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Performing a Comprehensive Neuro Exam

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MSE: assess alertness, arousal, attention, language, cognition, memory, judgement, praxis, mood

CN EXAM: localize brainstem or peri-brainstem dysfunction

MOTOR: assess bulk/tone, power, abnormal movements

SENSATION: assess peripheral neuropathy or localize spinal cord dysfunction

REFLEXES: localize upper vs. lower motor neuron dysfunction

COORDINATION: assess dysfunction of cerebellum or its connections

STATION & GAIT: assess weakness, pain, and integration of sensory inputs with motor outputs

See below for details:

 

MSE: alertness, arousal, attention, language, cognition, memory, judgement, praxis, mood

  • Awake or in coma? How much stimulation to maintain arousal?

  • Orientation: person / place / time

  • Attention (20-->1 / Mon --> Sun / serial 7s / WORLD) and neglect (line bisection, letter cancelation, double simultaneous stimulation)

  • Language: follows commands, fluency, repetition, naming, articulation/dysarthria

  • Cognition: draw a clock-face and put in a specified time; administer MMSE/MOCA

  • Memory: STM (recall 3 objects), ITM (current events), LTM (past 5 presidents)

  • Insight/Judgment: e.g. awareness of deficits, recognizes own body parts, ?OCD sx

  • Praxis: brush teeth, comb hair, tie shoelaces

  • Calculation: $1.75 = how many quarters? (also finger agnosia, right/left confusion)

  • Affect/Mood – describe and say if they are congruent

CN EXAM: localize brainstem or peri-brainstem dysfunction (*=technically not CN)

Cranial Nerve 2

  • Perform fundoscopic exam: examine retina and optic nerve head
  • Evaluate visual acuity: Snellen card, OKNs
  • Visual Fields: counting fingers in each visual quadrant or blink to threat
  • Assess for RAPD (CN 2, 3)

Cranial Nerve 3, 4, 6

  • Evaluate extraocular movements: H-test
  • Examine for ptosis
  • Assess pupillary reaction to light and accommodation
  • Cover/Uncover Test for skew deviation

Cranial Nerve 5

  • Check sensation in V1, V2, V3 distributions
  • Assess temporalis muscle by asking patient to bite down

Cranial Nerve 7

  • Assess facial symmetry and equal facial activation (check for nasolabial fold flattening and symmetric smile)
  • Check taste on anterior 1/3 of the tongue (Each side of tongue controlled by ipsilateral facial nerve)

Cranial Nerve 8

  • Evaluate hearing with whispered voice test or finger rub
  • Perform Weber/Rinne test with 512Hz tuning fork

Cranial Nerve 9, 10

  • Evaluate palate elevation by asking patient to say "ah"
  • Gag reflex (afferent limb CN 9; efferent limb CN 10)

Cranial Nerve 11

  • Check trapezius strength with shoulder shrug
  • Check sternocleidomastoid strength with head turn against resistance

Cranial Nerve 12

  • Evaluate whether tongue is midline by asking patient to stick tongue out

MOTOR: bulk/tone, power, abnormal movements

  • Assess bulk; assess tone - flaccid/rigid/spastic/paratonia/myotonia

  • Pronator drift/forearm rolling – corticospinal tract dysfunction (upward drift = parietal dysfunction)

  • Individual muscle testing per chart below. Always stabilize proximal to the joint.

  • Graded: 0 none | 1 twitch | 2 move in plane | 3 antigravity | 4/4+/5- weak | 5 Full

  • Evaluate for subtle weakness with maneuvers such as finger taps and orbiting

Motor Chart

SENSATION: touch, pain/pin, temperature, vibration, proprioception

  • Light touch (= control; if not present, further testing is not helpful for localization)

  • Spinothalamic tract: pinprick and temperature

  • Dorsal Columns: vibration (128Hz tuning fork), proprioception, two-point discrimination

REFLEXES: biceps, brachioradialis, triceps, patellar, achilles

  • Graded: 1+ slight | 2+ normal | 3+ brisk, often spread | 4+ elicited clonus

  • Brachioradialis and biceps reflexes – C5,6 (C5, C6 "pick up sticks")

  • Triceps reflex – C7, C8 (C7, C8 "open the gate")

  • Patellar reflex – L3, L4 (L3, L4 "kick in the door")

  • Achilles reflex - S1, S2 (S1, S2 "buckle my shoe")

Pathologic Reflexes

  • Babinski Sign
  • Hoffman's Sign
  • Jaw Jerk
  • Pectoral Spread

Primitive Reflexes (aka Frontal Release Signs)

  • Glabellar: performed by repetitive tapping of the glabella (area between the eye brows); positive reflex is nonsuppression of blinking
  • Palmomental: performed by stroking the thenar eminence; positive reflex is involuntary contraction of the mentalis muscle
  • Rooting: performed by stroking the chin, mouth, or cheek; positive reflex is involuntary turning of the head toward the stimuli
  • Snout: performed by tapping of the closed lips: positive reflex is contraction of the muscles that causes a snout

COORDINATION

  • Finger-nose-finger in upper extremities; in lowers, heel-to-shin or toe-to-finger

  • Rapid alternating movements: palm-dorsum-palm

  • Loss of check

  • Finger Chase

  • Hold tip of pinky (or index) in one hand to the tip of the pinky in the other

STATION & GAIT

  • Walk across the room

  • Walk on heels (tests ankle dorsiflexion strength) and toes (plantar flexion strength)

  • Heel to toe (tandem)

  • Further features: antalgia, focal weakness (e.g. steppage), proper cane usage

  • Romberg sign (can’t stand eyes closed & feet together >60s 🡪 sensory ataxia)