20:11
The Full Neurological Examination
UCL Clinical Skills
Overview
This video demonstrates a comprehensive neurological examination, emphasizing its importance over a focused assessment to avoid missing critical signs. It systematically guides the viewer through evaluating gait, mental status, cranial nerves, motor and sensory systems, reflexes, and coordination. The examination begins with general observations and progresses through detailed testing of each neurological component, concluding with an assessment of related structures and advice on patient care post-examination. The demonstration highlights specific techniques and rationales for each step, providing a practical guide for learners.
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Chapters
- Begin by washing hands, introducing yourself, and obtaining patient consent, ensuring they are comfortable and pain-free.
- Observe the patient's gait upon entry, noting limb weakness, arm swing, and coordination (e.g., heel-to-toe walking).
- Perform the Romberg's test to assess balance by having the patient stand with feet together, first with eyes open, then closed.
Observing gait and performing balance tests provides an immediate, high-level assessment of motor function, coordination, and proprioception, offering early clues to potential neurological deficits.
Asking the patient to walk heel-to-toe to assess coordination and balance.
- Assess mental status through general knowledge questions (e.g., current events, location) and memory tests (e.g., recalling a street name).
- Test the olfactory nerve (CN I) by having the patient identify common smells with eyes closed.
- Evaluate the optic nerve (CN II) by testing visual acuity (near and distant vision) and visual fields, and examining the fundus with an ophthalmoscope.
- Assess the oculomotor (CN III), trochlear (CN IV), and abducens (CN VI) nerves by testing eye movements for smoothness, nystagmus, and accommodation.
These tests evaluate higher cognitive functions and the initial cranial nerves responsible for senses like smell and vision, as well as crucial eye movements, which are fundamental to interaction and perception.
Using coffee to test the sense of smell for the olfactory nerve (CN I).
- Test the trigeminal nerve (CN V) by assessing sensation in its three divisions (ophthalmic, maxillary, mandibular), motor function (jaw clenching), and corneal reflex.
- Evaluate the facial nerve (CN VII) by observing facial expressions like frowning, puffing cheeks, and tightly closing eyes.
- Assess the auditory nerve (CN VIII) by testing hearing with whispered words and performing Weber's and Rinne's tests with a tuning fork to differentiate conductive from sensorineural hearing loss.
Examining these cranial nerves is vital for assessing facial sensation and movement, hearing, and distinguishing between different types of hearing impairment, all of which significantly impact a patient's quality of life.
Using a tuning fork on the mastoid bone and near the ear for Rinne's test to assess hearing.
- Examine the glossopharyngeal (CN IX) and vagus (CN X) nerves by observing the uvula's position and testing the gag reflex.
- Assess the accessory nerve (CN XI) by testing the strength of the sternomastoid and trapezius muscles.
- Evaluate the hypoglossal nerve (CN XII) by observing the tongue for wasting or fasciculations and assessing its protrusion.
- Observe the patient's overall musculature for wasting, involuntary movements, or tremors while they are lying down.
- Test muscle tone by gently moving the limbs to detect flaccidity or increased resistance.
These cranial nerves control swallowing, voice, and tongue movement, while the motor system examination assesses muscle bulk and tone, providing insights into the integrity of the neuromuscular pathways.
Asking the patient to shrug their shoulders against resistance to test the accessory nerve (CN XI).
- Assess muscle strength systematically in the arms and legs, comparing resistance against your own or normal strength.
- Test deep tendon reflexes (biceps, supinator, triceps, knee jerk, ankle jerk) using a reflex hammer, noting any diminished or exaggerated responses.
- Perform reinforcement maneuvers (e.g., clenching teeth) if reflexes are absent and test for clonus if reflexes are brisk.
- Assess coordination using tests like finger-to-nose and heel-to-shin, noting any dysmetria or dysdiadochokinesia.
Evaluating muscle strength, reflexes, and coordination is crucial for pinpointing the location and type of neurological lesion, whether it involves the upper motor neurons, lower motor neurons, or cerebellum.
Asking the patient to push their leg against your hand to test quadriceps strength.
- Test light touch sensation using a cotton wisp on the limbs and trunk with the patient's eyes closed.
- Assess pain sensation using a sharp/dull object, ensuring the patient can feel the stimulus and identify it correctly.
- Evaluate vibration sense using a tuning fork on bony prominences.
- Test proprioception (joint position sense) by moving a digit or toe with the patient's eyes closed and asking them to identify the direction of movement.
- Note any sensory loss in a 'glove and stocking' distribution or identify specific sensory levels.
A thorough sensory examination helps map out the extent of sensory pathway involvement, distinguishing between peripheral nerve issues, spinal cord lesions, or cortical sensory disturbances.
Moving the patient's toe up or down with their eyes closed and asking them to identify the direction of movement to test proprioception.
- Perform the plantar reflex (Babinski sign) by stroking the sole of the foot to check for extensor (abnormal) or flexor (normal) response.
- Re-test memory by asking the patient to recall the previously given information (e.g., street name).
- Examine related structures: skull for abnormalities, spine for curvature and tenderness, and skin for neurological markers (e.g., café-au-lait spots).
- Listen for bruits over the carotid arteries.
- Offer assistance with dressing and wash hands upon completion.
The plantar reflex is a critical indicator of upper motor neuron function, while examining related structures and performing final checks ensures a holistic assessment and proper patient care.
Stroking the sole of the foot to elicit the Babinski response.
Key takeaways
- A full neurological examination is preferred over a focused one to prevent missing subtle but significant findings.
- Systematic assessment of gait, mental status, cranial nerves, motor function, reflexes, coordination, and sensation is essential.
- Each component of the neurological exam tests specific pathways and structures, allowing for localization of potential lesions.
- Cranial nerve testing involves a combination of sensory and motor assessments for each nerve.
- Reflex testing assesses the integrity of the reflex arc and supraspinal influences.
- Sensory testing requires careful attention to detail, including patient cooperation and distinguishing between different sensory modalities.
- The Babinski sign is a key indicator of upper motor neuron lesions.
- Concluding the exam with related structures and patient care ensures a comprehensive approach.
Key terms
Neurological ExaminationGaitRomberg's TestCranial NervesOphthalmoscopeNystagmusCorneal ReflexWeber's TestRinne's TestGag ReflexMuscle ToneDeep Tendon ReflexesClonusBabinski SignCoordinationProprioceptionVibration SenseLight TouchPain Sensation
Test your understanding
- What are the key components of a full neurological examination, and why is it important to perform all of them?
- How would you test the function of the trigeminal nerve (CN V) and what specific actions would you ask the patient to perform?
- Describe the procedure for testing vibration sense and proprioception, and explain why testing these with the patient's eyes closed is crucial.
- What is the significance of the Babinski sign, and how is it elicited?
- How can you differentiate between conductive and sensorineural hearing loss using the tests described in the video?