Neurological examination
Encyclopedia
A neurological examination is the assessment of sensory neuron
and motor
responses, especially reflex
es, to determine whether the nervous system
is impaired. It can be used both as a screening tool and as an investigative tool, the former of which when examining the patient when there is no expected neurological deficit and the latter of which when examining a patient where you do expect to find abnormalities. If a problem is found either in an investigative or screening process then further tests can be carried out to focus on a particular aspect of the nervous system (such as lumbar puncture
s and blood test
s).
Generally a neurological examination is focused towards finding out if there are lesion
s in the central
and peripheral nervous system
s or whether there is another diffuse process which is troubling the patient. Once the patient has been thoroughly tested, it is then the role of the physician
to determine whether or not these findings combine to form a recognizable medical syndrome such as Parkinson's disease
or motor neurone disease
. Finally, it is the role of the physician to find the etiological reasons for why such a problem has occurred, for example finding if the problem was due to inflammation or congenital.
Handedness is important in establishing the area of the brain important for language (as almost all right-handed people have a left hemisphere which is responsible for language). As patients answer questions, it is important to gain an idea of the complaint thoroughly and understand its time course. Understanding the patient's neurological state at the time of questioning is important, and an idea should be obtained of how competent the patient is with various tasks and their level of impairment in carrying out these tasks. The interval of a complaint is important as it can help aid the diagnosis. For example, vascular
disorders occur very frequently over minutes and hours, whereas congenital disorders occur over a matter of years.
Carrying out a 'general' examination is just as important as the neurological exam as it may lead to clues to the etiology of the complaint. This is shown by cases of cerebral metastases
where the initial complaint was of a mass in the breast
.
due to compression of a specific spinal nerve by a tumor deposit). A differential diagnosis
may then be constructed that takes into account the patient's background (e.g. previous cancer, autoimmune diathesis) and present findings to include the most likely causes. Examinations are aimed at ruling out the most clinically significant causes (even if relatively rare, e.g. brain tumor in a patient with subtle word finding abnormalities but no increased intracranial pressure
) and ruling in the most likely causes.
Sensory neuron
Sensory neurons are typically classified as the neurons responsible for converting external stimuli from the environment into internal stimuli. They are activated by sensory input , and send projections into the central nervous system that convey sensory information to the brain or spinal cord...
and motor
Motor neuron
In vertebrates, the term motor neuron classically applies to neurons located in the central nervous system that project their axons outside the CNS and directly or indirectly control muscles...
responses, especially reflex
Reflex
A reflex action, also known as a reflex, is an involuntary and nearly instantaneous movement in response to a stimulus. A true reflex is a behavior which is mediated via the reflex arc; this does not apply to casual uses of the term 'reflex'.-See also:...
es, to determine whether the nervous system
Nervous system
The nervous system is an organ system containing a network of specialized cells called neurons that coordinate the actions of an animal and transmit signals between different parts of its body. In most animals the nervous system consists of two parts, central and peripheral. The central nervous...
is impaired. It can be used both as a screening tool and as an investigative tool, the former of which when examining the patient when there is no expected neurological deficit and the latter of which when examining a patient where you do expect to find abnormalities. If a problem is found either in an investigative or screening process then further tests can be carried out to focus on a particular aspect of the nervous system (such as lumbar puncture
Lumbar puncture
A lumbar puncture is a diagnostic and at times therapeutic procedure that is performed in order to collect a sample of cerebrospinal fluid for biochemical, microbiological, and cytological analysis, or very rarely as a treatment to relieve increased intracranial pressure.-Indications:The...
s and blood test
Blood test
A blood test is a laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a needle, or via fingerprick....
s).
Generally a neurological examination is focused towards finding out if there are lesion
Lesion
A lesion is any abnormality in the tissue of an organism , usually caused by disease or trauma. Lesion is derived from the Latin word laesio which means injury.- Types :...
s in the central
Central nervous system
The central nervous system is the part of the nervous system that integrates the information that it receives from, and coordinates the activity of, all parts of the bodies of bilaterian animals—that is, all multicellular animals except sponges and radially symmetric animals such as jellyfish...
and peripheral nervous system
Peripheral nervous system
The peripheral nervous system consists of the nerves and ganglia outside of the brain and spinal cord. The main function of the PNS is to connect the central nervous system to the limbs and organs. Unlike the CNS, the PNS is not protected by the bone of spine and skull, or by the blood–brain...
s or whether there is another diffuse process which is troubling the patient. Once the patient has been thoroughly tested, it is then the role of the physician
Physician
A physician is a health care provider who practices the profession of medicine, which is concerned with promoting, maintaining or restoring human health through the study, diagnosis, and treatment of disease, injury and other physical and mental impairments...
to determine whether or not these findings combine to form a recognizable medical syndrome such as Parkinson's disease
Parkinson's disease
Parkinson's disease is a degenerative disorder of the central nervous system...
or motor neurone disease
Motor neurone disease
The motor neurone diseases are a group of neurological disorders that selectively affect motor neurones, the cells that control voluntary muscle activity including speaking, walking, breathing, swallowing and general movement of the body. They are generally progressive in nature, and can cause...
. Finally, it is the role of the physician to find the etiological reasons for why such a problem has occurred, for example finding if the problem was due to inflammation or congenital.
History
A patient's history is the most important part of a neurological examination and must be performed before any other procedures unless impossible (i.e. the patient is unconscious). Certain aspects of a patients history will become more important depending upon the complaint issued. Important factors to be taken in the medical history include:- Time of onset, duration and associated symptoms (e.g. is the complaint chronicChronic (medicine)A chronic disease is a disease or other human health condition that is persistent or long-lasting in nature. The term chronic is usually applied when the course of the disease lasts for more than three months. Common chronic diseases include asthma, cancer, diabetes and HIV/AIDS.In medicine, the...
or acuteAcute (medicine)In medicine, an acute disease is a disease with either or both of:# a rapid onset, as in acute infection# a short course ....
) - Age, gender and occupation of the patient
- Handedness (right or left handed)
- Past medical history
- Drug history
- Family and social history
Handedness is important in establishing the area of the brain important for language (as almost all right-handed people have a left hemisphere which is responsible for language). As patients answer questions, it is important to gain an idea of the complaint thoroughly and understand its time course. Understanding the patient's neurological state at the time of questioning is important, and an idea should be obtained of how competent the patient is with various tasks and their level of impairment in carrying out these tasks. The interval of a complaint is important as it can help aid the diagnosis. For example, vascular
Vascular
Vascular in zoology and medicine means "related to blood vessels", which are part of the circulatory system. An organ or tissue that is vascularized is heavily endowed with blood vessels and thus richly supplied with blood....
disorders occur very frequently over minutes and hours, whereas congenital disorders occur over a matter of years.
Carrying out a 'general' examination is just as important as the neurological exam as it may lead to clues to the etiology of the complaint. This is shown by cases of cerebral metastases
Metastasis
Metastasis, or metastatic disease , is the spread of a disease from one organ or part to another non-adjacent organ or part. It was previously thought that only malignant tumor cells and infections have the capacity to metastasize; however, this is being reconsidered due to new research...
where the initial complaint was of a mass in the breast
Breast
The breast is the upper ventral region of the torso of a primate, in left and right sides, which in a female contains the mammary gland that secretes milk used to feed infants.Both men and women develop breasts from the same embryological tissues...
.
List of tests
Specific tests in a neurological examination include:| Category | Tests | Example of writeup |
|---|---|---|
| Mental status examination Mental status examination The mental status examination in the USA or mental state examination in the rest of the world, abbreviated MSE, is an important part of the clinical assessment process in psychiatric practice... |
|
"A&O x 3, short and long-term memory Long-term memory Long-term memory is memory in which associations among items are stored, as part of the theory of a dual-store memory model. According to the theory, long term memory differs structurally and functionally from working memory or short-term memory, which ostensibly stores items for only around 20–30... intact" |
| Cranial nerve examination Cranial nerve examination The cranial nerve exam is part of the neurological examination. It is used to identify problems with the cranial nerves by physical examination.-Components:-See also:* Cranial nerves* Cranial nerve nucleus* List of mnemonics for the cranial nerves... |
Cranial nerves Cranial nerves Cranial nerves are nerves that emerge directly from the brain, in contrast to spinal nerves, which emerge from segments of the spinal cord. In humans, there are traditionally twelve pairs of cranial nerves... (I-XII): sense of smell (I), visual fields and acuity (II), eye movements (III, IV, VI) and pupils (III, sympathetic and parasympathetic), sensory function of face (V), strength of facial (VII) and shoulder girdle muscles (XI), hearing (VII, VIII), taste (VII, IX, X), pharyngeal movement and reflex (IX), tongue movements (XII). These are tested by their individual purposes (e.g. the visual acuity can be tested by a Snellen chart Snellen chart A Snellen chart is an eye chart used by eye care professionals and others to measure visual acuity. Snellen charts are named after the Dutch ophthalmologist Herman Snellen who developed the chart during 1862... ). |
"CNII-XII grossly intact" |
| Motor Motor Motor is a device that creates motion. It usually refers to an engine of some kind. It may also specifically refer to:*Electric motor, a machine that converts electricity into a mechanical motion... |
Muscle Muscle is a contractile tissue of animals and is derived from the mesodermal layer of embryonic germ cells. Muscle cells contain contractile filaments that move past each other and change the size of the cell. They are classified as skeletal, cardiac, or smooth muscles. Their function is to... strength, often graded on the MRC Medical Research Council (UK) The Medical Research Council is a publicly-funded agency responsible for co-ordinating and funding medical research in the United Kingdom. It is one of seven Research Councils in the UK and is answerable to, although politically independent from, the Department for Business, Innovation and Skills... scale 1 to 5 (or I to V).
|
"strength 5/5 throughout, tone WNL" |
| Deep tendon reflexes | Reflexes Reflex action A reflex action, also known as a reflex, is an involuntary and nearly instantaneous movement in response to a stimulus. A true reflex is a behavior which is mediated via the reflex arc; this does not apply to casual uses of the term 'reflex'.-See also:... : masseter, biceps and triceps tendon, knee tendon, ankle jerk and plantar Plantar reflex The plantar reflex is a reflex elicited when the sole of the foot is stimulated with a blunt instrument. The reflex can take one of two forms. In normal adults the plantar reflex causes a downward response of the hallux... (i.e. Babinski sign). Globally, brisk reflexes suggest an abnormality of the UMN Upper motor neuron Upper motor neurons are motor neurons that originate in the motor region of the cerebral cortex or the brain stem and carry motor information down to the final common pathway, that is, any motor neurons that are not directly responsible for stimulating the target muscle... or pyramidal tract, while decreased reflexes suggest abnormality in the anterior horn Anterior horn The term anterior horn may refer to either of two separate anatomical structures within the central nervous system:... , LMN Lower motor neuron Lower motor neurons are the motor neurons connecting the brainstem and spinal cord to muscle fibers, bringing the nerve impulses from the upper motor neurons out to the muscles... , peripheral nerve or motor end plate. A reflex hammer Reflex hammer A reflex hammer is a medical instrument used by physicians to test deep tendon reflexes. Testing for reflexes is an important part of the neurological physical examination in order to detect abnormalities in the central or peripheral nervous system.... is used for this testing. |
"2+ symmetric, downgoing plantar reflex Plantar reflex The plantar reflex is a reflex elicited when the sole of the foot is stimulated with a blunt instrument. The reflex can take one of two forms. In normal adults the plantar reflex causes a downward response of the hallux... " |
| Sensation Sensation Sensation is the fiction-writing mode for portraying a character's perception of the senses. According to Ron Rozelle, “. . .the success of your story or novel will depend on many things, but the most crucial is your ability to bring your reader into it. And that reader will be most completely... |
Sensory system Sensory system A sensory system is a part of the nervous system responsible for processing sensory information. A sensory system consists of sensory receptors, neural pathways, and parts of the brain involved in sensory perception. Commonly recognized sensory systems are those for vision, hearing, somatic... testing involves provoking sensations of fine touch, pain and temperature. Fine touch can be evaluated with a monofilament test, touching various dermatome Dermatome Dermatome may refer to:*Dermatome , a surgical instrument used to produce thin slices of skin*Dermatome , an area of skin that is supplied by a single pair of dorsal roots*Dermatome... s with a nylon monofilament to detect any subjective absence of touch perception.
|
"intact to sharp and dull throughout" |
| Cerebellum Cerebellum The cerebellum is a region of the brain that plays an important role in motor control. It may also be involved in some cognitive functions such as attention and language, and in regulating fear and pleasure responses, but its movement-related functions are the most solidly established... |
|
"Romberg Romberg's test Romberg's test or the Romberg maneuver is a test used by doctors in a neurological examination, and also as a test for drunken driving. The exam is based on the premise that a person requires at least two of the three following senses to maintain balanced while standing:Proprioception ; Vestibular... negative, intact finger-to-nose Dysmetria Dysmetria refers to a lack of coordination of movement typified by the undershoot or overshoot of intended position with the hand, arm, leg, or eye... , gait Gait Gait is the pattern of movement of the limbs of animals, including humans, during locomotion over a solid substrate. Most animals use a variety of gaits, selecting gait based on speed, terrain, the need to maneuver, and energetic efficiency... WNL" |
Interpretation
The results of the examination are taken together to anatomically identify the lesion. This may be diffuse (e.g. neuromuscular diseases, encephalopathy) or highly specific (e.g. abnormal sensation in one dermatomeDermatomic area
A dermatome is an area of skin that is mainly supplied by a single spinal nerve.There are eight cervical nerves ,twelve thoracic nerves,five lumbar nerves and five sacral nerves....
due to compression of a specific spinal nerve by a tumor deposit). A differential diagnosis
Differential diagnosis
A differential diagnosis is a systematic diagnostic method used to identify the presence of an entity where multiple alternatives are possible , and may also refer to any of the included candidate alternatives A differential diagnosis (sometimes abbreviated DDx, ddx, DD, D/Dx, or ΔΔ) is a...
may then be constructed that takes into account the patient's background (e.g. previous cancer, autoimmune diathesis) and present findings to include the most likely causes. Examinations are aimed at ruling out the most clinically significant causes (even if relatively rare, e.g. brain tumor in a patient with subtle word finding abnormalities but no increased intracranial pressure
Intracranial pressure
Intracranial pressure is the pressure inside the skull and thus in the brain tissue and cerebrospinal fluid . The body has various mechanisms by which it keeps the ICP stable, with CSF pressures varying by about 1 mmHg in normal adults through shifts in production and absorption of CSF...
) and ruling in the most likely causes.
External links
- Overview at University of California, San DiegoUniversity of California, San DiegoThe University of California, San Diego, commonly known as UCSD or UC San Diego, is a public research university located in the La Jolla neighborhood of San Diego, California, United States...
- Overview at University of TorontoUniversity of TorontoThe University of Toronto is a public research university in Toronto, Ontario, Canada, situated on the grounds that surround Queen's Park. It was founded by royal charter in 1827 as King's College, the first institution of higher learning in Upper Canada...
- "Neurological History and Physical Examination"