Neurology Physical Exam

Cranial Nerves

The Autonomic Nervous System
  • Sympathetic
    • Arise from the thoracic and lumbar regions
    • Synapse in the autonomic chain ganglia.
  • Parasympathetic Fibers
    • Arise from the brainstem nuclei and the sacral cord levels
    • Synapse directly on nuclei of the organ systems involved
Sympathetic System
  • Alarm system of the body
    • Tachycardia
    • Dilation of the bronchi
    • Release of adrenaline
    • Decrease in bowel activity
    • Inhibition of micturition
    • Increased sweating
    • Dilation of the pupils
Parasympathetic System
  • Bradycardia
  • Constriction of the bronchi
  • Increased salivation
  • Lacrimation
  • Increased bowel motility
  • Constriction of the pupils
Innervation of the Bladder

Motor Control

  • Control of the external sphincters
    • Voluntary control <— pudendal nerve <— S2, S3, and S4 nerve roots
  • The internal sphincter control and contraction of the detrusor muscle of the bladder
    • Regulated by the parasympathetic nervous system <— sacral roots S2, S3, and S4
      • These parasympathetic fibers terminate on ganglia located in the wall of the bladder itself
      • Stimulation of parasympathetic fibers ==> emptying of the bladder <== contraction of the detrusor muscle &relaxation of the internal sphincter muscle
      • Sympathetic System —> minor role

Lower Extremities

  • I start always with hip abduction, This is to check Obturator Nerve(L2-L4)
  • Then I continue with hip flexion—> This way you start with Femoral nerve(L2, L3)
  • Then whilst hip is flexed simply ask pt to extend the knee! —> Still Femoral nerve(L2-L4)
  • Then I check knee flexion. This would check Sciatica nerve(L4-S3)
  • Defenitely you would like that big leg to be back on the bed! Check Hip Extension! —> This way you cover L5, S1 and S2 —> This is Gluteus Maximus muscle which is innervated by sup. Gluteal n.
  • Know go down to the ankle
    • First check dorsiflexion of ankle and toes
      • Tibialis anterior —> L4, L5 —> Common Peroneal n.
        • To continue with Common roneal nerve one can check foot eversion as well.
        • Injury to this nerve makes Foot Drop.
    • then plantar flexion
      • Gastrocnemius —> S1, S2 —> Tibial n.
        • Also ANKLE JERK

Upper Extremities

  1. I start with arm ( flexion, extension and abduction and sensation of lat arm)
    1. This covers Axillary Nerve(C5-C6)
  2. Then I start thinking of Radial Nerve(C5-C8) and I start with Elbow Extension
    • I keep in mind that elbow flex is for Musculocutaneous Nerve(C5-C6) but I leave it for now
    • I quickly go down and check Extension of: ( to complete Radial n. exam )
      1. Wrist
      2. Fingers
    • If I notice any deficit I ALWAYS check the triceps reflex right after if not I continue my exam.
  3. I am down with fingers so I start check Median Nerve(C6-T1).
    1. Flexion of
      1. Fingers
        1. Thumb
        2. Pointing
        3. Middle
      2. Wrist ( Ulnar n. is also involved )
    2. Forearm Pronation
      • I keep in mind that forearm supination is for Musculocutaneous Nerve(C5-C6) but I leave it for now
    3. Thumb Opposition
      1. Also look at the palm of the hand for Thenar Eminence
  4. I switch to Ulnar Nerve(C8-T1) and start with
    1. Little finger opposition
      1. Also look at the palm of the hand for Hypothenar Eminence
    2. Adduction and Abduction of fingers
    3. Flexion
      1. Wrist ( Median n. is also involved )
      2. Fingers
        1. Ring
        2. Little Finger
    4. To complete my exam I check Musculocutaneous Nerve(C5-C6)
      • This is the nerve I have thought about two times
      • Elbow Flexion
      • Forearm Supination
      • Biceps Reflex
  5. So I continue my exam with reflex
    1. Triceps reflex ( which is Radial n.)
  6. Last is check the sensation:
Arm%20Sensation.bmp

Extensor digitorum longus
L5, S1
Peroneal
Dorsiflexion of toes

Extensor digitorum brevis
S1
Peroneal
Dorsiflexion of toes

Peronei
L5, S1
Peroneal
Eversion of foot

Tibialis posterior
L4
Tibial
Inversion of foot

Gastrocnemius
S1, S2
Tibial
Plantar flexion of ankle

Soleus
S1, S2
Tibial
Plantar flexion of ankle

* Iliopsoas
L2, L3
Femoral
Hip flexion

Quadriceps femoris
L3, L4
Femoral
Knee extension

Adductors
L2, L3, L4
Obturator
Adduction of thigh

Gluteus maximus
L5, S1, S2
Inferior gluteal
Hip extension

Gluteus medius and minimus, tensor fasciae latae
L4, L5, S1
Superior gluteal
Hip abduction

Hamstrings
L5, S1
Sciatic
Knee flexion

Tibialis anterior
L4, L5
Peroneal
Dorsiflexion of ankle

Extensor digitorum longus
L5, S1
Peroneal
Dorsiflexion of toes

Extensor digitorum brevis
S1
Peroneal
Dorsiflexion of toes

Peronei
L5, S1
Peroneal
Eversion of foot

Tibialis posterior
L4
Tibial
Inversion of foot

Gastrocnemius
S1, S2
Tibial
Plantar flexion of ankle

Soleus
S1, S2
Tibial
Plantar flexion of ankle