnervesare
consideredseparatelyfromtheperipheralnervesderivedfromspinalnerveroots
becausetheyhaveuniquefunctionsandarelocatedinpreciselocations,sothat
examinationabnormalitiesoftenhaveveryspecificimplicationsregardingthesiteof
nervoussystemdamage.Inroughterms,thementalstatusexaminationassessesthe
cerebralcortexandthecranialnerveexaminationassessesthebrainstem;bothare
essentiallyindependentofspinalcordfunction.Theremainderoftheneurologic

examinationconsistsofassessmentofsensoryinputfromandmotoroutputtothe
trunkandthefourlimbs.Thisinvolvespathwaysthattraversetheentirenervous
system,fromthecortex,throughthebrainstemandspinalcord,vianerveroot,plexus,
andperipheralnervetomuscleorsensoryendorgan.Anindividualabnormalityon
thisportionoftheexaminationprovidesverylittleinformationaboutthelevelof
nervoussystemdamage,butaparticularcombinationofabnormalitiesmaybevery
informative.
Allofthecomponentsoftheneurologicexaminationrequireatleastsomedegreeof
centralprocessingbetweeninputandoutput.Reflexesarethenervoussystem
functionsforwhichthatcentralprocessingisminimized.Theyareautomaticoutput
functionstriggeredbyspecificinput,withoutanyneedforconsciousdeliberation
(althoughtheycanbemodifiedbycorticalactivity).Theyresultfromfixed
connectionsbetweenincomingsensorynervesandexitingmotornervesatthesame
levelofthespinalcordorbrainstem.Becausetheyarebasedonsuchlocalcircuits,
reflexabnormalitiesprovideveryusefulinformationindeterminingthesiteofnervous
systemdamage.Infact,mostspinalcordreflexesaremodulatedbychronicinhibition
fromhigherlevelsofthenervoussystem.Thishelpstoamplifytheinformation
derivedfromreflexabnormalities:damagetothenervoussystematthelevelofthe
reflexcircuitcausesthereflextobediminished,whereasdamageathigherlevels
causesittobeexaggerated.Becausetheydonotrequireconsciousdeliberation,
reflexesarealsoveryhelpfulinexamininguncooperativepatients.
Therearefairlybroadrangesofnormalfindingsformostcomponentsofthe
neurologicexamination.Forexample,somenormalindividualshavemuchbetter
languageskillsthanothers,somearestrongerthanothers,somehavebiggerpupils
thanothers,andsomehavebriskerreflexesthanothers.Thismakesitdifficultto
decidewhetheragivenfindingistrulyoutsidetherangeofnormal.Inpart,this
decisionisbasedonexperienceandcommonsense(e.g.,ifacollegegraduatecannot
rememberthecurrentyearorthenameofthepresident,thisisprobablyabnormal;ifa
tenyearoldboycannotovercometheexamineronformalstrengthtesting,thisis
normal).Formanypartsoftheexamination,patientscanbeusedastheirown
controls.Forexample,mildweaknessofelbowflexionisprobablysignificantina
youngweightlifterinwhomallothermusclesareextremelystrong,andprobablynot
inapatientwhohasbeenbedriddenandweakallover.Similarly,abriskbiceps
reflexismuchmoresignificantwhenthecontralateralbicepsreflexisnormalor
reducedthanwhentheyaresymmetric.Tofacilitatesuchcomparisons,thetwosides
ofthebodyshouldbecompareddirectlyateachstepoftheexamination.Forexample,
itisbesttoexaminethestrengthoftherightbicepsimmediatelyafterexaminingthe
leftbiceps,ratherthancompletingtheexaminationoftheentireleftupperextremity
beforeproceedingtotheright.
Thefollowingmaterialprovidesaconcretedescriptionofexaminationtechniques.No
diagramsareincluded.Thiswrittentextshouldbesupplementedwiththevideotape

availableatyourlabsessionsandintheLRC,and/orwiththeillustrationsinthe
recommendedtextsbyBatesandJudge.Acompleteneurologicexaminationwillalso
bedemonstratedinthelecture.
Toavoidconfusion,onlyonetechniqueforperformingeachpartoftheneurologic
examinationispresentedhere.Manyvariationsexist.Somecanbefoundinstandard
textbooks(includingtheonesbyBatesandJudge);othersmaybesuggestedby
instructorsinthelaboratorysessionorbyvariousteachersatlaterstagesofyour
career.Therearealsomanyusefulteststhatarenotevenincludedinthepresent
material,whichisintendedtodescribeonlythemostroutinecomponentsofthe
examination.Intime,youshoulddevelopyourownexaminationstyle,incorporating
examinationtechniquesfrommultiplesources.Thereisnostandardorderinwhichto
performtheexaminationthesequenceshowninthetableisusefulconceptuallyand
forwrittenororalpresentations,butisnotintendedtoguidetheorderinwhichyou
actuallydothetests.
II.

MentalStatus

A. LevelofAlertness
Thisissimplyassessedinthecourseofthehistoryandphysical;nospecialtestingis
required.Doesthepatientrespondbrisklytoquestionsandinstructions?Isthepatient
inattentive,sleepy,orunresponsive?
2. Language
1. Fluency.Thisisalsoassessedthroughoutthecourseofthepatientinteraction,
withoutinvolvingspecialtesting.Arethepatientsphrasesandsentencesofnormal
length,spokensmoothlyandatanormalrate,withnormalgrammaticalstructures?
Notethatfluencyisindependentofcontentspeechcanbecompletelyfluentandstill
benonsense.
2. Comprehension.Thisisoftenadequatelyassessedthroughtheroutinehistory
andphysical,butcanalsobetestingexplicitly.Givethepatientprogressivelymore
complexcommands,suchasonestep(Touchyournose.),twostep(Touchyour
nose,thenstickoutyourtongue.),andthreestep(Touchyournose,thenstickout
yourtongue,andthenraiseyourrightfoot).Commandsthatrequireabodypartto
crossthemidline(Touchyourrightearwithyourleftthumb.)aremorecomplex
thanthosethatdont.Increasinglycomplexgrammaticalstructurescanalsobeused
(Touchthecoinwiththepencil;Withthecomb,touchthecoin.).Askthepatient
progressivelymorecomplexquestions,eitheryesno(Doesastonesinkinwater?,
Doyouputonyourshoesbeforeyourstockings?)orotherwise.Again,more
complexgrammaticalstructuressuchaspassivevoiceorpossessivemaybeuseful(Is

myauntsuncleamanorawoman?;Ifalionwaskilledbyatiger,whichoneisstill
alive?).
3. Repetition.Askthepatienttorepeatphrasesorsentencesofprogressivelygreater
lengthorcomplexity(e.g.,Itiscoldoutside.;Weallwentovertheretogether.;
Thelawyersclosingargumentconvincedthejury.;Thefinalmovementofthe
symphonywasdisappointing.).
4. Naming.Thisispartlyassessedinroutineconversationdoesthepatientoften
pauseandgropeforwords?Itshouldalsobetestedexplicitly,byaskingthepatientto
nameitemsasyoupointtothem(e.g.,shirt,shoe,phone,collar,lapel,shoelace,heel,
receiver).Lesscommonobjectsaregenerallyhardertoname,andpartsofanobject
arehardertonamethantheentireobject.
5. Reading.Askthepatienttoreadaparagraphaloud.Listenforomittedoradded
words,orforwordsubstitutions.Askthepatienttosummarizethemeaningofthe
paragraph.
6. Writing.Askthepatienttowriteanoriginalsentence,andtowriteasentence
fromdictation.Again,lookforomittedoraddedwords,orforwordsubstitutions.
3. Memory
1. Immediate.Askthepatienttorepeatastringofsevendigitsimmediatelyafter
youcompleteit.Lengthenorshortenthestringuntilyoufindthelongeststringthe
patientcanrepeatcorrectly.Thisiscalledadigitspan.NOTE:Thisistraditionally
categorizedasimmediatememory,butitisreallymoreappropriatelyconsidered
attention.
2. Shortterm.Askthepatienttomemorizethreeunrelatedwords(e.g.,baseball,
horse,shirt),thendistractthepatientforfiveminutes(usuallybyperformingother
partsoftheexam).Thenaskthepatienttorecallthelist.Ifthepatientmissesanitem,
giveclues(e.g.,Onewasananimal.),andifthisisntenough,offeramultiple
choice(e.g.,Itwaseitheracat,abear,orahorse.).
3. Longterm.Testrecentmemory,includingorientationtotime(day,date,month,
season,year),place(state,city,building),andperson(patientsfullname).Recent
memoryalsoincludeseventsofthepastfewdaysorweeks,suchasWhoarethe
currentcandidatesforpresident?or(assuminganindependentsourceisavailablefor
verification)Whatdidyouhaveforsupperlastnight?Remotememorycanbetested
byaskingforthenamesofthepresidentsinreverseorderasfarbackasthepatientcan
remember,importanthistoricaleventsanddates,etc.,andalsobyaskingaboutdetails

ofpersonallifesuchasbirthdate,namesandagesofchildrenandgrandchildren,and
workhistory(again,assumingindependentverificationisavailable).
D. Calculation.
Asksomestraightforwardcomputationproblems(e.g.,5+8=?;6x7=?;3118=?)and
somewordproblems(e.g.,Howmanynicklesaretherein$1.35?;Howmany
quartersin$3.75?Whatisthechangefromadollarifyoubuysixpiecesofcandy
thatcosttwelvecentseach?).

E. Construction.
Askthepatienttodrawaclock,includingallthenumbers,andtoplacethehandsat
4:10.Askthepatienttodrawacube;forpatientswhohavetroubledoingso,drawa
cubeandaskthemtocopyit.
F. Abstraction.
Askthepatienttoexplainsimilarities(e.g.,Whatdoanappleandanorangehavein
common?;abasketballandagrapefruit?;atentandacabin?;a
bicycleandanairplane?;asculptureandasymphony?)anddifferences
(e.g.,Whatsthedifferencebetweenaradioandatelevision?;ariveranda
lake?;ababyandamidget?;characterandreputation?).
III.

CranialNerves

A. Olfaction.
Thisneednotbetestedroutinely.Itistestedbyhavingthepatientoccludeonenostril
andidentifyacommonscent(e.g.,coffee,peppermint,cinnamon)placedunderthe
othernostril.
B. Vision.
1. VisualFields.Havethepatientcoverhisorherlefteye.Standfacingthepatient
fromtwoarmslengthsaway,closeyourrighteye,andstretchyourarmsforwardand
tothesidessothatthehandsareattheverticalmidlineofyourvisionandjustbarely
visibleinyourperipheralvision.Theyshouldbethesamedistancefromyouandthe
patient.Holdtheindexfingeroneachhandextended.Wigglethefingeroneitherthe
left,right,orbothhands,andaskthepatienttoidentifywherethemovementoccurs
whilelookingdirectlyatyournose.Moveyourarmsupwardsothatyourhandsareat
roughly1:002:00and10:0011:00,andrepeatthetask.Moveyourhandsdown
toroughly4:005:00and7:008:00andtestagain.Thentestallthreepositions
usingthepatientslefteye(andyourrighteye).
2. Acuity.Placeahandheldvisualacuitycard14inchesinfrontofthepatients
righteye,whilethelefteyeiscovered(andwiththepatientwearinghisorherusual
correctivelenses).Askthepatienttoreadthelowestlineonthechart(20/20).Ifthe
patientcannotdoso,moveupaline,andcontinuedoingsountilyoureachaline
wherethemajorityofitemsarereadcorrectly.Notewhichlinethisis,andhowmany
errorsthepatientmakesonthisline.Repeattheprocessforthelefteye.
3. Funduscopicexamination.SeethechapterentitledComprehensive
OphthalmologyExamination.

C. PupillaryLightReflex.
Reducetheroomilluminationasmuchaspossible.Shineapenlightonthebridgeof
thepatientsnose,sothatyoucanseebothpupilswithoutdirectinglightateitherof
them.Checkthattheyarethesamesize.Nowmovethepenlightsothatitisdirectly
shiningontherightpupil,andchecktoseethatbothpupilshaveconstrictedtothe
samesize.Next,movethepenlightbacktothebridgeofthenosesothatbothpupils
dilate,andthenshinethelightdirectlyontheleftpupil,againcheckingforequal
constrictionofthetwoeyes.Finally,movethepenlightrapidlyfromtheleftpupilto
therightthepupilsizeshouldnotchange.Swingthelightbacktotheleftpupil
again,thepupilsizeshouldremainconstant.Repeatthisswingingmaneuverseveral
timestobesurethereisnoconsistenttendencyforthepupilstobelargerwhenthe
lightisdirectedatoneeyethanwhenitisdirectedattheotherone.
D. EyeMovements.
Observethepatientseyelidsforptosis.Havethepatientfixateonyourfingerheld
abouttwofeetaway,intheverticalandhorizontalmidline.Observefornystagmusa
repetitive,quickmovementoftheeyesinonedirection,followedbyaslowreturnof
theeyesintheoppositedirection,severaltimesinarow.Askthepatienttoavoidany
movementofthehead,buttocontinuewatchingyourfingerasyouslowlymoveitto
thepatientsright.Observethesmoothnessandrangeofthepatientseyemovements.
Keepyourfingeratthefarrightofthepatientsgazeforseveralsecondswhile
observingfornystagmus.Moveyourfingerslowlytothepatientsleftandrepeatthe
observations.Returnyourfingertotheverticalandhorizontalmidline,thenmoveit
slowlyup,repeatingtheobservations.Thenmoveyourfingerslowlydownandrepeat
theobservations.Finally,returntothemidlineposition,andmoveyourfinger
diagonallydownandtotheleft;thenreturntothemidlineandmoveyourfingerdown
andtotheright.
E. FacialSensation.
LightlytouchthepatientsrightforeheadONCE,andthendothesameontheopposite
side.Askthepatientifthetwostimulifeltthesame.Repeatthisprocedureonthe
cheekandonthechin.Thisisusuallyadequatetesting.Insomecircumstances,the
testingshouldberepeatedapplyinglightpressurewithapin.Thecornealreflexisnot
routinelynecessary,butisusefulinuncooperativepatientsorwhentherestofthe
examsuggeststhattheremaybeaproblemwithfacialsensationorstrength.Itis
testedbyhavingthepatientlooktothefarleft,thentouchingthepatientsrighteye
withafinewispofcotton(introducedfromthepatientsrightfieldofvision)and
observingthereflexiveblinkthatoccursineacheye.Theprocessisthenrepeatedwith
thelefteye.

F. FacialStrength.
1. Musclesofmastication.Havethepatientopenthejawagainstresistance,
thenclosethejawagainstresistance.Havethepatientmovethechinsidetoside.
2. Musclesoffacialexpression.Havethepatientclosehisorhereyestightly.
Observewhetherthelashesareburiedequallyonthetwosides,andwhetheryoucan
openeithereyemanually.Thenhavethepatientlookupandwrinkletheforehead;
notewhetherthetwosidesareequallywrinkled.Havethepatientsmile,andobserve
whetheronesideofthefaceisactivatedmorequicklyormorecompletelythanother.
G. Hearing.Forbedsideexaminationpurposes,itusuallysufficestoperformaquickscreen
byholdingyourfingersafewinchesawayfromthepatientsearandrubbingthem
softly.Alternatively,youcanholdyourhandupasasoundscreenandwhisperafew
numbersfrombehindyourhandwhilerhythmicallytappingtheoppositeeartokeepit
fromcontributing,thenaskthepatienttorepeatthenumberstoyou.Eachearshould
betestedseparately.Whenthereisreducedauditoryacuityinoneorbothears,
additionalinformationcanbeobtainedfromtheWeberandRinnetests(describedin
thetextbooks),butthesearestillimprecise.
H. PalatalMovement.Askthepatienttosayaaahoryawn,andobservewhetherthetwo
sidesofthepalatemovefullyandsymmetrically.Thepalateismostreadilyvisualized
ifthepatientissittingorstanding,ratherthansupine.Thereisgenerallynoneedto
testthegagreflexinascreeningneurologicexamination.Whenthereisreasonto
suspectreducedpalatalsensationorstrength,thereflexcanbecheckedbyobserving
theresponsewhenyoutouchtheposteriorpharynxononesidewithacottonswab,
andthencomparingtotheresponseelicitedbytouchingtheotherside.
I.

Dysarthria.Noteifthepatientsspeechisslurred,nasal,strangled,orirregularinrateor
volume.

J. HeadRotation.Havethepatientturntheheadallthewaytotheleft.Placeyourhandon
theleftsideofthechinandaskthepatienttopressagainstyourhandwhileyoutryto
turntheheadbacktotheright,palpatingtherightsternocleidomastoidmusclewith
yourotherhandatthesametime.Repeattheprocessforrightwardheadrotation.
K. ShoulderElevation.Askthepatienttoshrugtheshoulderswhileyouresistthe
movementwithyourhands.
L. TongueMovement.Havethepatientprotrudethetongueandmoveitrapidly
fromsidetoside,thenpushitintotheleftsideofthemouthwhileyoupush
againstitfromoutsidetheleftcheek,andthendothesameontherightsideofthe
mouth.

IV.

Motor

A. Gait.Observethepatientscasualgait,preferablywiththepatientunawareof
beingobserved.Havethepatientwalktowardyouwhilewalkingontheheels,then
walkawayfromyouwalkingontiptoes.Finally,havethepatientwalkintandem,
placingonefootdirectlyinfrontoftheotherasifwalkingonatightrope(thedrunk
drivingtest).Noteifthepatientisunsteadywithanyofthesemaneuvers,orifthere
isanyasymmetryofmovement.Alsolookforfestination,aninvoluntarytendencyfor
stepstoaccelerateandbecomesmaller.
B. Coordination.
1. Fingertapping.Askthepatienttomakeafistwiththerighthand,thenextendthe
thumbandindexfingerandtaptheindexfingeronthetipofthethumbasquickly
aspossible.Repeatwiththelefthand.Observeforspeed,accuracy,andregularity
ofrhythm.
2. Rapidalternatingmovements.Havethepatientalternatelypronateandsupinate
therighthandagainstastablesurface(suchasatable,orthepatientsownthighor
lefthand)asrapidlyaspossible;repeatforthelefthand.Again,observespeed,
accuracyandrhythm.
3. Fingertonosetesting.Askthepatienttousethetipofhisorherrightindex
fingertotouchthetipofyourindexfinger,thenthepatientsnose,thenyour
fingeragain,andsoforth.Holdyourfingersothatitisneartheextremeofthe
patientsreach,andmoveittoseveraldifferentpositionsduringthetesting.Repeat
thetestusingthepatientsleftarm.Observeforaccuracyandtremor.
4. Heeltoshintesting.Havethepatientliesupine,placetherightheelontheleft
knee,andthenmovetheheelsmoothlydowntheshintotheankle.Repeatusing
theleftheelontherightshin.Again,observeforaccuracyandtremor.
C. InvoluntaryMovements.
Observethepatientthroughoutthehistoryandphysicalfortremor,myoclonus(rapid
shocklikemusclejerks),chorea(rapid,jerkytwitches,similartomyoclonusbutmore
randominlocationandmorelikelytoblendintooneanother),athetosis(slow,
writhingmovementsofthelimbs),ballismus(largeamplitudeflinginglimb
movements),tics(abrupt,stereotypedcoordinatedmovementsorvocalizations),
dystonia(maintenanceofanabnormalpostureorrepetitivetwistingmovements),or
otherinvoluntarymotoractivity.
D. PronatorDrift.

Askthepatienttostretchoutthearmssothattheyarelevelandfullyextended,with
thepalmsfacingstraightupthentoclosetheeyes.Watchforfivetotensecondsto
seeifeitherarmtendstopronate(sothatthepalmturnsinward)anddriftdownward.

E. IndividualMuscles.
1. Strength.Forascreeningexaminationofstrength,thefollowingupperextremity
movementsshouldbetested:shoulderabduction,elbowextension,elbowflexion,
wristextension,wristflexion,fingerextension,fingerflexion,andfinger
abduction.Inthelowerextremities,thefollowingmovementsshouldbetested:hip
flexion,hipextension,kneeflexion,kneeextension,ankledorsiflexion,andankle
plantarflexion.
Foreachmovement,placethelimbnearthemiddleofitsrange,andthenaskthe
patienttoresistyouasyoutrytomovethelimbfromthatposition.Forexample,
intestingshoulderabduction,thepatientsarmsshouldbehorizontalforminga
letterTwiththebody,andthepatientshouldtrytomaintainthatpositionwhile
youpressdownonbotharmsatapointbetweentheshoulderandtheelbow.In
general,youshouldplaceonehandabovethejointbeingexaminedandexert
pressurewithyourotherhandjustbelowthejoint,toisolatethespecific
movementyouaretryingtotest.Themostcommonconventionforgrading
musclestrengthisthe0to5MedicalResearchCouncil(MRC)scale:
0=nocontraction
1=visiblemuscletwitchbutnomovementofthejoint
2=weakcontractioninsufficienttoovercomegravity
3=weakcontractionabletoovercomegravitybutnoadditionalresistance
4=weakcontractionabletoovercomesomeresistancebutnotfullresistance
5=normal;abletoovercomefullresistance
Notethatthisscaleisinsensitivetosubtledifferencesinstrengthinparticular,grade4
coversawiderangeofpossibilities.
2.Bulk.Whiletestingstrength,themusclesactiveineachmovementshouldbe
inspectedandpalpatedforevidenceofatrophy.Fasciculations(random,involuntary
muscletwitches)shouldalsobenoted.
3.Tone.Askthepatienttorelaxandletyoumanipulatethelimbspassively.Thisis
harderformostpatientsthanyoumightimagine,andyoumayneedtotrytodistract
thembyengagingtheminunrelatedconversation,oraskthemtolettheirlimbsgo
limp,likeawetnoodle.Severalformsofincreasedresistancetopassive
manipulationaredistinguished.Spasticitydependsonthelimbpositionandthe
velocitywithwhichthelimbismoved,classicallyresultinginaclaspknife
phenomenonwhenthelimbismovedrapidly:thelimbmovesfreelyforashort
distance,butthenthereisacatchandyoumustuseprogressivelymoreforceto
movethelimbuntilatacertainpointthereisasuddenreleaseandyoucanmovethe
limbfreelyagain.Spasticityisgenerallygreatestintheflexorsoftheupperextremity
andtheextensorsofthelowerextremity.Rigidity,incontrast,ischaracterizedby
increasedresistancethroughoutthemovement.Leadpiperigidityappliesto

resistancethatisuniformthroughoutthemovement.Cogwheelrigidityis
characterizedbyrhythmicinterruptionoftheresistance,producingaratchetlike
effect.Rigidityisoftenenhancedbydistractingthepatient.Paratoniaisincreased
resistancethatbecomeslessprominentwhenthepatientisdistracted.
V.

Reflexes

A. TendonReflexes.Thereflexesatthebiceps,triceps,brachioradialis,knee,andankleare
theonescommonlytested.Thejointunderconsiderationshouldbeatabout90oand
fullyrelaxeditisoftenhelpfultocradlethejointinyourownarmtosupportit.With
yourotherarm,holdtheendofthehammerandlettheheadofthehammerdroplikea
pendulumsothatitstrikesthetendon(specifically,justanteriortotheelbowforthe
bicepsreflex,justposteriortotheelbowforthetricepsreflex,about2inchesabove
thewristontheradialaspectoftheforearmforthebrachioradialisreflex,justbelow
thepatellaforthekneereflex,andjustbehindtheanklefortheanklereflex).Aimcan
sometimesbeimprovedbystrikingyourfingerorthumbafterpositioningitacrossthe
tendon.Youshouldstrivetodevelopatechniquethatresultsinareproduciblelevelof
forcefromoneoccasiontothenext.Themostreliableinformationcomesfromusing
theleastforcenecessarytoelicitthereflexinmanycases,yourfingersaresufficient
andthehammerisnotevennecessary.Attheotherextreme,whenapatienthas
reflexesthataredifficulttoelicit,youcanamplifythembyusingreinforcement
procedures:askthepatienttoclenchhisorherteethor(whentestinglowerextremity
reflexes)tohooktogethertheflexedfingersofbothhandsandpull.Thisisalsoknown
astheJendrassikmaneuver.
Reflexesaregradedonanessentiallysubjectivescale:
0=absent
1=reduced(hypoactive)
2=normal
3=increased(hyperactive)
4=clonus
Clonusisarhythmicseriesofmusclecontractionsinducedbystretchingthetendon.It
mostcommonlyoccursattheankle,whereitistypicallyelicitedbysuddenly
dorsiflexingthepatientsfootandmaintaininglightupwardpressureonthesole.
Someexaminersuseagradeof5todesignatesustainedclonus,reserving4for
unsustainedclonusthateventuallyfadesafter2to10beats.Also,someexaminers
includeareflexgradeof1/2toindicateareflexthatcanonlybeobtainedusing
reinforcement.
B. PlantarResponse.Usingablunt,narrowsurface(e.g.,atongueblade,key,orthehandle
ofareflexhammer),strokethesoleofthepatientsfootonthelateraledge,starting
neartheheelandproceedingalongthelateraledgealmosttothebaseofthelittletoe,

thencurvethepathmediallyjustproximaltothebaseoftheothertoes.Thisshould
taketheformofasmoothJstroke.Alwaysstartbyapplyingminimalpressure.This
isusuallyadequate,butifnoresponseoccurs,repeatthemaneuverwithgreater
pressure.
Thenormalresponseisforallthetoestoflex(aflexorplantarresponse).When
thereisdamagetothecentralnervoussystemmotorpathways,anabnormalreflex
occurs:Thegreattoeextends(dorsiflexes)andtheothertoesfanout.Thisiscalledan
extensorplantarresponse;itisalsoknownasaBabinskisign.
C. SuperficialReflexes.Theseincludetheabdominalreflexesandthecremastericreflexes.
Theyaredescribedinstandardtextbooks.Theyarenotrelevanttostandardscreening
examinations.
D. PrimitiveReflexes.Thesearealsocalledfrontalreleasesigns.Theyincludethegrasp,
root,snout,andpalmomentalreflexes.Again,theyaredescribedinstandard
textbooks,buttheyareoflimitedclinicalutilityexceptinchildren.
VI.

Sensory

A. LightTouch.Havethepatientclosehisorhereyesandtellyouwhetheryouare
touchingthelefthand,righthand,orbothsimultaneously.Repeatthisseveraltimes,
usingasastimulusasinglelighttouchappliedsometimestothemedialaspectofthe
handandsometimestothelateralaspect.Notewhetherthepatientconsistentlyfailsto
detectstimulationinonelocation.Alsonotewhetherthepatientconsistently
extinguishesthestimulusononesideofthebodywhenbothsidesarestimulated
simultaneously.Next,touchthepatientONCElightlyonthemedialaspectofeach
handsimultaneously,andaskiftheyfeelthesame.Askthesamequestionforthe
lateralaspectofeachhand.Ifanyabnormalitiesaredetected,extendyourregionof
testingproximallyinthelimbtomapoutthepreciseareaofabnormality.Perform
analogoustestingonthefeet.
B. Pain/Temperature.Explaintothepatientthatyouwillbetouchingeachfingerwith
eitherthesharporthedullendofasafetypin,anddemonstrateeach.Besurethe
safetypinispreviouslyunused.Then,withthepatientseyesclosed,lightlytouchthe
palmaraspectofthethumbwiththesharppointofthepin,andaskthepatienttosay
sharpordull.Repeatthisforeachfingerofeachhand,usuallyusingthesharp
pointbutincludingonedullstimulusoneachhandtobesurethepatientispaying
attention.Next,touchthepatientwiththepinONCElightlyonthemedialaspectof
eachhand,andaskiftheyfeelequallysharp.Askthesamequestionforthelateral
aspectofeachhand.Ifanyabnormalitiesaredetected,extendyourregionoftesting
proximallyinthelimbtomapoutthepreciseareaofabnormality.

Performanalogoustestingonthefeet.
Itisnotusuallynecessarytotestbothpainandtemperatureeitherwillsuffice.

Youcantesttemperatureinafashionanalogoustopain;areasonablestimulusisthe
flatportionofatuningforkafterithasbeenimmersedincoldwateranddried.

C. JointPositionSense.Withthefingerandthumbofonehand,stabilizethedistal
interphalangeal(DIP)jointofthepatientslefthandbyholdingitonthemedialand
lateralaspects.Withthefingerandthumbofyourotherhand,holdthemedialand
lateralaspectsofthetipofthethumb,andmoveitslightlyupordown.Havethe
patientclosehisorhereyesandidentifythedirectionofmovement.Repeatseveral
times.Mostnormalpatientscanidentifymovementsofafewdegreesorless.Perform
analogoustestingofthepatientsrightthumbandbothgreattoes.Ifabnormalitiesare
detected,proceedtomoreproximaljointsinthesamelimbuntilajointisfoundwhere
positionsenseisintact.TheRombergtestalsohelpstoassesspositionsense.Have
thepatientstandwithbothfeettogether,andthennotewhetherthepatientcan
maintainbalanceafterclosinghisorhereyes.
D. Vibration.Tapa128Hztuningforklightlyagainstasolidsurfacetoproduceaslight
vibration.Withthepatientseyesclosed,holdthenonvibratingendofthetuningfork
firmlyontheDIPjointofthepatientsleftthumb,andaskthepatientifthevibration
isdetectable.Letthevibrationfadeuntilthepatientnolongerdetectsit,thenapplythe
tuningforktoyourownthumbtoseeifyoucanstillfeelanyvibration.Repeatthis
testingonthepatientsrightthumbandbothgreattoes.Foroneofthelimbs,stopthe
vibrationbeforeapplyingthetuningforktothelimb,tobesurethatthepatientis
payingattentionifnot,clarifytothepatientthatyouareonlyinterestedinactual
vibration,notjustpressure.Ifanyabnormalitiesaredetected,applythetuningforkto
progressivelymoreproximaljointsuntiloneisfoundwherethevibrationisdetected
normally.
E. DoubleSimultaneousStimulation.SeeA.
F. Graphesthesia.Askthepatienttoclosetheeyesandidentifyanumberfrom0to9that
youdrawonhisorherindexfingerusingaballpointpen(withthestylettein!).Repeat
withseveralothernumbers,andcomparetotheotherhand.Performanalogoustesting
onthefeet,butyourdrawingmayneedtobelargerthere.
G. Stereognosis.Askthepatienttoclosetheeyesandidentifyasmallobject(e.g.,nickel,
dime,quarter,penny,key,paperclip)youplaceinhisorherrighthand.Testtheleft
handinthesameway.

OrganizationoftheNeurologicExamination

I.

Mentalstatus
GHearing(CN8)
A. Levelofalertness
H.Palatalmovement(CNs9,10)
B. Language
I.Dysarthria(CNs9,10,12)
1. Comprehension
J.Headrotation(CN11)
2. Fluency
K.Shoulderelevation(CN11)
3. Repetition
L.Tonguemovements(CN12)
4. Reading
5. Writing
III.Motor
C. Memory
A.Gait
1. Immediate
B.Coordination
2. Shortterm
C.Involuntarymovements
3. Longterm
D.Pronatordrift
a.Recent(includingorientation
E.Individualmuscles
toplaceandtime)
1.Strength
b. Remote
2.Bulk
3.Tone(resistancetopassive
D. Calculation
manipulation)
E. Construction
F. Abstraction

II.Cranialnerves
A. Olfaction(CN1)
B. Vision(CN2)
1. Visualfields
2. Visualacuity
3. Funduscopicexamination
C. Pupillarylightreflex(CNs2,3)
D. Eyemovements(CNs3,4,6)
E. FacialSensation(CN5)
F. FacialStrength
1. Musclesofmastication
(CN5)
2.Musclesoffacial
expression(CN7)

IV.Reflexes
A.Tendonreflexes
B.Plantarresponses
C.Superficialreflexes
D.Primitivereflexes
V.Sensory
A.Lighttouch
B.Pain/temperature
C.Jointpositionsense
D.Vibration
E.Doublesimultaneous
stimulation
F.Graphesthesia
G.Stereognosis