Table 10: Neurological Exam
|Physical Sign / Manoeuvre||Rationale||Technique(s)||Interpretation||Evidence||Pre-Clerkship||Clerkship|
|Gross contextual screening||Orientation to person, place and time||Gross assessment of connection to context (confusion)||Impaired consciousness K value of|
|Folstein Mini Mental (see also mental status section)||Test for cognitive impairment||Standard administration||Dementia||+LR of 14.5 for scores< 21|
McGee, 2001, p56.
McGee, 2001, p56.
|clock-drawing test (see also mental status section)||Test for cognitive impairment||Standard administration||Dementia||+LR of 14 to rule in dementia|
|Glasgow coma scale||Assessment of brain injury||Standard clinical record||Grading and evolution of brain injury||Consistency of scoring highest for best motor response.|
|Fundoscopy||Assessment of retina and optic nerve abnormalities||Examination of eye with ophthalmoscope or retinography||Increased intracranial pressure, retinal complications of hypertension, diabetes mellitus||No value in the management of HBP|
van den Born, 2005.
Useful in DM if combined with retino-graphy
Papilledema: high sensitivity, low specificity
Overall K: 0.65
|CN1||Gross assessment of olfactory dysfunction||Test smell with readily available scents||Anosmia||None available||1||1|
|CN2||Understanding of dysfunction and topography of lesions in the visual pathways||Visual field testing by confrontation, if abnormal needs further testing. Visual acuity. Papillary reaction to light and accommodation||Retinal disease|
Optic nerve damage
Occipital lobe stoke
Coma, optic nerve, drug effects stroke syndromes
|V.F. has a +LR between 4.2-18.3.|
Hemianopia is 98% specific in unilateral cerebral disease
V.A. no evidence found when it is used as gross screening.
PRLA :High sensitivity for optic nerve disease, ipsilateral brain herniation, and post communicating art aneurism. Very high sensit/specif for Horner’s syndrome
|CN3||Understanding of dysfunction and topography of lesions in the visual pathways||Observation of pupils, upper eye lid and examination of eye movements.||Diseases of the external eye muscles. Injury to CN 3 or disease of mid/brain stem nucleae. Increased ICP||Isolated palsy is most commonly caused by posterior communicating artery aneurysm or ischemic infarct. Pupil reaction +/- spared.|
Evidence not qualified.
|CN4||Understanding diplopia and its neurologic causes||Examination of eye movements.||Diseases of the external eye muscles. Head, cavernous sinus or orbital injuries. Disease of mid brain nucleae||Isolated palsy most commonly seen in head trauma (34%) and ischemic infarcts (22%).|
Evidence not quantified.
|CN6||Understanding diplopia and its neurologic causes||Examination of eye movements.||Diseases of the external eye muscles. Head, cavernous sinus or orbital injuries. Disease of brain stem nucleae||Isolated palsy most frequently seen in increased ICP, ischemia and lesions in the base of the skull.|
Evidence not quantified.
|CN5||Understand facial sensation, mastication||Test V1, V2, V3, sensation and corneal reflex. Test jaw clenching||Tic dolorous, stroke, cerebellopontine lesions. Herpes zoster||High sensitivity in thalamic or hemispheric injury but low specificity|
|CN7||Understanding facial expression dysfunction||Observation|
|Peripheral versus central nerve palsies|
|No appraisal of evidence found.|
Facial palsy, present or absent has a K value of 0.48-0.68
|CN8||Understanding hearing and vertigo||Whispered voice, Rinne and Weber not useful for general screening of hearing problems.|
Dix-Hallpike test BPPV.
|Whispered voice test has high sensitivity, good specificity and +LF of 6 for hearing loss.|
Dix-Hallpike test, widely used but accuracy not appraised
|CN 9, 10||Understanding swallowing||Test together|
Swallow test, gag reflex, observe for dysphonia
Brain stem lesions
|Water swallow test, reasonable sensitivity, specificity and +LR of 5.6 K value: 1|
|CN 11||Understanding of sternocleidomastoid muscle function||Turning of the head and shoulder elevation||Neck trauma|
Cerebral hemispheric lesions
Medullary and high spinal lesions
|No appraisal of evidence found||3||4|
|CN12||Understanding of tongue motor function||Motor||Brain stem lesions|
Lesions associated with lower cranial nerves. Lesions in upper neck and base of skull
|No appraisal of evidence found||3||4|
|10 g monofilament||Screening for future complications of PDN||Use instrument|
Test 10 times on dorsum and plantar aspect
|Peripheral neuropathy, risk for diabetic foot ulcer||Moderate to high predictor of foot ulcers, osteomyelitis and amputations. +LR of 2.9-7.2 |
|Light touch, pain sense||Mapping of sensory defects||Use non-reusable sharp object such as broken tongue depressorLight touch – spindle||Peripheral nerve, spinal cord lesions, stroke syndromes||Quite accurate in mapping peripheral nerve injuries, radiculopathy, spinal cord syndromes, lateral medullary, thalamic and hemispheric syndromes|
|Vibration sense||Adjunct in the investigation of certain neuropathies||Use 128 Hz tuning fork||Peripheral neuropathy and spinal cord disease||Diminished in peripheral neuropathies and spinal cord disease|
|Proprioception (Joint position sense)||Adjunct in the investigation of certain neuropathies.|
Associated with vibration sense.
|Slightly hold sides of digit and move up and down||Peripheral nerve, spinal cord disease, posterior column lesions and severe hemispheric disease||Diminished in peripheral neuropathies, spinal cord disease and cortico-hemispheric disease.|
No appraisal found
|Two point discrimination, stereognosis, graphesthesia||Complex sensation that requires intellectual elaboration||Two pressure points applied simultaneously to the skin.|
Recognition of a object in the hand.
Recognition of numbers traced on the palm of the hand
|Lesions in the posterior parietal cortex||Altered in lesions of the posterior parietal (sensory) cortex.|
No appraisal found
|Dermatomes||Mapping of spinal cord lesions and radiculopathy||Light touch and pain sensory examination||Peripheral nerves, spinal cord and nerve root lesions||Fairly accurate examination defining the level of spinal cord injury. High specificity with high +LR in C6, C7, C8 radiculopathy in sensory loss of thumb, middle and little finger|
|Muscle bulk||Associated with muscle disease or denervation||Inspection of muscle groups for wasting, hypertrophy and fasciculations||Muscle disease, upper and lower MN disease or injury, nerve and neuromuscular end plate disease||Comparative calf wasting accurate, indicates low radicular compression due to disc herniation, +LR 5.2.|
|Muscle tone||Associated with neurophysiologic control of muscle function||Test for flaccidity, spasticity, cogwheel rigidity||Stroke|
Spinal cord lesions
Extrapyramidal disease (Parkinson’s disease)
|Rigidity alone in the diagnosis of Parkinson’s disease has low sensitivity, low specificity and low +LR. Accuracy increases with the presence of bradykinesia and typical pill-rolling tremor. Spasticity/rigidity have a K value 0.21-01.64|
|Muscle Power||Assessment of corticospinal and neuromuscular function||British Medical Research Council (MRC) Scale for grading muscle strength
Medical Research Council, 1976.
|Assessment and progression of upper and lower MN disease and myopathy||Moderate to good sensitivity. Good to very good specificity. Good +LR.|
|Pronator drift||Hemispheric lesion||Hold arms up in pronated position, eyes closed||Unilateral cerebral hemispheric disease||High sensitivity: 79%|
Very high specificity, 98% and +LR, 33
|Reflexes (DTRs)||Assessment of motor neuron and peripheral nerve disease||Triceps, biceps, bracheoradialis, patellar, ankleGrade, reflex, amplitude0-4||Abnormal DTRs have diagnostic value ONLY when they are asymmetric or accompanied by other signs of motor neuron disease (McGee, 2001)||Diminished DTRs have a general moderate sensitivity but high specificity 90%+, and high +LR in the diagnosis of radiculopathy.|
|Plantar Reflex (Babinski)||Adjunct in assessment of hemispheric and pyramidal tracts disease||Scratching the lateral aspect of the sole of the foot with a hard, pointed object||Spino-cortical (pyramidal)tract lesion|
Severe metabolic disturbance
|Highly specific, 98% with high +LR, 19, for pyramidal tract lesions.|
K values: 0.17-0.61
|Primitive reflex (palmomental, glabellar and grasp)||Adjunct in the assessment of dementia, frontal lobe and Parkinson’s disease and advanced AIDS||Scratching of hand palm and twitching of chin.|
Tapping on glabella triggers sustained blinking.
Sliding a finger on the patient’s hand – the hand grasps the clinician’s finger
|These are frontal release reflexes. The palmomental and glabellar reflexes can be found in normal people.||Grasp reflex has a high specificity, 99%, and high +LR, 20.1 in the diagnosis of frontal, cortical, subcortical and thalamic nuclei lesions, with a K value of 0.46-1.0|
|Gait||Assessment of ambulation||Observation of ambulation||Stroke, Parkinson’s disease, myelopathy, peripheral neuropathy and cerebellar disease||8.8 +LR as predictor of falls|
Diagnosis of abnormal gait has a K value of 0.11-0.52
|Coordination/cerebellar||Assessment of cerebellar function||Ataxia (gate, finger-nose test and rapid alternating movements), nystagmus, hypotonia, dysarthria||Cerebellar disease||Positive cerebellar signs present with variable frequency in unilateral cerebellar disease, 10-93%, being the most frequent gate ataxia, 85% in unilateral disease, to 100% in alcoholic cerebellar syndromes|
Finger-nose test has a K value of 0.55-0.79
|Rhomberg||Not much rationale for teacing/performing this test. Has historic value.||Ability to stand for 60 seconds with feet together and eyes closed||Doubtful as it is very unspecific and has very low inter-observer agreement (not quantified)||Very unspecific and has very low inter-observer (K) agreement (not quantified)||3||4|
|Meningismus (Kernig/Brudzinski)||Acute, critical and treatable CNS pathology||Passive neck stiffness|
Kernig’s (patient resists extension of the knee from the hip/knee flexed position)
Brudzinski’s (passive flexion of the neck elicits flexion of hips/knees
|Meningeal irritation||Meningimus K value: 0.76|
Neck stiffness frequency in bacterial meningitis 57-92%
Neck stiffness in SAH: sensitivity 59%, specificity 94%, +LR 10
|Tinel’s and Phalen’s||Carpal tunnel syndrome||Tinel’s (percuss median nerve over the carpal tunnel)|
Phalen’s (forcible palmar flexion of the wrist produces symptoms)
|Median nerve compression|
Median nerve compression
|Straight leg raising test|
Crossed straight leg raising test
|Lumbar nerve root compression||Patient supine and posterior pain when raising the straight affected leg.|
Crossed test:pain in the affected leg when raising the straight opposite leg
|Lumbar disc herniation||Sens: 73-98%|
Overall K value:0.33-0.68
|Reliability or physical findings or inter-observer agreement is expressed by Kappa (K), 0 being a level of agreement as expected by chance and 1 being perfect - 100% -- agreement. According to convention, 0-0.2 indicates slight agreement; 0.2-0.4 fair agreement; 0.4-0.6 moderate agreement; 0.6-0.8 substantial agreement; and 0.8-1 almost perfect agreement.|
- Gabbe BJ, et al. The status of the Glasgow Coma Scale. Emerg.Med.(Fremantle) 2003 Aug;15(4):353-360.
- Harding SP, et al. Sensitivity and specificity of photography and direct ophthalmoscopy in screening for sight threatening eye disease: the Liverpool Diabetic Eye Study. BMJ 1995 Oct 28;311(7013):1131-1135.
- Johnson LN, et al. Accuracy of papilledema and pseudopapilledema detection: a multispecialty study. J.Fam.Pract. 1991 Oct;33(4):381-386.
- Juby A, et al. The value of clock drawing in identifying executive cognitive dysfunction in people with a normal Mini-Mental State Examination score. CMAJ 2002 Oct 15;167(8):859-864.
- Lee S, et al. Clinical usefulness of the two-site Semmes-Weinstein monofilament test for detecting diabetic peripheral neuropathy. J.Korean Med.Sci. 2003 Feb;18(1):103-107.
- McGee SR. Evidence-based physical diagnosis. Philadelphia, PA: Saunders; 2001.
- Medical Research Council (Great Britain), University of Edinburgh. Dept. of Surgery. Aids to the examination of the peripheral nervous system. London: H. M. Stationery Off.; 1976.
- O'Hare JP, et al. Adding retinal photography to screening for diabetic retinopathy: a prospective study in primary care. BMJ 1996 Mar 16;312(7032):679-682.
- Olaleye D, et al. Evaluation of three screening tests and a risk assessment model for diagnosing peripheral neuropathy in the diabetes clinic. Diabetes Res.Clin.Pract. 2001 Nov;54(2):115-128.
- van den Born BJ, et al. Value of routine funduscopy in patients with hypertension: systematic review. BMJ 2005 Jul 9;331(7508):73.