Pronator drift can indicate damage to

A prompt, consensual i. Patients are asked to follow a finger moving up, down, laterally, and diagonally with their eyes. Observe for the following: Paresis : absence of movement of one or both eyes Alterations in smooth pursuit e.

A normal response is constriction of the pupil. Eyelid ptosis Levator palpebrae superioris muscle dysfunction The patient is asked to open and close their eyes. Trigeminal nerve V Facial sensation The examiner lightly touches three distinct facial areas , typically the forehead, cheek, and jaw.

Normally, light touch should be felt by the patient in all three areas. If this is not the case, additional tests for abnormalities of other sensory modalities e.

Muscle function muscles of mastication The patient is asked to open and close their mouth. Vestibulocochlear nerve VIII Hearing Basic hearing test : Normally, the patient should be able to hear two fingers rubbing together before the external acoustic meatus ear canal.

Glossopharyngeal nerve and vagus nerve IX, X Palatal movement The physician asks the patient to open the mouth and performs a visual inspection of the uvula and soft palate : Palate and uvula should be symmetrical and not deviat e. The uvula and throat are better visible when the tongue is pressed down with a stick and the patient says "ah". CN IX only: sense of taste If the sense is intact, the patient should be able to taste bitter substances. CN X only recurrent laryngeal nerve : vocalization If the nerve is intact, the patient would not have h oarseness or a bovine cough.

Accessory nerve XI Trapezius muscle and sternocleidomastoid muscle motor function Trapezius muscle : The patient's shoulder is elevated against resistance. Sternocleidomastoid muscle : Th e patient's head is rotated against resistance.

Hypoglossal nerve XII Tongue muscles motor function The tongue should be pressed against the cheek from the inside, while the examiner tests the strength by pushing from the outside. The tongue should be symmetrical and not deviate when the patient sticks out the tongue. Cranial nerve reflexes Reflex Afferent limb Efferent limb Examination technique Normal response Pupillary reflex Optic nerve Oculomotor nerve Note the pupil size and shape at rest.

Consecutively illuminate the pupils with a flashlight, observing for direct and indirect reaction to light. Pupillary constriction Corneal reflex V 1 of trigeminal nerve Facial nerve Touch the cornea with a clean soft material e. Place a finger on their chin. Strike the finger with a reflex hammer. Jaw closure contraction of masseter muscle Gag reflex Glossopharyngeal nerve Vagus nerve Touch the posterior wall of the pharynx with a tongue depressor.

Elevation of the palate Cough reflex Vagus nerve cough receptors in trachea and large and medium diameter bronchi Vagus nerve Phrenic nerve Spinal nerves Not routinely examined Cough. Upper motor neuron UMN injury vs. Fasciculations are absent. Abnormal muscle movements Disorder Description Causes Myoclonus Sudden brief contraction of an isolated muscle group Metabolic abnormalities e. Hepatic encephalopathy Akathisia Subjective feeling of restlessness manifesting in the inability to stay still Use of medications dopamine antagonists such as neuroleptics and metoclopramide , SSRIs Athetosis Involuntary writhing movements of the fingers, hands, feet, and, less commonly, arms, legs, and neck Lesions affecting striatum Huntington disease Sydenham chorea Chorea Continuous, irregular movements of the extremities and trunk Dystonia Sustained contraction of a muscle group leading to abnormal posturing , tremor , or both Idiopathic e.

Routinely assessed muscles Muscle Innervation Movement Upper extremity Deltoid C5—C6 axillary nerve Abduction of upper arm to horizontal level Biceps brachii C5—C7 musculocutaneous nerve Flexion of the forehand at elbow Triceps brachii C6—C8 radial nerve Extension of the forehand at elbow Flexor carpi ulnaris C8—T1 muscular branches of the ulnar nerve Palmar flexion of the hand at wrist Extensor carpi radialis C5—C8 radial nerve Dorsiflexion of the hand at wrist Abductor pollicus brevis C8—T1 median nerve Thumb abduction Interossei C8—T1 deep branch of the ulnar nerve Finger abduction Lower extremity Iliopsoas L1—L3 femoral nerve Flexion of the leg at hip Quadriceps femoris L2—L4 femoral nerve Extension of the leg at knee Hamstrings L5—S2 sciatic nerve Flexion of the leg at knee Tibialis anterior L4—L5 deep peroneal nerve Foot dorsiflexion Gastrocnemius S1—S2 tibial nerve Foot plantar flexion.

Brachioradialis reflex Striking the lower end of the radius with a reflex hammer elicits movement of the forearm.

Lower limbs L2—L4 Adductor reflex Tapping the tendon on the medial epicondyle of femur elicits the adductor reflex.

Knee reflex Striking the tendon just below the patella leg is slightly bent induces knee extension. L5 Posterior tibial reflex The tibialis posterior muscle is tapped with a reflex hammer, either just above or below the medial malleolus. The reflex is positive when an inversion of the foot occurs. S1—S2 Ankle reflex Striking the Achilles tendon with a reflex hammer elicits a jerking of the foot towards its plantar surface. Alternatively, the reflex is triggered by tapping the ball of a foot from the plantar side.

Alternatively, the response is only elicited with reinforcement maneuvers. The anterior abdominal wall is lightly stroked with a spatula from lateral to medial bilaterally in the following areas: Below the costal arch Around the umbilicus Above the inguinal ligament A normal response is the contraction of the abdominal muscles, while the absence of contractions is indicative of nerve root damage.

L1—L2 Cremasteric reflex The reflex is elicited by stroking the medial , inner part of the thigh. A normal response is contraction of the cremaster muscle that pulls up the testis on the same side of the body. S3 —S5 Anal reflex anal wink Stroking the skin around the anus with a spatula elicits the anal reflex , which results in contraction of the anal sphincter muscles. Bulbocavernosus reflex The reflex is elicited by squeezing the glans penis or clitoris , resulting in contractions of the pelvic floor muscles.

Overview of most important corticospinal tract signs Sign Test Result Upper limb signs Finger flexor reflex Tromner sign The examiner taps the terminal phalanx of a relaxed finger usually the middle finger on the palmar side while holding the patient's hand in level with the proximal phalanges.

The sign is positive when either of the following is present There is significant flexion in the terminal phalanx of the tapped finger and the thumb When the flexion is very asymmetrical comparing both hands. Hoffmann sign The examiner flicks the nail of the middle finger downward while loosely holding the patient's hand, allowing it to flick upward reflexively.

Lower limb signs Babinski sign The examiner strokes the sole of the patient's foot on the lateral edge using, e.

The sign is positive i. An exception are children up to the age of 2 years , in which case an upgoing Babinski sign is considered physiological. The test is inconclusive when only the big toe responds. Gordon sign The examiner compresses the calf muscles.

Oppenheim sign The examiner strokes the patient's anterior tibia downward. Schaeffer sign The examiner squeezes the Achilles tendon. In cases of suspected radicular lesions, the particular dermatome should be examined individually. In cases of suspected peripheral nerve lesions , diagnostics should involve checking the areas innervated by the corresponding sensory nerves.

Monofilament test can be used to quantitatively assess light touch sensation. The patient reports when the vibration stops. Abnormalities of vibration: described as mild, moderate, or severe loss of vibration sense pallhypesthesia Loss of vibration sense may also indicate peripheral neuropathy or myelopathy. Proprioception joint position To test proprioception , the most distal joint of the big toe or the distal interphalangeal joint of the thumb is held at the sides and moved up and down.

The patient should be able to identify the positional change with eyes closed. Abnormalities of proprioception suggest peripheral polyneuropathy or myelopathy. Pain and temperature sensation Spinothalamic tract A broken spatula or a toothpick can be used to test pain sensation bilaterally e. Temperature sensation is tested using two objects of different temperatures e. Decreased hypoalgesia or increased hyperalgesia sensitivity to nociceptive stimuli.

Overview [12] Test Purpose Examination Interpretation Observation of casual gait Detection of gait abnormalities The patient is asked to walk a few steps forward and backward. Normal gait is steady with natural arm swing. Heel to toe walking Assessment of gait ataxia vestibular, sensory, or cerebellar The patient is asked to place one foot directly in front of the other as if walking on a tightrope.

The test is positive when the patient is unable or has difficulty in placing one foot directly in front of the other. Romberg test Test to differentiate between the causes of truncal ataxia Used to distinguish between sensory and cerebellar ataxia The patient is asked to stand with both feet together, raise the arms, and close the eyes.

Positive Romberg The patient's coordination is impaired when the eyes are closed and the patient starts swaying or swaying increases Indicates sensory ataxia An increased tendency to fall sideways after closing the eyes can also indicate a vestibular disorder. In the case of a unilateral vestibular disorder, the patient usually falls towards the side of the lesion. Negative Romberg Closing the eyes does not affect the patient's balance i. Uncontrollable swaying, even with the eyes open, is indicative of cerebellar ataxia.

Unterberger test Test for detecting the presence of vestibular or cerebellar lesions The patient is asked to walk on the spot with their eyes closed for 50 paces. A positive test indicates a cerebellar lesion or vestibular impairment. Trendelenburg sign Test for neurological insufficiency of the gluteus medius and gluteus minimus muscles , which are innervated by the superior gluteal nerve The patient is asked to stand on one leg.

Negative Trendelenburg sign physiological : T he pelvis remains level as it is stabilized by the gluteus medius and minimus. Positive Trendelenburg sign pathological : Because of insufficiency of the gluteus medius and minimus on the side of the standing leg, t he pel vis drops towards the contralateral , unimpaired side. Duchenne sign : The torso tilts toward the contralateral side, compensating the pelvic drop on the unimpaired side.

Overview of abnormal gait patterns [12] Type Description Associated disease Hemiplegic gait Loss of natural arm swing and dragging of the affected leg in a semicircle circumduction On the affected side, the arm may be flexed, adducted , and internally rotated , while the leg is extended and the foot is plantarflexed.

Stroke Myopathic gait Drop of the pelvis on the unaffected side Trendelenburg sign or on both sides waddling when walking. Respectively caused by unilateral or bilateral weakness of one or multiple pelvic girdle muscles especially gluteus muscles Myopathies e. Unilateral: pero neal nerve palsy, L5 radiculopathy Bilateral: amyotrophic lateral sclerosis , peripheral neuropathies e.

Disorders of the dorsal columns e. References Abadi RV. Mechanisms underlying nystagmus. Nystagmus and Saccadic Intrusions.. Continuum Minneapolis, Minn. Caloric Testing. Nystagmus Types. Central Oculomotor Disturbances and Nystagmus. Deutsches Aerzteblatt Online.

Neuroanatomy Through Clinical Cases. Miller Fisher Syndrome. Hauser S, Josephson SA. Harrison's Neurology in Clinical Medicine. Field Guide to the Neurologic Examination.

The Annals of Family Medicine. Diabetes Care. Rydel-Seiffer fork revisited: Beyond a simple case of black and white. Bradley's Neurology in Clinical Practice. Inter- and intra-rater reliability of the Modified Ashworth Scale: a systematic review and meta-analysis. European Journal of Physical and Rehabilitation Medicine. Aids to the examination of the peripheral nervous system.

Fundamentals of Neurology: An Illustrated Guide. Chapter 6: Disorders of the Motor System. Updated: January 1, Accessed: July 28, Butterworths ; The Mental Status Examination. Updated: April 6, Accessed: April 6, Larner AJ. A Dictionary of Neurological Signs. Spatial neglect.

Pract Neurol. Open in Read by QxMD. Broca area inferior frontal gyrus. Telegraphic and grammatically incorrect speech Comprehension is largely spared difficulty understanding complex language may occur. Impaired repetition. Wernicke area superior temporal gyrus. Fluent speech that lacks sense paraphasic errors, neologisms , word salad Comprehension is impaired.

Broca area , Wernicke area , and arcuate fasciculus. Severe impairment of speech production and comprehension Patient may be mu te or only utter sounds Inability to comprehend speech.

Arcuate fasciculus of the parietal lobe. Mostly intact comprehension and fluent speech production Impaired repetition with paraphasia patients substitute or transpose sounds and try to correct mistakes on their own. Isolated difficulty finding words Paraphrasing occurs when patients cannot find the word they seek. Supplementary motor area in the frontal lobe , with Broca area intact exception: may occur during the recovery phase of Broca aphasia. Difficulty initiating speech Difficulty in expressing a thought process Difficulty producing own phrases Intact repetition and comprehension.

Various areas of the temporal lobe , with the Wernicke area intact. Impaired speech expression and comprehension Errors in paraphrasing Poor comprehension Intact repetition.

Broca area , Wernicke area , and arcuate fasciculus intact, with the surrounding watershed areas affected. Poor comprehension of spoken and written language. Test the patient's ability to detect and identify an aroma in each nostril. Visual acuity. Ask the patient to read from a Snellen chart using one eye at a time, and correct for refractive errors with glasses or a pinhole. Color vision color blindness.

Ask the patient to identify with both eyes a number or shape within the Ishihara plates , which contain dots of different color and size. Visual field. Assess each eye by confrontation i. Fundoscopic examination : uses the ophthalmoscope to examine elements of the fundus of the eye Optic disc papilla : examine color , size, degree of swelling, and elevation Retina : examine color, texture, and retinal vessels size, presence of hemorrhages or exudates.

Pupillary light reflex. The examiner shines a light into the patient's eye. Eye movement. Patients are asked to look back and forth between two widely spaced targets e. Visual accommodation.

The physician moves a finger towards the patient. Eyelid ptosis Levator palpebrae superioris muscle dysfunction. Facial sensation. The examiner lightly touches three distinct facial areas , typically the forehead, cheek, and jaw.

Muscle function muscles of mastication. The patient is asked to open and close their mouth. At the same time, the examiner Inspects the masseter muscles for asymmetry Palpates them to investigate if there is pain elicited by palpation.

Motor function muscles of expression. If motor function is intact, the patient should be able to perform the following: Forehead wrinkling Closing the eyes tightly Nose wrinkling Inflate the cheeks Smiling showing teeth. Sense of taste. Basic hearing test : Normally, the patient should be able to hear two fingers rubbing together before the external acoustic meatus ear canal. Palatal movement. The physician asks the patient to open the mouth and performs a visual inspection of the uvula and soft palate : Palate and uvula should be symmetrical and not deviat e.

CN IX only: sense of taste. If the sense is intact, the patient should be able to taste bitter substances. CN X only recurrent laryngeal nerve : vocalization. If the nerve is intact, the patient would not have h oarseness or a bovine cough. Trapezius muscle and sternocleidomastoid muscle motor function. Trapezius muscle : The patient's shoulder is elevated against resistance.

Tongue muscles motor function. The tongue should be pressed against the cheek from the inside, while the examiner tests the strength by pushing from the outside. Optic nerve. Oculomotor nerve. Note the pupil size and shape at rest. Pupillary constriction. V 1 of trigeminal nerve. Facial nerve. Touch the cornea with a clean soft material e. Eye closure contraction of orbicularis oculi muscle. Touch the conjunctiva with a clean soft material e. V 3 of trigeminal nerve muscle spindles in masseter muscle.

V 3 of trigeminal nerve motor efferents. Ask the patient to open their mouth slightly. Jaw closure contraction of masseter muscle. Glossopharyngeal nerve. Vagus nerve. Touch the posterior wall of the pharynx with a tongue depressor. Elevation of the palate.

Vagus nerve cough receptors in trachea and large and medium diameter bronchi. Vagus nerve Phrenic nerve Spinal nerves.

Not routinely examined. These first two cases discussed highlight the importance of performing a neurologic examination on patients with diplopia. The presence of additional neurologic symptoms cranial neuropathy and weakness that the patient may or may not be aware of should prompt you to pursue a more urgent work-up.

If this patient had been evaluated from purely an ophthalmic standpoint, the CN VI palsy may have been presumed ischemic or vasculopathic, given the poor control of systemic disease. However, the discovery of a concurrent new-onset neurologic symptom raised significant concern and warranted immediate neuroimaging. While a cranial nerve palsy may be secondary to vasculopathic risk factors, it is important to consider that a diagnosis of exclusion.

The first indication of cerebellar dysfunction may be observed as the patient walks to the exam room. Those with the condition may exhibit an ataxic, or clumsy, gait.

You can also ask the patient to walk heel-to-toe in a straight line. Wheelchair-bound patients can slide their heel along their contralateral shin toward their foot. Inability to perform any of these tasks indicates potential cerebellar dysfunction or intoxication.

Any hesitation, overshoot or undershoot, shaking or difficulty when they are about to touch your finger may indicate ataxia. Stand far enough away so that these patients have to fully extend their arm to reach your finger. You can move your finger to different areas to increase difficulty. To assess rapid alternating movements, ask the patient to tap the palm of their hand on their leg repeatedly and quickly.

Then ask them to flip their hand from palm to the back of the hand on their leg. Inability to do so is known as dysdiadokinesia and is often a sign of cerebellar disease, including stroke and atrophy. The classic ocular manifestation of cerebellar dysfunction is nystagmus, with other potential ocular complications such as abnormal pursuits and optokinetic response. However, nystagmus is not only caused by cerebellar disease and can be due to vestibular dysfunction as well as other etiologies such as albinism and medication use such as anti-seizure medications.

Therefore, performing a neurologic exam on patients with nystagmus and paying special attention to their coordination and gait can help increase or decrease your clinical suspicion for a lesion within the cerebellum. A year-old woman presented with complaints of glare and reduced vision.

She demonstrated a 0. A neurologic exam revealed tandem gait ataxia and a positive Romberg test, suggestive of cerebellar dysfunction. She also demonstrated fine motor weakness affecting the left hand more than the right. Records of recent lab work demonstrated significant vitamin B12 and folate deficiencies, which supported a nutritional optic neuropathy diagnosis.

This case highlights how a neuro exam helps to refine your differential diagnosis of an optic neuropathy. Potential causes of bitemporal pallor include inflammatory, infectious, nutritional and toxic conditions. Anemia is a common early symptom of vitamin B 12 deficiency, while neurologic symptoms are typically found later.

Neurologic symptoms arise due to demyelination and can include cerebellar ataxia and limb weakness. General sensory exam. Pain, temperature, proprioception, two-point touch, light touch, pressure and vibratory sense are all general sensations. The stimulus travels from the site of stimulation to the cerebral cortex. Depending on the sensation, the pathway decussates, or crosses, the midline in either the low medulla or spinal cord. Lesions below the decussation cause ipsilateral loss of sensation.

In general, lesions within the brainstem or the brain cause contralateral loss of sensation. We recommend integrating tests of sensation with other elements of the neurologic exam. While the patient has their arms outstretched with closed eyes to test for pronator drift, lightly touch the backside of one of their hands and ask them to identify which hand was touched. Touch one hand, then the other and then both simultaneously while asking the patient to note any asymmetry. Proprioception can be assessed by asking the patient to stand with their feet touching, known as the Romberg test.

Patients can usually keep their balance with their eyes open due to visual cues; however, if they are unable to maintain their balance with their eyes closed—a positive test—they may have loss of proprioception. This test may also indicate cerebellar dysfunction.

Sensory exam case. A year-old male presented with tearing affecting the left eye more than the right, a left-sided, non-congruous, homonymous hemianopia and intermittent diplopia. He reported a history of a hemorrhagic stroke affecting the right side of his brainstem. Neuro exam revealed left-sided weakness of the left upper and lower extremities.

He also demonstrated notable sensory defects and a left-sided facial palsy that was not grossly evident by observation alone. By correlating our findings with the anatomical location of the stroke, we attributed his presentation to the prior stroke of the right pons, therefore avoiding any further testing or work-up. His previous MRI report was remarkable for gliosis involving the right optic tract, which corresponded with his visual field defect.

Ultimately, a neurology consult is often indicated, but an in-office screening may help narrow a list of differentials to help develop a sense of urgency. With practice, the neurologic exam can be performed and interpreted quickly and efficiently, with significant implication for patient care.

Maglione is an assistant professor at the Pennsylvania College of Optometry at Salus University and clinical instructor in the primary care and neuro-ophthalmic disease services at The Eye Institute. She is currently completing a two-year advanced residency program at The Eye Institute in neuro-ophthalmic disease. Detecting dementia with the mini-mental state examination MMSE in highly educated individuals. Arch Neurol. Finsterer J, Grisold W. Disorders of the lower cranial nerves.

J Neurosciences in Rural Practice. Campbell W. Philadelphia: Wolters Kluwer; B12 deficiency with neurological manifestations in the absence of anaemia. BMC Research Notes. Toggle navigation Leadership in clinical care. Demonstration of upper extremity strength assessment. Clinicians can tackle the neurologic examination by breaking it into five sections: 1.

Here is a brief review of the clinical applications of testing each cranial nerve: 2 Click table to enlarge. A pupil-involved CN III palsy is more concerning for an aneurysm because pupillary fibers travel on the external surface of the nerve and are subject to compression CN IV: This is also routinely tested with extraocular motility.

Beyond Visual Field Testing Visual field testing can unmask a number of associated neurologic conditions, given the expansive visual pathway. Goodwin D. Homonymous hemianopia: challenges and solutions. Clinical Ophthalmol. Humphrey visual fields OS and OD show a more severe visual loss in the left eye compared with the right.

OCT of the optic nerves reveal temporal retinal nerve fiber layer thinning flagged on the deviation map. Ashizawa T, Xia G. Continuum: Lifelong Learning in Neurology.