BEDSIDE NEUROLOGICAL
EVALUATION
Eva Vlčková
Clinic of Neurology, Masaryk University and
University Hospital Brno - Bohunice
MEDICAL HISTORY – PRESENT ILLNESS
= getting information from the patient or – in some cases – from other
observer (important in seizures, dementia, aphasia…)
STANDARD PRACTICE IS TO RECORD:
 PATIENT´S CHIEF COMPLAINT („what brings you to see me?“) these
data focus attention on particular questions to be addressed in taking the
history and focused neurological examination
 HISTORY OF PRESENT ILLNESS including a history of development
of particular symptoms:
 mode of onset
 duration a and progression are critical in investigating the etiology! –
sudden onset x paroxysmal episodes x exacerbations and remissoins
x slow progression)
 CHARACTERISTICS OF THE SYMPTOMS (intensity – VAS, Likert
scale, localisation, what relieves/makes the symptom worse)
MEDICAL HISTORY – OTHER DATA
 history of MEDICAL ILLNESSES AND PREVIOUS SURGICAL
PROCEDURES:
 neurological system is affected by many non-neurological diseases (DM)
 adversely neurological diseases may involve the function of many
systems (Parkinson disease, diabetic neuropathy)
 And/or may be a part of multiorgan involvement
 sarciodosis,
 vasculitis,
 mitochondrial diseases
 storage diseases
 current (and sometimes) MEDICATIONS AND ALLERGIES
 previous – chemotherapy, izoniazid, neuroleptic agents
 current – hypolipidemics, corticoid hormones, neuroleptics,
opioids, hypnotics….
MEDICAL HISTORY – OTHER DATA
 timing of developmental milestones (sitting, walk, first
words)
 in infants
 In young children
 in adults whose illness started during childhood also the
 personal and social history
 occupation
 marital status
 excessive stress at home, in school or in the workplace
 did the patient ever use of alcohol, tobacco or any other
prescription or illegal drugs (dependence)
 family history (cave! misinterpreting the symptoms and
sings! – consequence of aging, family secret…)
EVALUATION OF THE PATIENT
 History of the symptoms and the clinical examination of the
patient are the KEY TO ACHIEVING AN ACCURATE DIAGNOSIS
 in all branches of medicine and particularly in neurology
 DIAGNOSTIC PROCESS CONSIST OF A SERIES OF
FOLLOWING STEPS:
 MEDICAL HISTORY usually starting with chief complaint of the
patient, following the general medical history and including the
review of any symptoms and signs involving the neurological or nonneuroloical
body systems
 NEUROLOGICAL EXAMINATION and general medical examination
 based on the findings: differential diagnosis with generation of a
list of possible causes of patient´s symptoms and signs
GENERAL ASPECTION OF THE PATIENT
 assessed while recording the history
 you can see e.g.:
 CHANGES OF FACIAL EXPRESION or mimics:
 lack of facial expression (hypomimia) may suggest parkinsonism or
depression
 a worried or astonished facial expression may suggest progressive
supranuclear palsy
 unilateral ptosis may suggest myasthenia gravis or a brainstem lesion
 the PATTERN OF SPEECH may suggest dysarthria, aphasia, or
spasmodic dysphonia
 the PRESENCE OF ABNORMAL INVOLUNTARY
MOVEMENTS may indicate an underlying movement disorder.
REVIEW OF ANY SYMPTOMS AND
SIGNS IN ALL BODY SYSTEMS
 orthostatic faintness
 headaches
 special senses
 swallowing
 limb coordination
 slowness of movement
 hallucinations
 strength and sensation
 pain
 gait and balance
 sphincter, bowel and sexual
function
Ask the patient (and/or the relatives) about all elements of nervous
system function that did not surface in taking the history:
 cognition, personality and mood change
 seizures or other impairments of consciousness
 speach and language function
 involuntary movements or vocalisation
→ a positive response may help clarify the diagnosis
+ review of all of the organ systems (GIT, liver, kidney, heart…)
NEUROLOGICAL EXAMINATION
 STARTS ALREADY DURING THE INTERVIEW:
 mental status
 changes of facial expresion or mimics
 Hypomimia
 Ptosis
 Rattern of speech (dysarthria, aphasia),
 Presence of abnormal involuntary movements
 …..
 FULL NEUROLOGICAL EXAMINATION TESTS in detail
every central nervous system region, peripheral nerve,
muscle, sensory modality and reflex
 → too lengthy to perform in practice.
NEUROLOGICAL EXAMINATION
 in practice: FOCUSED NEUROLOGICAL EXAMINATION
 to examine in detail the neurological functions that are
relevant to the history
 + then SCREENING NEUROLOGICAL EXAMINATION
 to check remaining parts of the nervous system
 both the presence
 and the absence
of abnormalities may be of diagnostic importance
 (e.g. separation of hemiparesis arising from spinal cord
and right cerebral cortex lesion….)
SCREENING NEUROLOGICAL EXAMINATION
= QUICK EVALUATION OF:
 mental status
 cranial nerves
 motor system
 Strength
 muscle tone and tendon reflexes
 presence of involuntary movements and postures
 coordination
 gait and balance
 Sensation
MORE COMPLEX FUNCTIONS
ARE TESTED FIRST (no need to
test the simplex ones may happened)!
https://el.lf1.cuni.cz/neuronorma/
EXAMINATION OF THE LIMBS/TRUNK
Separate testing of each limb:
 Presence OF INVOLUNTARY MOVEMENTS, ABNORMAL LIMB
POSITION (pain release, flexion, extension)
 MUSCLE MASS (atrophy x (pseudo- hypertrophy) and look for fasciculations
 MUSCLE TONE in response to passive flexion and extension
 ACTIVE MOVEMENTS in particular segments or joints (pasive motility?)
 Paretic signs
 Power of main muscle groups
 TENDON REFLEXES
 Plantar responses or other ABNORMAL REFLEXES
 COORDINATION
 Finger-to-nose and heel-to-shin test x rapid alternating movements
12
MOTOR UNIT (MU)
= is made up of a motor neuron + the
skeletal muscle fibers innervated by that
motor neuron's axonal terminals (3-200).
- All muscle fibres in a motor unit are of
the same fibre type.
- In a muscle, particular MUs are
intertwined with the others
Contraction of single motor unit =
a fasciculation
- a small, local, involuntary muscle
contraction and immediate relaxation
which may be visible under the skin. In
deeper areas, they can be detected
by EMG.
 Small rapid flickering or vermicular
twitching
 https://www.youtube.com/watch?v=xu
wdvBXcr30
MUSCLE ATROPHY
MOTOR
PATHWAYS
 1. (central) motoneuron:
GYRUS PRECENTRALIS
  PYRAMIDAL TRACT
 Branches towards cranial
nerves nuclei
 CROSS OVER IN THE
MEDULLA LEVEL
 resulting in muscles being
controlled by the opposite
side of the brain
 2. (peripheral) motoneuron:
ANTERIOR HORN OF THE
SPINAL CORD
  PERIPHERAL NERVE 
MUSCLE
15
MOTOR SYSTEM
• Consists of 2 basic types of movements:
• VOLUNTARY MOVEMENTS
• EASY (locomotion, rythmic movements)
• COMPLICATED
• REFLEX RESPONSES
• Fast, stereotypic, involuntary, evoked by a stimulus
• A part of many voluntary movements
• E.g. Maintain muscle tone
• Relax antagonists during agonist contraction
 ABNORMAL MOTOR FUCTION RESULT TO MUSCLE WEAKNESS =
PARESIS = loss of voluntary movements (reflex movements may be
perserved)
 COMPLETE LOSS OF VOLUNTARY MOVEMENTS = PLEGIA
 INCOMPLETE = PARESIS.
16
DEEP TENDON
REFLEXES
• Intact REFLEX ARC
• BASIC PRINCPLE :
• Blow upon the tendon with a hammer
• → short muscle stretching
• → leads to muscle contraction
• Quantification:
GRADE Reflex
0 (--) Absent
1 (-) Decreased (hypoactive)
2 (N) Normal
3 (+) Increased (hyperactive)
without clonus
4 (++) Hyperactive with clonus
 = proprioceptive reflexes
General interpretation:
 Decreased DTR = periheral paresis (flaccid)
 Increase DTR = central paresis (spastic)
 Note interindividual differences (intraindividually ± stable)
 Following the sudden development of central paresis
(stroke…) = the central paresis is flaccid (decreased DTR).
DEEP TENDON REFLEXES
18
DEEP TENDON REFLEXES - UE
Biceps reflex (C5-6): reflex contraction
of the biceps muscle and jerk of the
forearm.
Styloradial (pronatinon) (C6)
(periosteal): tapping the processus
styloideus radii (elbow in flexed in 90
degrees and semiproned forearm)
leads to the slight forearm pronation
Triceps reflex (C6-8,mainly C7):
tapping the triceps tendon while the
forearm is hanging loose at a right
angle to the arm causes the forearm
extension.
Reflex of finger flectors (C8): tapping
the ligamentum carpi transversum
leads to slight flection of the fingers
19
DEEP TENDON REFLEXES - LE
Patellar reflex L2-L4 (knee-jerk) =
striking the patellar tendon with a
hammer just below the patella
causes the quadriceps femoris
contraction and shank extension
Ankle jerk reflex S1/S2 (Achilles
reflex) occurs when the Achilles
tendon is tapped while the foot is
dorsi-flexed leading to the jerking of
the foot towards its plantar surface
MUSCLE TONE
 DECREASED (flaccidity) in lower motor neuron/ peripheral nerve disseases
 INCREASED in central nervous system disease: spasticity or rigidity
 In SPASTICITY, the increased tone is caused by an exaggeration of the
stretch reflex and accordingly is dependent on stretch rate:
 if the muscle is slowly stretched, tone may be normal
 if the muscle is stretched more rapidly, increasing amounts of
resistance occur
 ⇒ rate-sensitive, preferential involvement of extensors
 „clasp knife“ or pocket knife fenomenon
 RIGIDITY: increased muscle tone, not depending on the rate of movement.
 found equally in both extensors and flexors.
 caused by extrapyramidal disease (or side effect of antidopaminergic drugs)
PARETIC SIGNS
 Not much used in English literature
 Signs of paresis: FUNCTIONAL TESTS OF MUSCLE ENDURANCE,
reflect global impairment of muscle strength in particular extremity,
not only the dysfunction of pyramidal tracks
 UE: Mingazzini – holding the extended arms raising forward,
eyes closed (15 seconds or more) (decrease?)
Duffour (pronator drift) – supination in the same position
(pronation?)
 LE: Mingazzini – in lying position, lower extremities flexed in hipps and knees
(90 degrees angle)
ACTIVE MOVEMENT TESTING
 Active movement in each big joint:
 Shoulders - abduction
 Elbow – flection, extension
 Wrist – flection, extension
 Make a pinch
 Hip – flection
 Knee – extension, flection
 Ankle – dorsal and plantar extension
 Movements of the big toe
WEAKNESS (MUSCLE STRENGTH)
5-POINT MEDICAL RESEARCH COUNCIL (MRC) GRADING SCALE
 Grade 5 represents normal strength.
 Grade 4 = ability to move the limb only against gravity and resistance, but
not full strength: represents “weakness” somewhere between 3 and 5.
Covers such a large range, that should be expanded into mild, moderate, or severe: 4+, 4, and 4–
 Grade 3 = ability to move the limb only against gravity (not against resistance)
 Grade 2 = active movement only with gravity eliminated
 Grade 1 = is just a flicker or trace of contraction (visible contraction without
visible joint movement).
 Grade 0 = no contraction
ABNORMAL REFLEXES
 Primitive Reflexes or Atavistic Reflexes
 present at birth or with very early stages of the nervous system
development and disappear in most people in early infancy (in some
patients may not dissapear and persistence of single reflex does not
represent a reliable sign of abnormity)
 The snout reflex can be assessed by gently tapping over the
patient's upper lip. If this reflex is present, a puckering of the lips will
be seen. The snout reflex is present in 30% to 50% of healthy adults
over age 60
ATAVISTIC REFLEXES
 A suck reflex may also be elicited and is considered a more
worrisome reflex. When present, the suck reflex is elicited by
stimulation of the lips; this is followed by sucking movements of the
lips, tongue, and jaw.
 The palmomental reflex is an ipsilateral contraction of the mentalis
and orbicularis oris after stimulation of the thenar region of the hand.
This reflex is present in 20% to 25% of healthy adults in their thirties
and forties.
 The grasp reflex (physiological in infants, sign of deliberation of
frontal lobes) – patient grasps the examinator fingers inserted into
his/her hands (palms). When being ased, patient does not know why
he/she performed the grasp maneuver. Alternatively: is elicited by
stroking the palm of the patient's hand. The reflex is present if the
patient's fingers flex or the hand closes.
ABNORMAL REFLEXES (EXTENSION)
 Elicited by scratching the
skin (not painful!) of the
bottom of the foot along
its lateral aspect from the
heel forward
 A = plantar reflex (normal
response = flection of the foot
and toes)
 B = Babinski sign
(extensor plantar response )
 C= Triple flexion
response (a spinal reflex
characterized by hip and knee
flexion accompanied by ankle
dorsiflexion)
ABNORMAL REFLEXES - LE
 Other abnormal reflexes with EXTENSOR RESPONSE:
 Roch - scratching the skin of lateral aspect of the foot from the heel
forward to the half of the distance hell-fingers
 Chaddock - scratching the skin below the external ankle
 Oppenheim – stimulation of the skin of anterior aspect of the shank
(crura) by the examinator thumb and second finger
 Gordon – distal calf massage
 Abnormal reflexes with FLEXOR RESPONSE:
 Rossolimo: tapping the balls of the fingers (from plantar aspect) by
hammer produces their flection
ABNORMAL REFLEXES - UE
 JUSTER PHENOMENON (CUTANEOUS OR SUPERFICIAL
REFLEX, counterpart of an extensor plantar reflex, a positive
proof of pyramidal tract dysfunction): Elicited by scratching
the skin of the palm along its lateral aspect (antithenar side) in
the distal direction and then along the metacarpo-phalagneal
joints to the thumb.
 Normal reaction = no reaction
 Slow tonic slight adductuion of the thumb with slight
opposition represents abnormity = sign of pyramidal
dysfunction
ABNORMAL REFLEXES - UE
 TRÖMNER´S SIGN - with the fingers of the patient partially
flexed, the tapping of the volar aspect of the tip of the middle or
index finger
 https://www.youtube.com/watch?v=59Tw9hbbAZE
 A HOFFMANN REFLEX — evoked by flicking a dorsal aspect
of the relaxed finger tip with the fingers held in semiflexion
 https://www.youtube.com/watch?v=saUkeRHkeCw
 Positive response in both of them = flexion of all four fingers
and thumb;
 simply implies increased muscle tone
 not a direct counterpart of an extensor plantar reflex, which is
positive proof of pyramidal tract dysfunction
FLACCID VS. SPASTIC PARESIS
(CENTRAL VS. PERIPHERAL)
 The term "flaccid" indicates the absence of spasticity or other signs
of disordered central nervous system motor tracts such as
hyperreflexia, clonus, or extensor plantar responses
 Spastic paresis = central (upper motor neuron dysfunction)
 Flaccid paresis = peripheral (lower motor neuron dysfunction)
 Following the sudden development of central paresis (stroke…),
the central paresis is flaccid for few days (weeks?)
CUTANEOUS REFLEXES (TRUNK)
abdominal reflexes (superficial) : epigastric (T6-9)
mesogastric (T9-11)
hypogastric (T11-L1)
EXTEROCEPTIVE REFLEXES
= decreased both in central
and peripheral nerve lesions
CEREBELLUM
 located in the posterior cranial fossa
 It is separated from the overlying cerebrum by a layer of dura mater
(called tentorium cerebelli)
 two hemispheres + a narrow midline zone (the vermis)
 Superficial cortex (grey matter)
 white matter in the depth
 FUNCTION
 Important role in the motor control
 contributes to coordination, precision,
 and accurate timing of precise movements
 Responsible for muscle synergy
 Modifies the muscle tone
 Upright body position, balance maintenance
COORDINATION (CEREBELLUM): TERMS
 ATAXIA denotes a syndrome of imbalance and incoordination
involving gait, limbs, and speech
 lack of voluntary coordination of muscle movements
 usually results from a disorder of the cerebellum or its connections
 DYSMETRIA refers to a lack of coordination of movement typified by
the undershoot or overshoot of intended position with the hand, arm,
leg, or eye. It is a type of ataxia.
 HYPERMETRIA and HYPOMETRIA refer, respectively, to
overshooting and undershooting the intended position
 DYSDIADOCHOKINESIA, DYSDIADOCHOKINESIS, (from Greek dys
"bad", diadocho "receive", kinesia "movement) – a term for an impaired ability to
perform rapid, alternating movements (i.e. diadochokinesia).
Complete inability is called adiadochokinesia
TESTS FOR CEREBELLAR FUNCTION
 RAPID ALTERNATING AND REPETITIVE MOVEMENTS
(supination – pronation – symmetry?) (ADIADOCHOKINESIA?)
 FINGER TO NOSE / HEEL TO SHIN TESTS (NEXT SLIDE)
 STEWART-HOLMES TEST: The subjects are asked to perform a
strong isometric biceps contraction (UE flexed in elbows) against resistance,
performed by examiner. Sudden release of the resistance, the healthy patient
is able to stop his hand immediately, the patient with cerebellar dysfunction
may not be able to stop his hand fast enought (prevent hitting the face!)
 WALKING, AND RUNNING
 note involuntary movements (e.g., tremor, dystonia, chorea,
athetosis, tics, myoclonus) and conditions under which they are
enhanced or suppressed.
 Note abnormal gait (e.g. waddling, wide based, tiptoed).
35
EVALUATION OF ATAXIA AND
DYSMETRIA
• UPPER EXTREMITIES
• FINGER TO NOSE TEST
• Eyes opened
• OR ONLY TOUCH OF THE NOSE
BY THE INDEX FINGER – eyes
opened or closed
• Missing of the goal: DYSMETRIA
• Overshooting: HYPERMETRIA
• LOWER EXTREMITIES
• HEEL TO SHIN TESTS
36
CEREBELLAR SYNDROMES
 The result of the dysfunction of the cerebellum or its pathways
 IPSILATERAL!!!
 PALLEOCEREBELLAR SYNDROME (vermis dysfunction)
 Dyscoordination of the stance and gait (a broad-based gait, „drunken
sailor“)
 The ataxia of whole the body including axial muscles.
 NEOCEREBELLAR SYNDROME (hemispheral dysfunction)
 The lack of coordination of limb muscles
 Ataxia
 dysmetria
 dysdiadochokinesia
 hypotonia (decreased muscle tone),
 intention tremor
37
CEREBELLAR TREMOR
• involuntary movement caused
by alternating contractions of
opposing muscle groups),
• ACTION (only during the
movement, minimal or no tremor
at rest)
• INTENTIONAL =
• the amplitude increases before the
goal
• Patrly increased also at the
beginning of the movement
• Atactic = GROSS,
IRREGULAR
EXTRAPYRAMIDAL SYSTEM
 EXTRAPYRAMIDAL SYSTEM is a neural network that is part of the motor
system that causes involuntary reflexes and movement, and modulation
(tuning) of movement (i.e. coordination).
 The disorders of extrapyr. system usually cause two types of symptoms:
 1. PARKINSONISM (PARKINSON´S SYNDROME) characterized by
tremor, hypokinesia, rigidity, and postural instability
 2. abnormal involuntary movements, i.e. HYPERKINESIAS OR
DYSKINESIAS, terms used interchangeably
 are usually evident when a patient is at rest,
 are frequently increased by action,
 and disappear during sleep (with some exceptions – e.g. myoclonus
can persist in sleep).
HYPERKINESIAS
 CHOREA delineates brief, irregular contractions and movements (that,
although rapid, are not as lightning-like as myoclonic jerks). The jerks affect
individual muscles as random events that seem to flow from one muscle
to another. They are not repetitive or rhythmic.
 presumably related to disorders of the caudate nucleus (sometimes not)
 BALLISM is a form of chorea in which the choreic jerks are of large
amplitude, producing flinging movements of the affected limbs.
 often related to lesions of the subthalamic nucleus.
 The term MYOCLONUS refers to ultrabrief, shock like movements that
may arise from contractions or inhibitions (negative myoclonus) – various topics
 TREMORS are rhythmic oscillatory movements. They result from
alternating contractions of opposing muscle groups (e.g., parkinsonian
tremor at rest) or from simultaneous contractions of agonist and
antagonist muscles (e.g., essential tremor).
DYSTONIA
 DYSTONIA Is a syndrome of sustained muscle contraction that
frequently causes twisting and repetitive movements or abnormal
postures. Dystonia is represented by the following presentations:
 (1) sustained contractions of both agonist and antagonist muscles
simultaneously (cocontraction) and persisting in the same muscle
groups repeatedly (“patterning”), in contrast to the flowing of choreic
movements;
 (2) an increase of these involuntary contractions when voluntary
movement in other body parts is attempted (“overflow”);
 (3) rhythmic interruptions (dystonic tremor) of these involuntary,
sustained contractions when the patient attempts to oppose them;
 (4) inappropriate or opposing contractions during specific voluntary
motor actions (action dystonia); and
 (5) torsion spasms that may be as rapid as chorea but differ because
the movements are continual, patterned, and of a twisting nature in
contrast to the random and seemingly flowing movements of chorea.
GAIT AND BALANCE
 SPONTANEOUS GAIT should be observed; stance, base, cadence,
arm swing,
 tandem gait (straight line), toe + heel walking, walking backward
eventually hopping on one foot should be noted
 Postural stability should be assessed by the PULL TEST (examiner
abruptly pulls the patient off balance – usually backwards - while
being ready to catch the patient in the event of a fall)
 Examination of the stand stability: ROMBERG TEST: Stand with
eyes open and then closed (I= normal stand, II= stand with both feet
together, III = + eyes closed, IV = + rotation of the head to the right
or V= left)
EVALUATION OF SENSORY DEFICITS
On each limb, trunk, face
 Pinprick and light touch (wisp of cotton) on hands and feet
 Test tubes filled with cold and warm water to test temperature
sensation
 Double simultaneous stimuli on hands and feet
 Joint position sense in hallux and index finger
 Vibration sense at ankle and index finger
COMPARATIVE PRINCIPLE.
SENSORY LEVELS
Hypoesthesia/ anesthesia….. for each of the modalities
Hyperalgesia/ hypoalgesia/ alodynia -II-
SENSORY
PATHWAY
DERMATOMES
PERIPHERAL NERVOUS SYSTEM –
SENSORY NERVES
Areae nervinae
46
MENINGEAL SYNDROME:
CLINICAL EXAMINATION
(OBJECTIVE SIGNS)
UPPER
• NUCHAL RIGIDITY
•- BRUDZINSKI: forced flexion of the neck
elicits a reflex flexion of the hips, with the
patient lying supine.
MIDDLE
• SPINE SIGN – inability to touch the knees by
the head
• KERNIG I. –knee flection during passive
sitting
• AMOS SIGN – when sitting, support by the
arm /behind the trunk/ is necessary
•LOWER
• LASSEGUE;
• KERNIG II. – in lying patient with the hip and
knees flexed in 90 degree ankle, the extension
of the knees is not possible.
OTHER SIGNS ATTRIBUTED
TO BRUDZINSKI
The symphyseal sign, in which pressure on the pubic
symphysis leads to abduction of the leg and reflexive hip
and knee flexion.
The cheek sign, in which pessure on the cheek below the
zygoma leads to rising and flexion in the forearm.
Brudzinski's reflex, in which passive flexion of one knee
into the abdomen leads to involuntary flexion in the
opposite leg, and stretching of a limb that was flexed leads
to contralateral extension.
47
Illustrated as a series of steps
in which the neurologist collects
data (Task) with the objective of
providing information on the
anatomical localization and
nature of the disease process
(Goal).
THE DIAGNOSTIC
PATH IN
NEUROLOGY
EXAMINATION OF CONSCIOUSNESS
 assessed while recording the history
TWO TYPES OF ALTERATION OF THE CONSCIOUSNESS (a state of
awareness of self and surroundings):
 The first type AFFECTS AROUSAL – described on four levels (not very
accurate – more than this it is a continuum of subtly changing status)
 ALERT – perfectly normal state of arousal
 LETHARGY (drowsinness) – between alertness and stupor („sleepy“, fine stimuli
enough)
 STUPOR – a state of baseline unresponsiveness that requires repeated
application of vigorous stimuli to achieve arousal
 COMA - coma is a state of complete unresponsiveness to arousal, in which
the patient lies with the eyes closed
 The second type INVOLVES COGNITIVE AND AFFECTIVE MENTAL
FUNCTION, sometimes referred to as the “content” of mental function
(dementia, delusions, confusion)
THE GLASGOW
COMA SCALE
BEST MOTOR RESPONSE:
Obeys 6
Localizes 5
Withdraws 4
Abnormal flexion 3
Extensor response 2
Nil 1
VERBAL RESPONSE:
Oriented 5
Confused conversation 4
Inappropriate words 3
Incomprehensible sounds 2
Nil 1
EYE OPENING
Spontaneous 4
To speech 3
To pain 2
Nil 1
 Widely used scale to assess the initial severity
of traumatic brain injury.
 Separate assessment of three aspects of a
patient's behavior: the stimulus required to induce eye
opening, the best motor response, and the best verbal
response
 Each symptom is scored, sum score is obtained
 Simple and reproducible
 An ideal method of assessment for nonneurologists
involved in the care of comatose patients
 Limited use in patients who are intubated or who
have suffered facial trauma or have aphasia.
MENTAL STATUS EXAMINATION
Partially assessed already while RECORDING THE HISTORY –insight can be gained into the
subject's recent memory, orientation, language function, affect or mood, insight, and judgment.
Must not be omitted even in patients who seem “alert and oriented“ (subtle deficits may be
masked by formal social contact)
 ORIENTATION (time, place, person, situation)
 MEMORY: immediate (recalling of 3 unrelated words X reproducing drawings)
short-term: hours to weeks
long-term (remote): decades (names of children x other relatives – verified by relative)
 FUND OF INFORMATION (recent presidents or other political figures, athletic stars or television celebrities)
 SPEECH AND LANGUAGE (spontaneous speech, naming, repetition, auditory comprehension, reading+ writing)
 PRAXIS (use of both imaginary and real objects – „Show me what to do with a saw, hammer, or pencil)
 CALCULATIONS (serial-7 subtraction test)
 VISUAL-CONSTRUCTIONAL ABILITIES (line bisection, copying a cube or other design,
drawing a clock or a house, MMSE - copying of intersecting pentagons )
 INSIGHT AND JUDGMENT : tested by assessing the patient's understanding of his own illness
- interpretation of proverbs, such as “Those who live in glass houses should not throw stones „
- stating why an apple and an orange are similar
 ABSTRACT REASONING, SEQUENTIAL PROCESSES
MMSE - BEDSIDE MENTAL STATUS TESTING
 Folstein's Mini-Mental State Examination (MMSE) - perhaps the most
widely used test.
 CONSISTS OF 30 POINTS:
▪ 5 for orientation to time (year, season, month, date, and day)
▪ 5 for orientation to place (state, county, town, hospital, and floor)
▪ 5 for attention (either serial 7subtractions from 100 with 1 point for each of the first five
or “spell world backward”)
▪ 3 for registration of three items (unrelated words - shovel, scarf, vase)
▪ 3 for recall of three items after 5 minutes
▪ 2 for naming a pencil and a watch
▪ 1 for repeating “no ifs, ands, or buts”
▪ 3 for following a three-stage command (take the paper, fold it, lay it down to the floor)
▪ 1 for following a printed command (“close your eyes”)
▪ 1 for writing a sentence
▪ 1 for copying a diagram of two intersecting pentagons
MMSE
THE ADVANTAGES: short time of administration and quantitation,
useful in documentation for changes of clinical status.
THE DISADVANTAGES:
 the normal range of scores depends on education. (The low-normal
cutoff 19 for uneducated people, 23 for graduates of elementary or
junior high school, 27 for high school graduates, and 29 for college
graduates).
 depends on age
 the test is weighted toward orientation and language, and results
can be normal in patients with right hemisphere or frontal lobe
damage.
 even an abnormal score does not distinguish a focal lesion from a
more diffuse disorder, such as an encephalopathy or dementia.
SPONTANEOUS
CLOCK DRAWING
AND COPYING OF A
CROSS TESTS
Spontaneous clock drawing and
copying of a cross by a patient
with a right parietal infarction.
The patient had only mild
hemiparesis but dense left
hemianopia and neglect of the
left side of the body. The neglect
of the left side of space is
evident in both drawings
EXAMINATION OF LANGUAGE FUNCTIONS
 Monitored during the clinical interview (minor word-finding difficulty,
occasional paraphasic error, turn-taking in conversation and the use
of humor and iron)
BEDSIDE LANGUAGE EXAMINATION
6 steps to complex assessment of language function
1. SPONTANEOUS SPEECH
 a. Informal interview
 b. Structured task (ask the patient to describe the weather or the reason for coming to the doctor)
 c. Automatic sequences (recitation of lists, such as counting or listing days of the week)
PARAMETERS OF SPONEOUS SPEECH
 Fluency: fluent= effortless and rapid
nonfluent speech = uttered in single words or short phrases, with frequent pauses and hesitations
 Initiation difficulty
 Articulation, phonation or voice volume
 Rate of speech and a presence of word-finding pauses and circumlocutions
 Prosody or melodic intonation of speech
 Phrase length
 Content
 Errors such as neologisms or paraphasias ( = substitutes one word/phonem for another)
 Phonemic paraphasia, also literal paraphasia – Mispronunciation – treen/ train.
 Verbal paraphasia - Substitution of words
 Semantic paraphasia - The substituted word is related to the intended word by content. e.g. „I
spent the whole day working on the television (computer)."
 Morphologic paraphasia - The substituted word is similar by its form, e.g. „you are lazy (crazy).
BEDSIDE LANGUAGE EXAMINATION - II
2. NAMING (name objects, object parts, pictures, colors, or body parts to confrontation)
3. AUDITORY COMPREHENSION
 ask the patient to follow a series of commands of one, two, and three steps
 CAVE APRAXIA: the inability to carry out a motor command despite normal comprehension and
normal ability to carry out the motor act in another context.
 nonsense questions (e.g., “Do you vomit every day?”) - tendency of some aphasics to cover up
comprehension difficulty with social chatter.
4. REPETITION
 better repetition of familiar or “high-probability” phrases than unfamiliar ones = “no ifs, ands, or buts”.!
5. READING
 a. Reading aloud
 b. Reading comprehension
6. WRITING = most sensitive indicator of mild aphasia, record for future
 a. Spontaneous sentences
 b. Writing to dictation
 c. Copying
EXAMINATION OF CRANIAL NERVES – I, II
 I: Gross assessment – ask the patient about the ability to smell and
changes of foot flavor
 More detailled testing: in all persons who experience spontaneous loss
of smell, in patients suspected to have Parkinson's disease, and in
patients who have suffered head injury
 familiar odoriferous substance (using a small bottle of coffee, oil of
cloves, or oil of peppermint, soap) held beneath each nostril in turn while
the other is occluded by a finger.
 II: Each eye:Gross visual acuity (optotypes)
 Visual fields by confrontation (perimeter)
 Funduscopy
EXAMINATION OF CRANIAL NERVES – III, IV, VI
 III, IV, VI:
 Horizontal and vertical eye movements (full range of
movements/ limitations)
 Position of the ocular bulbi: parallel, squint (=strabismus –
convergent, divergent)
 Presence of nystagmus or other ocular oscillations
 Nystagmus: direction, degree, amplitude, frequency
 Pupil size (norma – midposition, miotic, mydriatic, symmetry –
isocoria, anisocoria)
 Pupil shape (round, irregular)
 Pupillary response to light – direct (illuminated pupil), indirect
(consesual)
 Ability of convergence and pupilary reaction to it (constriction)
EXAMINATION OF CRANIAL NERVES – V, VII, VIII
 V: Pinprick and touch sensation on face
corneal reflex
pressure to points where the 3 divisions emerge from the bone - painful ?
 VII: facial symmetry in rest and action (Close eyes, show teeth:
wrinkles, eyebrows, mouth angle drop)
 VIII: Perception of whispered voice in each ear or rubbing of fingers; if
hearing is impaired, look in external auditory canals and use tuning
fork for lateralization and bone versus air sound conduction
No vertigo, no tinnitus
EXAMINATION OF CRANIAL NERVES – IX-XII
 IX, X: Palate (uvula) in rest in the midline position,
 lifts symetrically during phonation,
 no dysarthria, no dysphonia (hoarse voice)
Gag reflex (pharyngeal reflex) = a reflex contraction of the back of
the throat evoked by light touching the soft palate (e.g. by cotton wool bud)
Palate reflex: particular (left or right) palatine arch lifts slighly in a
response to slight touch of particular arch
 XI: Shrug shoulders, turn (rotate) the head against counteraction
 XII: Protrude tongue (tongue position in rest in the mouth and during
protrusion) (mid-position,no atrophy,no fasciculations)
EXAMINATION OF THE NECK
 cervical column - movement and its limitation in directions of
motion
 forward flexion – anteflexion
 extension – retroflexion
 lateral flexion
 Rotation
 carotid arteries : auscultation for the sake of bruits
MAIN SOURCE OF
INFORMATION
Daroff RB, Jankovic J, Mazziotta JC, Pomeroy SL.
Bradley's Neurology in Clinical Practice, 7th Revised
edition. Philadelphia US: Elsevier 2015
Lewis ED, Mayer SA, Rowland LP. Merritt's Neurology,
13th edition. LWW 2015.
Ambler Z, Bednařík J, Růžička E (eds.). Klinická neurologie
(část obecná). Praha: Triton 2015 (most of the pictures)