Neurological Examination Guide

Download Neurology station Overview PDF Download Lower Limbs Examination PDF Download Cerebellar Examination PDF Download Cranial Nerves PDF Download Neuro Developmental Assessment PDF

 

General

Around the room:

Mobility aids

Splints

Oxygen

Suction

Feed pump

Medication or drips

Shoes Orthotic boots

View from a distance

Wheelchair bound child (top to bottom)

  • Posture- Flexed, extended. What does their central tone look like ie do they have poor truncal tone with a brace? What is their head position, and do they have head support?.
  • Type of wheelchair- electric? What additional support does it provide? Any attachments?
  • Communication aids

Non wheelchair bound.

  • Presence of mobility aids such as walking frame.
  • Additional supports such as ankle-foot orthosis

Child from a distance

  • Dysmorphism
  • Top to toe: -

1. Head and face and neck: Size of head and shape

o   Macrocephaly (Sotos, Zellweger, NF 1, Hydrocephalus)

o   Microcephaly ( Anything impairing brain development)

o   Brachycephaly (down’s syndrome) and cranial synostosis (Cruzons)

o   Plagiocephaly (Normal variant, ex prem)

o   Scaphocephaly (like a boat) (Ex prem, craniosynostosis)

o   Turricephaly (like a tower) (Aperts)

2. Neck

o   Tracheostomy

o   Shunt

o   Webbing

o   Torticolis

o   Old central access scar

3.  Eye

o   Hyper or hypotelorism

o   Squint

o   Palpabral fissures

o   Glasses

o   Cateracts

o   Fixing and following

3. Ears

o   Hearing aids

o   Position ie low set

o   Ear tags

4. Mouth and nose

o   NG tube

o   Gum hypertrophy

o   Dentition

o   Bulbar function- tongue, drooling, speech

You will then be asked to focus on one area of examination. It is unlikely that you will be asked to complete a full neurological examination, unless on a non mobile child.

 

A)   Lower limbs

Observe and expose:

 Posture

  • Adducted and extended
  • Frog leg
  • CDH, short leg adducted

Scars- tendon releases

Muscle bulk- ie wasting

Champagne bottle leg and high foot arch (HSMN type 1)

Skin Neuro-cutaneous stigmata

Symmetry- Limb hypertrophy,

Fatty change (SMA)

 

Approach child:

Expose and examine back.

Gait

Tone

Increased, normal or decreased

Test for clonus (Up to 2 beats normal), and is it sustained?

Power

All joints

Grade 1-5

Reflexes

Absent, reduced, normal and increased. If unable to elicit should try reinforcement.

Knee L2-L4

Ankle S1

Plantars can be up-going till 1 year age

Sensation

Test following dermatomal distribution (see figure) Start peripherally and work up, demarcating the level of change in sensation.

Pain and temperature- spinothalamic tracts

Light touch and proprioception- posterior column

Other notes:

Reflexes:

- Corneal reflex- Afferent CN V, efferent CN VII

-Abdominal reflex-Contraction of superficial abdominal muscles when stroking abdomen lightly. Significant if asymmetric- usually signifies UMN on absent side.

-Cremesteric reflex- Gain consent first.

Author: Dr. Jonathan Round and Dr. Claire Head, 2014

________________________________________________________________________________________

 

B)    Cerebellar Examination

  1. General Inspection as above
  2. Posture:

- Whilst the child is sitting, get him/her to lift his feet from the ground with arms crossed (Truncal ataxia)

-  Get the child to stand up and maintain position with feet together and eyes opened. And then with eyes closed (Rhomberg ’s test). If the child is ataxic and unsteady with eyes closed (Rhomberg ’s test positive), then there is sensory ataxia.

  1. Gait

-       Get patient to walk (broad-based ataxic gait, falls towards the side of the  lesion) , then ask him to STOP, turn back and do :

-       Heel-to-toe walk

  1. Face

-   Eyes : H test for extraocular muscles and pause at lateral gaze – horizontal nystagmus, towards the side of the lesion (lateral cerebellar lesion)

-   Speech: Ask the child question / ask him to read/ for older child, ask him to say baby hippotamus, West register street/ british constitution (staccato speech/ scanning  dysarthria)

  1. Upper limbs

-Pronator drift – ask patient to hold his arms out with his palm facing upwards and his eyes closed : Pronator drift – weakness ; Upward drift – cerebellar lesion

-Rebound test- whilst patients arms are held out, push his wrist down quickly (Holmes’ rebound phenomenon – over correction of passive displacement of limb)

-Hypotonia

- Rapid palm test (Dysdiadoschokinesia)

-Finger-nose test (Dysmetria)

  1. Lower limbs

-   Hypotonia

-    Reflex: pendular reflex, best seen when patients limb left hanging in the air

-    Heel-shin test

 

I would like to complete the examination by:

-checking the fundi for papilloedema (space occupying lesion)

- performing a full neurological examination

 

Causes of cerebellar lesions:

  1. Stroke
  2. Trauma
  3. Alcohol
  4. Drugs- phenytoin / lead poisoning
  5. Multiple sclerosis
  6. Tumour (carebellopontine angle tumour)
  7. Friedreich’s ataxia
  8. Arnold-Chiari malformation

 

Author: Dr. Huey Miin Lee,  September 2014

___________________________________________________________________________________________

C)    Cranial Nerve Examination

II Optic Nerve

  1. Visual acuity – Establish whether patient wears glasses. Get patient to see read covering right and left eye. If this is not possible, ask patient how many fingers you are showing him/ detect hand movements/distinguish light from dark
  2. Visual field

a) Ask patient to cover one of his right eye with his right hand and focus on doctor’ s nose. Doctor then wriggles his own fingers from the corner slowly to the centre and tells patient :  ‘Say YES when you see my fingers wriggling from the corner of your eyes’

b)Repeat the step a) for all four corners.

c) Repeat Steps a) and b) for patient’s left eye

  1. Accommodation – ask patient to look at your finger which is moving towards his nose . This will cause the patient to look cross-eyed and the pupils should constrict.
  2. Direct and consensual light reflex

 

III Oculomotor , IV Trochelar, VI Abducens Nerves

- H test for extraocular muscles . Doctor says ‘Tell me if you see double vision’ .

 V Trigeminal Nerve

  1. Sensation at ophthalmic, maxillary and mandibular region – say yes when you feel me touching you. Is it the same on both side?
  2. Motor – Doctor says ‘Clench your teeth’ – Doctor palpates masseter muscles
  3. ‘Open you jaw against my hands’

VIII Vestibulocochlear Nerve

-        Test hearing by whispering into patient’s ear and ask him to repeat after you.

-        Weber and Rinne test (Mention at the end of the examination)

IX Glossopharyngeal Nerve

-   Ask patient to say ‘aah’ – uvula deviates away from the site of the lesion

-   Ask patient to cough

X Vagus Nerve

-       Hoarse voice

 XI Accessory Nerve

-   ‘Shrug your shoulder’

-  ‘Push your jaw against my hand’

XII Hypoglossal Nerve

-        ‘Stick your tongue out’: Deviates towards the site of the lesion

-        ‘Move your tongue from side to side’

 

I would like to complete my cranial nerve examination by

  1. Performing a fundoscopic examination to check for papilloedema
  2. Performing a Weber and Rinne test

Author: Dr. Huey Miin Lee, 2014

____________________________________________________________________________________

D)Neurodevelopmental Assessment of a Baby/ Infant

-     For neurodevelopmental assessment of a baby, describe the examination as you go as there are many things to assess. The sentences in Italic are examples of what you should be observing and describing. For the purpose of learning, the patient’s name is David

  1. General observation Observe as notes above. (I note that there is a Tumble Form chair next to the bed)
  2. Lie the baby supine ( David is moving all 4 limbs. There is antigravity movement of all 4 limbs. He has hand regard, and he is playing with his foot. He is visually active. He attempts to roll. He has abnormal movement / muscle wasting etc)

- Test for Moro reflex as appropriate for age

-Asymmetric tonic neck reflex

  1. Top to toe examination:

-Head: Palpate the patient’s head. Comment on head shape. Check rooting reflex if young enough (I would like to measure the head circumference at the end of my examination)

-Eyes: (He is visually alert, he fixes and follows 180 degrees, and there is no nystagmus/strabismus)

-Face: (There is no obsvious dysmorphism. There is no facial asymmetry. He is smiling at me. He has just opened his mouth and there is no visible cleft palate. He is vocalising and cooing. He is turning towards noise)

  1. Exposure: Examine skin (He has no neurocutaneous stigmata)
  2. Upper Limb:

-Tone

-Power as mentioned

-Offer something for patient to hold. If patient does not transfer à get permission from examiner whether it is ok to ask mother question à ask mother whether patient transfer

- Reflexes – biceps, triceps and supinator reflexes

- Primitive reflex: Grasping reflex

  1. Lower Limb:

-Tone

-Power as mentioned

-Reflexes – Knee reflex, ankle reflex

-Clonus

-To test if reflex is brisk :

Crossed Adductor Reflex – Tap left thigh and there is response on right leg

Tap lower leg – get reflex

  1. Sit patient up by pulling the hands and watch for head lag

-       Sit by support?

-       Whether there is any attempt of the child to hold his trunk back to position

-       Sideward parachute (push patient laterally and observe whether he repositions himself)

  1. Stand patient up by getting parents to hold him up

– If young enough- test for stepping reflex

-Downward parachute reflex (6 months old)

  1. Lie patient prone:

-Head above midline?

-Support himself on forarm/ armstraight?

-Check spine for kyphoscoliosis, meningomyelocoele, sacral pit

-Watch movement of legs

 

I would like to complete the examination by:

-Performing a fundoscopic examination

-Measuring head circumference and plot it on a centile chart

-Measuring blood pressure

After examination, you can give a short summary of your positive findings.

After presenting and if there is abnormality and depending on what the abnormality is, you can say:

The cause of this could be congenital or acquired which could be due to trauma, infection meningitis/ encephalitis), endocrine (hypothyroidism), nutritional (Vitamin B12 deficiency), tumour, neurometabolic (mucopolysaccharidosis, glycogen storage disorder), epilepsy, Rett syndrome.

 

Notes: If examination is abnormal, 2 questions to ask mother:

-Was he born premature?

-Did he regress?

Author: Dr. Huey Miin Lee, 2014

4 comments on “Neurological Examination Guide
  1. hasanul says:

    excellent work.it will help us

  2. Ashraf says:

    In the “Lower limbs” section:
    It is mentioned see figure referring to dermatomes but I could not find any figure!

  3. Fatima Urooj says:

    I could’nt fine the Cranial nerve V11 exam. Kindly suggest

  4. CP says:

    How about the facial nerve during the CN exam?

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