Neurologic System. comprehensive head to toes assessment
1. Neurologic System Assessment
The physical exam of the nervous
system assesses the following:
• Motor
• Sensory
• Autonomic
• Cognitive
• Behavioral
Equipment needed:
• Penlight
• Tongue blade
• Cotton swab
• Cotton ball
• Tuning fork
• Percussion hammer
2. Neurologic System Assessment
• Mental status
• Cranial nerves
• Motor function
• Sensory function
• Reflexes
Nervous system divided into two
parts:
1. Central nervous system (CNS),
which includes brain and spinal
cord
2. Peripheral nervous system
(PNS), which includes all nerve
fibers outside brain and spinal
cord
(Includes 12 pairs of cranial nerves)
3. History of Present Illness Related to Nervous
System
Ask about
Seizures and/or convulsions
Pain
Gait coordination, falling
Weakness or paresthesia
Tremors
Traumas
Infants
Congenital anomalies/deformities
Children
Hyperactive, impulse behavior
Developmental milestones
Pregnant Women
Seizures
Headaches
Older Adult
Hearing and/or vision loss
Incontinence
Alzheimer's
4. Mental Status Exam
Mental status is a person’s
emotional and cognitive
functioning
• Optimal functioning aims toward
simultaneous life satisfaction in
work, caring relationships, and
within the self
• Usually, mental status strikes a
balance between good and bad
days, allowing person to function
socially and occupationally
Main components of a mental
status examination
• Sequence of steps forms a
hierarchy in which the most basic
functions are assessed first
• First steps must be accurately
assessed to ensure validity of
steps that follow
• Appearance
• Behavior
• Cognition
• Thought processes
5. Mental Status Exam
Posture
• Erect and position relaxed
Body Movements
• Body movements voluntary,
deliberate, coordinated, and
smooth and even
Dress
• Appropriate for setting, season,
age, gender, and social group
Grooming and Hygiene
• Person is clean and well groomed;
hair is neat and clean
• Use care in interpreting clothing
that is disheveled, bizarre, or in
poor repair, as well as piercings and
tattoos, because these may reflect
person’s economic status or
deliberate fashion trend, especially
among adolescents
• Disheveled appearance in previously
well-groomed person is significant
6. Mental Status Exam
Level of Consciousness
• Person is awake, alert, aware of
stimuli from environment and
within self, and responds
appropriately and reasonably
soon to stimuli
Facial Expression
• Appropriate to situation and
changes appropriately with topic;
comfortable eye contact unless
precluded by cultural norm
Speech
• Judge the quality of speech, noting
that person makes sounds
effortlessly and shares conversation
appropriately
• Pace of conversation is moderate,
and stream is fluent
• Articulation (the ability to form
words) is clear and understandable
• Word choice is effortless and
appropriate to educational level;
person completes sentences,
occasionally pausing to think
7. Mental Status Exam
Mood and Affect
• Judge by body language and facial
expression and by asking directly,
“How do you feel today?” or “How
do you usually feel?”
• Mood should be appropriate to
person’s place and condition and
should change appropriately with
topics; person is willing to
cooperate
Orientation
• Discern orientation through course of
interview, or ask for it directly, using tact:
“Some people have trouble keeping up with
dates while in the hospital; what is today’s
date?”
• Time: day of week, date, year, season
• Place: where person lives, address, phone
number, present location, type of building,
name of city and state
• Person: own name, age, who examiner is,
type of worker
• Many hospitalized people normally have
trouble with exact date but are fully oriented
on remaining items
8. Mental Status Exam
Attention Span
• Check person’s ability to concentrate by
noting whether he or she completes a
thought without wandering
• Attention span commonly is impaired in
people who are anxious, fatigued, or
intoxicated
Recent Memory
• Assess in context of interview by 24-hour
diet recall or by asking time person arrived at
agency
• Ask questions you can corroborate to screen
for occasional person who confabulates or
makes up answers to fill in gaps of memory
loss
Remote Memory
• In the context of the interview, ask
the person verifiable past events; for
example, ask to describe past health,
the first job, birthday and anniversary
dates, and historical events that are
relevant for that person
• Remote memory is lost when cortical
storage area for that memory is
damaged, such as in Alzheimer
disease, dementia, or any disease
that damages cerebral cortex
10. Cranial Nerves
Cranial nerve I: olfactory nerve (not
tested routinely) Sensory and Smell
• Test sense of smell in those who report
loss of smell (anosmia), head trauma,
Covid-19 (temporary loss of smell), and
abnormal mental status, and when
presence of intracranial lesion
suspected
• With person’s eyes closed, occlude one
nostril and present familiar aromatic
substance, e.g., coffee, orange, vanilla,
soap, or peppermint
• Normally person can identify an odor
on each side of nose; normally
decreased with aging; any asymmetry
in sense of smell is important
Cranial Nerves II, III, IV, and VI Motor and
Eye Movement, Pupil Size, Eyelid Opening
Cranial nerve II: optic nerve
• Test visual acuity and visual fields
• Using ophthalmoscope, examine ocular fundus
to determine color, size, and shape of optic disc
Cranial Nerves III, IV, and VI: oculomotor,
trochlear, and abducens nerves
• Inspect eye lids for drooping
• Check pupils for size, regularity, equality, direct
and consensual light reaction, and
accommodation
• Assess extraocular movements by cardinal
positions of gaze
• Nystagmus is back-and-forth oscillation of eyes
11. Cranial Nerve V: Trigeminal Nerve
Cranial nerve V: trigeminal nerve
Mixed muscle tone and sensation
• Inspect face for atrophy or tremors
• Palpate jaw for tone and strength by
palpating temporal and masseter
muscles as person clenches teeth
• Muscles should feel equally strong on
both sides; try to separate jaws by
pushing down on chin; normally you
cannot
• Test for pain and sensation with a
person’s eyes closed, test light touch
sensation by touching a cotton wisp to
designated areas on person’s face:
forehead, cheeks, and chin
• Corneal reflex: omit test, unless
person has abnormal facial
sensation or abnormalities of
facial movement
• Remove any contact lenses; with
person looking forward, bring wisp
of cotton in from side (to minimize
defensive blinking) and lightly
touch cornea, not conjunctiva
• Normally person will blink bilaterally
• Corneal reflex may be decreased or
absent in those who have worn
contact lenses
12. Cranial Nerve VII and VIII
Cranial Nerve VII: Facial Expressions and
Taste
Motor function:
• Inspect facial symmetry as person responds
to requests to smile, frown, close eyes tightly
(against your attempt to open them), lift
eyebrows, show teeth
• Have person puff cheeks, then press puffed
cheeks in, to see that air escapes equally
from both sides
Sensory function: (not tested routinely)
• Test only when you suspect facial nerve
injury
• When indicated, test sense of taste by
applying cotton applicator covered with
solution of (salt and sweet) Ex sugar, salt, or
lemon juice to tongue and ask person to
identify taste
Cranial Nerve VIII: Acoustic Nerve
(Vestibulocochlear) Sensory, Hearing
and Balance
Test hearing acuity by ability to
hear normal conversation and by
whispered voice test
Compare bone and air
conduction performing the Rinne
and Weber Test
13. Cranial Nerves IX and X
Cranial Nerves IX and X:
Glossopharyngeal and Vagus Nerves
Motor function
• Depress tongue with tongue blade, and
note pharyngeal movement as person
says “ahhh” or yawns; uvula and soft
palate should rise in midline, and
tonsillar pillars should move medially
• Touch posterior pharyngeal wall with
tongue blade, and note gag reflex;
voice should sound smooth, not
strained
Sensory function
• Cranial nerve IX does mediate taste on
posterior one third of tongue, but
technically too difficult to test
Cranial Nerve XI: Spinal
Accessory Nerve (motor and
muscles strength)
• Examine sternocleidomastoid and
trapezius muscles for equal size
• Check equal strength by asking
person to rotate head against
resistance applied to side of chin
• Ask person to shrug shoulders
against resistance
• These movements should feel
equally strong on both sides
14. Cranial Nerve XII
Cranial Nerve XII: Hypoglossal Nerve (Motor and Tongue Strength)
• Inspect tongue; no wasting or tremors should be present
• Note forward thrust in midline as person protrudes tongue
• Evaluate speech sounds by asking person to say “light, tight, dynamite,”
and note that lingual speech (sounds of letters l, t, d, n) is clear and
distinct
15. Inspect and Palpate Motor System
Size: Inspect all Muscle Groups
for Size
• Compare right side with left. If
muscles are asymmetric,
measure in centimeters and
record difference; difference of
1 cm or less is not significant
• Note that it is difficult to
assess muscle mass in very
obese people
Strength: Test Muscle Groups of
Extremities, Neck, and Trunk
Tone: normal tension in relaxed
muscles
• Persuade person to relax completely,
and move each extremity smoothly
through a full range of motion;
normally note mild, even resistance to
movement
Involuntary movements
• Normally none occur; if present, note
location, frequency, rate, and
amplitude; note if movements can be
controlled at will
16. Cerebellar Function Tests
Balance/Equilibrium Tests
Gait: Observe as person walks 10 to 20
feet, turns, and returns to starting
point; normally person moves with a
sense of freedom; gait is smooth,
rhythmic, and effortless; opposing arm
swing is coordinated
Heel Toe Walking: Ask person to walk
straight line in heel-to-toe fashion; this
decreases base of support and
accentuates any problem with
coordination; normally person can
walk straight and stay balanced
Romberg Test:
Ask person to stand up with feet together
and arms at sides; when in stable position,
ask person to close eyes and to hold
position for about 20 seconds
• Normally person can maintain posture
and balance even with visual orienting
information blocked
Ask person to perform shallow knee bend
or hop in place, first on one leg, then
other
• Demonstrates normal position sense,
muscle strength, and cerebellar function
• Some individuals cannot hop because of
aging or obesity
17. Coordination and Skilled Movements
Rapid Alternating Movements (RAM)
Ask person to pat knees with both hands, lift up, turn hands over, and pat knees with backs
of hands; then ask person to do this faster
• Normally done with equal turning and quick rhythmic pace
Alternatively, ask person to touch thumb to each finger on same hand, starting with the
index finger, then reverse direction
18. Assess Sensory System
Ask person to identify various sensory
stimuli in order to test intactness of
peripheral nerve fibers, sensory tracts,
and higher cortical discrimination
• Routine screening procedures include
testing superficial pain, light touch, and
vibration in few distal locations, and
testing stereognosis
• Complete testing of sensory system
warranted in those with neurologic
symptoms (e.g., localized pain,
numbness, and tingling) or if you
discover abnormalities
Compare sensations on symmetric parts
of body
• Person’s eyes should be closed during tests
• Explain what will be happening and exactly
how you expect person to respond
• Superficial touch – use cotton wisp/
fingertip and in a random order of sites
and at irregular intervals; include arms,
forearms, hands, chest, thighs, and legs;
ask person to say “yes” when touch is felt
• Superficial pain – broken tongue blade, dull
end of an object
• Deep pain – pinprick, test only if no
response to superficial pain
19. Sensory Function
Tactile discrimination
Stereognosis: test person’s ability to
recognize a familiar object (key, coin)
Graphesthesia: ability to “read” a number,
letter, shape by having it traced on skin
Two-point discrimination: test ability to
distinguish separation of two simultaneous
pin points on skin
Extinction: simultaneously touch both
sides of body at same point; normally both
sensations are felt
Point location: touch skin and withdraw
stimulus promptly; ask person to put finger
where you touched
Deep Tendon Reflexes (DTRs)
Measurement of stretch reflexes
reveals intactness of reflex arc at
specific spinal levels and normal
override on reflex of higher cortical
levels
Limb should be relaxed and muscle
partially stretched
Stimulate reflex by directing short,
snappy blow of reflex hammer onto
muscle’s insertion tendon
Compare right and left sides
responses should be equal
20. Deep Tendon Reflexes
Reflex Response Graded on 4-point
Scale
4 = very brisk, hyperactive with
clonus, indicative of disease
3 = brisker than average, may
indicate disease
2 = Average, normal, expected
response
1 = diminished, low normal, or
occurs with reinforcement
0 = no response
Testing Reflexes
Biceps Reflex, C5 to C6
Support the person’s forearm on yours;
place your thumb on biceps tendon and
strike a blow on your thumb
• Normal response is contraction of biceps
muscle and flexion of forearm
Triceps Reflex, C7 to C8
Tell person to let arm “just go dead” as
you strike triceps tendon directly just
above the elbow
• Normal response is extension of forearm
21. Deep Tendon Reflexes
Testing Reflexes
Brachioradialis Reflex, C5 to C6
Hold person’s thumbs to suspend forearms in
relaxation and strike forearm directly, about 2 to 3 cm
above radial styloid process
• Normal response is flexion and supination of forearm
Quadriceps Reflex, L2 to L4 (“knee jerk”)
Let lower legs dangle freely to flex knee and stretch
tendons; strike tendon directly just below patella
• Normal response is extension of lower leg
Achilles Reflex, L5 to S2 (“ankle jerk”)
Position person with knee flexed; hold foot in
dorsiflexion and strike Achilles tendon directly
• Normal response is foot plantar flexes against your
hand
Clonus: Test when Reflexes
Hyperactive
Support lower leg in one hand and
with other hand, move foot up and
down to relax muscle; then stretch
muscle by briskly dorsiflexing foot;
hold the stretch
• Normal response: you feel no
further movement
• When clonus present, you will note
rapid rhythmic contractions of calf
muscle and movement of foot
22. Superficial Reflexes
Superficial (Cutaneous) Reflexes
Sensory receptors in skin rather than in
muscles; motor response is localized
muscle contraction
Abdominal Reflexes: Upper: T8 to T10;
Lower: T10 to T12
• Person in supine position, knees slightly
bent; use handle end of reflex hammer to
stroke skin
• Move from each corner toward midline at
both upper and lower abdominal levels
• Normal response is ipsilateral contraction
of abdominal muscle with observed
deviation of umbilicus toward stroke
Plantar Reflex: L4 to S2
Position thigh with slight external
rotation
With reflex hammer, draw a light
stroke up lateral side of sole of foot
and inward across ball of foot, like an
upside-down “J”
• Normal response is plantar flexion
of toes and inversion and flexion of
forefoot
23. Additional Tests
Meningeal Signs:
• Brudzinski - The Brudzinski's sign is positive when passive forward
flexion of the neck causes the patient to involuntarily raise his knees
or hips in flexion.
• Kernig - One of the physically demonstrable symptoms of meningitis
is Kernig's sign. Severe stiffness of the hamstrings causes an inability
to straighten the leg when the hip is flexed to 90 degrees
24. Cranial Nerves: Infants
CN II,III, IV, and VI
• Optical blink reflex
• Gaze and tracking
• Doll’s eye
CN V
• Rooting
• Sucking
CN VII
• Facial expressions
• Forehead wrinkling
• Smile
CN VIII
• Acoustic blink reflex
• Doll’s eye maneuver
CN IX and X
• Swallow and gag reflex
CN XII
• Sucking and swallowing ability
• Tongue position with pinch test
25. Infants
Routinely Evaluate:
• Palmar grasp (birth)
• Plantar grasp (birth)
• Moro (birth)
• Placing (4 days of age)
• Stepping (between birth and 8
weeks)
• Asymmetric tonic neck (by 2 to 3
months)
• Inspect muscles for strength and
tone
• Observe the infants spontaneous
activity for symmetry and
smoothness of movement
• Coordinated sucking and
swallowing
26. Neuromuscular Development
Children
Observe neuromuscular
development progress and skills
during a physical exam or at play
• Gait and fine motor
• Heel to toe walking, hopping,
jumping
Older Adult
• Medications can impair CSN
• Test gait for decreases in speed,
balance and grace
• Check tactile and vibratory
senses for impairment
• Check deep tendon reflexes for
diminished response
27. Abnormalities in Cranial Nerves
CN I, olfactory nerve
Anosmia
CN II, optic nerve
Defect or absent central vision
Defect in peripheral vision,
hemianopsia
Absent light reflex
Papilledema
Optic atrophy
Retinal lesions
CN III, oculomotor nerve
Dilated pupil, ptosis, eye turns out
and slightly down
Failure to move eye up, in, down
Absent light reflex
CN IV, trochlear nerve
Failure to turn eye down or out
CN V, trigeminal nerve
Absent touch and pain, paresthesias
No blink
Weakness of masseter or temporalis
muscles
28. Abnormalities in Cranial Nerves
CN VI, Abducens Nerve
Failure to move laterally, diplopia on
lateral gaze
CN VII, Facial Nerve
Absent or asymmetric facial
movement
Loss of taste
CN VIII, Acoustic Nerve
Decrease or loss of hearing
CN IX, Glossopharyngeal Nerve
No Gag Reflex
CN X, Vagus Nerve
Uvula deviates to side
No gag reflex
Voice quality:
Hoarse or brassy, nasal twang or husky
Dysphagia, fluids regurgitate through
nose
CN XI, Spinal Accessory Nerve
Absent movement of sternomastoid or
trapezius muscles
CN XII, Hypoglossal Nerve
Tongue deviates to side
Slowed rate of tongue movement
29. Abnormalities in Muscle Tone and Movement
Abnormalities in Muscle Tone
• Flaccidity
• Spasticity
• Rigidity
• Cogwheel rigidity
Abnormalities in Muscle Movement
• Paralysis
• Fasciculation's
• Tic
• Myoclonus
• Seizure disorder
• Tremor
• Rest tremor
• Intention tremor
• Chorea
• Athetosis
30. Motor System Dysfunctions
Abnormal Gaits
Spastic hemiparesis
Cerebellar ataxia
Parkinsonian (festinating)
Scissors
Steppage or footdrop
Waddling
Short leg
Common Patterns of Motor
System Dysfunction
Cerebral palsy
Muscular dystrophy
Hemiplegia
Parkinsonism
Cerebellar
Paraplegia
Multiple sclerosis
32. Abnormal Postures
Decorticate Rigidity
Upper extremities
Flexion of arm, wrist, and fingers
Adduction of arm: tight against thorax
Lower extremities
Extension, internal rotation, plantar flexion;
indicates hemispheric lesion of cerebral
cortex
Decerebrate Rigidity
Upper extremities: stiffly extended,
adducted, internal rotation, palms pronated
Lower extremities: stiffly extended, plantar
flexion; teeth clenched; hyperextended back
More ominous than decorticate rigidity;
indicates lesion in brain stem at midbrain or
upper pons
Flaccid Quadriplegia
Complete loss of muscle tone
and paralysis of all four
extremities, indicating
nonfunctional brain stem
Opisthotonos
Prolonged arching of back,
with head and heels bent
backward; indicates
meningeal irritation
