Neurologic examination === [TOC] ## Cognition ### Conscious level * see also [Consciousness assessment](/s/By8ylJWl4). * Glasgow coma scale[^Teasdale1974] <font size=2> <table> <tr> <td rowspan="4">Eye opening</td> <td>Spontaneous</td> <td>4</td> </tr> <tr> <td>To speech</td> <td>3</td> </tr> <tr> <td>To pain</td> <td>2</td> </tr> <tr> <td>None</td> <td>1</td> </tr> <tr> <td rowspan="5">Best verbal response</td> <td>Oriented</td> <td>5</td> </tr> <tr> <td>Confused</td> <td>4</td> </tr> <tr> <td>Inappropriate (words)</td> <td>3</td> </tr> <tr> <td>Incomprehensive (sounds)</td> <td>2</td> </tr> <tr> <td>None</td> <td>1</td> </tr> <tr> <td rowspan="6">Best motor response</td> <td>Obeys commands</td> <td>6</td> </tr> <tr> <td>Localizes to pain</td> <td>5</td> </tr> <tr> <td>Withdraws to pain</td> <td>4</td> </tr> <tr> <td>Flexor (decorticate)</td> <td>3</td> </tr> <tr> <td>Extensor (decerebrate)</td> <td>2</td> </tr> <tr> <td>None</td> <td>1</td> </tr> </table> </font> [^Teasdale1974]: Teasdale G et al. **Assessment of coma and impaired consciousness. A practical scale.** [Lancet. 1974;2:81](https://www.ncbi.nlm.nih.gov/pubmed/4136544) ### Mental status * MSE ![](https://i.imgur.com/dVWXpyF.png) * JOMAC <font size=2> <table> <tr> <td>Judgement</td> <td>simple scenarios</td> </tr> <tr> <td>Orientation</td> <td>person, time, place</td> </tr> <tr> <td>Memory</td> <td>immediate, short-term, long-term</td> </tr> <tr> <td>Abstraction</td> <td>similarity</td> </tr> <tr> <td>Calculation</td> <td>serial 7s</td> </tr> </table> </font> #### MMSE * Orientation (10) * Date: season, yy/mm/dd, day (5) * Location: country, city, building, hospital, floor (5) * Registration (3) * 3 objects (3) * Attention & calculation (5) * Serial 7s (5); spell "WORLD" backwards (5) * Recall (3) * Language (9) * Naming (2), Repetition (1) * Comprehension: 3-step command (3) * Reading (1), Writing (1) * Drawing (1) ### High cortical function - [Cognition evaluation](/s/rk9P6YfA7) - MMSE - [Executive functions](/s/HkYOFXFY-) - [Cerebral syndromes](/s/SyTRcdACQ) - Frontal - frontal releasing signs: glabella, palmomental reflex, grasping, rooting, snouting. - [Frontal Assessment Battery (FAB)](/s/rk6GC-nKb) - Broca's aphasia - contralateral gaze palsy - Temporal - Wernicke's aphasia - Parietal - Gerstmann syndrome - hemineglect, anosognosia, constructional apraxia - agraphethesia, tactile astereognosis. - Balint syndrome (simultagnosia, optic apraxia, optic ataxia) - Occipital - hemianopia - Anton syndrome ## Cranial nerves ### CN1 * smelling. ### CN2 * pupils: size and light reflex * visual acuity * visual field * fundoscopy ### CN3,4,6 * EOM * pursuit and saccade * convergence * oculocephalic reflex (Doll's eye) * Nystagmus * Optokinetic nystagmus (OKN) ### CN5 * motor: temporalis and massater * sensory: V1-V3 or onion skin pattern by light touch or pinprick. * corneal reflex (CN5->7) * jaw jerk (CN5->5) ### CN7 * Frontalis: look upward * Orbicularis oculi: close eyes * Risorius: say E-E-E-E * Orbicularis oris: say Wu-Wu-Wu-Wu * Taste: anterior 2/3 of the tongue * Lacrimal gland ### CN8 * Rubbing and whistling of fingers in each ear * Weber/Rhine test (if necessary) * Vestibular function * Nystagmus. * Caloric testing: "COWS". * Head thrust, past pointing, Dix-Hallpike, Star walking test, Fukuda stepping test, etc... * ![](https://i.imgur.com/nheOFSl.png) (<cite>DeJong 7e</cite>) ### CN9,10 * Palatal elevation/uvula deviation * Gag reflex (CN9->10) * Articulation (dysarthria): “pa”(labial, CN7), “ta”(lingual, CN12), “ka”(velar/pharyngeal, CN9,10) * Hoarseness (CN10) ### CN11 * SCM * trapezius ### CN12 - Tongue protrusion - Tongue fasciculation/atrophy ### multiple CN syndromes - [Brainstem and Multiple Cranial Nerve Syndromes](/s/r1DIYYMpQ) ## Motor system ### Muscle power * MRC scale of muscle strength <font size=2> <table> <tr> <td>no contraction</td> <td>0</td> </tr> <tr> <td>contraction</td> <td>1</td> </tr> <tr> <td>active movement</td> <td>2</td> </tr> <tr> <td>against gravity</td> <td>3</td> </tr> <tr> <td>slight resistance</td> <td>4-</td> </tr> <tr> <td>moderate resistance</td> <td>4</td> </tr> <tr> <td>strong resistance</td> <td>4+</td> </tr> <tr> <td>normal power</td> <td>5</td> </tr> </table> MRC, Medical Research Council </font> * Minimal requirement: proximal and distal * Detailed examination: [Muscles, nerves, and roots](/S6kSjcphSyuXT_NJkdx1ug) * Pronator drift, Leg raising test * Gower sign * Hoover test ### Deep tendon reflex * C5/6/7, L4/S1 * grading: -, +, ++, +++, ++++, clonus * Babinski's reflex: plantarflexion vs. dorsiflexion * Hoffman's reflex * Jaw jerk ## Sensory system * light touch * pinprick * joint position * vibration: 128Hz fork * temperature * [Aberrant sensations](/GcH_sEyeRKWCZOPtQ8jz_w) ## Cerebellar system mnemonics: **"HANDS DTR"** - Hypotonia - [Ataxia](/O_4k3E--TLmP_TT5KKcB6w) - Nystagmus; saccade, pursuit - Dysdiadochokinesia - Scanning speech - Dysmetria - Titubation - Rebound phenomenon ## Gait and posture - [Gait and posture examination](/ZiIlwW5zRK2EGOITU0ap5A) * Gait * ordinary gait * tandem gait * walk on heels/toes * Romberg test ## Extrapyramidal system Parkinsonism * mnemonics: **"TRAPFF"** * Tremor, Rigidity, Akinesia/bradykinesia * Postural instability, Festinating gait, Flexor posture Involentary movement * mnemonics: **"ABCDMTT"** * Athetosis, Ballism, Chorea, Dystonia, Myoclonus, Tremor, Tics ## Others * Meningismus * neck stiffness * Bruzdinski * Kernig * Lhermitte's Sign * Orthopedics: * spurling's test * strait leg raising test (SLRT)