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Neurological examination

A neurological examination is the assessment of sensory neuron and motor responses, especially reflexes, to determine whether the nervous system is impaired.

A neurological assessment includes a physical examination and a medical history.

The neurological examination can be used both as a screening tool and as an investigative tool.

The neurological examination is focused on finding if there are lesions in the central and peripheral nervous systems, and to determine whether these findings combine to form a recognizable medical syndrome or neurological disorder

The presence of any neurological disorder may be an indication for performing a neurological examination.

The most important part of a neurological examination is the history: Time of onset, duration and associated symptoms, age, gender, and occupation of the patient, handedness, past medical history, and drug history,

Handedness is important factor in establishing the area of the brain most important for language.

Almost all right-handed people have a left hemisphere, which is responsible for language.

The interval of a complaint is important as vascular disorders occur very frequently over minutes or hours, whereas chronic disorders occur over a matter of years.

Specific neurological examination testing include:

Mental status examination: often using the Glasgow Coma Scale (GCS)

Mental status examination, often including the abbreviated mental test score (AMTS) or mini mental state examination (MMSE)

Intracranial pressure estimate by fundoscopy

Short and long-term memory assessment

Cranial nerve examination Cranial nerves (I-XII): sense of smell (I), visual fields and acuity (II), eye movements (III, IV, VI) and pupils (III, sympathetic and parasympathetic), sensory function of face (V), strength of facial (VII) and shoulder girdle muscles (XI), hearing (VII, VIII), taste (VII, IX, X), pharyngeal movement and reflex (IX, X), tongue movements (XII).

These cranial nerves are tested by their individual purposes.

Muscle strength, often graded on the scale 0 to 5.

Muscle tone and signs of rigidity.

Examination of posture

Decerebrate

Decorticate

Hemiparetic

Resting tremors

Abnormal movements

Seizure

Fasciculations

Tone

Spasticity

Pronator drift

Rigidity

Cogwheeling

Gegenhalten

Tone

Deep tendon reflexes

Reflexes: masseter, biceps and triceps tendon, knee tendon, ankle jerk and plantar.

Brisk reflexes suggest an abnormality of the upper motor neuron or pyramidal tract.

Decreased reflexes suggest abnormality in the anterior horn, lower motor neuron, or motor end plate.

Sensory system testing involves sensations of fine touch, pain and temperature.

The monofilament test can evaluate fine touch, by detecting any subjective absence of touch perception.

Sensation includes testing for:

Light touch

Pain

Temperature

Vibration

Position sense

Graphesthesia

Two-point discrimination

Romberg test

Cerebellar testing

Dysmetria

Finger-to-nose test

Ankle-over-tibia test

Dysdiadochokinesis

Rapid pronation-supination

Ataxia

Assessment of gait

Nystagmus

Intention tremor

Staccato speech

Finger-to-nose, gait

The results of the neurological examination can anatomically identify the lesion.

It is necessary to determine if there is focal asymmetry, and to decide whether the process involves the peripheral nervous system (PNS), central nervous system (CNS), or both, or whether finding, or findings, can be explained by a single lesion or whether it requires a multifocal process.

If an abnormality involves the CNS, it is necessary to clarify its location: cortical, subcortical, or multifocal.

If subcortical, is it in white matter, basal ganglia, brainstem, or spinal cord.

PNS lesions need to determined whether it localizes to the nerve root, plexus, peripheral nerve, neuromuscular junction, muscle or whether it is multifocal.

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