The Neurological Examination

1. The Neurological Examination Robin Meek, M.D. Introduction to the Medical Profession March 22, 2006

2. Objectives: 1. List and discuss the 3 essential questions to consider when assessing neurological function. 2. Describe the 6 components of the neurological exam.

3. Three Key Questions • Is there evidence of nervous system disease or dysfunction? • Where is the problem located? • What is the nature of the problem?

4. 1. Is there evidence of nervous system disease or dysfunction ? • Focal – stroke • Diffuse – multiple sclerosis • Systemic –peripheral neuropathy

5. 2. Where is the problem? • CNS vs. PNS • Tracts vs. neurons • UMN vs. LMN • Cortical vs. subcortical

6. Peripheral - Muscle - Neuromuscular junction - Spinal or cranial nerves - Plexus - Nerve roots CNS Spinal cord Brainstem Cerebellum Cerebrum Right vs. left Cortex vs. subcortical Peripheral vs. Central

7. 3. What is the nature of the problem? PIT VET 3-D

8. PIT - pressure - infection - toxic or metabolic VET - vascular - epilepsy - trauma 3 - D - demyelinating - degenerative - developmental PIT VET 3 - D

10. Six Components 1. Mental status 2. Cranial nerves 3. Motor 4. Sensory 5. Reflexes 6. Coordination

11. Six Components 1. Mental status 2. Cranial nerves 3. Motor 4. Sensory 5. Reflexes 6.Coordination

12. Mental Status • Alertness or awareness • Orientation

13. Six Components 1. Mental status 2. Cranial nerves 3. Motor 4. Sensory 5. Reflexes 6.Coordination

14. I Olfactory II Optic III Oculomotor IV Trochlear V Trigeminal VI Abducens VII Facial VIII Acoustic IX Glossopharyngeal X Vagus XI Spinal accessory XII Hypoglossal The Cranial Nerves

16. Olfaction (CN I) • Almost never tested • Smell • Coffee, mint, essence of orange • Impaired olfaction: • Inflammation (allergies or colds) • Smoking • Aging • Anosmia

17. CN II - Vision • Three steps: 1.Visual fields by confrontation 2. Visual acuity testing – patient should wear their usual corrective lenses 3. Funduscopic examination –red reflex, optic disc, retinal vessels

18. Pupillary Light Reflex (CN II,III) • Check pupil symmetry • Swinging penlight– pupils should remain equally constricted • Anisocoria – one pupil is larger than the other - Normal variant - Sympathetic vs. parasympathetic

19. Sympathetic – responsible for dilation - asymmetry greatest in the dark • Parasympathetic – responsible for constriction - asymmetry greatest in the light

23. IV Trochlear • Downward and inward movement of the eye • Innervates the superior oblique

24. VI Abducens • Lateral deviation of the eye • Innervates the lateral rectus

26. Nystagmus

27. Experiment on your buddy!

28. V Trigeminal • Mixed nerve – somatic sensory and somatic motor • Sensory nucleus – pons and medulla, becoming continuous with the posterior horn of the spinal cord • Motor nucleus – confined to the pons

29. Trigeminal - Sensory • Three branches: opthalmic, maxillary, mandibular • Sensory input from the face and mucus membranes (ocular, nasal, and oral) excluding the external ear and the posterior head, via the trigeminal ganglion

30. Trigeminal - Motor • Supplies the muscles of mastication (masseter, temporal, internal and external pterygoid) muscles and other minor pharyngeal muscles

31. Trigeminal Examination • Pinprick and fine touch sensation in forehead, cheek, and mandible bilaterally • Corneal reflex • Jaw movements and jaw reflex • Palpation of jaw muscles for tone and strength with teeth clenched

34. VII Facial • Mixed nerve • Motor – facial musculature except for levator palpebrae (CN III) • Superior salivatory nucleus – submandibular and sublingual glands

35. VII Facial Sensory • Nucleus solitarius – taste from anterior 2/3 of the tongue ( sweet and salty) • Sensory nucleus 5 – sensation from the external ear

36. VII – Three Steps • Inspection at rest and with facial expression • Wrinkling the forehead – differentiates central from peripheral lesion • Identifying sweet and salty tastes on both sides of the tongue

40. Try it out!

41. VIII Acoustic • Hearing - cochlear division • Balance – vestibular division - seldom tested in basic neuro. exam

42. VIII – Two Steps • Assess hearing, covering opposite ear: whispered words rubbing your fingers ticking watch • Rinne test – bone and air conduction

45. IX Glossopharyngeal • Mixed nerve • Motor – pharynx • Sensory – posterior portions of the eardrum and ear canal, the pharynx, and the posterior tongue (salty, sweet, sour, and bitter)

46. X Vagus • Mixed • Motor – palate, pharynx, and larynx • Sensory – pharynx and larynx

47. Testing IX and X • Listen to the patient’s voice – is it hoarse or does it have a nasal quality? • Say “ah” – look at the soft palate and the pharynx. • Gag reflex – stimulate both sides of the back of the throat and note the gag response (warn the patient)

48. XI Spinal accessory • Shoulder and neck movements • Look for atrophy or fasiculations in the trapezius muscles, compare one side to the other • Shrug shoulders • Turn head against your hand