This presentation is about some neurological exams for better understanding of nervous system

1. Neurological exam
By
H.Khorrami Ph.D.
khorrami4@yahoo.com

2. Instruments

3. • Receptive field(two point discrimination test)
• Vibration test

5. Sensory system
• Fine touch
• Temperature
• Shape
• Deep sense
• Vibration
• Name objects

6. Deep sense of vibration

7. Vibration sense
• Use a 128 Hz tuning fork and ensure the tuning
fork is vibrating
• Place it on the sternum to start with so that the
patient can feel the sensation
• Then place it on the big toe
• If no vibration is sensed, move backwards to the
bony malleolus of the ankle, the tibial shaft and
tuberosity and the anterior iliac crest
• Asking the patient to tell you when the tuning
fork stops vibrating can be helpful if there is
doubt that their vibration sense is intact

8. Plexuses

10. Interpretation
• All of the sensory modalities can be affected in
peripheral neuropathies and nerve injuries,
radiculopathy due to disc lesions and spinal
injuries
• If an individual nerve or sensory root is affected,
all sensory modalities can be reduced
• If there is a spinal cord lesion, there may not be
equal diminution across all of the sensory
modalities: light touch, vibration and joint
position sense may remain intact while sharp
touch and temperature are lost
• This is because the lateral spinothalamic
pathways may be damaged while the dorsal
columns remain intact

11. Interpretation, cont.
• Problems with joint position sense or vibration usually
occur distally first
• Joint position sense is also required for balance, gait
and co-ordination
• Vibration sense can be lost before joint position sense
in peripheral neuropathy or myelopathy affecting the
dorsal columns
• Vibration sense over the ankles is often diminished or
lost in elderly people with no apparent neurological
lesion
• The distal parts of the limbs tend to be affected in
polyneuropathy, the legs usually being involved before
the arms, A 'glove and stocking' effect is produced

12. Tone
• Tone is the resistance felt when a joint is
moved passively through its normal range of
movement
• Hypertonia is found in upper motor neuron
lesions
• Hypotonia is found in lower motor neuron
lesions and cerebellar disorders
• Clonus is rhythmic and involuntary muscle
contraction that can be provoked by stretching
a group of muscles

13. Test tone
• Ask the patient to let their legs 'go floppy’
• Internally and externally rotate the 'floppy' leg
• Assess for any increased or reduced tone
• Then lift the knee off the bed with one hand
• Note whether the ankle raises off the bed as well,
signifying increased tone
• Test for ankle clonus:
• Flex the patient's knee, resting the ankle on the
bed
• Dorsiflex the foot quickly and keep the pressure
applied
• You will be able to see the foot moving up and
down if clonus is present

14. Tactile sense

20. Cranial Nerve Number Innervation(s) Primary Function(s) Test(s)
Olfactory I Sensory Smell Identify odors
Optic II Sensory Vision
Visual acuity, fields, color,
nerve head
Oculomotor III Motor
Upper lid elevation,
extraocular eye
movement, pupil
constriction,
accommodation
Physiologic "H" and near
point response
Trochlear IV Motor Superior oblique muscle Physiologic "H"
Trigeminal V Motor Muscles of mastication Corneal reflex
Trigeminal V Sensory Scalp, conjunctiva, teeth
Clench jaw/palpate, light
touch comparison
Abducens VI Motor Lateral rectus muscle Abduction, physiologic "H"
Facial VII Motor
Muscles of facial
expression
Smile, puff cheeks, wrinkle
forehead, pry open closed
lids
Facial VII Sensory
Taste-anterior two thirds of
tongue
Vestibulocochlear VIII Sensory Hearing and balance
Rinne test for hearing,
Weber test for balance
Glossopharyngeal IX Motor Tongue and pharynx Gag reflex
Glossopharyngeal IX Sensory
Taste-posterior one third
of tongue
Vagus X Motor
Pharynx, tongue, larynx,
thoracic and abdominal
viscera
Gag reflex
Vagus X Sensory
Larynx, trachea,
esophagus
Accessory XI Motor
Sternomastoid and
trapezius muscles
Shrug, head turn against
resistance
Hypoglossal XII Motor Muscles of tongue Tongue deviation

21. Olfactory nerve

23. Optic nerve

24. Trochlear nerve

26. Corneal reflex
• Desensitization

27. Facial nerve

28. Glossopharyngeal nerve(IX)

29. Accessory nerve(XI)

30. Accessory nerve

31. Hypoglossal nerve(XII)

32. Signs of UMN and LMN lesions
Sign UMN lesions LMN lesions
Weakness Yes Yes
Atrophy Mild/No Yes
Fasciculation No Yes
Reflexes Increased Decreased
Tone Increased Decreased

33. Grading Motor Strength
Grade Description
0/5 No muscle contraction
1/5
Visible muscle movement, but
no movement at the joint
2/5
Movement at the joint, but not
against gravity
3/5
Movement against gravity, but
not against added resistance
4/5
Movement against resistance,
but less than normal
5/5 Normal strength

34. Motor test

35. Myotatic reflexes
• Response
– Amplitude
– Speed
– Pattern
• Descending pathway effects
• Attention
• Calcium status
– Chvostek’s sign
– Trousseau’s sign

36. Chvostek’s sign

37. Trousseau’s sign

38. Tendon Reflex Grading Scale
Grade Description
0 Absent
1+ or + Hypoactive
2+ or ++ "Normal"
3+ or +++ Hyperactive without clonus
4+ or ++++ Hyperactive with clonus

39. https://www.facebook.com/fisionotizie/videos/1838505773092800/

43. Clasp-knife reflex

45. Peripheral myotatic reflexes
• Biceps
• Triceps
• Brachioradialis
• Tromner
• Mayer
• Adductor
• Quadriceps
• Achill(ankle jerk)

46. Biceps reflex

47. Triceps reflex

48. Brachioradialis reflex

49. Adductor reflex

50. Knee jerk reflex

51. Achilles reflex

52. Reinforcement
• Jendrassick maneuvers
–

53. Corticospinal tract
• Wartenberg
• Babinski’s sign(1857-1932) Plantar reflex
• Oppenheim’s sign
• Gordon’s sign

55. Cerebellar tests
(Archi-cerebellum )
(Neo-cerebellum )

59. Cerebellar tests
• Finger to nose
• Rapid alternating finger movements
• Rapid alternating hand movements
• Romberg test
• Heel to shin testing
• Rebound phenomenon

60. Cerebellar tests

61. Finger to nose

63. Romberg

64. Romberg test
• The subject stands with feet together, eyes open and hands by
the sides
• The subject closes the eyes while the examiner observes for a full
minute
• Because the examiner is trying to elicit whether the patient falls
when the eyes are closed, it is advisable to stand ready to catch
the falling patient For large subjects, a strong assistant is
recommended
• Romberg's test is positive if, and only if, the following two
conditions are both met:
1. The patient can stand with the eyes open; and
2. The patient falls when the eyes are closed
• The test is not positive if either:
1. The patient falls when the eyes are open; or
2. The patient sways but does not fall when the eyes are
closed

66. Heel-to-shin

67. Auditory & Vestibular system

74. Nystagmus
• Pandular
• Jerk
– Slow phase
– Fast phase

75. Vestibulo-cerebellum
• Real rotation
• Barany’s chair
• Caloric test

77. Auditory system
• Conductive
• Neural
Rinne test, use a 512Hz tuning fork
AC>BC
Weber test, use a 256/512Hz tuning fork
R=L
Shwabach
Ex=Pt

78. Auditory & Vestibular system

79. Rinne

80. Weber test

81. Auditory system
Test Expectation Based on Diagnose
Rinne AC>=BC Air conduction Conductive
deafness
Weber No lateralization Bone conduction Neural/conductive/
both
Schwabach EX=Pt Bone conduction Neural/conductive,
bilateral