- Taking a detailed history and performing a careful examination can help the doctor to determine the site of a specific neurological lesion and reach a diagnosis, or at least differential diagnoses.
- A systematic approach is required.
- This is a general article, attempting to cover all aspects of neurological history and examination. You are referred to other related articles where relevant for more detail.
- Mental state examination may also be an important consideration and this is covered in the separate article Mini Mental State Examination (MMSE).
Observation of the patient
- Is there a problem with articulation (dysarthria)? Here comprehension is retained and speech construction is normal. There is usually weakness or incoordination of the orolingual muscles. Ask the patient to say 'West Register Street' if you are uncertain.
- Is there a problem with phonation (dysphonia)? This is usually due to laryngeal problems which can cause voice hoarseness. There may be reduced speech volume.
- Is there a problem with language function (dysphasia)? This is due to a lesion in the language areas of the dominant hemisphere.
- A separate article discusses Dysarthria and Dysphasia in more detail.
Specific emphasis should be placed on the following:
- Add notes to any clinical page and create a reflective diary
- Automatically track and log every page you have viewed
- Print and export a summary to use in your appraisal
- Ask about the symptoms:
- What are they?
- Which part of the body do they affect? Are they localised or more widespread?
- When did they start?
- How long do they last for?
- Were they sudden, rapid or gradual in onset? Is there a history of trauma?
- Are the symptoms static or deteriorating, or are there exacerbations and remissions?
- Does anything trigger the symptoms, eg exercise, sleep, posture or external stimuli such as light or smell?
- Ask about any associated symptoms (other features of neurological disease):
- Try to understand how the symptoms may affect the patient's life, ask about activities of daily living.
Past medical history
Some neurological problems can present years after a causative event.
- Enquire about other medical problems, past and present. These may give clues to the diagnosis. For example:
- Ask about pregnancy, delivery and neonatal health.
- Ask about any infections, convulsions or injuries in infancy, childhood or adult life. Particularly ask about head or spinal injury, meningitis or encephalitis.
The systematic enquiry is very important here. For example:
- Loss of weight and appetite may suggest malignancy and this may be a paraneoplastic syndrome.
- Gain in weight may have precipitated diabetes.
- Polyuria may suggest diabetes. Difficulty with micturition or constipation may be part of the neurological problem but was not volunteered in the general history. In men, enquire about erectile dysfunction.
- Note smoking and drinking habits. Alcohol is a significant neurotoxin, both centrally and peripherally.
- Ask about drugs including prescribed, over-the-counter and illicit. This includes complementary and alternative medicines.
- Ask about occupation and what it involves. There may be exposure to toxins. Is repetitive strain injury likely? Is there prolonged visual work which may predispose to tension headache or migraine? The job may involve driving but the patient has admitted to convulsions. He may work at heights or in a dangerous environment.
- Ask about marital status. Has there been recent bereavement or divorce which may have affected symptoms?
- Ask about sexual orientation and consider likelihood of sexually transmitted infection, eg syphilis, HIV
Consider if there may be a genetic basis or predisposition. For example:
- A cousin with Duchenne muscular dystrophy or Becker muscular dystrophy would be very important for a boy who cannot run like his peers.
- Huntingdon's chorea is unusual in that it is a familial disease that does not present until well into adult life.
- A family history of, eg type 2 diabetes, cerebral aneurysm, neuropathies, epilepsy, migraine or vascular disease may be important.
Examination of speech
- Look for spontaneous speech, fluency and use of appropriate words during conversation.
- Ask the patient to name objects.
- Ask the patient to carry out some commands to assess their comprehension.
- Ask the patient to read aloud. This can show evidence of any dyslexia.
- Ask the patient to repeat a simple sentence. Inability to do this suggests a conduction dysphasia.
- Look at the patient's handwriting. There may be problems with form, grammar or syntax which may suggest a more global language problem and not just a speech disorder.
Examination of the neck
- Examine the neck movements:
- Is there evidence of degenerative disease which may be producing radicular symptoms in the upper limbs? Examine flexion, extension and rotation.
- Look for Lhermitte's sign. This is when neck flexion causes an electric shock-like feeling on the limbs. It is due to disease in cervical spinal cord sensory tracts (seen in, eg multiple sclerosis, syringomyelia, tumours).
- Is there any neck stiffness (can be a sign of meningeal irritation)? The chin can normally touch the chest when the neck is flexed but this is not possible if neck stiffness is present. This may be a sign of meningitis or subarachnoid haemorrhage.
- Palpate the supraclavicular fossae:
- Look for enlarged lymph nodes or cervical ribs.
- Listen for any bruits:
- Listen at the carotid bifurcation at the angle of the jaw for carotid bruits.
- Listen over the supraclavicular fossa for vertebral or subclavian bruits.
- A common carotid bruit may be heard by listening between these two sites.
- Listen with the bell of the stethoscope over a closed eyelid for bruits due to cerebral arteriovenous malformations.
- Listen for cardiac murmurs to ensure that any bruit heard is not just due to transmission of these.
- Note that just because a bruit is not heard, it does not mean that there is no significant stenosis present.
- Examination of the cranial nerves takes practice. The cranial nerves and their function is summarised below.
- I (olfactory nerve): smell
- II (optic nerve): visual acuity, visual fields and ocular fundi
- II, III (optic nerve and oculomotor nerve): pupillary reactions
- III, IV, VI (oculomotor, trochlear and abducent nerves): extra-ocular movements, including opening of the eyes
- V (trigeminal nerve): facial sensation, movements of the jaw, and corneal reflexes
- VII (facial nerve): facial movements and gustation
- VIII (vestibulocochlear nerve): hearing and balance
- IX, X (glossopharyngeal and vagus nerves): swallowing, elevation of the palate, gag reflex and gustation
- V, VII, X, XII (trigeminal, facial, vagus and hypoglossal nerves): voice and speech
- XI (accessory nerve): shrugging the shoulders and turning the head
- XII (hypoglossal nerve): movement and protrusion of tongue
- A separate article describes Examination of the Cranial Nerves in detail.
Brief cranial nerve examination
- Olfactory nerve:
- Tested using bottles containing characteristic substances such as peppermint, coffee or vanilla and ask the patient to identify each in turn.
- Test each nostril separately and occlude the other.
- Patient's eyes should be closed.
- If such bottles are not available, simply ask the patient if he has any problems with smell or taste.
- Remember that most of what we call taste is really smell.
- Optic nerve:
- Visual acuity can easily be tested with a Snellen chart. If the patient normally wears spectacles, they should wear these.
- Test the visual fields by confrontation. Sit about 40cm away from the patient and ask them to keep their eyes fixed on your nose. Ask them to cover one eye. Hold your finger half way between you and the patient with your arm extended. Test each quadrant of their visual field in that eye by moving your finger laterally to medially along the diagonal. Move inwards from the periphery at a number of points in the upper and lower, nasal and temporal quadrants. Ask the patient when your finger appears into view. If you also fix on their nose, you can compare their response with yours, taking your own as normal. Repeat for the other eye.
- Take the ophthalmoscope and ask the patient to fix their gaze on something in the distance. First shine the light on each eye and then remove it. The pupil should be brisk in its response. Check direct and consensual reflexes (the reaction of the pupil on the side that you shine the light in is called the direct light reflex; the constriction of the other pupil is the consensual light reflex).
- Test accommodation by asking the patient to look in the distance and then at an object close up. Look for any change in pupil size.
- Then use the ophthalmoscope to examine the back of each eye. Check that the optic disc is clear and that there is no papilloedema. Note the vessels of the retina and try to see the periphery.
- Oculomotor, trochlear and abducent nerves:
- Hold the patient's head still with your left hand on their forehead.
- With your arm extended, hold out your right index finger about 40cm in front of the patient.
- Ask them to follow your finger with their eyes.
- Move your finger up and down and left and right. There should be a full range of movements of both eyes.
- Then move the finger to the left and hold it there for several seconds whilst the eyes are observed for nystagmus. Repeat to the right and up and down. False positive tests for nystagmus can result from holding the finger too close and by moving it too far to the extreme of vision.
- Test convergence by bringing in your finger from a distance towards the tip of the patient's nose and asking them to focus on it.
- Trigeminal and facial nerves:
- Lightly touch each side of the face in the three sensory regions (forehead, cheek/side of nose and chin) and ask if it feels normal and symmetrical. Ask the patient to clench their teeth. Both masseters should feel firm and strong. Ask the patient to open their jaw against resistance. In this brief assessment it is fair to omit the corneal reflex.
- Ask the patient to give a smile, demonstrating what you want. Is it full and symmetrical? Ask them to screw up their eyes. Gently try to prise them open. You should fail. If there is any facial weakness, ask them to raise their eyebrows. The upper motor neurone innervation of the muscles of the forehead is bilateral. Hence a lower motor neurone lesion will cause asymmetry but an upper motor neurone lesion will not.
- Vestibulocochlear nerve:
- Either whispering into each ear or using a high frequency tuning fork can give a very crude assessment of hearing. The separate article entitled Hearing Tests gives more details.
- Glossopharyngeal, vagus nerves:
- Ask the patient to open their mouth wide and to say, "Arhh". Phonation should be clear and the uvula should not move to one side.
- Elicit the gag reflex by touching the tonsil or the pharynx. There should be elevation of the pharynx and the palate. Test each side.
- Ask the patient to puff out the cheeks.
- Accessory nerve:
- This nerve supplies the trapezius and sternomastoid muscles.
- Ask the patient to shrug their shoulders up and try to push them down. Then ask them to rotate their head to the right against resistance on the right side of the chin from your hand. Repeat for the left side. Both these movements should be very difficult to resist.
- Hypoglossal nerve:
- Ask the patient to protrude their tongue and note any deviation or wasting. Assess tongue movement from side to side.
Examination of the sensory system
There are separate articles that describe sensory examination in detail:
Both the upper and lower limbs should be examined. Work in a methodical way. A logical progression is required when examining each sensory modality.
- With the lower limbs, you may want to start testing over the groin and to move down the front of the leg and up the posterior side as this moves progressively from L1 to S3 dermatomes.
- With the upper limbs, you may want to start testing over the shoulder and to move along the lateral aspect of the arm and up the medial side as this moves progressively from C4 to T3 dermatomes.
- The dermatomal (segmental) and peripheral nerve innervation is labelled in the diagrams below.
The following sensory modalities should be tested:
- Light touch and pin prick (sharp touch)
- Both light touch and pin prick are conducted along the same pathways.
- Light touch can be tested by using a light touch of the finger, a piece of cotton wool or a small brush. It is important to touch and not to stroke as moving sensations, such as rubbing and scratching are conducted along pain pathways.
- Test sharp touch using a dedicated disposable pin. Test light touch using the light touch of a finger, a piece of cotton wool or a piece of tissue paper.
- One approach is to touch the patient with a tuning fork as the metal feels cold.
- Containers of warm and cool water may be used for more accurate assessment. Ask the patient to distinguish between warm and cool on different areas of the skin with their eyes closed.
- Proprioception (joint position sense)
- This can be tested at the distal interphalangeal joint of the index finger and at the interphalangeal joint of the big toe.
- The examination technique is described in the articles on neurological examination of the upper and lower limbs.
- Vibration sense
- This can be examined using vibrating 128 Hz tuning fork.
- Please refer to the above mentioned articles for examination technique.
- Two-point discrimination
- This is usually just performed on the pulp of the fingers using a two-point discriminator.
- The technique is described in the article neurological examination of the upper limbs (link below).
Examination of the motor system
There are separate articles that describe motor examination in detail:
Both upper and lower limbs should be examined. The following gives a brief outline of the examination.
- Start by looking at the patient.
- Note the resting posture. Is there unusual rotation or posture of a joint? Is the patient symmetrical?
- Look for muscle wasting or hypertrophy. Is it focal or diffuse? An upper motor neurone (UMN) lesion will produce disuse atrophy but a lower motor neurone (LMN) lesion or myopathy will produce much more marked wasting.
- Look for muscle fasciculation (sign of lower motor neurone disease process). These are subcutaneous twitches over a muscle belly at rest. Tapping the belly may stimulate fasciculation.
- Hypertonia is found in upper motor neurone lesions; hypotonia is found in lower motor neurone lesions and cerebellar disorders.
- In the upper limbs:
- Ask the patient to let their shoulders and arms 'go floppy'.
- Flex and extend their shoulder passively and feel for abnormality of tone.
- Repeat for the elbow and wrist.
- In the lower limbs:
- Ask the patient to let their legs 'go floppy'.
- Internally and externally rotate the 'floppy' leg. Assess for any increased or reduced tone.
- Then lift the knee off the bed with one of your hands. Does the ankle raise off the bed as well signifying increased tone?
- Ankle clonus can also be tested and is discussed in the article on Neurological Examination in the Lower Limbs.
- As with sensation, test each group of muscles in a systematic order.
- The Medical Research Council (MRC) has a recommended grading system for power (see table).
- Examination of power in both the upper and lower lower limbs is described in the articles on neurological examination of the upper and lower limbs and so will not be repeated here.
|MRC scale for muscle power|
|0||No muscle contraction is visible.|
|1||Muscle contraction is visible but there is no movement of the joint.|
|2||Active joint movement is possible with gravity eliminated.|
|3||Movement can overcome gravity but not resistance from the examiner.|
|4||The muscle group can overcome gravity and move against some resistance from the examiner.|
|5||Full and normal power against resistance.|
- Deep tendon reflexes
- Eliciting deep tendon reflexes requires good technique and an appropriate tendon hammer is required.
- How to elicit the various tendon reflexes is described in the articles on neurological examination of the upper and lower limbs.
- Tendon reflexes tend to be brisk when there is an UMN lesion and depressed in a LMN lesion. Isolated loss of a reflex can point to a radiculopathy affecting that segment.
- Reflexes can either hyperactive (+++), normal (++), sluggish (+) or absent (-). ± is used when the reflex is only present on reinforcement.
- Superficial tendon reflexes
- In the lower limbs, this is the plantar response.
- To elicit this, the patient should be lying down with their legs extended.
- Use a blunted point and run this along the lateral border of the foot, starting at the heel and moving towards the big toe.
- Stop on the first movement of the big toe.
- An extensor plantar response (upgoing big toe) is pathological and signifies an upper motor neurone lesion.
- The cerebellum helps in the coordination of voluntary, automatic and reflex movement.
- Tests of cerebellar function in the upper limbs are described in the article neurological examination of the upper limbs (link above) and include:
- The finger-nose test
- Rapid alternating movement
- Tests of cerebellar function in the lower limbs are described in the article neurological examination of the lower limbs and include:
- The heel-shin test
- The heel-toe test
- Romberg's test examines lower limb cerebellar function but also tests balance mechanisms that rely on the cerebellar, vestibular and proprioceptive systems.
- Ask the patient to keep their eyes open and stand with their feet together, arms by their sides.
- Then ask them to maintain this position when they close their eyes.
- Patients who have cerebellar lesions often cannot stand in this position even with their eyes open. If balance is only lost when the eyes are closed, this signifies a proprioceptive or vestibular lesion.
- Be ready to catch the patient by standing behind.
Further reading & references
- Russell F, Triola R; The Precise Neurological Exam; From New York University School of Medicine
- Neuroexam.com - neurological examination including short realtime demonstrations
- Macleod J, Munro JF, Campbell IW; Macleod's Clinical Examination. Churchill Livingstone, 2000
- Russell F, Triola R; The Precise Neurological Exam; From New York University School of Medicine
|Original Author: Dr Michelle Wright||Current Version: Dr Michelle Wright|
|Last Checked: 21/05/2010||Document ID: 2509 Version: 23||© EMIS|
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