Neurologic Assessment
Maria Carmela L. Domocmat, RN, MSN
Instructor, Nursing Health Assessment
School of Nursing
Northern Luzon Adventist College
Nervous System Anatomy: Review
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http://sciencecity.oupchina.com.hk/biology/student/glossary/img/peripheral_nervous_system.jpg
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� The right cerebral hemisphere controls movement of the left side of the body.
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� The cerebellum processes input from other areas of the brain, spinal cord and sensory receptors to provide precise timing for coordinated, smooth movements of the skeletal muscular system. A stroke affecting the cerebellum may cause dizziness, nausea, balance and coordination problems.
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Neurologic Assessment:
OVERVIEW
Neurologic System Assessment
�Organized into 5 major areas:
1. Mental Status
2. Cranial Nerves2. Cranial Nerves
3. Sensory System
4. Motor System & Cerebellar
5. Reflexes
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Mental Status and Level of
Consciousness
�Observe the following:
• LOC
• posture and body movements
• dress, grooming and hygiene • dress, grooming and hygiene
• facial expression
• speech
• mood, feelings, and expressions
• thought processes and perceptions
• cognitive abilities 6/26/2011 14
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Cranial Nerves
• I (olfactory)
• II (optic)
• III (oculomotor), IV (trochlear), VI (abducens)
• V (trigeminal)• V (trigeminal)
• VII (facial)
• VIII acoustic/vestibulocochlear)
• IX (glossopharyngeal), X (vagus)
• XI (spinal accessory)
• XII (hypoglossal) 6/26/2011 15
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Motor and cerebellar systems
�assess condition and movement of muscles
�evaluate balance
�assess coordination
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Sensory Systems
• assess light touch, pain, and temperature
sensations
• test vibratory sensations
• sensitivity to position • sensitivity to position
• tactile discrimination (fine touch)
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Reflexes
• deep tendon
reflexes
o biceps
o brachioradialis
• superficial
reflexes
o plantar o brachioradialis
o triceps
o patellar
• Achilles
o plantar
o abdominal reflex
o cremasteric
reflex
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Tests for meningeal irritation or
inflammation
• Neck mobility
• Brudzinski’s sign
• Kernig’s sign
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MENTAL STATUS AND
LEVEL OF
CONSCIOUSNESS6/26/2011
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Observe the following
• LOC
• posture and body movements
• dress, grooming and hygiene
• facial expression • facial expression
• speech
• mood, feelings, and expressions
• thought processes and perceptions
• cognitive abilities
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• Decorticate posture is
an abnormal posturing that
involves
• rigidity, flexion of the arms,
• clenched fists,
• Decerebrate posture is an
abnormal body posture that
involves
• arms and legs being held
straight out, • clenched fists,
• extended legs (held out
straight).
• arms are bent inward toward
the body
• wrists and fingers bent and
held on the chest.
straight out,
• toes being pointed
downward,
• head and neck being arched
backwards.
• muscles are tightened and
held rigidly.
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For children under 5, the verbal response
criteria are adjusted as follow
SCORE 2 to 5 YRS 0 TO 23 Mos.
5 Appropriate words or phrases Smiles or coos appropriately
4 Inappropriate words Cries and consolable
3 Persistent cries and/or screamsPersistent inappropriate crying &/or screaming
2 Grunts Grunts or is agitated or restless
1 No response No response
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http://www.unc.edu/~rowlett/units/scales/glasgow.htm
CRANIAL NERVES
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I (olfactory)
o abnormal finding: � inability to smell : neurogenic anosmia, olfactory
tract lesion, tumor or lesion of frontal lobe� loss of smell: congenital, nasal dse, smoking, use � loss of smell: congenital, nasal dse, smoking, use
of cocaine
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CN II (optic)
o visual acuity – both far and near o confrontation test o asses retina using ophthalmoscope o OD – R eye; OS – L eye; OU - both eyes o OD – R eye; OS – L eye; OU - both eyes
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CN II (optic)
o normal finding: � round red reflex� optic disc – 1.5 mm; round or slightly oval; well-
defined margins,creamypink defined margins,creamypink � paler physiologic cup� retina – pink
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CN II (optic)
o abnormal finding: � blurred optic disc margins; dilated, pulsating veins
- Papilledema (swelling of optic nerve) – due to increased ICP from tumor or hemorrhageincreased ICP from tumor or hemorrhage
� optic atrophy – brain tumors
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III (oculomotor), IV (trochlear), VI (abducens)
o (a) inspect margin of eyelidso (b) extraocular muscles o (c) pupillary response to light
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CN III, IV, VI
o normal finding: � (a) eyelid covers abt 2 mm of iris � (b) eyes move smooth, coordinated motion in all
directions directions � (c) bilateral constriction
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CN III, IV, VI
o abnormal finding: � (a) ptosis (drooping of eyelids) – myasthenia
gravis � (b) abnormal eye movements� (b) abnormal eye movements
• nystagmus (rhythmic oscillation of the eyes) -cerebellar disorder
• limited eye movement – increased ICP• paralytic strabismus – paralysis of oculomotor, trochlear
or abducens nerves
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Nystagmus video
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CN III, IV, VI
� (c) dilated pupil (6-7 mm) – oculomotor nerve paralysis
� Argyll Robertson pupils – CNS syphilis, meningitis, brain tumor, alcoholism meningitis, brain tumor, alcoholism
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Argyll Robertson pupils
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CN III, IV, VI
� constricted, fixed pupils – narcotics abuse, damage to pons
� unilaterally dilated pupil unresponsive to light or accommodation – damage to CN IIIaccommodation – damage to CN III
� constricted pupil unresponsive to light or accommodation – lesions of the SNS (sympathetic nervous sys)
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CN V (trigeminal)
omotor function o sensory function :
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CN V (trigeminal)
omotor function � temporal and master muscles contraction � (Note: may be difficult to perform and evaluate
in client without teeth)in client without teeth)
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CN V (trigeminal)
o sensory function : � sharp or dull sensation and light touch on
forehead, chin and cheeks • safety pin, paper clip, or cut tongue depressor; wisp • safety pin, paper clip, or cut tongue depressor; wisp
of cotton
� corneal reflex (blinking reflex) � (Note: may be absent or reduced in clients who
wear contact lenses)
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Corneal refle
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CN V
o normal finding: � temporal and masseter muscles contract bilaterally � correctly identifies sharp or dull, light touch
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CN V
o abnormal finding: � inability to identify – lesions in trigeminal nerve,
lesions in spinothalamic tract or posterior columns � absent corneal reflex – lesions of CN V, lesions of � absent corneal reflex – lesions of CN V, lesions of
motor part of CN VII
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CN VII (facial)
o motor function
o sensory function
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CN VII (facial)
o motor function
� smile, frown, wrinkle forehead, show teeth, puff out
cheeks, purse lips, raise eyebrows, close eyes tightly
against resistance against resistance
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CN VII (facial)
o sensory function
� taste test – anterior 2/3 of tongue – salt, sugar, or
lemon juice
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CN VII
o abnormal finding:
� inability to close eyes, wrinkle forehead, or raise
forehead along with paralysis of lower part of face
on affected side – Bell’s palsy (peripheral injury to on affected side – Bell’s palsy (peripheral injury to
CN VII)
� paralysis of lower part of face on opposite side
affected - central lesions that affects the upper
motor neurons ex: CVA
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Bell’s palsy
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CN VIII acoustic/vestibulocochlear)
o hearing: acoustic/ cochlear
� Whisper, Weber, Rinne tests
�balance: vestibular
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CN VIII
o abnormal finding:
� vibratory sound lateralizes to good ear –
sensorineural loss
� AC is greater than BC but not twice as long � AC is greater than BC but not twice as long
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CN IX (glossopharyngeal),
CN X (Vagus)
�uvula and soft palate
�gag reflex
�ability to swallow ability to swallow
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CN IX & X
o abnormal finding:
� soft palate does not rise – bilateral lesion of CN X
� unilateral rising of soft palate, deviation of uvula to
normal side –unilateral lesion CN Xnormal side –unilateral lesion CN X
� dysphagia or hoarseness – lesion CN IX or X
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CN XI (spinal accessory)
o trapezius muscle - shrug shoulders against
resistance
o sternocleidomuscle – turn head against
resistance resistance
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CN XI
o abnormal finding:
� asymmetric, drooping of shoulders – paralysis or
muscle weakness due to neck injury or torticollis
� atrophy with fasciculations – peripheral nerve dse� atrophy with fasciculations – peripheral nerve dse
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Torticollis
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Atrophy with fasciculations
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CN XII (hypoglossal)
o strength and mobility tongue
o protrude tongue, move to side against resistance,
put back in mouth
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CN XII
o normal finding: symmetric and smooth, bilateral
strength
o abnormal finding:
� atrophy with fasciculations – peripheral nerve dse� atrophy with fasciculations – peripheral nerve dse
� deviation to affected side – unilateral lesion
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MOTOR AND
CEREBELLAR SYSTEMS
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Condition and movement of muscles
o size and symmetry muscle grps
o strength and tone
o note unusual involuntary movement (i.e,
fasciculations, tics, tremors)fasciculations, tics, tremors)
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o normal finding
� muscles- fully developed
� symmetric size (bilateral sides may vary 1 cm from
each other)
� relaxed muscles contract voluntarily; show mild, � relaxed muscles contract voluntarily; show mild,
smooth resistance to passive movement
� equally strong against resistance, without flaccidity,
spasticity, rigidity
� no fasciculations, tics, tremors
� elderly –hand tremor or dyskinesia (repetitive
movements of lips, jaw, tongue)6/26/2011 63
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o abnormal finding
� muscle atrophy – dses of lower motor neurons or
muscle disorders
� soft, limp, flaccid muscles
� fasciculations - muscle twitching� fasciculations - muscle twitching
� tics – twitch of face, head or shoulders – stress,
neurologic disorder
� tremors – rhythmic, oscillating movements –
Parkinson’s dse, cerebellar dse, multiple sclerosis (with
movement), hyperthyroidism, anxiety
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Fasciculations
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Tics
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Tremors
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o abnormal finding
� unusual bizarre face, tongue, jaw, lip
movements – chronic psychosis, long term
use of psychotropic drugs use of psychotropic drugs
� slow, twisting movements in extremities and
face – cerebral palsy
� brief, rapid, irregular, jerky movements (at
rest) - Huntington’s chorea
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Balance, Gait
o walk normally
o tandem walk – heel-to-toe walk
o romberg test
o hop with one foot o hop with one foot
o elderly – may be difficult to perform
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o normal finding:
� steady gait, opposite arms swing
� maintains balance with little difficulty
� elderly – may be very difficult � elderly – may be very difficult
� (-) Romberg test - erect with minimal swaying
� hops without losing balance
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o abnormal finding
� (+) Romberg test – swaying, moving feet apart to
prevent fall – dse of posterior columns, vestibular
dysfunction, cerebellar disorders dysfunction, cerebellar disorders
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Coordination
�Point-to-point
�Rapid Alternating Movements (RAM)
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o Point-to-point
� finger-to-nose test
� Finger- nose- to-finger
� heel-to-shin test � heel-to-shin test
� Note: dominant side may be more coordinated than
nondominant side
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http://cloud.med.nyu.edu/modules/pub/neurosurgery/coordination.html
Rapid Alternating Movements
(RAM)
� Thumb to Fingers
� Hands on Lap
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Rapid Alternating Movements
(RAM)
� normal finding:
• elderly – may be difficult – bcoz decreased reaction
time and flexibility
� abnormal finding: � abnormal finding: • inability to perform – cerebellar dse, upper motor neuron
weakness, extrapyramidal dse
• dysdiadochokinesia -
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�Dysdiadochokinesia
�impairment of the ability to make movements
exhibiting a rapid change of motion that is caused by
cerebellar dysfunctioncerebellar dysfunction
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SENSORY SYSTEM
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�Light Touch, Pain, and Temperature Sensations
�Vibratory sensations
�Proprioception (sensitivity to position)
�Tactile discrimination (fine touch)�Tactile discrimination (fine touch)
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Light Touch, Pain, and Temperature
Sensations�scatter stimuli – distal and proximal parts of all
extremities and trunk to cover most of dermatomes
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Dermatomes
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o abnormal finding
� anesthesia – absence of touch sensation
� hypesthesia – decreased sensitivity to touch
� hyperesthesia –increased sensitivity to touch
� analgesia – absence of pain sensation � analgesia – absence of pain sensation
� hypalgesia – decreased sensitivity to pain
� hyperalgesia – increased sensitivity to pain
�
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• Vibratory sensations
o tuning fork – bony surface fingers or big toe
o usually decreased by 70
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• Proprioception (sensitivity to position)
oNote: if position sense is intact distally, then it is
intact proximally
o normal findingo normal finding
� some – sense position of great toe may be reduced
o abnormal finding
� inability to identify directions – posterior column dse,
peripheral neuropathy (e.g., diabetes, chronic alcohol
abuse)
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Tactile discrimination (fine touch)
�Tests for lesions of the sensory cortex
�Stereognosis
�Point Locations
�Graphestesia �Graphestesia
�Two-Point Discrimination
�Extinction
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http://cloud.med.nyu.edu/modules/pub/neurosurgery/sensory.html
REFLEXES
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Deep tendon reflexes
o biceps
o brachioradialis
o triceps
o patellar o patellar
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Biceps reflex
�elicited by placing your thumb on the biceps tendon and striking your thumb with the reflex hammer and observing the arm movement.
�Repeat and compare with the other arm. �Repeat and compare with the other arm.
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Briceps reflex
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Brachioradialis reflex
�striking the brachioradialis tendon directly with the hammer when the patient's arm is resting.
�Strike the tendon roughly 3 inches above �Strike the tendon roughly 3 inches above the wrist.
�Note the reflex supination. Repeat and compare to the other arm.
�The biceps and brachioradialis reflexes are mediated by the C5 and C6 nerve roots.
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Brachioradialis reflex
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http://img.medscape.com/fullsize/migrated/408/540/mos5854.01.fig6.jpg
Triceps reflex
�strike the triceps tendon directly with the hammer while holding the patient's arm with your other hand.
�Repeat and compare to the other arm�Repeat and compare to the other arm
�.The triceps reflex is mediated by the C6 and C7 nerve roots, predominantly by C7.
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Triceps reflex
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Patellar reflex
� With the lower leg hanging freely off the edge of the bench, the knee jerk is tested by striking the quadriceps tendon directly with the reflex hammer. Repeat and compare to the other leg.The knee jerk reflex is mediated by the L3 and L4 nerve roots, mainly L4.Insult to the cerebellum may lead to pendular reflexes. Pendular reflexes are not brisk but involve less damping of the limb movement than is usually not brisk but involve less damping of the limb movement than is usually observed when a deep tendon reflex is elicited. Patients with cerebellar injury may have a knee jerk that swings forwards and backwards several times. A normal or brisk knee jerk would have little more than one swing forward and one back. Pendular reflexes are best observed when the patient's lower legs are allowed to hang and swing freelly off the end of an examining table.
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Patellar reflex
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http://cloud.med.nyu.edu/modules/pub/neurosurgery/reflexes.html
http://www.brown.edu/Courses/Bio_160/Projects2000/Polio/Reflexcopy.jpg
Ankle reflex
�elicited by holding the relaxed foot with one hand and striking the Achilles tendon with the hammer and noting plantar flexion. Compare to the other foot.The ankle jerk reflex is mediated the other foot.The ankle jerk reflex is mediated by the S1 nerve root.
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Plantar or Achilles
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http://www.beltina.org/pics/achilles_tendon.jpg
Rate the reflex with the following scale:
5+ Sustained clonus
4+ Very brisk, hyperreflexive, with clonus
3+ Brisker or more reflexive than normally.
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2+ Normal
1+ Low normal, diminished
0.5+ A reflex that is only elicited with reinforcement
0 No response
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http://www.wrongdiagnosis.com/bookimages/8/2546.png
deep tendon reflexes are graded as follows:0 = no response; always abnormal1+ = a slight but definitely present response; may or may not be normal
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2+ = a brisk response; normal3+ = a very brisk response; may or may not be normal4+ = a tap elicits a repeating reflex (clonus); always abnormal
Superficial reflexes
o Plantar reflex
o Abdominal reflex
o Cremasteric reflex
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Plantar reflex
�The plantar reflex (Babinski) is tested by coarsely running a key or the end of the reflex hammer up the lateral aspect of the foot from heel to big toe.
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�Normal finding : toe flexion.
�Abnormal finding:
�(+) Babinski's sign - toes extend and separate
� indicative of an upper motor neuron lesion affecting
the lower extremity in question.
Plantar reflex
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Abdominal reflex
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Abdominal reflex
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Cremasteric reflex
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Cremasteric reflex
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Other tests
Hoffman response
� elicited by holding the patient's middle finger between the
examiner's thumb and index finger.
� Ask the patient to relax their fingers completely. Once the
patient is relaxed, using your thumbnail press down on the
patient's fingernail and move downward until your nail "clicks" patient's fingernail and move downward until your nail "clicks"
over the end of the patient's nail.
� Repeat this maneuver multiple times on both hands.
� Normal finding: nothing occurs.
� Abnormal finding:
� (+) Hoffman's response - other fingers flex transiently after the "click".
� indicative of an upper motor neuron lesion affecting the upper extremity in question.
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Hoffman response
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� Hoffmann's sign, which is elicited by flicking the distal phalanx of the long finger.
� A negative response, as shown here, is no motion of the thumb.
� A positive response is flexion of the thumb at the interphalangeal joint.
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http://img.medscape.com/fullsize/migrated/408/540/mos5854.01.fig6.jpg
Test of Clonus
�Test clonus if any of the reflexes appeared hyperactive. Hold the relaxed lower leg in your hand, and sharply dorsiflex the foot and hold it dorsiflexed. Feel for oscillations between flexion
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dorsiflexed. Feel for oscillations between flexion and extension of the foot indicating clonus. Normally nothing is felt.
Tonus video
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