Physical Exam: Neurological System

I. History
II. Mental Status

• Mini-Mental Status Exam (MMSE) - commonly used assessment tool to quantify a person's cognitive ability. It assesses orientation, registration, attention and calculation and language. Scoring is from 0 to 30, with 30 indicating intact cognition.

III. Emotional Status

• Normal findings: affect matches speech

IV. Cranial Nerve Function

CRANIAL NERVE FUNCTION

CN I. Olfactory Nerve

• can identify variety of smells
• deviation: inability to identify aroma

CN II. Optic Nerve

• has visual acuity and full visual fields
• fundoscopic exam reveals no pathology
• deviation: inability to identify full visual fields - total or partial blindness of one or both eyes

CN III (Oculomotor), CN IV (Trochlear), CN VI (Abducens)

• follows up to six cardinal positions of gaze
• pupils are unremarkable
• exhibits no nystagmus and no ptosis
• deviation: one or both eyes will deviate from its normal position

CN V. Trigeminal Nerve

• clenches teeth with firm bilateral pressure
• has no lateral jaw deviation with mouth open 
• feels a cotton wisp touched to forehead, cheek and chin
• differentiates sharp and dull sensations on the face
• Corneal Reflex: blinks when cotton is touched to each cornea
• deviation: absent or one-sided blinking of eyelids

CN VII. Facial Nerve

• has facial symmetry with an without a smile
• can raise the eyebrows symmetrically and grimace
• can shut eyes tightly
• can identify sweet, sour, salt or bitter on the anterior tongue
• deviation: irregular and unequal facial movements
• deviation: inability to taste or identify taste
• deviation: inability to taste or identify salt, sweet, sour or bitter substances on the anterior two-thirds of the tongue
• deviation: inability to smile symmetrically

CN VIII. Acoustic Nerve

• can hear a whisper at 1-2 feet
• can hear a watch tick at 1-2 feet
• does not lateralize the Weber test
• can hear AC (air conduction) better than BC (bone conduction) in the Rinne's Test
• deviation: inability to hear a spoken word

CN IX (Glossopharyngeal), CN X (Vagus)

• swallows and speaks without hoarseness
• palate and uvula rise symmetrically when patient says "ah"
• bilateral gag reflex
• can identify taste on the posterior tongue
• deviation: unequal or absent rise of uvula and soft palate as client says "ah"
• deviation: absent gag reflex
• deviation: inability to taste or identify taste on the posterior tongue

CN XI. Spinal Accessory Nerve

• resists head turning
• can shrug against resistance
• deviation: weak or absent shoulder and neck movement

CN XII. Hypoglossal Nerve

• can stick tongue out and move it from side to side
• can push tongue strongly against resistance
• deviation: tongue deviates to side

PhotoCredit: dejana.nl

V. Level of Consciousness (LOC): Normal Findings

• alert
• responds appropriately to visual, auditory, tactile and painful stimuli
• able to carry out simple commands
• Glasgow Coma Scale
• alterations in LOC

ALTERATIONS IN LEVEL OF CONSCIOUSNESS

Alert

• Awake and aware of person, place, time and situation
• Responds appropriately and to verbal stimuli

Lethargic

• Sleeps but easily aroused
• Speaks and responds slowly and appropriately

Obtunded

• Difficult to arouse
• Returns to sleep quickly; may respond inappropriately

Stuporous

• Aroused only through pain
• No verbal response

Semicomatose

• Responds only through pain
• Gag and blink reflexes intact

Comatose

• No response to pain
• No reflexes or muscle tone

Note: Dying clients will proceed through these levels in this above-listed sequence.

VI. Sensory Function: Normal findings

• Visual - recognize objects
• Auditory - identifies sounds
• Tactile - identifies objects though blind touch; perceives pain, hot and cold and vibration; two-point discrimination
• Olfactory - identifies familiar smells

ASSESSMENT OF SENSORY NERVE FUNCTION (Done with Client's Eyes Closed)

Superficial Pain

• Prick with sterile needle
• Have client identify whether sharp or dull

Temperature

• Two test tubes - one filled with hot water, the other with cold water
• Client identifies hot versus cold sensation and where it is felt

Light Touch

• Cotton ball; apply light wisp of cotton to different surface points
• Client identifies when touched

Vibration

• Low pitched tuning fork
• Apply to distal interphalangeal joint of finger then toe
• Client identifies when vibration stops

Position

• Grasp client's finger or great toe, holding by its sides
• Client identifies if moving up or down

Two-Point Discrimination

• Two safety pins
• Apply lightly and simultaneously to two different places on skin's surface
• Usually start with finger pads
• Find minimal distance at which client can discriminate one from two points, normally <5mm on finger pads
• Client identifies when can discriminate one from two points

Stereognosis

• Use coin or paper clip or any familiar object with client's eyes closed
• Client identifies object to identify by touch and manipulation

Graphesthesia (Number Identification)

• Number is traced on the client's palm by a blunt object
• Client identifies number

Extinction

• Corresponding areas on both sides of body are simultaneously stimulated
• Client identifies where touched

VII. Cerebellar Function: Position and Balance

CEREBELLAR FUNCTION

• Romberg Test - tests position sense, note client's ability to stand upright when standing with feet together and eyes closed for 20-30 seconds
• Hop in Place - maintains balance while hopping on one foot
• Knee Bends - maintains balance while bending at knees
• Tandem Walking - walks heel to toe in straight line
• Rapid Skills

1. pronates and supinates hands rapidly with equal timing and purposeful movements
2. touches alternate finger to nose rhythmically with eyes open and closed
3. moves fingers alternately from nose to examiner's finger in coordinated fashion
4. runs contralateral heel down shin with bilateral coordination

• One Foot Balance

1. maintains balance on one foot for at least five seconds
2. bilateral response with eyes open and closed

VIII. Speech and Language: Normal Findings

• Smooth flowing speech
• Able to formulate words without difficulty
• Varied inflection
• Able to write letters and numbers to dictation
• Vocabulary appropriate to educational level

IX. Intellectual: Normal Findings

• Memory - immediate recall and remote recall
• Oriented to person, place and time
• Able to abstract
• Demonstrates consistent insight and perception of self

X. Reflexes: Assessmend and Grading

TESTS FOR REFLEXES

I. Deep tendon reflexes with selected site stimulus

• Biceps reflex (C5, C6) - flexion of arm at elbow
• Triceps reflex (C6, C7) - extension of arm at elbow and contraction of triceps muscles
• Brachioradialis (supinator) reflex (C5, C6) - flexion at elbow and pronation of forearm
• Quadriceps (knee-jerk or patellar) reflex (L2, L3, L4) - extension of leg at knee and contraction of quadriceps
• Achilles (ankle-jerk) reflex (S1, S2)

II. Superficial reflexes

• Pharyngeal reflex (CN IX, CN X)
• Upper abdominal reflex (T8, T9, T10) - upward movement of umbilicus toward stimulus above umbilicus
• Lower abdominal reflex (T10, T11, T12) - downward movement of umbilicus toward stimulus below umbilicus
• Cremasteric reflex (T12, L1) - elevation of ipsilateral testicle (the side stimulated)
• Gluteal reflex (L4-S3) - contraction of anal sphincter with gloved finger insertion

III. Pathologic reflexes in adults - documented as "positive for ___"

• Babinski reflex (plantar) (L4-S2) - stroking lateral sole of foot causes dorsiflexion of great toe with fanning of other toes (normal expectation in children up to age 18 months on the average)
• Chaddock reflex (L4-S2) - stroking below lateral malleolus causes dorsiflexion of great toe with fanning of other toes
• Ankle clonus - brisk dorsiflexion of foot with knee flexed causes up and down movement of foot; found in severe preeclampsia
• Oppenheim - stroking tibial surface causes great toe fans out
• Gordon - squeezing calf muscle; great toe fans out
• Hoffman - flicking middle finger down; flexion of the tumb

IV. Common Expected Reflexes: normal for all ages

• Gag
• Corneal

REFLEX GRADING

0     -     No response

1+   -     Sluggish or diminished response

2+   -     Normal

3+   -     Brisker than normal

4+   -     Hyperactive and very brisk (may be associated with spinal cord disorder)

XI. Geriatric Alterations in Neuro Status

• Longer response time to sensory stimulation
• May resist new ideas or change
• Thought patterns may become more concrete
• Kinesthesia diminishes - the ability to perceive extent, direction or weight of movement
• Superficial and deep reflexes may be diminished or absent

POINTS TO REMEMBER:

• Glasgow Coma Score

1. not valid in patients who have used alcohol or other mind-altering drugs
2. possibly not valid in patients who are hypoglycemic, in shock, or hypothermic (below 34 degrees Celsius)

• Reflexes are normally less brisk or even absent in older clients
• Reflex response diminishes in the lower extremities before the upper extremities are affected
• Absent reflexes may indicate neuropathy or lower motor neuron disorder
• Hyperactive reflexes suggest an upper neuron disorder