Neurological examination
Encyclopedia
A neurological examination is the assessment of sensory neuron
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 chronic
    Chronic (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 acute
    Acute (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...

  • The assessment of consciousness
    Consciousness
    Consciousness is a term that refers to the relationship between the mind and the world with which it interacts. It has been defined as: subjectivity, awareness, the ability to experience or to feel, wakefulness, having a sense of selfhood, and the executive control system of the mind...

    , often using the Glasgow Coma Scale
    Glasgow Coma Scale
    Glasgow Coma Scale or GCS is a neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment...

     (EMV)
  • 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...

    , often including the abbreviated mental test score
    Abbreviated mental test score
    The abbreviated mental test score was introduced by Hodkinson in 1972 to rapidly assess elderly patients for the possibility of dementia. Its uses in medicine have become somewhat wider, e.g. to assess for confusion and other cognitive impairment, although it has mainly been validated in the...

     (AMTS) or mini mental state examination (MMSE)
  • Global assessment of higher functions
  • 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...

     is roughly estimated by fundoscopy; this also enables assessment for microvascular disease
    Microvascular disease
    Microangiopathy is an angiopathy affecting small blood vessels in the body. It can be contrasted to macroangiopathy....

    .
"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
    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).
  • Muscle tone and signs of rigidity.

    • Examination of posture
      Abnormal posturing
      Abnormal posturing is an involuntary flexion or extension of the arms and legs, indicating severe brain injury. It occurs when one set of muscles becomes incapacitated while the opposing set is not, and an external stimulus such as pain causes the working set of muscles to contract. The posturing...

      • Decerebrate
        Decerebrate
        Decerebration is the elimination of cerebral brain function in an animal by removing the cerebrum, cutting across the brain stem, or severing certain arteries in the brain stem....

      • Decorticate
      • Hemiparetic
    • Resting tremor
      Tremor
      A tremor is an involuntary, somewhat rhythmic, muscle contraction and relaxation involving to-and-fro movements of one or more body parts. It is the most common of all involuntary movements and can affect the hands, arms, eyes, face, head, vocal folds, trunk, and legs. Most tremors occur in the...

      s
    • Abnormal movements
      • Seizure
        Seizure
        An epileptic seizure, occasionally referred to as a fit, is defined as a transient symptom of "abnormal excessive or synchronous neuronal activity in the brain". The outward effect can be as dramatic as a wild thrashing movement or as mild as a brief loss of awareness...

      • Fasciculation
        Fasciculation
        A fasciculation , or "muscle twitch", is a small, local, involuntary muscle contraction and relaxation visible under the skin arising from the spontaneous discharge of a bundle of skeletal muscle fibers...

        s

      • Tone
        • Spasticity
          Spasticity
          Spasticity is a feature of altered skeletal muscle performance in muscle tone involving hypertonia, which is also referred to as an unusual "tightness" of muscles...

          • Pronator drift
            Pronator drift
            In medicine, pronator drift refers to a pathologic sign seen during a neurological examination. Jean Alexandre Barré is credited with having first described it thus it is sometimes known as the Barré test. A positive result indicates spasticity...

        • Rigidity
          • Cogwheeling (abnormal tone suggestive of Parkinson's disease)
          • Gegenhalten - is resistance to passive change, where the strength of antagonist muscles increases with increasing examiner force. More common in dementia.
    "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.
    • Sensory
      • Light touch
      • Pain
      • Temperature
      • Vibration
      • Position sense
      • Graphesthesia
        Graphesthesia
        Graphesthesia is the ability to recognize writing on the skin purely by the sensation of touch. Its name derives from Greek graphē and aisthēsis...

      • Stereognosis
        Stereognosis
        Stereognosis is the ability to perceive and recognize the form of an object using cues from texture, size, spatial properties, and temperature...

        , and
      • Two-point discrimination
        Two-point discrimination
        Two-point discrimination is the ability to discern that two nearby objects touching the skin are truly two distinct points, not one. It is often tested with two sharp points during a neurological examination and reflects how finely innervated an area of skin is....

         (for discriminative sense)
      • Extinction
    "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...

  • Cerebellar testing
    • Dysmetria
      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...

      • Finger-to-nose test
      • Ankle-over-tibia test
    • Dysdiadochokinesis
      • Rapid pronation
        Pronation
        In anatomy, pronation is a rotational movement of the forearm at the radioulnar joint, or of the foot at the subtalar and talocalcaneonavicular joints. For the forearm, when standing in the anatomical position, pronation will move the palm of the hand from an anterior-facing position to a...

        -supination
        Supination
        Supination is a position of either the forearm or foot; in the forearm when the palm faces anteriorly, or faces up . Supination in the foot occurs when a person appears "bow-legged" with their weight supported primarily on the anterior of their feet.The hand is supine in the anatomical position...

    • Ataxia
      • Assessment of gait
    • Nystagmus
    • Intension tremor
    • Staccato speech
    • Romberg test to examine proprioception or cerebellar function
  • "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 dermatome
    Dermatomic 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 Diego
      University of California, San Diego
      The 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 Toronto
      University of Toronto
      The 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"
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