Neurologic Exam

Neurologic Exam


>>Hello. I’m Eve Bargmann, and
this is Bill Garant [phonetic], and we’ll be demonstrating
today a brief neurologic exam. You can do a much longer
neurologic exam, and you will if you find any abnormalities, but this is the brief
screening neurologic exam that you’ll be doing as part
of your physical examination. Now, the neurologic exam
has five main sections: The first is mental status where you ask the patient a few
questions; and cranial nerves, testing the cranial
nerves; sensation; strength; and coordination. And we’ll do those
more or less in order. So we’ll start with
mental status. And with mental status, I just
ask you several silly questions and you get to answer me. And I can pick questions
at random. Can you tell me today’s date?>>Today’s date is December 21.>>Okay. Can you
tell me the year and the day of the week, too?>>Today is Thursday;
the year is 2000.>>Good. Thank you. And do you know what this
place is that we’re in?>>We’re in the Davis Building.>>Well, good. And how about the
town [inaudible]?>>This place is
Charlottesville, Virginia.>>Good. Thank you. And those are orientation
questions. You can also ask
questions like calculation. Can you take 100 and subtract 7?>>Uh-huh, I can. It’s 93.>>Good. And take
seven from that.>>That would be 86.>>Excellent. So Bill would have no trouble
with mental status whatsoever. Next thing you do
is cranial nerves, and you’ll recognize
some of those from having done them before
when we were examining the eye and examining the ear. Cranial nerves we test
usually 2 through 12 because we don’t have
things that really smell, just has cranial nerve 1. So cranial nerve 2, you’ll
remember, is the eye. And you remember doing the pupil
reflexes, and that’s, again, a test for cranial nerve 2; so we’ll do pupil
reflexes first to light. So to light you take
the light and shine it in from the outside, okay,
toward the patient like this. Okay. And you look at
both pupils as we do that. And you do the same thing on the
other side, then the outside, and in like this, and
look at both pupils. Okay. Then you check
for accommodation. And for that, let me let you
look at that sign way over there on the wall and look straight at
that, and now look at my finger. Good. And you can see how
the pupils [inaudible]. Now, one test for the second
cranial nerve is the field of vision, which you test
through confrontation. What I’m going to ask you to
do is look straight at my nose and just tell me when
you see my finger move.>>Now. Now. Now. Now.>>Good. And that’s perfect. He should see the
finger move just about the same time that you do. For the third, fourth,
and sixth cranial nerve, you check extraocular
movements; so you take a finger, and just look at my
finger with your eyes. [ Pause ] Perfect. Just like that. Good. Thank you.>>Uh-huh.>>Okay. For fifth cranial
nerve, that’s strength of the masseter muscles
and sensation of the face; so just tell me, can you tell
when I touch you on both sides?>>Uh-huh. Yes.>>Good. And I have a
little sharp thing here. Does that feel kind
of [inaudible]?>>Yes.>>Good. And now clench
down your jaws really tight. Good. And relax. Good. All right. Seventh cranial nerve
is strength in the face; so close your eyes real tight. Real tight. Don’t let me open them. Good. And open up. Wrinkle up your forehead. Good. Show me your teeth. Whistle. [ Whistle ] Perfect. Okay. Good. Eighth cranial
nerve is hearing. And you check that with — can you hear my finger
rubbing over here?>>Yes, I can. Yes.>>Right over there?>>Uh-huh.>>And, again, when you
did it with the ear, I got you to close
the other one. Can you still hear?>>Yes.>>And there?>>Yes.>>Good. And three feet
out is very, very good. Okay. For ninth and tenth, I have to [inaudible]
do one weird thing, which is check for gag reflex. I apologize. The tongue has to go back
all the way back to the back of the throat just for
a brief gag reflex. Okay. Now, go “ah.”>>Ah.>>Sorry about that. Good. Eleventh cranial nerve is
strength in the shoulder shrug. Shrug up against my hand. Shrug your shoulders. Good. And sternocleidomastoids. Push against my hand here. Good. And push against
my hand there. Great. Good. Okay. And for the
twelfth cranial nerve, stick out your tongue and
move it from side to side. Perfect. All right. Good. Thank you.>>Did I pass?>>You — beautifully. Good. That was the
cranial nerves. Good. For sensation, we’re
going to do the same things. We check sensations
for touch, sharper pin, position, and vibration. So first I’m just going to check
on your arms and your legs. Good. Now I’ll get you to close
your eyes and just tell me when I touch you if it’s kind
of a dull touch like this or a sharp touch like that. Okay. Now, just tell
me as you feel it.>>It feels sharp; sharp; sharp;
sharp; sharp; soft; soft; soft; sharp; sharp; soft; sharp.>>Great. Okay. Good. Now, let me get you
to keep your eyes closed and I’m going to check
for position sensation. For position, I put my hands
on either side of the joint and just tell me as I move it,
if I’m moving it up toward you or down away from you.>>Up towards me;
down; down; up.>>Good. Same thing
with the finger.>>Down; up; up; down.>>Good. Great. Good. You can open your
eyes for vibration. For vibration, we’ll
check again, and I’ll just give
you a light — can you feel kind of a
buzzing feeling here.>>Uh-huh.>>Good. Tell me when
you feel it go away. [ Pause ]>>It’s gone now.>>Okay. Over there.>>I can feel that.>>Okay. Okay. When do you fill it go away?>>It’s gone now.>>Good. Can you feel it there?>>Yes, I can feel it. [ Pause ] It’s gone now.>>Okay. And fourth. [ Pause ]>>It’s gone now.>>Good. Pretty similar
everywhere. Good. For strength, we can
just check some easy things. Hold on real tight. Real tight. Good. That’s great. Now make a fist like that. Good. And push down against me. Good. And push out and back. Good. That’s great. Now, you can relax your hands. Good. Now, push up
here against my hand. Good. And push up there. Great. And push out
against my hands. Good. Now, push up your toes
and push back down again. Good. That’s it for strength. Reflexes. Now, for reflexes,
I can do the arms here. So I’ll do arms here and then
I’ll get you to show us the rest of your leg so we can check. This is the biceps, it’s
right in the biceps muscle, and you push — you
hit your finger and you can see little
movement and feel the movement with your finger as well. Then you check, it should be
about the same on both sides. With the biceps, you
don’t necessarily see it but you can always feel
the muscle contracting and you can see it
pretty well here. Brachioradialis is here. And back there again. For triceps, just lift up and let me just hold
your arm completely, and just completely
hold your arm here. Yes. Good. That’s great. Here it is. Good. Thank you. Good. Same thing over here. You have to be a little patient
here; not everybody can relax as quickly as Bill can. Yeah, there it is again. And you have to make sure
that the entire weight is in your hand when you do that. So that’s biceps,
triceps, brachioradialis. Let me show you the
leg reflexes, too. Let me just get you
to pull up your pants up to — both of them. Got to compare two sides always. Good. All right. And again. They match. Good. You will not get
a very pretty knee-jerk. Okay. Good. Patella. Good. Yes. Good. Okay. Now, there’s the ankle here, we
can strike there, the Achilles. Okay. Ankle, just a
little light pressure. Good. And here is
— this is Babinski, this will feel ticklish.>>Uh-huh.>>Okay. Sorry about that. And that’s the Babinski there. And the toe goes down,
that’s a normal Babinski. Next, we’ll do tests
of coordination. We will start off by
testing coordination, cerebellar function. So we’ll do what’s called
a finger-to-nose test. What I’m going to ask you to
do is to take your finger, touch my finger, and then touch
your nose and just go back and forth as quickly
as you can perfectly. Good. Great. Now do the same thing
with the other hand. Same finger, the other hand. And I’ll move my finger
around while you do that. Good That’s perfect. Good. Next is called
heel-to-shin, and what you’ll do is you’ll
take the heel of one foot and run it down the
shin of the other. Good. Now do the same
thing with the other side. Take the heel and run it down
the shin of the other foot. Perfect. Okay. For the rest of the tests
I’ll need you to stand up. First thing I’ll do is get
you just to do a normal gait, so I’m going to ask you
just to walk down to the end of the room, turn
around, and come back. [ Pause ] Good. Perfect. Now, stop there and
do a couple of steps. And I usually explain
this to the patient as the “drunk test” heel-to-toe gait,
walking with one heel in front of the other, and I’m just
usually demonstrating this to folks as well. Just like that. Heel-to-toe gait. Perfect. That’s great. Good. Beautiful. No hands. Okay. Good. Now, this is
called the Romberg test. What you do is put your feet
right next to each other, hold your hands straight out in
front of you with the palms up, and close your eyes
and keep them there. This is a coordination test,
it’s also a subtle test of strength, because
if someone’s very weak, they’re a little
weak in one hand, that hand will drift a
little, but this is perfect. Good. You can open your eyes. That’s just right. Good. Okay. Thank you. Another test for fine
coordination of the hands, you take the thumb
and touch each finger in sequence just like that. Just like that. Good. Perfect. Great. Okay. Good. So, again, this was
a brief neurologic exam which Bill did perfectly. We first checked mental status;
we checked the cranial nerves; we checked his sensation;
we checked his strength, including his reflexes; and
we checked his coordination. And he did all those very well. And as you can see, you can
do this very briefly as part of a normal examination.

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