pe_neuroexam
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pe_neuroexam


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Neuro Exam
Charlie Goldberg, M.D.
Professor of Medicine, UCSD SOM
Charles.goldberg@va.gov
Elements of The Neuro Exam
\u2022 Cranial Nerves
\u2022 Motor \u2013 bulk, tone, strength
\u2022 Cerebellum \u2013 fine movements, balance
\u2022 Sensation \u2013 pain, touch, position sense, 
vibration
\u2022 Reflexes
\u2022 Gait
Motor/Strength
Anatomy and Physiology
\u2022 Impulse starts brain
\u2022 Axon (upper motor neuron) crosses opposite 
side @ brain stem
\u2022 Travels down spinal cord Æspecific level 
Corticospinal (Pyramidal) Tracts
\u2022 Synapses w/2nd neuron (lower motor neuron)
\u2022 Leaves cord & travel to target muscle
\u2022 Muscle moves
Anatomy of Motor Pathways - Wash U, St Louis
Muscles \u2013 Observation/Bulk 
and Palpation
\u2022 Bulk (amount of 
muscle mass) \u2013
accounting for size 
patient, activity level, 
age \u2013 if decreased, ? 
symmetric
\u2022 Palpation major 
muscle groupsÆ
insight to bulk, also ? 
any Inflammation, 
pain
L calf hypertrophy and 
R calf atrophy
L hand muscle wasting 
from de-nervation
Muscle Tone; Observe For 
Tremor
\u2022 Tone \u2013 move major joints 
(wrists, elbows, shoulders, hips, 
knees, feet) Æ range of motion
\u2013 normal Æ fluid
\u2013 increased w/UMN lesion; 
decreased (flacid) w/LMN lesion
\u2022 Obvious tremor, unintended 
movements, fasciculations 
(small fibrillations muscleÆ de-
nervation (rare!))
Anatomic Position
Flexion/Extension & Abduction/Adduction
\u2022 Anatomic Position & Planes Of The Body
\u2022 Flexion: Moving forward out of the frontal plane 
of the body (except knee and foot)
\u2022 Extension: Movement in direction opposite to 
flexion
\u2022 Abduction: movement that brings a structure 
away from the body (along frontal plane)
\u2022 Adduction: movement that brings a structure 
towards the body (along frontal plane)
Extension/Flexion, Abduction/Adduction @ 
Major Joints
Wrist Extension
Flexion
Elbow Flexion
Extension
Shoulder Abduction
Adduction
Hip Flexion
Hip Extension Hip 
Abducition
Hip 
Adduction
Knee
Extension
Knee
Flexion
Plantarflexion
Dorsiflexion
Strength \u2013 Scoring System
Quantify with 0 Æ 5 Scale (quasi-objective)
\u2022 0/5 - No movement
\u2022 1/5 - Barest flicker movement Ænot enough to 
move structure to which attached.
\u2022 2/5 - Voluntary movement not sufficient to overcome 
force of gravity. E.g. patient able to slide hand across table - but 
not lift it from surface.
\u2022 3/5 - Voluntary movement capable of overcoming gravity, not any 
applied resistance. E.g. patient raises hand off table, but not w/any 
additional resistance applied.
\u2022 4/5 - Voluntary movement capable of overcoming \u201csome\u201d resistance
\u2022 5/5 - Normal strength
+ and \u2013 can be added to allow for more nuanced scoring
Specific Muscle Group 
Testing
\u2022 Interossei of Hand \u2013 finger 
abduction & adduction
\u2022 Grip strength
\u2022 Wrist - extension & flexion
\u2022 Elbow - flexion & extension
\u2022 Shoulder - abduction & 
adduction
Compare right to leftÆshould be 
similar (accounting for 
handedness).
Muscle Group Testing (cont)
\u2022 Hip - flexion & extension
\u2022 Hip \u2013 abduction & adduction
\u2022 Knee - flexion & extension
\u2022 Ankle \u2013 plantar flexion & dorsiflexion
Pronator Drift: A test for subtle upper extremity 
weakness. 
\u2013 Have patient stand, close their eyes & 
extend both hands, palm up. 
\u2013 E.g. If R arm slightly weak, it will pronate 
& \u201cdrift\u201d down ward.
Cerebellar Testing:
Coordination & Fine Motor Movement
\u2022 Several tests \u2013 providing same info
\u2022 Testing doesn\u2019t solely examine 
cerebellum \u2013 i.e. also requires strength,
crude motor function, joint movement,
vision, etc.
Specifics:
\u2022 Finger-to-nose: 
\u2013 Place your finger in space in front of patient
\u2013 Have pt move their index finger between their nose & 
your finger tip
\u2022 Heel-to-shin:
\u2013 Have patient run heel of 1 foot up & down opposite 
shin
Cerebellar Testing (cont)
Specifics (cont):
\u2022 Rapid Alternating Hand Movement
\u2013 Have patient alternately touch back & then front of 1 
hand against palm of other
\u2022 Rapid Alternating Finger Movement
\u2013 Have patient alternately touch tips of ea finger against 
thumb of same hand
Normal movement is both smooth & accurate.
Sensory Testing
Anatomy & Physiology
\u2022 2 main pathways: Spinothalamics & Dorsal 
columns.
\u2022 Spinothalamics 
\u2013 Pain, temperature, crude touch
\u2013 Impulses enter from peripheryÆ cross to other side of 
cord within ~ 2 vertebral levelsÆ travel up that side to 
brain
\u2022 Dorsal Columns
\u2013 Vibration, position, light touch
\u2013 Impulses from periphery enter cordÆtravel up that 
sideÆcross to opposite @ base of brainÆthen travel 
to their terminus
Nerves and Their Distributions
\u2022 Specific dermatomes not usually memorzied \u2013
reference chart helpful to pin down deficits
\u2022 Distributions (& spinal root contributions) for 
specific peripheral nervesÆ looked up in 
appropriate setting
Map of Dermatomes
(http://www.maturespine.com)
Distribution of Cutaneous Sensory Peripheral Nerves
(http://www.neuroguide.com/)
Spinothalamics \u2013 Pain, 
Temperature & Crude Touch
\u2022 Break Q-tip in half, creating 
sharp, pointy end.
\u2022 Ask patient to close eyesÆ
unable to get visual clues. 
\u2022 Start @ top of foot. 
\u2013 Orient patient by first touching 
w/sharp implement, then non-
sharp object (e.g. the soft end of 
a q-tip)Æ clarifies for patient 
what you\u2019re defining as sharp & 
dull 
Spinothalamics \u2013 Pain, Temperature 
and Crude Touch (cont)
\u2022 Touch lateral aspect of 
foot w/either sharp or dull 
toolÆ patient reports their 
response. 
\u2022 Move medially across top 
of foot, noting their 
response to ea touch. 
\u2022 Temperature tested by 
touching test tubes 
holding cool v warm 
water against region of 
interest \u2013 often omitted 
for practical reasons 
Spinothalamics \u2013 Pain, Temperature 
& Crude Touch (cont)
\u2022 Light touch assessed 
by gently brushing 
your finger against 
extremity & asking 
patient (eyes closed) 
to note when they feel 
it
\u2022 Upper extremities 
checked in same 
fashion
Dorsal Columns - Proprioception
\u2022 Allows body to \u201cknow\u201d where it 
is in space
\u2022 Important for balance, walking
\u2022 Ask patient to close eyesÆ
don\u2019t receive any visual cues. 
\u2013 Grasp either side of great toe. 
\u2013 Orient patient as to up and 
down:
\u2022 Flex the toe (pull it upwards) 
while telling patient what you\u2019re 
doing. 
\u2022 Extend toe (pull it downwards) 
while informing them of which 
direction you\u2019re moving it.
Dorsal Columns \u2013
Proprioception (cont)
\u2022 Alternately deflect toe up 
or down w/out telling 
patient in which direction 
you\u2019re moving itÆ should 
be able to correctly 
identify movement & 
direction \u2013Test both feet.
\u2022 Can be checked @ a 
more proximal joint (e.g. 
ankle) if abnormal.
\u2022 Upper extremities 
assessed in same 
fashion, deflecting finger 
up & down
Dorsal Columns \u2013 Vibratory 
Sensation
\u2022 Ask patient to close eyesÆdon\u2019t 
receive visual cues. 
\u2022 Grasp 128 Hz tuning fork by stem & 
strike forked ends against heel of 
your handÆ vibrate. 
\u2013 Place stem on top of interphalangeal 
joint of great toe
\u2013 Place fingers of your other hand on 
bottom-side of joint 
\u2013 Ask patient if they can feel vibration. 
\u2013 You should be able to feel same 
sensation w/fingers on bottom side of 
joint. 
Dorsal Columns \u2013 Vibratory Sensation 
(cont)
\u2022 Patient determines when 
vibration stopsÎ correlates 
w/when you can\u2019t feel it 
transmitted through joint 
\u2022 Test both feet.
\u2022 Check more proximal joints 
(e.g. ankle) if sensation 
impaired. 
\u2022 Upper extremities assessed 
similarly, w/fork placed on 
distal finger joint
Special Sensory Testing
TWO POINT DISCRIMATION
\u2022 2 point discrimination (Dorsal Columns) 
particularly useful when assessing for discrete 
peripheral nerve injury (e.g. traumatic 
disruption)