PHYSICAL EXAMINATION OF THE NEUROLOGIC SYSTEM Flashcards
Obtain neurologic history
. Review of Related History
(1) History of Present Illness
(a) Seizure or convulsions
1) Patients with seizures should be asked about the sequence of events, including
character of symptoms, presence of aura, level of consciousness, automatisms,
muscle tone, and postictal behavior. Relationship of seizure to time of day,
meals, fatigue, emotional stress, or activity before attack should be recorded, as
well as frequency of seizure activity and any medications taken.
(b) Pain
1) Pertinent data include the onset, quality, intensity, location, and path of the pain.
Patients should also be asked about associated manifestations (e.g., crying,
sweating, and tremors), as well as efforts to treat and medications taken.
(c) Gait coordination
1) Areas to assess include balance problems and falling tendencies. Associated
problems (e.g., arthritis, stroke, or seizure) should be explored, as well as
medications taken.
(d) Weakness or paresthesia
1) Patients should be asked to describe the onset and character of the problem, as
well as any associated symptoms (e.g., tingling, pain, or joint stiffness),
concurrent chronic illness, and medications taken.
(e) Tremor
1) Pertinent data include onset (sudden or gradual) and character (e.g., worse with
rest). Also note any associated problems, methods that provide relief, and any
medications taken.
Obtain neurologic history
Past Medical History
Relevant data to include past incidence of trauma (e.g., head, spinal cord, or
localized injury), meningitis, congenital anomalies, cardiovascular problems, or
neurologic disorders.
Obtain neurologic history
Family History
Pertinent data include family history of neurofibromatosis, Huntington’s chorea,
muscular dystrophy, or Tay-Sachs disease. Incidence of mental retardation, seizure
disorder, headaches, alcoholism, Alzheimer disease, learning disorders, gaitproblems, or metabolic problems (e.g., thyroid or hypertensive disease) should also
be noted.
Obtain neurologic history
Personal and Social History
Ask patient about environmental or occupational hazards, use of alcohol or moodaltering drugs, medications taken, ability to care for self, and sleeping or eating
patterns. Hand, eye, and foot dominance should also be assessed.
Evaluate coordination and fine motor skills:
(a) Assess rapid, rhythmic, alternating movements.
(b) Assess accuracy of movements by performing the following tests:
1) Finger-to-finger test
2) Finger-to-nose test
3) Heel-to-shin test
Evaluate balance
(a) Perform Romberg test to assess equilibrium.
(b) Observe and assess gait.
1) Have patient walk around exam room and observe for expect gait sequence
2) Heel-toe walking will exaggerate unexpected gait abnormalities
Sensory Function
(1) Evaluate primary sensory functions, using proper technique described, by performing
the following tests:
(1) Evaluate primary sensory functions, using proper technique described, by performing the following tests: (a) Superficial touch (b) Superficial pain (c) If superficial pain sensation is not intact, perform temperature and deep pressure sensation tests (d) Vibration (e) Position of joints
Sensory Function
Evaluate cortical sensory functions, using proper technique described, by performing the
following tests:
(a) Stereognosis
(b) Two-point discrimination
(c) Extinction phenomenon
(d) Graphesthesia
(e) Point location
Reflexes
(1) Evaluate superficial reflexes: abdominal, cremasteric, and plantar reflex.
(2) Evaluate deep tendon reflexes: biceps, brachioradial, triceps, patellar, achilles, and ankle
clonus.
Grading Scale
4- Very brisk, often with clonus (record the number of beats)
3- Brisk
2- Normal
1- Minimal
0- Absent
Additional procedures for further evaluation of the neurologic system when problems are
detected with routine examination:
(1) Use the 5.07 monofilament to test for protective sensation on the feet of patients with
diabetes mellitus or peripheral neuropathy.
(2) Test for the following signs of meningitis:
(a) Nuchal rigidity
(b) Brudzinski sign
(c) Kernig sign
Determine neurologic examination findings.
Neurologic Examination Findings
Cranial Nerve
(1) Unexpected findings (focal deficits) indicate trauma or a lesion in the cerebral
hemisphere or local injury to the nerve
Determine neurologic examination findings.
Neurologic Examination Findings
Coordination and Fine Motor Skills:
Observe for involuntary movements, tremors, tics, or fasciculation. Note body part
affected, quality, rate and rhythm.
(2) Rapid Rhythmic Alternating Movements:
(a) Movements should be smooth, and rhythmic with increasing speed. Stiff, slowed,
nonrhythmic, or jerky clonic movements are unexpected.
(3) Accuracy of Movements:
(a) Movements should be rapid, smooth, and accurate. Consistent past pointing may
indicate cerebellar disease.
Determine neurologic examination findings.
Neurologic Examination Findings
Equilibrium
(1) Slight sway is expected with Romberg, but not to the extent that the patient falls. Loss
of balance indicates cerebellar ataxia, vestibular dysfunction, or sensory loss.
(a) If a slight push is given to the patient, recovery of balance should occur quickly.
(b) Balancing on one foot should be maintained for 5 seconds, with slight sway
expected.
(2) Expected continuous gait sequence of stance and swing step after step.
(a) Gait should be smooth, have regular rhythmic and symmetric stride length.
(b) Trunk posture should sway with gait phase, and arm swing should be smooth and
symmetric.
(3) Note any extension of arms for balance, instability, tendency to fall, or lateral staggering
and reeling during the heel-toe walking.
(a) Note any shuffling, widely placed feet, toe walking, foot flop, leg lag, scissoring,
loss of arm swing, staggering, or reeling.
Determine neurologic examination findings.
Neurologic Examination Findings
Sensory
(1) With each sensory stimulus, expected findings include:
(a) Minimal differences side to side.
(b) Correct interpretation of sensations.
(c) Discrimination of the side of the body tested.
(d) Location of sensation and whether proximal or distal to the previous stimuli
1) If sensory impairment is found, map the boundaries of impairment and
determine if the sensory loss has a dermatomal pattern or is in the distribution
pattern of major peripheral nerves.
2) Loss of sensation can indicate peripheral nerve, spinal tract, brainstem, or
cerebral lesions.
(e) Stereognosis.
(f) Two-point Discrimination.
(g) Extinction Phenomenon.
(h) Graphesthesia.
(i) Point location.
Determine neurologic examination findings.
Neurologic Examination Findings
Reflexes
(1) Symmetric visible or palpable responses should be noted.
(a) Evaluation of spinal levels for specific superficial and deep tendon reflexes.
(b) Deep Tendon Reflex grading scale.
(c) Characteristics of Upper and Lower Motor Neuron Disorders
