Info
🌱 來自: Huppert’s Notes
The Neurologic Exam🚧 施工中
The Neurologic Exam
Mental status
• Orientation: Person, place, time, situation
• Language: Fluency, repetition, naming (high and low frequency items), comprehension (axial [“close eyes, stick out tongue”] and appendicular [“show two fingers, give thumbs up”] commands, complex commands [“take your right thumb, touch your left ear, and stick out your tongue”])
• Attention: Ask patient to spell “WORLD” forward, then backward. Alternatively: Recite months of the year or days of the week backward.
• Memory: Working (digit span forward (normal >5–7 digits), backward) and delayed (remember three words ×5 minutes)
Cranial nerves
• I – Olfactory nerve: Not frequently tested
• II – Optic nerve/III parasympathetic fibers: Visual fields/pupillary constriction (afferent – optic nerve, efferent parasympathetic fibers)
• III, IV, VI – Oculomotor, trochlear, and abducens nerves: Extraocular muscle movements
• V – Trigeminal nerves: Facial sensation, motor for muscles of mastication
• VII – Facial nerve: Facial movement, eyelid closure, lacrimation and salivation, taste in the anterior 2/3 of the tongue
• VIII – Vestibulocochlear nerve: Hearing from the cochlear nerve, balance from the vestibular nerve
• IX, X – Glossopharyngeal and vagus nerve: Palate elevation, gag, cough
Motor
• Bulk and tone: Increased = spasticity, rigidity, or paratonia; decreased = flaccidity
• Screening motor exam: Pronator drift (sign of upper motor neuron weakness; evaluate for finger flexion and/or pronation with arms outstretched and eyes closed), finger taps and toe taps (evaluate for large, symmetric, rapid movements)
• Confrontational strength testing:
- Power: Score motor strength in each muscle group from 0 to 5:
• 0: No contraction
• 1: Trace movement
• 2: Full range of motion when gravity is eliminated
• 3: Full range of motion against gravity
• 4: Movement against gravity with resistance, but still less than full strength
• 5: Full/normal strength
- Preferential muscle groups to test:
• Upper extremity: Shoulder abduction (deltoids), flexion and extension at elbow (biceps, triceps, resp), wrist extension, finger extension and abduction
• Lower extremity: Hip flexion (ilioposas), knee flexion and extension (hamstrings, quads), ankle dorsiflexion (tibialis anterior)
Sensory
• Screening exam: Assess ability to sense light touch
• Small fiber: Pain (safety pin) and temperature (alcohol swab, cold tuning fork)
• Large fiber: Vibration (tuning fork) and proprioception (joint position sense)
Reflexes
• Upper extremity reflexes: Biceps (C5–6), triceps (C7–8)
• Lower extremity reflexes: Patellae (L3–4), Achilles tendon (S1–S2)
• Plantar response: Apply noxious stimulus starting at the lateral aspect of the sole of the foot, moving medially across the ball of the foot. Normal response is flexor (toes down); abnormal response is extensor (large toe goes up and remaining toes fan out = Babinski sign)
Coordination
• Appendicular (limb) ataxia: Finger-nose-finger, heel-knee-shin
• Truncal ataxia: Sitting upright unsupported, gait ataxia
Gait
• Description of gait: Stance (normal, wide, or narrow-based), stride length, foot clearance (shuffling; foot drop → steppage gait), arm swing (decreased in parkinsonism)
• Romberg test: Balance requires visual, vestibular (inner ear), and proprioceptive (positional sense) systems. Romberg testing eliminates vision and tests the remaining two; this is NOT a test of cerebellar function!