Short Course [Return to MD Home Page]
How to Think Like a Neurologist.
Part 1: Pearls of the Neurological Examination
Martin L. Kutscher, MD. Departments of Pediatrics and Neurology,
New York Medical College, Valhalla, NY
This brief course starts with the physical examination, with emphasis on useful
"pearls." Tests of particular utility are printed in italics; they are
summarized in Table 1 below. A full pediatric neurological examination is
summarized in Table 2.
Table 1. Some of the Best Screening Tests in the Pediatric Neurological Examination.
- Mental state: level of consciousness
- Cranial N.: fundoscopic examination
- extraocular movements
- Motor: drift and triceps
- (for upper extremities) extensor hallicus and dorsiflexors
- (for lower extremeties)
- Reflexes: deep tendon reflexes
- Cerebellar: rapid alternating movements
- Gait: regular, toe, heel, tandem
- running and turning
The Neurological Examination
The childs level of consciousness is probably the most important part of the
neurological examination of the acutely ill child, as alterations in the level of
consciousness will often be the first manifestation of a problem.
A great way to awaken people is to get them upright. The standing position is even
better than sitting. Humans have an alerting reflex in the vertical positionthe same
reflex we utilize in newborns when we tilt them upwards so that they open their eyes.
Conversely, when people are in the reclining position, they are ready to sleep.
Describe level of consciousness. Amplify on words like
"lethargic" which mean different things to different examiners. I like to use a
sentence which describes four states:
- Patients activity as you enter the room, such as chatting, sleeping, posturing,
- Stimulus required to awaken patient, such as calling her name, pinching, etc.
- Patients best mental state seen, such as chatty conversation, sluggish answers,
semi-purposeful movements, etc.
- Patients activity when you stop stimulating her.
Ask, "Is your child acting like him/herself?" Always listen to
the mother. It is okay to assess the child as sicker than the mother feels, but it may be
risky for the doctor to assess the child as less sick than the mother thinks.
Spell "WORLD" backwards. This activity taps into large areas of cortex,
including language, memory, and executive function. Seeing a child groaning on a
stretcher, yet able to do this, is a reassuring sign that cognitive abilities are largely
preservedat least at present.
Four Part Command. Say: "When I say go, then I want you to
close your eyes, stick out your tongue, and put your left hand on your right ear."
Many children will still have some left/right confusion with this test (especially
children less than ten years old).
Oriention. Usually orientation to person, place and time are lost in the
Memory. Age appropriate tests might include immediate (digit span forwards and
backwards), short term (food for breakfast), and long term (name of teacher or school).
Developmental, speech, academic, and psychiatric mental status exams are covered in
appropriate textbooks. Here, we have focused on evaluation of the mental status in the
Avoid "2-12 intact" as well as "WNL," both of which frequently mean
"We Never Looked." Rather, document what was explicitly observed.
I (Olfactory) nerve. Not routinely tested.
II (Optic) nerve
Fundoscopic Exam. The key to seeing the optic disc is the childs visual
fixation at a point straight ahead and 15 degrees up. Have the young child fixate on the
mother, who often needs to be exceptionally animated in order to get the youngsters
attention. Sometimes, it helps for the child to point at the target with their finger or a
flashlight. If you are having trouble finding the disc, do not despair. First, examination
of the rest of the fundus is important anyway, especially to look for retinal hemorrhages.
Second, be patient. If you got a brief but incomplete look, stay where you are. When the
child re-fixates, the disc will come back into view. Third, when you find a vessel, just
follow it. If it is getting smaller, you are going in the wrong direction. Otherwise, all
vessels lead to the optic discs.
Disc sharpness refers to the sharpness of the distinction between the yellow optic disc
and the pink retina.
Disc flatness refers to whether or not the optic disc is mounded up when it comes out
of the retina. When the disc is elevated, the vessels may be noted to course downwards as
they traverse over the optic disc.
Disc color and retinal vessels.
Spontaneous venous pulsations (SVPs.) While acute papilledema may take 48 hours or more
to manifest itself, the first sign is usually loss of SVPs. Their presence is reassuring
that there is probably no significant elevation of intracranial pressure at this moment.
This does not mean that there is no serious intracranial pathology, nor that there will
not be signs and symptoms of raised pressure later. Note that SVPs may not be detected in
many normal patients.
PERRL means Pupils Equal, Round, Reactive to Light. If you also can also check
the response to Accommodation, write PERRLA. While Cr. N. II is the sensory limb of this
reflex, Cr.N. III is the motor limb. [Although pupil reactivity is a critical part of the
exam, "blowing a pupil" is a late sign! Mental status changes are much more
likely to be useful early warning signs.]
Visual acuity. If the visual acuity can be demonstrated to be normal through a pinhole,
glasses, the near card, or the distant chart, then the acuity disturbance it is unlikely
to be of primary neurological origin.
Normal optic disc.
Alternate moving your cursor over the picture, and then off again.
This will simulate "spontaneous venous pulsations" ( just below the black circle
Note retinal hemorrhages.
III (oculomotor), IV (trochlear), and VI (abducens) nerves are involved in the extraocular
movements (EOMs). VI controls the lateral rectus (abducts the eye), IV controls the
superior oblique (pulls the eye down and in), and III does all other extraocular
movements. There are 9 directions of gaze: left: up, horizontal, down; straight: up,
horizontal, down; &right: up, horizontal, down.
Eye Palsy simulation page. Very cool demonstration of any extraoccular
V (trigeminal) nerve function includes:
Corneal sensation (the afferent limb of the corneal reflex)
Muscles of mastication (masseter)
VII (facial) nerve includes:
Facial movement. Upper motor neurons send innervation to both sides of the upper face
(eye closure and forehead wrinkling) but only to the contralateral part of the lower face.
Thus a "central 7th" tends to spare the upper part of the face. In contrast,
lower motor neuron lesions (such as Bells palsy) affect the final common pathway and
thus involve muscles of both the lower face and upper face.
Taste on anterior 2/3 of tongue
Chordae tympani which dampens loud sounds. Loss of this function causes hyperaccusis,
which is the symptom of sounds seeming too loud. Test for this by placing a stethescope in
the patients ears and then asking if one side seems too loud when you scratch the
stethescopes diaphragm. Hyperaccusis should not be confused with tinnitus (ringing
in the ears) or hearing loss, which are VIII nerve symptoms.
VIII (cochlear) nerve
IX (glossopharyngeal), X (vagal) nerves
XI (spinal accessory) nerve
Sternocleidomastoid (turns head to the opposite side)
Trapezius (shrugs shoulder)
XII (hypoglossal) nerve
Tongue protrusion forward and to the sides.
Tongue fasciculations seen in anterior horn cell disease.
Careful observation of the childs activity.
Pronator Drift. This is a superb and sensitive test for upper motor neuron
weakness. It will often detect weakness missed on manual motor testingand it
is quick. Use this test all of the time. First, the child extends his arms palms down.
Then, the eyes are closed, and a few seconds later, the child turns his arms palms up.
During this turning maneuver, a child with upper motor neuron weakness may pull the elbow
down and in. Finally, observe the arm position when the palms are up. The eyes should
remain closed. Observe for any asymmetric pronation, drift, or finger flexion. Mild
symptoms may be provoked by asking the patient to shake his head "no."
Pronator Drift: Start with hands palm down, then turn palms
Manual motor testing can usually be done with children starting around five
years of age. Test flexion and extension at each joint. In a central lesion, the weakest
muscles will be the extensors in the upper extremities and the flexors in the lower
extremities. So, rather than focusing on the grip, screen for upper extremity weakness
by testing the triceps and drift. For the lower extremities, the extensor hallicus (great
toe extensor) and ankle dorsiflexors (pulling the foot up at the ankle by asking the child
to "reel in the fish") are the best screening tests for upper motor neuron
lesions. Muscle weakness can best be detected if the muscles are tested at mechanical
disadvantage, i.e., starting with the muscle fibers stretched. For example, test the
triceps starting with the elbow flexed, and then asking the patient to push away.
Wrist Extensor Testing
Ankle Dorsiflexion Testing
Functional motor tests, such as getting up from the ground, using stairs, and gait
testing have several uses. First, they may be the best way to pick up proximal
weakness, such as seen in myopathies. Second, they may be the only way to gain the
cooperation of younger children. Third, functional tests can often be used as
developmental landmarks. These include the parachute (child puts arms out when tilted
forward by 12 months age), and then the wheelbarrow. Asymmetry of these reflexes may
indicate focal weakness.
Muscle tone and bulk. Distinguish between the peripheral muscle tone (the tone of the
extremities) vs. truncal tone (which includes pelvic tilt, posture, tendancy to fall
through the examiners hands, and jaw tone). A common pattern in static motor
encephalopathy is hypertonia in the extremities (especially the legs) and truncal
hypotonia including lax jaw tone.
Light touch is the most commonly tested sensation but least reliable
screen since it is carried by multiple spinal cord columns.
Pain and temperature are carried by the spinothalamic tract in the spinal cord.
Position sense and vibration are carried by the posterior columns.
Cortical sensation by the parietal cortex can be tested if the above primary sensory
modalities are intact. Double simultaneous distinction, graphesthesia, and stereognosis
are most commonly checked.
Deep tendon reflexes.
Babinski response can be present (toes up with flaring) or absent. They should
always be symmetric, but can be present or absent up to one year of age. Primary reflexes
such as the Moro, root, and atonic neck should not be present after six months of age.
Rapid alternating movements may be awkward with both cerebellar and upper
motor neuron problems. They should be tested each side individually. Otherwise, the
good side may slow down to match up with the problem side, masking the difficulty.
Finger to nose
Heel to shin
Along with fundoscopy and the drift, this is an essential test in medically stable
patients. Gait testing not only checks for midline cerebellar dysfunction, but it is
also a fantastic screening test for weakness. Watch the arm swing, hip movement,
broadness of gait, and heel strike.
Regular walking. A young child is more likely to cooperate if expected to walk
towards the mother first, rather than towards yourself. If the mother puts her arms out,
then the child will put out her arms also, eliciting a type of drift test.
Heel walking. (This is particularly difficult in upper motor neuron diseases.)
It is easier to observe if done while the child walks towards you.
Toe walking is easier to observe if done while the child walks away from you.
Running, including rapid turns, is an even better test.
The General Examination
Certain elements of the general physical examination are of particular interest.
These include examination of the:
Skull (including bruits over the temples, mastoids, and orbits. Hemotympanum may
be found in head trauma.)
Sinuses and mastoids
Neck (including carotid thrills and bruits, especially in trauma.)
Spine (including dimples, birthmarks, or hair tufts. These lesions may signify
underlying tracts or spinal cord pathology.)
Table 2. Summary of the Pediatric
General: Skull (bruits)
Neuro: Mental Status: Level of consciousness (incl. 4 part commands;
spell world backwards)
Speech and language
II Visual acuity; visual fields; PERRLA, pupils; disc;
III, IV, VI EOMs in 9 fields of gaze
V Facial sensation; chewing
VI I Facial movement [peripheral 7th involves forehead]
IX, X Gag
XII Tongue [fasciculations in anterior horn cell disease]
Motor: Manual motor testing (> 5 years old)
flexion/ext. at each joint, starting with muscle at disadvantage
especially triceps, ankle and toe dorsiflexors
walking/crawling (having mother extend arms elicits drift)
Sensory: Light touch (least reliable)
cortical sensation (2 pt discrimination; graphesthesia, stereognosis)
Cerebellar: Finger to nose
Heel to shin
Rapid alternating movements (test each side separately)
Gait: Regular, toe, heel, tandem, running, turning
Detailed descriptions of the
(adult) neurological exam can be found at:
http://www.neuroexam.com/ which has videos of each part of the exam!
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