- [Matthew] Hello, my name is Matthew Davies,
and today, we will be discussing
the neurological examination.
The clinical neurological exam is used to assess
the overall function of the nervous system,
including the central and peripheral nervous systems.
To assess the central nervous system,
the examination covers functions of five major divisions,
the cerebrum, the diencephalon, the brainstem,
the cerebellum, and the spinal cord.
The diencephalon is not easily examined
and will not be included in this clinical examination.
We begin with an assessment of the cerebrum.
To do so, we assess general cortical functioning
covering the following domains,
level of consciousness, orientation, language,
memory, Broca and Wernicke's area,
and the frontal eye field.
The level of consciousness can be assessed
just by observing your patient.
Orientation can be assessed by asking a few simple questions
such as,
can you tell me your full name, please?
- Monica (indistinct).
- [Matthew] And where are we today?
- Burlington.
- [Matthew] Okay, and what's today's date.
- August 13th.
- [Matthew] Very good.
Language can be assessed
by having the patient repeat phrases
and to name objects with their functions.
Could you repeat a phrase for me?
Could you repeat the phrase no ifs, ands or buts?
- No ifs, ands or buts.
- Okay.
And you can also have them name a few objects such as...
Can you tell me what this is?
- A hummer.
- And what do you do with the hammer?
- Hit stuff.
- Very good.
And what is this?
- A pen.
- And what do you do with the pen?
- You write?
- [Matthew] Very good.
You can also assess short-term and long-term memory.
To assess long-term memory,
you can ask the patient about a specific event
in their life.
Could you tell me when your birthdate is please?
- 9/15/72.
- [Matthew] Very good.
And for short-term memory,
you can assess by naming three objects
and having them repeat those back to you at five minutes.
Could you repeat it three objects for me?
I'm gonna have you remember them for five minutes
and I'll ask you again later.
Can you repeat ball, cat and tree?
- Ball, cats and tree.
- Very good.
This gives you roughly enough time
to complete your cranial nerve examination
and ask for these objects again later.
To test for Broca's area,
you will also listen to the patient's speech.
This patient will be able to understand,
but will not be able to vocalize words,
and this is known as expressive aphasia.
With Wernicke's area,
the patient will have no understanding,
but will be able to mouth sounds
and it will come out in something known as a word sound.
To assess frontal eye fields you assess two functions,
smooth pursuit and saccades,
which is the ability to look from point to point.
I will ask you if you can just follow my finger
while I move it slowly from side to side, please.
With this, you're looking for a nice, smooth movement,
all the way to the left and all the way to the right.
To test the cards,
you have the patient look from one finger to the other
quickly as possible.
Very good.
And you can see the quick movements of the eyes.
This is a good time to point out
that when you're looking right
you're just controlled by the left cortex,
and when you're looking at left,
you're just controlled by the right cortex.
Also these eye movements
involve cranial nerves III, IV, and VI.
The next thing that we assess
in the neurological examination is brainstem function
through assessment of the cranial nerves.
This consists of 12 nerves, somewhat similar functions,
which necessitates multiple tests.
What we do first is at rest we assess ptosis,
and we also make sure that the pupils are equal and round
and that the face is symmetric.
Cranial nerve I or the olfactory nerve
is not assessed during the clinical neurological examination
as this is the sense of smell
and it's objective and can vary significantly
from person to person.
Cranial nerve II test visual acuity
and it also tests visual fields.
This is the coolest cranial nerve of all
as you can look directly at this nerve,
through the fundoscopic exam.
We will not be showing you
that part of the examination today.
What we will show you is the assessment of visual fields.
Can I ask you to tell me how many fingers I'm holding up
when I hold them up.
- Two, well, four.
- Four, total, okay.
- Two. - Good.
- Two.
Four. - Very good.
And as you can see, all of her visual fields are intact.
The next cranial nerves that we will discuss
are cranial nerves III, IV, and VI,
which control the extra ocular movements and accommodation.
The easiest way to check all the extra ocular movements
is to make an H with your finger
and have the patient follow with their eyes.
Can you please follow my finger?
As you can see, she has full range of motion of her eyes.
Okay.
One other function of cranial nerve III
is the pupillary reflex.
And you can attest this by shining a bright light
into the patient's eye
and to look for pupillary constriction.
I'll just ask if you can look right at my forehead
while I shine a light in your eye.
And both of her pupils constrict equally.
The next cranial nerve that we all test
is cranial nerve V or the trigeminal nerve,
which tests for facial sensation.
It also innervates the muscles of mastication
used for chewing.
To assess for facial sensation,
you can ask for the patient to close their eyes, please.
And let me know if it feels equal
on both sides of your face.
Does it feel the same? - Yes.
- And here? - Yes.
- And here? - Mm-hmm.
- The trigeminal nerve gets its name
because it innovates three different portions of the face
as seen with the forehead, over the cheekbone
and over the jaw.
Cranial nerve V also controls the muscles of mastication,
which can be tested by having the patient clench their jaw
and feeling directly over the masseter muscle.
In her, you can feel the muscle contract.
The next cranial nerve that we test
is cranial nerve VII or the facial nerve,
which constitutes facial strength
involving wrinkling of the forehead,
being able to smile and being able to close the eyes.
Wrinkling of the forehead is the most important
because this can distinguish between central nervous system
and peripheral nervous system lesions.
With the peripheral nervous system lesion
of cranial nerve VII,
the patient will be unable to wrinkle up the forehead.
With a central nervous system lesion,
the patient will still be able to wrinkle the forehead,
essentially, this is innervated bilaterally.
So can I have you do a few things for me?
Can you give me a big smile with your teeth, please?
Very good.
And can you close your eyes nice and tight?
Very tight, don't let me open them.
Good, you can open your eyes.
Can you wrinkle up your forehead?
Good.
And the last thing you can have them do
to test for subtle facial weakness
is to have them puff out their cheeks
and don't let me push the air out.
Very good.
The eighth cranial nerve or the vestibular cochlear nerve
test both hearing and the vestibular reflex.
The vestibular component is tested via the Romberg exam,
which we will do it later on.
To test for hearing,
you can have the patient occlude one ear with their finger.
Can you put your right finger in it right ear?
And then can you please tell me
when you hear the rubbing sound?
- Now. - Okay.
And then you can put your finger in the other ear.
And let me know when you can hear the sound.
- Yes. - Very good.
- Now.
- Her hearing is intact.
Cranial nerves IX and X,
the glossopharyngeal and the vagal nerves
are involved in palate movement
such as when a patient says, ah,
and also are involved in the gag reflex.
So this can be assessed by having the patient say, ah,
and looking at the palate movement.
Can I have you stick out your tongue please and say, ah?
- Ah.
- Very good.
And in her, her palate elevates symmetrically.
You can also assess the functions of cranial nerve VII,
IX, and XII, by having them say a simple three word phrase.
Can you repeat the phrase pa?
- Pa.
- Ka. - Ka.
- And ta. - Ta.
- Pa, ka, ta, a very unique and interesting phrase,
gives you a lot of information
about the function of cranial nerves.
The pa sound is the function of cranial nerve VII.
As you need the...
You need that nerve intact to make a P.
Cranial nerve IX is involved in making the ka sound
or the K, and cranial nerve XII
is involved in making the ta sound or the T.
A key point is that swallowing
involves cranial nerves IX, X and XI.
So this requires analysis of other components
of these cranial nerves.
Cranial nerve X also controls blood pressure and heart rate.
This can be used to assess other functions
of cranial nerve X.
Cranial nerve XII, which we'll test next
can be assessed by doing shoulder shrugs
and by turning the neck.
During these motions,
what you're trying to assess is for atrophy
of either the trapezius or the sternocleidomastoid muscle.
So to test cranial nerve XI
you can have the patient look at the left,
turn the head to the left, and then push back towards me.
Good.
And then look to the right and push back towards me.
What you're looking for is the sternocleidomastoid muscle
right here.
You're looking for some atrophy.
To test another function of cranial nerve XI
you can have the patient shrug their shoulders
and don't let me push them down.
Very good.
Cranial nerve XII,
or the hypoglossal nerve controls tongue movement,
which is very easy to test.
What you can do is just have the patient
stick their tongue out at you.
Very good.
And assess for deviation and for atrophy.
Now is the perfect time for your patient
to repeat the three objects
that we talked about early to test the short-term memory.
Can you repeat those three objects
that we spoke about earlier?
- Cat, ball and tree.
- Very good.
The next part that we will assess is the motor function,
which is an assessment of both cortical
and spinal functioning.
Assessment includes the following components,
muscle bulk, muscle tone, pronator drift,
and muscle strength.
Muscle bulk can be assessed just by looking for atrophy
of any major muscle group,
which would be a sign of a lower motor neuron disease.
Muscle tone can be assessed by the following,
can I have your wrist please?
And you can just have your wrist nice and loose.
And you're looking for either rigidity
or spasticity of the muscle groups.
You can test both sides
to make sure that there's symmetrical
The pronator drift,
which helps distinguish between upper motor neuron sign.
When the patient's arms are extended,
their arms tend to pronate versus a muscular disease
such as shoulder weakness,
where their arm would drop without pronating.
This can be assessed
by having your patients stick their arms out
in front of them with their palms up and closing their eyes.
Typically, you would do this for about 30 seconds.
All right, thank you very much.
The last component of the motor function exam
is the muscle strength.
What you want to assess is major muscle groups,
such as the biceps, the triceps, the quads,
and then the ankle dorsi and plantar flexion.
We will just show you an example of a few of those today.
Can I have you make a nice big fist?
And don't let me pull your arm away.
Good.
And then you wanna test on both sides
and look for symmetry.
Very good.
And can you lift this leg up in the air?
Very good.
Don't let me push.
And same with this side, don't let me push down.
Good.
In the muscle groups that we tested, she has full strength.
The next part of the neurological examination
is to assess coordination,
which gives us important information about the cerebellum.
This assessment includes finger tapping,
rapid alternating movements and the finger to nose test.
Finger tapping, which we'll demonstrate shortly (coughs)
is an assessment of dexterity.
Can I just have you rapidly tap your fingers?
Very good.
In her it's quick and symmetrical.
The next part to assess is rapid alternating movements,
which tests cerebellar function.
This can be assessed by having the patient
put their hands with their palms down on their legs
and having them quickly flip back and forth,
and then to go as fast as possible.
Again, you're looking for symmetry.
Very good.
The last part of this cerebellar and coordination function
is the finger to nose test.
A tremor in the horizontal direction
is a finding in cerebellar disease
versus a resting tremor such as in Parkinson's disease
can actually improve with movement during this exam.
So what you have the patient do,
is take their right index finger
and then go towards my index finger
and back towards their nose and keep going back and forth.
Make sure that you move far and make you difficult.
And then you can assess
the left index finger (Monica laughs)
and do the same.
Very good.
Next, we will assess reflexes,
both deep tendon and superficial reflexes.
Deep tendon reflexes are assessed with a reflex hammer.
Hyperreflexia is a sign of an upper motor neuron disease,
whereas hyperreflexia is a sign of a motor neuron disease.
You can test several muscle groups
and several deep tendon reflexes this way.
The one that we will give an example with
is the patella reflex.
Okay.
So you can just ask the patient to just relax
and I'm gonna tap on your knee with the reflex hammer.
Very good.
Yeah, her reflexes are intact.
Superficial reflex is involved with Babinski
when you scratch the undersurface of the toe,
a positive the Babinski sign or present Babinski sign
is this simple.
An example of an upper motor neuron disorder.
We will not be testing that in this exam today.
Next, we will assess body sensation,
which is another assessment of both cortical
and spinal functioning.
Similar to cranial nerve V and facial sensation,
we need to test the function of the spinal nerves
controlling sensation to the rest of the body.
Most importantly,
again, is to note the differences between the right
and the left side symmetrically.
The different modalities that you can test are light touch,
sharp sensation, proprioception, and vibration.
To test light touch
you can simply touch on different surfaces of the body.
And can I have you close your eyes, please?
Does it feel the same when I rubbed my fingers on here
on both sides?
- Yes, it does.
- And the same on the feet? - Mm-hmm.
- Very good.
To test sharp you can use the end of a reflex hammer,
or you can use any other sharp object.
Just make sure that it's not dangerous for the patient.
I'm gonna be putting a sharp object on your hand,
it will feel like this. - Mm-hmm.
- And I just want you to let me know when you can feel it,
okay?
- Yes.
- And here? - Yes.
- And then on your foot as well.
- Yes.
No.
- Okay.
And you can open your eyes for a second.
We'll demonstrate how to do a proprioception exam.
If you stick your hand out with your thumb up in the air.
And I want you to tell me whether it's up, down,
or in the neutral position.
And now we'll do it with your eyes closed.
- Up.
Down.
Neutral. - Very good.
And we can test the other hand as well.
- Up.
Down.
Neutral.
- You can also assess the toes this way.
And the last modality to test is the vibration sense,
which can be done with a tuning fork.
So we'll do this with the eyes open first to demonstrate.
So you would be feeling for a vibration sense like this.
I'm gonna ask when you can feel it
and when you don't feel it anymore.
The key to this is doing it over a bony part of the hand.
So can I have you close your eyes, please?
- Yes.
- And let me know when you don't feel it anymore.
- No.
- Okay.
Same with the other side.
- Yes.
No.
- Very good.
Last we will be assessing stance and gait.
This includes the Romberg exam.
To test the Romberg the brain requires input
from two out of three domains to maintain balance.
These domains are proprioception, vestibular and vision.
Romberg takes away the vision component,
so we have a complete assessment of proprioception
and vestibular reflexes.
To test Romberg,
you can have the patient stand
with their feet close together,
with the hands at their sides,
and then ask them to close their eyes
while you help them maintain their balance.
She has a negative Romberg
as she is able to maintain her balance during this exam.
You can open your eyes.
And the last thing that we will test is her gait.
This can be assessed by multiple different modalities,
including a normal gait, toe walking, heel walking,
and then a tandem gait.
Make sure that when you're assessing this,
you walk by the side of your patient
in case they do have a balance problem.
All right, I'll just ask you if you can take a few steps
with your normal gait towards the door.
Good.
And then you can turn around and walk back towards the wall
on your toes.
- My toes?
- Yes, very good.
Okay.
And turn around and back towards the door on your heels.
And one last time, walk back towards the wall
with one foot in front of the other.
Very good.
All right, that's the end of the gait.
So that concludes
the end of the clinical neurological examination.
I thank you very much for joining us today
and I wish you the very best in your class.