Note for neurological ass

Neurological examination
Objectives
• Understand neurological examination
Perform a neurological examination
Mental status
Cranial nerves
Motor system
Sensory system
• Interpret neurological examinationGetenet D.(BscN,Msc fellow) 1

The Nervous System
Getenet D.(BscN,Msc fellow) 2

Central Nervous System
The Brain:
• The brain has four regions: the cerebrum, the
diencephalon, the brainstem & the cerebellum
• The cerebral hemispheres contain the greatest
mass of brain tissue.
• Each hemisphere is subdivided into frontal,
parietal, temporal, and occipital lobes

The Brain…
• The brain is a vast network of interconnecting
neurons (nerve cells).
• Brain tissue may be gray or white.
• Gray matter consists of aggregations of
neuronal cell bodies, forming the cerebral
cortex.

The Brain…
• White matter consists of neuronal axons that are
coated with myelin.
• The myelin sheaths, which create the white color,
allow nerve impulses to travel more rapidly.

The Brain…
• The thalamus processes sensory
impulses and relays them to the cerebral cortex.
• The hypothalamus maintains homeostasis and
regulates temperature, heart rate, and blood
pressure.
• The hypothalamus affects the endocrine system
and governs emotional behaviors such as anger
and sexual drive.

The Brain…
• Consciousness depends on the interaction between intact
cerebral hemispheres and an important structure in the
diencephalon and upper brainstem, the reticular activating
(arousal) system.
• The cerebellum, which lies at the base of the brain,
coordinates all movement and helps maintain the body
upright in space.

The Spinal Cord
• Below the medulla, the central nervous system extends itself
as the elongated spinal cord, encased within the bony
vertebral column and terminating at the first or second
lumbar vertebra.
• The cord provides a series of segmental relays with the
periphery, serving as a conduit for information
flow to and from the brain.
• The motor and sensory nerve pathways relay neural signals
that enter and exit the cord through posterior and anteriorGetenet D.(BscN,Msc fellow) 9

The spinal cord…
• The spinal cord is divided into five segments:
– Cervical; from C1 to C8
– Thoracic; from T1 to T12
– Lumbar; from L1 to L5
– Sacral; from S1 to S5
– And coccygeal

Peripheral Nervous System
The Cranial Nerves:
• Twelve pairs of special nerves called cranial nerves emerge
from within the skull or cranium.
• Cranial nerves III through XII arise from the diencephalon
and the brainstem.
• Cranial nerves I and II are actually fiber tracts emerging
from the brain.
• Some cranial nerves are limited to general motor or sensoryGetenet D.(BscN,Msc fellow) 12

Neurological Examination
• The neurologic examination is one of the most
unique exercises in all of clinical medicine.
• neurologic examination is performed to localize a
lesion in the central nervous system (CNS) or
peripheral nervous system (PNS).

Neurological Examination…
• The statement has been made, "History tells you
what it is, and the examination tells you where it
is.’’
• The history and examination allow the neurologist
to arrive at the etiology and pathology of the
condition, which are essential for treatment
planning.

Three important questions govern the neurologic
examination:
 Is the mental status intact?
 Are right-sided and left-sided findings symmetric?
 And, if the findings are asymmetric or otherwise
abnormal, does the causative lesion lie in the central
nervous system or the peripheral nervous system.

Tools required
 v/s equipment's
 Eye and ear examination tools
 Penlight or flashlight
 Tongue blade
 Cotton swab
 Hot and cold pack
 reflex hammer, supplies for cranial nerve testing

Common neurological symptoms and suspected causes
General weakness
• Common neurological causes include
demyelinating disorders, amyotrophic lateral
sclerosis, Guillain-Barre syndrome, multiple
sclerosis, myasthenia gravis, and degenerative
disc disease

impaired gait: common neurological causes
• Multiple sclerosis, Parkinson’s disease, stroke,
cerebral palsy

• Unilateral weakness, disturbed speech, and
symptoms longer than 10 minutes increase risk of
stroke
• Suspect head injury if there is a witnessed loss of
consciousness for more than 5 minutes, history of
amnesia of more than 5 minutes, abnormal
drowsiness, more than three vomiting episodes.

• Symptoms of meningitis include high fever, stiff
neck, drowsiness, and photosensitivity.
• Symptoms of degenerative disease include
weakness, tingling or numbness, difficulty seeing,
and elimination-control problems
• History of high blood pressure: Systolic blood
pressure above 140, diastolic blood pressure
above or equal to 90, or both are a risk factor for
stroke. Getenet D.(BscN,Msc fellow) 21

• Dizziness or Vertigo: Common causes include
• multiple sclerosis, Parkinson’s disease, cerebellar ischemia
or infarction, benign or malignant neoplasms, and arterial-
venous malformation of blood vessels in the brain
• Dysphagia: associated with cranial nerve dysfunction, is a
common symptom of stroke or neuromuscular disease
• Aphasia is a common symptom of stroke, especially when
it affects the speech centers in the left hemisphere

• Paresthesia (abnormal prickly or tingly sensations)
is most common in the hands, arms, legs, and feet.
Causes include neurological disease or traumatic
nerve damage.
• Diplopia Central causes include stroke, vascular
malformation, tumor, mass, trauma, meningitis,
hemorrhage, and muscular sclerosis
• Hearing Loss or Tinnitus: Common causes include
noise, autoimmune disorders, Meniere's disease,
ototoxic medications, and head trauma.

Steps in the neurological examination
1. Mental Status
2. Cranial nerves (CNs)
3. Sensory system
4. Motor system
5. Reflexes
6. Cerebellum Meninges and system survey

MENTAL STATUS
• Mental status: is person emotional and cognitive
functioning, mental status assessment include
– Appearance(A)
– Behavior(B)
– cognition and thought processes(C), or A , B, C,

MENTAL STATUS…
I. Appearance
• Posture is erect and position is relaxed, body
movements are voluntary, deliberate, Coordinated,
and smooth and even.
• Dress is appropriate for setting, season, age, gender,
and social group.
• Grooming and hygiene should be noted, clean and
well- groomed, hair neatGetenet D.(BscN,Msc fellow) 30

MENTAL STATUS…
II. Behavior
• Level of consciousness: the person is awake, alert,
and aware of stimuli from the environment and
responds appropriately to stimuli.
• If pt. consciousness alter - Glasgow coma scale

MENTAL STATUS…
• Facial Expression: look is appropriate to situation
and changes appropriately with the topic.
• Speech: pace of conversation is moderate, and
talking is fluent. Articulation is clear and
understandable.
• Mood and affect:- judge this by body language and
facial expression, and by asking directly, how do
you feel today, “ the mood should be appropriate.Getenet D.(BscN,Msc fellow) 33

MENTAL STATUS…
III. Cognitive function:
.orientation- assess orientation for :
• time: day of week, date, and year
• place: present location, name of city, zone
• person; own name, age, type of work

MENTAL STATUS…
Thought processes and perception:
• Thought processes:
– Ask yourself, does this person make sense? Can I follow
what the person is saying? “ the way a person thinks
should be logical, goal directed, coherent, and relevant.
– Abnormal; Illogical, unrealistic thought processes,
evidence of blocking and logical

• Calculation:substract 7 from 101 until 0
• Attention :give words and ask him to call
backward
• Judgment ;ask simple questions and see how he
tray to solve it
• Abstract :give simple proverb
• Memory :short term tested by asking for
immediate repetition of material name after u call
them for one second

• Language and speech If the patient’s speech lacks meaning
test aphaxia:
• Reception :Ask “take this paper with your right hand, fold
in half and place on the floor
• Repeat “No ifs, ands or buts” /Nonsense phrase to assess
repetition
• Repeat “British constitution,” “Baby
hippopotamus”…..Articulation
• Name the strap of a watch, or nib of a pen….to assess
Nominal dysphasia

2.EXAMINATION OF THE CRANIAL NERVES
I --------Smell
II --------Visual acuity, visual fields
II, III------ Pupillary reactions
III, IV, VI -----Extra ocular movements
V---- Corneal reflexes, facial sensation, and jaw mov’ts
VII -----Facial movements
VIII -----Hearing
IX, X -----Swallowing and rise of the palate, gag reflex
V, VII, X, XII ----Voice and speech
XI Shoulder and neck movements
XII Tongue symmetry and positionGetenet D.(BscN,Msc fellow) 38

EXAMINATION OF THE CRANIAL NERVES…….
 Olfactory nerve- CN I (smell)
Test the sense of smell (occlude one nostril at the
time) by presenting the patient with familiar and
nonirritating odors, and tell the patient to close his
or her eyes
• Note :Avoid those that stimulate trigeminal nerve
endings or taste buds (e.g., peppermint, menthol,
ammonia)
• Anosmia — Head injury, tumor, nasal congestion.Getenet D.(BscN,Msc fellow) 39

 Optic nerve- CN II (Visual acuity, visual fields and ocular
fundi)
• The following testing is appropriate:
– Acuity: by using the Snellen chart
– Visual fields: by means of confrontation
– Color: by using common objects, such as a multicolored
tie or color accent markers

CRANIAL NERVES…
Oculomotor nerve: CN III, Trochlear nerve (CN
IV), abducen (CN VI ) can be assess together
through :
Cardinal position test
Corneal light refelex
Cover uncover test

CRANIAL NERVES…
• Trigeminal nerve: CN V: Sensation to face(
Ophthalmic, Maxillary ,Mandibular
• Motor to muscles of mastication( master and
temporal )
• Corneal reflex (sensory)
• Jaw jerk (both components)

Compare the symmetry if there is Unilateral decrease in
or loss of facial sensation suggests a lesion of CN V

Cranial nerve seven (VII)
1.Motor
• to muscles of facial expression
Tested by:
Inspect face at rest, Corneal reflex (motor),Wrinkle
forehead, Close eyes, Blow out cheeks, Show teeth
2.sensation to ear canal and palate
3.Taste (tongue anterior 2/3: sweet, sour, salt

Abnormal finding
• UMN lesion:
• Injury from the primary motor cortex to the facial
nucleus within the pons (i.e., upper motor neuron to
the facial nerve nucleus)affect contralateral face.
• flattened left nasolabial fold
• decreased up turning of the left corner of the mouth
on smiling, and symmetric wrinkling of forehead
bilaterally, in addition to a left hemiparesis.Getenet D.(BscN,Msc fellow) 45

• LMN lesion :Lower motor neuron palsy implies a
lesion involving the facial nerve at the nucleus in the
pons or along the course of the facial nerve ipsilateral
to the side of facial weakness
• Can involve forehead as:
• LMN only innervates one side

Lower motor lesion
Bell’s palsy
• unilateral flattening of the nasolabial
• inability to upturn the corner of the mouth upon smiling,
• inability to wrinkle his forehead,
• delayed or absent blinking due to weakness of the
eyelid, and inability to hold air in the cheeks due to
escape of air through the corner of the mouth which is
weak.

LMN

• Acoustic
(vestibulocochlear) nerve:
CN VIII (Hearing): Hallpike
maneuver if the patient has
vertigo : The head is tilted
backward below the plane of
his body and turned to one
side 45 degree. The patient is
asked to look in the direction
that his head is turned

• Watch for nystagmus in the direction his head
turn and ask the patient if he feels vertigo.
• If no nystagmus in 15 seconds, have the patient
sit up and repeat the maneuver in the contralateral
direction.
• The absence of nystagmus suggests normal
vestibular nerve function.

Cont.……d
• peripheral vestibular nerve dysfunction patient will
complain of vertigo, and rotary nystagmus will appear after
a 1- to 5-second latency toward the direction in which the
eyes are deviated

•If rotational nystagmus occurs then the test is considered
positive for benign positional vertigo
•Upbeating or downbeating nystagmus, a central nervous
system (CNS) dysfunction is indicated.
•Up beating nystagmus indicates that the vertigo is present in
the posterior semicircular canal of the tested (lower ear) side.
•Down beating nystagmus indicates that the vertigo is in the
anterior semicircular canal of the contralateral (upper ear)
side.

EXAMINATION OF THE…
• Glossopharyngeal CN IX
• Examination
• Checking for taste over the posterior third of the
tongue (bitter test).
• A portion of the ninth nerve and a portion of the
tenth nerve are tested by the gag reflex, elicited by
stimulating the posterior tongue with a tongue
depressor. Getenet D.(BscN,Msc fellow) 53

• VAGUS CN X:Sensory and motor supply to the
pharynx, larynx together with the ninth
• watching movement of the uvula, which normally
rises to the midline during phonation (“ah” reflex).
• If a unilateral lesion is present, the uvula will deviate
from the lesion to the side opposite.
• Hoarseness of the voice and difficulty in swallowing

• Spinal accessory nerve- CN XI (Innervate the
sternomastoid and upper portion of the trapezius)
• The patient is asked to keep his shoulders shrugged while
the examiner attempts to push them down.
• The patient is then asked to turn his chin against the
examiner’s resisting hand, first to one side and then to the
other.
• Functional impairment of the nerve is manifested by
weakness in these maneuvers.Getenet D.(BscN,Msc fellow) 55

• Hypoglossal nerve: CN- XII (tongue):
• Innervates muscles of the tongue.
• Listen to patient articulation
• Inspect the resting tongue for atrophy
• observing the movements of protrude tongue.
• Weakness that is secondary to hypoglossal nerve
involvement on one side is manifested by deviation of the
tongue toward the side of the lesion.

3.EXAMINATION OF THE SENSORY SYSTEM
 Points remembered during sensory assessment:
• It is important for the patient’s eyes to be closed to prevent
visual cues from influencing responses
• Avoid asking “Do you feel this?” which cues the patient to
respond.
• Begin with light stimulation; increase pressure until the
patient reports a sensation.
• Dispose sharp materials after pain testing; avoid using them
on another patient.
• Explain each test very well before you do it.
• Compare symmetrical areas and also compare distal from
proximal ones. Getenet D.(BscN,Msc fellow) 57

• PERIPHERAL SENSATION
• Peripheral sensations like pain, temperature,
pressure touch, and vibration are affected in all
lesions below the cortex including the thalamus.

EXAMINATION OF THE SENSORY SYSTEM
Pain:
 use safety pin and ask the patient "is this sharp or dull"
Example:
• Analgesia refers to absence of pain sensation
• Hypoalgesia refers to decreased sensitivity to pain
• Hypralgesia to increased
sensitivity(neuritis,iritiatin)…prolonged use of opoids.

EXAMINATION OF THE SENSORY….
 Temperature: include it if there is any abnormality, and ask
the patient to identify hot or cold substances (water)
• Abnormal temperature sensation is common in neuropathies
 Light touch; Touch the patient's skin with a fine wisp of
cotton, and ask the patient to respond whenever a touch is
felt, and compare one side to the other side
Example; Anesthesia is absence of touch sensation,
hypoesthesia is decreased sensitivity, and
hyperesthesia is increased sensitivity.Getenet D.(BscN,Msc fellow) 60

• Vibration Sensation.
• Strike a low pitched tuning fork on the side or heel of the
hand. Ask the patient to close the eyes.
• Hold the fork at the base; place it over body prominences,
beginning at the most distal location
• If the sensation is felt at the most distal point, no further
testing is necessary.
• Ask the patient to state where the sensation is felt and when
it disappears. To stop, dampen the tuning fork by pressing on
the tongs. Getenet D.(BscN,Msc fellow) 61

• Peripheral neuropathy is a consequence of
peripheral vascular disease and diabetic
• more severe distally and improves centrally
• Often, vibration sense is the first lost.
• With damage to a specific dermatome, the line of
sensory loss is usually marked and specific

• CENTRAL (CORTCAL) SENSATION
• The cortical sensation is also referred to as central
or discriminative sensation. In lesions of the cortex
not affect pain, temperature, pressure, touch, and
vibration are not affected.
1- Sterognosis-identify objects by touching while the
eyes are closed
• Inability to identify objects correctly (astereognosis)
may result from damage to the sensory cortex
caused by stroke

• CENTRAL (CORTCAL) SENSATION cont…….
2- Graphstesia-identify numbers or letters written on
the skin surface with eyes closed
• Cortical sensory function may be compromised
following a stroke

3.Point Localization.
• Ask the patient to close the eyes. Using finger,
gently touch the patient’s hands, lower arms,
abdomen, lower legs, and feet. Have the patient
identify where he or she feels the sensation.
• Don’t cue the patient by asking, “Do you feel this?”
Observe areas of sensory loss.
• Compare side to side.

Two-point Discrimination.
• Ask the patient to close the eyes.
• Hold the blunt end of two cot-ton swabs 2 inches
apart and move them together until the patient feels
them as one point. The fingertips are most sensitive,
with a minimal distance of 3 to 8 mm, while the
upper arms and thighs are least sensitive, with a
minimal distance of 75 mm.
• There is more discrimi-nation distally than centrallyGetenet D.(BscN,Msc fellow) 67

Two-point Discrimination…….
• Lesions of the sensory cortex increase the distance
between two recognizable points.

• Extinction: Simultaneously stimulate corresponding
areas on both sides of the body. Ask where the
patient feels your touch.
• Normally both stimuli are fel
• With lesions of the sensory cortex, only one stimulus
may be recognized.
• The stimulus on the side opposite the damaged
cortex is extinguished.

Cont…..d
• Motion and Position Sense(Sensory proprioception).
Ask the patient to close the eyes. Move the distal
joints of the patient’s fingers and then the toes up or
down.
• If the patient cannot identify these movements, test
the next most proximal joints.
• if he know the position Motion and position sense
are intact Getenet D.(BscN,Msc fellow) 70

general pattern of sensory loss.
 “Stocking-glove distribution: no sensation for pain
to light touch ,vibration) e.g. DM neuropathy…
 Dermatomal distribution suggests isolated nerves or
nerve roots;
 reduced sensation below a certain level is
associated with the spinal cord.
 A crossed face-body pattern suggests the brainstem,

Thalamic :contralateral loss of all sensory modalities in the
face, extremities and trunk. In addition, stimulation may be
perceived as uncomfortable and painful.
• Cerebral cortex all in contralateral
• Medulla : Pain and temperature are lost on the ipsilateral
side of the face and contralateral side of the body. Light
touch and proprioception are lost on the contralateral side
of the body.

4.EXAMINATION OF THE MOTOR
FUNCTION
• The examination of motor function includes
evaluation of muscle bulk, strength, tone,
coordination’ and reflexes.
• Inspection
• The muscles of the limbs are specifically observed
for
• Resting position of the limbs
• Size, Symmetry, Presence of atrophy
• Fasciculation's (fine twitching movements) and
Involuntary movements such as a tremor.

MOTOR FUNCTION…
Testing for muscle tone: This can be accomplished
by movement of the limbs passively at every joint
while the patient is completely relaxed.
Muscle tone may be
• Normotonic: - found in normal individuals
• Hypotonic: - found in patents with lower motor
lesion, spinal shock etc.
• Hypertonic (spasticity / rigidity):-this may be of
different type

• Tone - abnormalities
• Normal----------resistance to movement
• Reduced resistance to movement---LMN or cerebellar
lesion
• “Lead pipe” (Increased resistance throughout movement )---
-UMN lesion
• “Clasp knife” (High resistance that suddenly releases)----
Extrapyramidal lesion
• “Cogwheel rigidity”(Jerky resistance) ----Extrapyramidal
lesion.

• Muscle strength: Test muscle strength by asking
the patient to move actively against your resistance
or to resist your movement
• Example: Impaired strength is called weakness
(paresis).
– Absence of strength is called paralysis (plegia)

Muscle strength is graded on a 0 to 5 scale:
0—No muscular contraction detected
1—A barely detectable flicker or trace of contraction
2—Active movement of the body part with gravity
eliminated
3—Active movement against gravity
4—Active movement against gravity and some
resistance
5—Active movement against full resistance without
evident fatigue. This is normal muscle strength.
• Thus 4+ indicates good but not full strength, while 5
means a trace of weakness.Getenet D.(BscN,Msc fellow) 77

MOTOR FUNCTION…
– Hemiparesis :is weakness of the entire left or right side
of the body.
– Hemiplegia refers to paralysis of one half of the body .it
is most severe form, complete paralysis of half of the
body
– Paraplegia means paralysis of the legs,
– Quadriplegia refers to paralysis of all four limbs

• To localize lesions in the spinal cord or the peripheral
nervous system more precisely, additional testing
may be necessary
• Methods for testing the major muscle groups are
described below

Muscle strength …..
• Test flexion (C5, C6—biceps) and extension (C6, C7,
C8—triceps) at the
• elbow by having the patient pull and push against
your hand.

• Test extension at the wrist (C6, C7,C8, radial
nerve) by asking the patient to make a fist and
resist your pulling it down.

• Cause of Weakness of extension
• peripheral nerve disease (e.g., radial nerve damage)
• and in central nervous system disease producing
hemiplegia (e.g., stroke or multiple sclerosis).

• Hand Grip ((C7, C8, T1)):
- is assessed by testing and
comparing bilateral hand
grips. The patient is asked
to grip objects or while the
examiner tries remove
object from his hand.

• A weak grip may be due to either central or
peripheral nervous system disease.
• It may also result from painful disorders of the
hands.

• Test finger abduction (C8,
T1, ulnar nerve).
• Position the patient’s hand
with palm down and
fingers spread. Instructing
the patient not to let you
move the fingers, try to
force them together.
• Weak finger abduction in
ulnar nerve disorders Getenet D.(BscN,Msc fellow) 85

• Test opposition of the
thumb (C8, T1, median
nerve).
• The patient should try to
touch the tip of the little
finger with the thumb,
against your resistance.
• Weak opposition of the
thumb in median nerve
disorders such as carpal
tunnel syndrome

Muscle strength
• Assessment of muscle strength of the trunk
may includes:
• Flexion, extension, and lateral bending of the
spine, and
• Thoracic expansion and diaphragmatic
excursion during respiration

Muscle strength
• Test flexion at the hip (L2,
L3, L4—iliopsoas) by
placing your hand on the
patient’s thigh and asking
the patient to raise the leg
against your hand.

Muscle strength
• Test extension at the knee
(L2, L3, L4—quadriceps).
Support the knee in
• flexion and ask the patient
to straighten the leg against
your hand.
• The quadriceps is the
strongest muscle in the
body, so expect a forceful
response.

Muscle strength
• Test flexion at the knee
(L4, L5, S1, S2—
hamstrings) Place the
patient’s leg so that the
knee is flexed with the
foot resting on the bed.
• Tell the patient to keep
the foot down as you try
to straighten the leg.Getenet D.(BscN,Msc fellow) 90

Muscle strength
• Test dorsiflexion (mainly
L4, L5) and plantar flexion
(mainly S1) at the ankle
• by asking the patient to pull
up and push down against
your hand.

Muscle strength

MOTOR FUNCTION…
• Coordination:
• Coordination of muscle movement requires that
four areas of the nervous system function in an
integrated way:
• The motor system, for muscle strength
• The cerebellar system
• The vestibular system, for balance and for
coordinating eye, head, and body movements
• The sensory system, for position sense.Getenet D.(BscN,Msc fellow) 93

1. Cerebellar Function
– Rapid alternating
movements: Ask the patient to
strike one hand on the thigh,
raise the hand, turn it over, and
then strike the back of the hand
down on the same place: - urge
the patient to repeat these
alternating movements as
rapidly as possible – Observe
the speed, rhythm, and
smoothness of the movements.

Cerebellar Function
• In cerebellar disease, one movement cannot be
followed quickly by its opposite and movements are
slow, irregular, and clumsy.
• This abnormality is called dysdiadochokinesis.
• Upper motor neuron weakness and basal ganglia
disease may also impair rapid alternating movements,
but not in the same manner.

Cerebellar Function ……
• Pont-to-point movements:Ask the patient to touch
your index finger and then his or her nose alternately
several times- Observe the accuracy and smoothness
of movements and watch for any tremor.
• Normally the patient's movements are smooth and
accurate.
• In cerebellar disease, movements are clumsy,
unsteady, and inappropriately varying in their speed,
force, and direction.

Cerebellar Function ………..

MOTOR FUNCTION…
• Gait: ask the patient to walk across the room, then
turn, and come back- observe posture, balance,
swinging of the arms, and movements of the legs
– Example; A gait that lacks coordination, with reeling and
instability, is called ataxic, this may be due to cerebral
disease, or intoxication

MOTOR FUNCTION……
• Walk heel-to-toe in a
straight line—a pattern
called tandem walking.
• Tandem walking may
reveal an ataxia not
previously obvious.

MOTOR FUNCTION
• Walk on the toes, then on the heels—sensitive tests
respectively for plantar flexion and dorsiflexion of
the ankles, as well as for balance.
• Walking on toes and heels may reveal distal
muscular weakness in the legs.
• Inability to heel-walk is a sensitive test for
corticospinal tract weakness.

MOTOR FUNCTION
• THE ROMBERG TEST.
• he patient should first stand
with feet together and eyes
open and then close both
eyes for 20 to 30 seconds
without support.
• Note the patient’s ability to
maintain an upright
posture. Normally only
minimal swaying occurs.Getenet D.(BscN,Msc fellow) 101

• Moderate swaying with eyes open and closed
indicates vestibule-cerebellar dysfunction
• Pronounced increase in swaying (sometimes with
falling) with the eyes closed usually indicates a
lesion in the posterior columns of the spinal cord.

Motor function
• pronator drift: Ask the patient to
close the eyes and outstretch the
arms straight ahead with palms
• upward for 10 seconds
• The patient extends the hands for
10 seconds without drifting.
• If possible, ask the patient to
walk down :Points to
observe include smoothness of
gait, position of feet, height and
• length of step, and symmetry of
arm and leg movement.

Motor function
• Now, instructing the patient to keep the arms up and
eyes shut, as shown above, tap the arms briskly
downward.
• The arms normally return smoothly to the horizontal
position.
• This response requires muscular strength,
coordination, and a good sense of position.

Motor function
• The pronation of one forearm suggests a
contralateral lesion in the corticospinal tract;
downward drift of the arm with flexion of fingers
and elbow may also occur.
• These movements are called a pronator drift.

Motor function……
• A sideward or upward drift,
sometimes with searching,
writhing movements of the
hands, suggests loss of position
sense.

Motor function
• A weak arm is easily displaced and often remains so.
A patient lacking position sense may not recognize
the displacement and, if told to correct it, does so
poorly.
• In cerebellar incoordination, the arm returns to its
original position but overshoots and bounces

EXAMINATION OF REFLEXES, CEREBELLUM,
AND MENINGES
1. SUPERFICIAL REFLEXES
• In the presence of upper motor neuron lesions, the
superficial reflexes are attenuated.it includes :
 The superficial abdominal reflex:
 The cremasteric reflex:
 Plantar reflex

EXAMINATION OF REFLEXES, CEREBELLUM, AND
MENINGES cont……d
• The superficial abdominal reflex (T8-12): - is
tested by lightly stroking the skin of the abdomen
• from above downward and laterally to medially.
Generally reflex is more easily elicited in the upper
abdomen.
• The umbilicus moves toward each area of
stimulation symmetrically.

Superficial reflex ……
• Depression or absence of this reflex may result
from upper or lower motor lesion, central lesion,
obesity, lax skeletal muscles, or spinal cord injury

SUPERFICIAL REFLEXES……
• The cremasteric reflex:To identify the integrity of
L1 to L2
- is tested by pinching or stocking the skin of the
medical aspect of the thigh.
• Contraction of the cremasteric muscle occurs,
resulting in elevation of the testis on the same side.
• Response is diminished or absent indicates
abnormality Getenet D.(BscN,Msc fellow) 112

SUPERFICIAL REFLEXES…………
• Plantar reflex: - is tetrad by scratching the sole of the
patient's foot from the heel toward the toes and observes
the moment of the toes. The response could be
• Normal :- downward ( plantar ) flexion of all toes
• Up going plantar (Babinisky’s Sign):-. An upward
movement of the great toe with fanning or spreading of
the other toes. This is a pathological reflex which is often
found in Upper motor neuron lesions.

Superficial reflex…..

2.EXAMINATION DEEP TENDON REFLEXES
• DTRs tested include biceps, triceps, brachioradialis,
patellar, and Achilles.it should be graded.
DTRs are graded as follows:
4+ Very brisk, hyperactive with clonus
3+ Brisker than average
2+ Average, normal
1+ Diminished, low normalGetenet D.(BscN,Msc fellow) 116

EXAMINATION OF REFLEXES….
Biceps reflex(C5, C6)
Place your thumb on the
patient's biceps tendon (in
the antecubital fossa) and
strike your thumb with the
reflex hammer.
The forearm may move and
you should feel the tendon
jerk

Biceps reflex(C5, C6)
• Observe for flexion at the elbow and contraction of
the biceps muscle. If the patient’s reflexes are
symmetrically diminished or absent, ask the patient
to clench the teeth for reinforcement.

Triceps reflex(C6, C7):
Hold the patient's arm abducted
and bent at the elbow
prosperously, about 2.5 cm
above the olecranon process
strike the tendon directly.
The forearm should extend and
we see triceps muscle
contraction. Getenet D.(BscN,Msc fellow) 119

Brachioradiallis /supinator
reflex (C5, C6) :
• strike the forearm about 2.5
cm above the wrist over
radius.
• Observe for pronation of the
forearm, flexion of the
elbow, and contraction of the
muscle.

Achilles reflex:
• support the foot in your
hand and strike the Achilles
tendon. The foot should
move in to your hand
• Observe for plantar flexion
of the foot and contraction
of the gastrocnemius muscle

The Knee reflex (L2, L3, and
L4)
• Briskly tap the patellar
tendon just below the
patella.
• Note contraction of the
quadriceps with extension at
the knee

• Special Techniques
• Asterixis. Asterixis helps
identify a metabolic
encephalopathy in patients
whose mental functions are
impaired. Ask the patient to
“stop traffic” by extending
• both arms, with hands
cocked up and fingers
spread.
• Sudden,brief,nonrhythmic
flexion of the hands and
fingers indicates asterixis.
• Liver diseases,
uremia,hypercapnia

• Winging of the Scapula. When the shoulder
muscles seem weak or atrophic, look for winging.
Ask the patient to extend both arms and push
against your hand or against a wall. Observe the
scapulae. Normally they lie close to the thorax.
• In winging, shown below, the medial border of the
scapula juts backward. It suggests weakness of the
serratus anterior muscle, as in muscular dystrophy
or injury to the long thoracic nerve. 124

In very thin but normal people, the scapulae may appear
“winged” even when the musculature is intact.

Meningeal signs
Neck mobility
• Assess the patient's neck mobility by placing your
hand behind the patients head and flex the neck
forward until the chin touches the chest if possible.
• Example: pain in the neck and resistance to
flexion can arise from meningeal inflammation,
arthritis, or neck injury

Meningeal signs …
Brudzinski's sign
• As you flex the neck, watch the hips and knees in
reaction to your maneuver.
• Normally, they should remain relaxed and
motionless
• Example: Flexion of the hips and knees is a
positive Brudzinski's and suggests meningeal
inflammation Getenet D.(BscN,Msc fellow) 127

Meningeal signs …Kernig's sign
• Flex the patient's leg at both the hip and the knee,
and then straighten the knee.
• Discomfort behind the knee during full extension
occurs in many normal people, but this maneuver
should not produce pain.Example; Pain and
increased resistance to extending the knee are a
positive Kernig's sign. When bilateral, it suggests
meningeal irritationGetenet D.(BscN,Msc fellow) 128

findings
• The patient is with headache, one side of weakness,
and tremors; confusion ,difficulty with balance,
coordination, or gait. Denies dizziness, vertigo,
dysphagia, and intellectual changes; complains
difficulty with concentration, memory, attention
span, and expression or comprehension of
speech/language; no alteration in sense of touch,
taste, or smell. Getenet D.(BscN,Msc fellow) 129

findings
• No loss, blurred vision, or diplopia; no hearing loss,
tinnitus, altered sensation, numbness, or paresthesia.
Not Well-groomed and poor eye contact. Poor
attention span and judgment. Speech unclear and
inappropriate. Immediate and recent memory lose.
Paralysis of half of the face.Can correctly identify
light touch on face, arms, and legs in one side only;
strength 5+ unilaterally: no tremors.

Nursing diagnosis
• Impaired verbal communication related head
trauma AEB disarticulation words during
speaking.
Intervention:
• Maintain eye contact.
• Ask yes and no questions.
• Anticipate patient’s needs.
• Use touch as appropriateGetenet D.(BscN,Msc fellow) 131

Dx:Acute confusion related to stroke AEB patient
not know where he is.
• Intervention
• Perform mental status examination.
• Provide environmental cues (eg, large clock and
calendar).
• Orient to time, place, and person frequently

• Dx:Unilateral neglect related to left-sided muscle
weakness AEB patient can not move away from
painful stimuli.
• Intervention
• Provide safe, well-lit, and clutter-free environment.
• Set up environment so that most activity is on
unaffected side.
• Encourage patient to compensate for neglect.

• Dx:Risk for aspiration related to muscle
weakness and impaired swallowing.
Intervention
• Auscultate lungs before and after feeding.
• Elevate head of bed when eating

Reference…
• Beth Hogan-Quigley, Mary Louise Palm, Lynn S. Bickley. BATES
'NURSING GUIDE to Physical Examination and History Taking
• Janet R. Weber, Jane H. Kelley. Health Assessment in
Nursing. 5th edition. 2014.
• Bickley, L.S. (2008). Bates' pocket guide to physical examination
and history taking. 5th Ed. Lippincott, Williams & Wilkins
• Jensen, Sharon, Pocket guide for nursing health assessment : a
best practice approach / Sharon Jensen Tokyo 2011.

Acknowledgment
I THANKS!!!

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