Neurological Case Study

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22-2

Key Points

Ball: Seidel’s Guide to Physical Examination, 8th Edition

Chapter 22: Neurologic System

Key Points

This review discusses examination of the neurologic system.

Before the exam, gather the necessary equipment: a penlight; tongue blade; sterile needles; 200- to 400- and 500- to 1000-Hertz tuning forks; familiar-feeling objects; cotton wisp; 5.07 monofilament; reflex hammer; vials of aromatic substances to smell; vials of sweet, salty, sour, and bitter solutions to taste; test tubes of hot and cold water; and the Denver Developmental Screening Test (for an infant or child).

You can assess the neurologic system almost constantly while examining the rest of the body. For example, the musculoskeletal examination, as described in the audio review of the musculoskeletal system, provides important information about the neurologic system.

To examine the cranial nerves (CNs) , perform the following.

Evaluate CN s I through XII . Keep in mind that taste and smell usually are tested only if a problem is suspected. No matter which nerves you test, their function should be intact.

For CN I (the olfactory nerve), test the patient’s ability to identify familiar odors, such as coffee and mint extract, one naris at a time with the eyes closed.

For CN II (the optic nerve), test visual acuity and the visual fields as described in the audio review of the eyes.

For CN s III, IV, and VI (the oculomotor, trochlear, and abducens nerves, respectively), assess the six cardinal points of gaze; inspect the eyelids for drooping; and observe the pupils for equality of size, shape, and reaction to light and accommodation.

For CN V (the trigeminal nerve), perform four assessments. First, inspect the face for muscle atrophy, jaw deviation, and tremors. Second, palpate the clenched jaw muscles for tone and strength. Third, test superficial pain and touch sensations in each branch of the nerve. If the results are unexpected, also test temperature sensation in these areas. Fourth, test the corneal reflex.

For CN VII (the facial nerve), observe for facial symmetry while the patient makes a series of facial expressions. Test the ability to identify tastes on the sides of the tongue.

For CN VIII (the acoustic nerve), test the sense of hearing and bone and air conduction of sound and note sound lateralization, as described in the audio review of the ears, nose, and throat.

For CN IX (the glossopharyngeal nerve), test the patient’s ability to identify tastes on the posterior third of the tongue.

For CN X (the vagus nerve), inspect the palate and uvula for symmetry with speech sounds. Check the gag reflex and the ability to swallow, keeping in mind that this also tests part of CN IX . Evaluate the patient’s speech sounds to detect any hoarseness, nasal quality, or difficulty with guttural sounds.

For CN XI (the spinal accessory nerve), evaluate the size, shape, and strength of the trapezius and sternocleidomastoid muscles, as described in the audio review of the musculoskeletal system.

For CN XII (the hypoglossal nerve), perform four assessments. First, inspect the tongue at rest and while protruded, noting symmetry, tremors, and atrophy. Second, observe tongue movement from side to side and toward the nose and chin. Third, test tongue strength by pressing your index finger against the cheek as the tongue presses against it from the inside. Finally, evaluate the quality of lingual speech sounds, such as l, t, d, and n.

To assess proprioception and cerebellar function, perform the following.

Evaluate coordination and fine motor skills in two ways.

First, observe as the seated patient performs rapid rhythmic alternating movements, such as patting the knees with both hands while alternating the palm and back of the hands. The movements should be smooth and rhythmic even with increasing speed.

Second, watch for accuracy of movements, using the finger-to-finger test, finger-to-nose test, and heel-to-shin test on both sides of the body. Hand movements should be rapid, smooth, and accurate. The heel should move in a straight line with no deviations to the side.

Evaluate balance by checking the patient’s equilibrium using four techniques.

First, perform the Romberg test. Have the patient stand with the eyes closed, feet together, and arms at the sides. Slight swaying is expected. During this test, remember to stand close by and be ready to catch the patient in case he or she starts to fall.

Second, throw the standing patient off balance by pushing on the shoulders. The patient should quickly recover his or her balance.

Third, test for balance with the patient standing on one foot with the eyes closed and arms at the sides. The patient should maintain balance on each foot for 5 seconds, although slight swaying is expected.

Fourth, have the patient hop in place on one foot and then the other. The patient should hop on each foot for 5 seconds without losing balance.

Further evaluate balance by observing the gait with the patient’s eyes open and then closed.

Look for the expected gait sequence, including posture and arm movements. The gait should have a smooth, regular rhythm and symmetrical stride length. The trunk posture should sway with the gait phase, and the arm swing should be smooth and symmetrical.

If you see an unexpected gait, have the patient perform heel – toe walking forward and back, with the eyes open and arms at the sides. The patient should maintain consistent contact between the heel and toe but may sway slightly.

To evaluate sensory function, perform the following.

With the patient’s eyes closed, test these primary sensory functions.

To test superficial touch sensation, lightly stroke the skin with a cotton wisp or the fingertip and have the patient identify the area touched.

To assess superficial pain sensation, touch the skin with the sharp and smooth edges of a broken tongue blade and have the patient identify each sensation as sharp or dull and its location. Remember to allow 2 seconds between each stimulus to avoid a summative effect.

If superficial pain sensation is not intact, test temperature sensation by rolling test tubes of hot and cold water on the skin. The patient should identify them correctly. Also test deep pressure sensation by squeezing the trapezius, calf, or biceps muscle, which should cause discomfort.

To check vibration sensation, place the stem of a vibrating tuning fork over several bony prominences on the upper and lower extremities. The patient should report and locate a buzzing or tingling sensation.

To evaluate joint position sensation, move the great toe or a finger up or down on each hand. The patient should accurately identify each movement.

While the patient’s eyes are closed, test cortical sensory functions in five ways.

First, assess stereognosis by handing the patient a familiar object, such as a coin or key. Through touching and manipulating the object, the patient should be able to identify it.

Second, evaluate two-point discrimination. Touch the skin with one or two sterile needles to determine the distance at which the patient can no longer distinguish two points.

Third, elicit the extinction phenomenon by simultaneously touching the cheek or hand on each side of the body with the sharp edge of a broken tongue blade. The patient should feel similar sensations bilaterally.

Fourth, assess graphesthesia by tracing a letter, number, or shape on the palm of the hand. The patient should be able to recognize it.

Fifth, check point location by touching different areas of the body. The patient should point to the area you touched.

To test the reflexes, perform the following.

Evaluate three superficial reflexes: the abdominal, cremasteric, and plantar reflexes.

To elicit the abdominal reflexes, stroke each quadrant with the end of a reflex hammer or the edge of a tongue blade. For the upper abdominal reflexes, stroke up and away from the umbilicus. For the lower abdominal reflexes, stroke down and away. Expect the umbilicus to shift toward the stroked side bilaterally and equally.

To test the cremasteric reflex, stroke the male patient’s inner thigh from the proximal to distal area. The testicle and scrotum should rise on the stroked side.

To check the plantar reflex, stroke the lateral side of the foot from the heel to the ball and then across the ball to the medial side. The expected response is plantar flexion of all toes.

With the patient relaxed and seated or lying down, test five deep tendon reflexes. When using a reflex hammer, remember to tap briskly but not too forcefully. Score each reflex from 0 (for no response) to 4+ (for a hyperactive response with clonus).

For the biceps reflex, hold your thumb over the biceps tendon and strike the thumb with the reflex hammer. This should cause elbow flexion.

For the brachioradial reflex, strike the brachioradial tendon (about 1 to 2 inches above the wrist) with the reflex hammer. The expected response is forearm pronation and elbow flexion.

For the triceps reflex, strike the triceps tendon directly, which should produce elbow extension.

For the patellar reflex, strike the patellar tendon just below the patella. Expect to see lower leg extension.

For the Achilles reflex, strike the Achilles tendon at the level of the ankle malleoli. In response, the foot should plantar flex.

Test for ankle clonus, especially if the reflexes are hyperactive. Briskly dorsiflex the patient’s foot and hold it in place. You should feel no clonus (or rapid, rhythmic contractions).

When routine examination reveals problems, perform these additional procedures.

Use 5.07 monofilament to test for protective sensation on the foot in patients with diabetes mellitus and peripheral neuropathy.

Assess for meningeal signs by checking for a stiff neck with the supine patient’s head raised and by eliciting Brudzinski sign and Kernig sign.