What are the key components of a complete neurological exam for the motor system, coordination, sensory, and deep tendon reflexes?

Complete Neurological Examination Write-Up for Motor System, Coordination, Sensory, and Deep Tendon Reflexes

A comprehensive neurological examination must include systematic assessment of motor function, coordination, sensory testing, and deep tendon reflexes to accurately identify neurological deficits and guide appropriate management. 1

Motor System Examination

Strength Assessment

• Observation: Note muscle bulk, tone, and presence of atrophy or fasciculations
• Manual Muscle Testing: Grade using the 0-5 scale:
  • 0: No contraction
  • 1: Visible contraction but no movement
  • 2: Movement with gravity eliminated
  • 3: Movement against gravity
  • 4: Movement against resistance but not full strength
  • 5: Normal strength

Key Muscle Groups to Test

• Upper Extremities:
  • Shoulder abduction (C5)
  • Elbow flexion (C5-C6)
  • Elbow extension (C7)
  • Wrist extension (C6)
  • Finger extension (C7)
  • Finger abduction (T1)
  • Grip strength (C8-T1)
• Lower Extremities:
  • Hip flexion (L2-L3)
  • Hip extension (L5-S1)
  • Knee extension (L3-L4)
  • Knee flexion (L5-S1)
  • Ankle dorsiflexion (L4-L5)
  • Ankle plantarflexion (S1)
  • Great toe extension (L5)

Muscle Tone Assessment

• Test for resistance to passive movement
• Note presence of:
  • Spasticity (increased resistance with rapid movement)
  • Rigidity (increased resistance throughout range)
  • Hypotonia (decreased resistance)
• Document any asymmetry 1

Functional Observation

• Observe antigravity movements
• Note any use of Gower maneuver (using arms to push up from floor - indicates proximal weakness)
• Assess gait pattern (normal, wide-based, ataxic, etc.) 2

Coordination Testing

Upper Extremity Tests

• Finger-to-nose test: Patient alternately touches examiner's finger and own nose
• Rapid alternating movements: Pronation/supination of hands, finger tapping
• Finger-to-finger test: Patient touches each finger to thumb sequentially

Lower Extremity Tests

• Heel-to-shin test: Patient slides heel down opposite shin
• Toe tapping: Assess speed and rhythm

Truncal Coordination

• Sitting balance: Observe stability with and without support
• Standing balance: Romberg test (standing with feet together, eyes open then closed)

Additional Observations

• Note presence of dysmetria (overshooting targets)
• Assess for dysdiadochokinesia (impaired rapid alternating movements)
• Evaluate for intention tremor (worsening as approaching target) 1, 2

Sensory Examination

Primary Sensory Modalities

• Light touch: Use cotton wisp, test dermatomes bilaterally
• Pain: Use pinprick, compare sides for symmetry
• Temperature: Optional, use cold tuning fork or test tube
• Vibration: Use 128-Hz tuning fork on bony prominences (distal to proximal)
• Proprioception: Test joint position sense in fingers and toes 1

Cortical Sensory Testing

• Stereognosis: Identify objects placed in hand with eyes closed
• Graphesthesia: Identify numbers traced on palm
• Two-point discrimination: Determine minimum distance for perceiving two points
• Extinction: Simultaneous stimulation on both sides

Systematic Approach

• Test all four limbs in a proximal-to-distal pattern
• Compare right versus left sides
• Document specific dermatomes or peripheral nerve distributions affected 1

Deep Tendon Reflexes

Standard Reflexes to Test

• Upper Extremities:
  • Biceps (C5-C6)
  • Brachioradialis (C5-C6)
  • Triceps (C7)
• Lower Extremities:
  • Patellar/knee jerk (L3-L4)
  • Achilles/ankle jerk (S1)
• Abdominal reflexes: Upper (T8-T10) and lower (T10-T12) 3, 4

Grading Scale (0-4+)

• 0: Absent
• 1+: Diminished
• 2+: Normal
• 3+: Increased
• 4+: Hyperactive with clonus 5

Technique Tips

• Position limb in partial flexion
• Strike tendon directly with reflex hammer
• Use Jendrassik maneuver (patient interlocks fingers and pulls) to reinforce diminished reflexes
• Note symmetry between sides 3, 5

Pathological Reflexes

• Babinski sign: Dorsiflexion of great toe with fanning of other toes when sole is stimulated
• Hoffman sign: Flexion of thumb and index finger when middle finger nail is flicked
• Clonus: Rhythmic contractions with sustained stretch 1

Documentation Format

Motor System

Motor: Tone normal/increased/decreased in all extremities. Strength 5/5 throughout except [specify deficits]. No fasciculations or atrophy noted.

Coordination

Coordination: Finger-to-nose testing intact bilaterally. Rapid alternating movements normal. Heel-to-shin testing intact. No dysmetria or dysdiadochokinesia.

Sensory

Sensory: Light touch, pinprick, vibration, and proprioception intact in all extremities. No sensory level identified. Cortical sensory functions intact.

Deep Tendon Reflexes

Reflexes: Biceps 2+, triceps 2+, brachioradialis 2+, patellar 2+, and Achilles 2+ bilaterally. Plantar reflexes downgoing bilaterally. No clonus.

Common Pitfalls and Caveats

• Inadequate exposure: Ensure proper visualization of all muscle groups
• Inconsistent effort: Distinguish true weakness from poor effort or pain limitation
• Distraction techniques: Use when suspecting non-organic findings
• Reflex reinforcement: Always try Jendrassik maneuver before documenting absent reflexes
• Sensory testing reliability: Be aware that sensory testing is subjective and requires patient cooperation
• Fatigue effects: Perform critical tests early in the examination 1, 6, 7

Remember that findings must be interpreted in the context of the patient's history and other examination findings to determine clinical significance.