Chapter 19

Neurologic System

Equipment

• Penlight

• Familiar objects (coins, keys, paper clip)

• Sterile needles

• Cotton wisp

• Tongue blades (one intact and one broken with pointed and rounded edges)

• Cup of water

• Tuning forks, 200 to 400 Hz and 500 to 1000 Hz

• Reflex hammer

• 5.07 monofilament

• Test tubes of hot and cold water

• Vials of aromatic substances (coffee, orange, peppermint, banana)

• Vials of solutions (glucose, salt, lemon or vinegar, quinine) with applicators

• List of tastes

Examination

Assess the neurologic system as the rest of the body is examined. When history and examination findings have not revealed a potential neurologic problem, perform a neurologic screening examination as shown in the box on pp. 218-219, rather than a full neurologic examination. See Chapter 18 for evaluation of muscle tone and strength, because these findings are important for interpreting neurologic system examination findings. The mental status portion of the neurologic system examination can be found in Chapter 3.

Neurologic Screening Examination

This shorter screening examination is commonly used for health visits when no known neurologic problem is apparent.

Cranial Nerves

Cranial nerves (CNs) II through XII are routinely tested; however, taste and smell are not tested unless some aberration is found (pp. 220-224).

Proprioception and Cerebellar Function

One test is administered for each of the following: rapid rhythmic alternating movements, accuracy of movements, balance (Romberg test), gait, and heel-toe walking (pp. 224-226).

Sensory Function

Superficial pain and touch at a distal point in each extremity are tested; vibration and position senses are assessed by testing the great toe (pp. 226-232).

Deep Tendon Reflexes

All deep tendon reflexes and the plantar reflex are tested, excluding the test for clonus (pp. 232-235).

Cranial Nerves I To XII

The following table summarizes the CN examination, and details of examination follow on pp. 220-224. When a sensory or motor loss is suspected, be compulsive about determining the extent of the loss.

Procedures for Cranial Nerve Examination

Cranial Nerve (CN)	Procedure
CN I (olfactory)	Test ability to identify familiar aromatic odors, one naris at a time with eyes closed.
CN II (optic)	Test distance and near vision. Perform an ophthalmoscopic examination. Test visual fields by confrontation and extinction of vision.
CN III, CN IV, CN VI (oculomotor, trochlear, abducens)	Test extraocular movement. Inspect eyelids for drooping. Inspect pupil size for equality, and direct and consensual response to light and accommodation.
CN V (trigeminal)	Inspect face for muscle atrophy and tremors. Palpate jaw muscles for tone and strength when patient clenches teeth. Test superficial pain and touch sensation in each nerve branch. (Test temperature sensation if findings to pain and touch sensation are unexpected.) Test corneal reflex.
CN VII (facial)	Inspect symmetry of facial features with various expressions (e.g., smile, frown, puffed cheeks, wrinkled forehead). Test ability to identify sweet, salty, sour, and bitter tastes on each side of tongue.
CN VIII (acoustic)	Test sense of hearing with whisper screening tests or by audiometry. Compare bone and air conduction of sound. Test for lateralization of sound.
CN IX (glossopharyngeal)	Test taste sensation (see CN VII). Test gag reflex and ability to swallow.
CN X (vagus)	Inspect palate and uvula for symmetry with speech sounds and gag reflex. Observe for swallowing difficulty. Evaluate quality of guttural speech sounds (presence of nasal or hoarse quality to voice).
CN XI (spinal accessory)	Test trapezius muscle strength (shrug shoulders against resistance). Test sternocleidomastoid muscle strength (turn head to each side against resistance).
CN XII (hypoglossal)	Inspect tongue in mouth and while protruded for symmetry, tremors, atrophy. Inspect tongue movement toward nose and chin. Test tongue strength with index finger when tongue is pressed against cheek. Evaluate quality of lingual speech sounds (l, t, d, n).

Technique	Findings
Assess olfactory nerve (CN I)
Ask patient to close eyes. Occlude one naris, hold vial (using least irritating aromatic substances first [e.g., orange or peppermint extract]) under nose, and ask patient to breathe deeply and identify odor. Allow patient to breathe comfortably, then occlude other naris and repeat with different odor. Continue, alternating two or three odors.	EXPECTED: Able to perceive and usually identify odor on each side.
	UNEXPECTED: Anosmia, loss of smell or inability to discriminate odors.
Assess optic nerve (CN II)
See tests for near and distance visual acuity and visual fields in Chapter 8.	EXPECTED: Vision 20/20 without or with lenses each eye; full visual fields.
Assess oculomotor, trochlear, abducens nerves (CN III, CN IV, CN VI)
See tests for six cardinal points of gaze, pupil size, shape, response to light and accommodation, and opening of upper eyelids in Chapter 8.	EXPECTED: Equal pupil size, equal and consensual response to light and accommodation, symmetric eye movements in all six cardinal points of gaze.
	UNEXPECTED: Absence of lateral gaze. Absence of any expected finding, ptosis.
Assess trigeminal nerve (CN V)
• Facial muscle tone Inspect face for symmetry or muscle twitching. Ask patient to clench teeth tightly as you palpate muscles over jaw.	EXPECTED: Symmetric tone.
	UNEXPECTED: Muscle atrophy, deviation of jaw to one side, or fasciculations.
• Sensation Ask patient to close eyes and report if sensation to touch is sharp or dull as you touch each side of face at scalp, cheek, and chin areas, alternately using sharp and rounded edges of tongue blade or paper clip in an unpredictable pattern. Ask patient to report when the stimulus is felt as you stroke same six areas with cotton wisp or brush. Finally, test sensation over buccal mucosa with wooden applicator.	EXPECTED: Symmetric discrimination of sensations in each location to all stimuli.
	UNEXPECTED: Impaired sensation with identified distribution. If impaired, use test tubes of hot and cold water to evaluate temperature sensation. Testing sensation over distribution of cranial nerve V.
• Corneal reflex See test for corneal sensitivity in Chapter 8.	EXPECTED: Symmetric blink reflex. May be diminished or absent if patient wears contact lenses.
Assess facial nerve (CN VII)
• Expressions Assess motor function by asking patient to make the following facial expressions: • Raise eyebrows and wrinkle forehead • Smile • Frown • Puff out cheeks • Purse lips and blow out • Show teeth • Squeeze eyes shut against resistance	EXPECTED: Facial symmetry.
	UNEXPECTED: Tics, unusual facial movements, or asymmetry of expression (flattened nasolabial fold, lower eyelid sagging, side of mouth drooping). Assessing motor function of cranial nerve VII.
• Speech Listen to articulation and clarity of speech	UNEXPECTED: Difficulty with enunciation of b, m, and p (labial sounds).
• Taste (CN VII and CN IX) Hold card listing tastes in patient’s view. Ask patient to extend tongue. Apply one of four solutions to lateral side of tongue in appropriate taste-bud region. Ask patient to point to taste perceived. Offer patient a sip of water, and repeat with different solution and applicator, testing each side of tongue with each solution.	EXPECTED: Able to identify sweet, salty, sour, bitter taste bilaterally when placed in appropriate taste-bud region. Sites for taste assessment.
Assess acoustic nerve (CN VIII)
• Hearing See screening tests in Chapter 9 or use an audiometer to test hearing.	EXPECTED: Adequate hearing bilaterally.
• Balance See Romberg test on p. 225.
Assess glossopharyngeal nerve (CN IX)
• Taste See CN VII.
• Gag reflex (nasopharyngeal sensation) See CN X.
Assess vagus nerve (CN X)
• Motor function Ask patient to say “aah” while observing movement of palate and uvula.	EXPECTED: Soft palate rises with uvula in midline.
	UNEXPECTED: Failure of soft palate to rise or uvula deviates from midline.
• Gag reflex (nasopharyngeal sensation; CN IX and CN X) Tell patient you will be testing gag reflex. Touch posterior wall of pharynx with applicator while observing palate, pharyngeal muscles, and uvula.	EXPECTED: Upward movement of palate and contraction of pharyngeal muscles, with uvula in midline.
	UNEXPECTED: Drooping or absence of arch on either side of soft palate; uvula deviates from midline.
• Swallowing (CN IX and CN X) Ask patient to swallow water.	EXPECTED: Water easily swallowed.
	UNEXPECTED: Retrograde passage of water through nose.
• Speech	UNEXPECTED: Hoarseness, nasal quality, or difficulty with guttural sounds.
Assess spinal accessory nerve (CN XI)
See Chapters 7 and 18 for evaluations of size, shape, strength of trapezius and sternocleidomastoid muscles.	EXPECTED: Symmetric size, shape, and strength.
Assess hypoglossal nerve (CN XII)
• Tongue resting and protruded Inspect while at rest on floor of mouth and while protruded. Assessing motor function of cranial nerve XII.	EXPECTED: Tongue midline, symmetric size.
	UNEXPECTED: Fasciculations, asymmetry, atrophy, or deviation from midline.
• Tongue movement Ask patient to move tongue in and out, side to side, curled up toward nose, curled down toward chin.	EXPECTED: Able to perform most tongue movements.
• Tongue strength Ask patient to push tongue against cheek while you apply resistance with index finger.	EXPECTED: Steady, firm pressure.
• Speech	UNEXPECTED: Problems with l, t, d, or n (lingual sounds).
Proprioception and Cerebellar Function
Evaluate coordination and fine motor skills
Have patient sit.
• Rapid, rhythmic, alternating movements Ask patient to pat knees with both hands, alternately patting with palmar and dorsal surfaces of the hands. Or ask the patient to touch the thumb to each finger of the same hand sequentially from index finger to little finger and back, one hand at a time.	EXPECTED: Smooth execution, maintaining rhythm with increasing speed.
	UNEXPECTED: Stiff, slowed, nonrhythmic, or jerky clonic movements.
• Accuracy of movement: Finger-to-nose test Position your index finger 40–50 cm from patient. Ask patient to touch his or her nose and your index finger with the index finger of one hand, as shown below. Change location of your index finger several times. Repeat with patient’s other hand. Alternatively ask the patient to close both eyes and touch his or her nose with index finger of each hand while alternating hands and gradually increasing speed.	EXPECTED: Movements rapid, smooth, accurate.
	UNEXPECTED: Consistent past pointing (missing examiner’s index finger).
Assess the patient’s accuracy of moving a finger between A, the nose, and B, the examiner’s finger.
• Accuracy of movement: Heel-to-shin test (can be performed sitting, standing, or supine). Ask patient to run heel of one foot along shin of opposite leg from knee to ankle. Repeat with other heel.	EXPECTED: Able to move heel up and down shin in straight line.
	UNEXPECTED: Irregular deviations to side.
Evaluate balance
• Balance: Romberg test Ask patient to stand with feet together and arms at sides, with eyes first open, then closed. Stand close by in case patient starts to fall.	EXPECTED: Slight swaying movement, no danger of falling.
	UNEXPECTED: Staggering, losing balance, or swaying to the extent of falling.
• Balance: Recovery After explaining test to patient, ask patient to spread feet slightly, then push shoulders with enough effort to throw patient off balance. Be prepared to catch patient.	EXPECTED: Quick recovery of balance.
	UNEXPECTED: Must catch patient to prevent a fall.
• Balance: Standing and hopping Have patient (eyes closed) stand in place on one foot, then the other. Then have patient (with eyes open) hop on each foot.	EXPECTED: Able to stand and hop on each foot for 5 seconds without losing balance.
	UNEXPECTED: Instability, need to continually touch floor with opposite foot, or tendency to fall.
• Gait: Walking Ask patient to walk without shoes around examining room or down hallway, with eyes open, then closed.	EXPECTED: Smooth, regular gait rhythm and symmetric stride length; upright trunk posture swaying with gait phase; and arm swing smooth and symmetric.
	UNEXPECTED: Shuffling, widely placed feet, toe walking, foot flop, leg lag, scissoring, loss of arm swing, staggering, lurching, or waddling motion.
• Gait: Heel-toe walking Ask patient (arms at side and eyes open) to walk a straight line, first forward and then backward. Ask patient to touch toe of one foot with heel of other.	EXPECTED: Consistent contact between toe and heel, slight swaying.
	UNEXPECTED: Extension of arms for balance, instability, tendency to fall, or lateral staggering and reeling.
Sensory Function
Test primary sensory functions
Ask patient to close eyes for all tests. Use minimal stimulation initially, then increase gradually until patient becomes aware. Test contralateral areas, asking patient to compare perceived sensations side to side.	EXPECTED: For all tests, minimal differences side to side, correct interpretation of sensations (e.g., sharp, dull), distinguishes side of body tested and location of sensation (e.g., proximal or distal to previous stimulus).
	UNEXPECTED: For all tests, map boundaries of any impairment by distribution of major peripheral nerves or dermatomes (see figures on pp. 227-228).
A, Dermatomes of the body, anterior view. B, Dermatomes of the body, posterior view.
• Superficial touch Lightly touch skin with cotton wisp or your fingertips, as shown at right. Ask patient to point to area touched or indicate when sensation is felt.	Superficial touch assessment.
• Superficial pain Alternate the sharp and smooth edges of broken tongue blade or round and end point of a paper clip, touching the skin in an unpredictable pattern. Allow 2 seconds between sensations. Ask patient to identify sensation (sharp or dull) and where it is felt.	Superficial pain assessment.
• Temperature and deep pressure Perform test only if superficial pain sensation is not intact.
• Temperature: Alternately roll test tubes of hot and cold water against skin in an unpredictable pattern. Ask patient to indicate hot or cold and where it is felt.	EXPECTED: Distinguishes between hot and cold and location of sensation.
• Deep pressure: Squeeze trapezius, calf, or biceps muscle.	EXPECTED: Discomfort with deep pressure.
• Protective sensation Perform test only if patient has diabetes mellitus or impaired sensation is suspected. Apply 5.07 monofilament until filament bends. Use a random pattern to test several sites on plantar surface of foot and once on dorsal surface. Avoid calloused areas and broken skin. Monofilament testing of superficial touch.	EXPECTED: Sensation felt at all sites touched.UNEXPECTED: Loss of sensation at any site.
• Vibration Place stem of vibrating tuning fork against several bony prominences (e.g., toes, ankle, shin, finger joints, wrist, elbow, shoulder, sternum), beginning distally. Ask patient when and where sensation is felt and what it feels like. Dampen tines occasionally to see whether patient notices the difference.	EXPECTED: Buzzing or tingling sensation, correct location of stimulus.
	UNEXPECTED: Does not distinguish vibration from touch of nonvibrating tuning fork. Assessment of vibration sensation.
• Position of joints Hold joint to be tested (great toe or finger) by lateral aspects in neutral position, then raise or lower the digit. Ask the patient which way the joint was moved. Return the digit to neutral before moving it another direction. Repeat and test a joint in both feet and both hands.	EXPECTED: Patient correctly identifies position of joint. Position sense assessment.
Test cortical sensory functions
Ask patient to close eyes for all tests.
• Stereognosis Hand patient familiar objects (e.g., key, coin) and ask patient to identify by touch.	UNEXPECTED: Inability to recognize objects (tactile agnosia). Stereognosis.
• Two-point discrimination Use two sterile needles or two tongue blade sharp edges, to touch patient’s skin with one or both points simultaneously at various locations. Find distance at which patient can no longer distinguish two points.	EXPECTED: Correctly identifies one or two point used. On the fingertips and toes, points are commonly felt when 2–8 mm apart. Discrimination of two points varies on other body parts, such as the back (40–70 mm) or chest and forearms (40 mm). Two-point discrimination.
• Extinction phenomenon Use sharp points of a broken tongue blade to simultaneously touch cheek and hand, or two other areas on each side of body. Ask patient the number of stimuli and locations.	EXPECTED: Correct number and location of both sensations identified bilaterally.
• Graphesthesia With blunt pen or applicator stick, draw letter, number, or shape on palm of patient’s hand, and ask patient to identify it. Repeat with different figure on other hand.	EXPECTED: Letter, number, or figure readily recognized. Graphesthesia.
• Point location Touch area on patient’s skin and withdraw stimulus. Ask patient to point to area touched.	EXPECTED: Able to locate stimulus.
Reflexes
Test superficial reflexes
Have patient supine.
• Abdominal Stroke each quadrant of abdomen with end of reflex hammer or with tongue blade edge.	EXPECTED: Slight, bilaterally equal movement of umbilicus toward each area of stimulation. May have diminished response in obese patient or when abdominal muscles stretched by pregnancy. Abdominal reflex assessment.
• Cremasteric (male patients) Stroke inner thigh, proximal to distal.	EXPECTED: Testicle and scrotum rise on stroked side.
• Plantar reflex Using pointed object, stroke lateral side of foot from heel to ball and then across ball of foot to medial side. Plantar reflex assessment.	EXPECTED: Plantar flexion of all toes. Dorsiflexion of great toe and fanning of other toes in children younger than 2 years.
	UNEXPECTED: Fanning of toes or dorsiflexion of great toe with or without fanning of other toes (Babinski sign positive) in all patients older than 2 years.
Test deep tendon reflexes
Patient relaxed and either sitting or lying for most procedures. Test each reflex, comparing responses side to side. Score deep tendon reflexes on scale shown in table below.	EXPECTED: Symmetric visible or palpable responses.
	UNEXPECTED: Absent or diminished responses (0 or 1+), or hyperactive reflexes (3+ or 4+).

Scoring Deep Tendon Reflexes

Grade	Deep Tendon Reflex Response
0	No response
1+	Sluggish or diminished
2+	Active or expected response
3+	More brisk than expected, slightly hyperactive
4+	Brisk, hyperactive, with intermittent or transient clonus

Technique	Findings
• Biceps Flex arm 45 degrees at elbow, then palpate biceps tendon in antecubital fossa. Place thumb over tendon and fingers under elbow. Strike your thumb with reflex hammer.	EXPECTED: Visible or palpable flexion of elbow, contraction of biceps muscle. Biceps deep tendon reflex.
• Brachioradial Flex patient’s arm up to 45 degrees while resting patient’s forearm on your arm, with hand slightly pronated. Strike brachioradial tendon directly.	EXPECTED: Pronation of forearm and flexion of elbow. Brachioradialis deep tendon reflex.
• Triceps Flex patient’s arm at elbow up to 90 degrees. Allow patient’s lower arm to hang freely or rest patient’s forearm on your arm. Palpate triceps tendon and strike directly with reflex hammer, just above elbow.	EXPECTED: Visible or palpable extension of elbow, contraction of triceps muscle. Triceps deep tendon reflex.
• Patellar Flex patient’s knee up to 90 degrees, allowing lower leg to hang loosely. Support upper leg so it does not rest against edge of examining table, then strike patellar tendon just below patella.	EXPECTED: Extension of lower leg, contraction of quadriceps muscle. Patellar deep tendon reflex.
• Achilles Ask patient to sit. Then flex patient’s knee and dorsiflex ankle up to 90 degrees, holding heel of foot. Strike Achilles tendon at level of ankle malleoli.	EXPECTED: Plantar flexion, contraction of gastrocnemius muscle. Achilles deep tendon reflex.
• Clonus Support patient’s knee in partially flexed position and briskly dorsiflex foot with other hand, maintaining foot in flexion.	EXPECTED: No rhythmic oscillating movements.
	UNEXPECTED: Sustained clonus, rhythmic oscillating movements between dorsiflexion and plantar flexion palpated. Clonus assessment.

Differential Diagnosis of Upper and Lower Motor Neuron Disorders

Assessment Parameters	Upper Motor Neuron	Lower Motor Neuron
Muscle tone	Increased tone, muscle spasticity, risk for contractures	Decreased tone, muscle flaccidity
Muscle atrophy	Little or no muscle atrophy, but decreased strength	Loss of muscle strength; muscle atrophy or wasting
Sensation	Sensation loss may affect entire limb	Sensory loss that follows the distribution of dermatomes or peripheral nerves
Reflexes	Hyperactive deep tendon and abdominal reflexes; positive Babinski sign	Weak or absent deep tendon, plantar, and abdominal reflexes, negative plantar reflex, no pathologic reflexes
Fasciculation	No fasciculations	Fasciculations
Motor effect	Paralysis of voluntary movements	Paralysis of muscles
Location of insult	Damage above level of brainstem will affect contralateral side of body, damage below the brainstem will affect the ipsilateral side of the body	Damage affects muscle on ipsilateral side of body

Aids To Differential Diagnosis

Subjective Data	Objective Data
Multiple Sclerosis
Fatigue; vertigo, weakness, numbness; blurred vision, diplopia, vision loss; urinary frequency, urgency, hesitancy; sexual dysfunction; emotional changes	Muscle weakness, ataxia; hyperactive deep tendon reflexes; paresthesias, sensory loss; intention tremor; optic neuritis; cognitive changes
Generalized Seizure Disorder
Premonition or aura, stiff body followed by rhythmic jerking movements, eyes rolled upward, drooling; loss of bladder and bowel control	Tonic phase (brief flexion then extension for 10–15 minutes, eyes deviated upward, dilated pupils), clonic phase (alternating muscle contraction and relaxation), postictal (coma followed by confusion and lethargy)
Meningitis
Fever, chills, headache, stiff neck, lethargy, malaise, vomiting, irritability, seizures	Altered mental status, confusion, nuchal rigidity, may see positive Brudzinski and Kernig signs
Encephalitis
Recovery from mild viral illness with fever, then lethargy, restlessness, mental confusion	Altered mental status, confusion, stupor, coma, photophobia, stiff neck, muscle weakness, paralysis, ataxia
Intracranial Tumor
Headaches, may awaken from sleep; nausea and vomiting; memory loss and confusion; unsteady gait, impaired coordination; behavioral or personality changes	Signs vary by location of lesion; altered consciousness, confusion, papilledema, CN impairment, aphasia, vision loss, gait disturbance, ataxia
Stroke (cerebrovascular accident or brain attack)
Sudden numbness or weakness, often unilateral; sudden confusion, difficulty speaking or understanding speech; sudden trouble seeing in one or both eyes; sudden trouble walking, loss of balance, or loss of coordination; sudden severe headache with no known cause	Altered consciousness, elevated blood pressure, difficulty managing secretions, weakness or paralysis of extremities or facial muscles on one or both sides of body, aphasia (receptive or expressive), articulation impairment, impaired horizontal gaze or hemianopia
Parkinson Disease
Tremors at rest and with fatigue that disappear with intended movement and sleep; slowing of voluntary movement; bilateral pill rolling of fingers; may have numbness, aching, tingling and muscle soreness	Tremors; muscle rigidity; stooped posture; instability of balance; short steps, shuffling, freezing gait; difficulty swallowing, drooling, voice softening, slowed, slurred, monotonous speech; impaired cognition, dementia
Peripheral Neuropathy
Gradual onset of numbness, tingling, burning in hands and feet; sensation of walking on cotton or floors feel strange; inability of fingers to feel difference between coins; night pain in feet	Reduced protective sensation in foot and may progress up lower leg; distal pulses diminished, diminished ankle and knee deep tendon reflexes, loss of vibratory sensation below knee, distal muscle weakness, cannot stand on toes or heels
Trigeminal Neuralgia
Sharp pain episodes on one side of face potentially caused by chewing, swallowing, talking, brushing teeth, or cold exposure	May have slight sensory impairment in regions of pain, may have normal neurologic findings
Bell’s Palsy
Rapidly progression of muscle weakness on one side of face, feeling of facial numbness	Facial creases and nasolabial fold disappear on affected side, eyelid does not close and lower lid sags on affected side, facial sensation is intact
Cerebral Palsy
Delays in gross motor development, activity limitation; may have hearing, speech, or language disorders, feeding difficulties	Increased or decreased muscle tone, tremors, scissor gait or wide-based gait, toe walking, exaggerated posturing, mental retardation or learning disabilities, persistent primitive reflexes, inconsistent muscle tone

PEDIATRIC VARIATIONS
EXAMINATION
Neurologic findings in the infant and child change as the child matures. (For a complete description of expected developmental findings by age, see Chapter 21.)

Technique	Findings
Indirectly evaluate CNs in newborns and infants
• Optical blink reflex (CN II, CN III, CN IV, CN VI) Shine a light at infant’s open eyes. Observe quick closure of eyes and dorsal flexion of head.	EXPECTED: Gazes intensely at close object or face. Focuses on and tracks an object with both eyes.
	UNEXPECTED: No response may indicate poor light perception.
• Rooting reflex (CN V) Touch one corner of infant’s mouth.	EXPECTED: Infant should open mouth and turn head in direction of stimulation. If infant has been fed recently, minimal or no response is expected.
• Sucking reflex (CN V) Place your finger in infant’s mouth, feeling sucking action. Note pressure, strength, pattern of sucking.	EXPECTED: Tongue should push up against your finger with good strength.
• Infant’s facial expression (CN VII) Note wrinkling of forehead when crying and symmetry of smile.	EXPECTED: Facial symmetry with all expressions.
• Acoustic blink reflex (CN VIII) Loudly clap your hands about 30 cm from infant’s head; avoid producing an air current.	EXPECTED: Blink and movement of eyes in response to sound. Infant will habituate to repeated testing. Freezes position with high-pitched sound.
	UNEXPECTED: No response after 2–3 days of age.
• Doll’s eye maneuver (CN VIII) Hold infant under axilla in upright position, head held steady, facing you. Rotate infant first in one direction and then in other.	EXPECTED: Infant’s eyes turn in direction of rotation and then opposite direction when rotation stops.
	UNEXPECTED: Eyes do not move in expected direction.
• Swallowing and gag reflex (CN IX and CN X)	EXPECTED: Coordinated sucking and swallowing ability.
• Sucking and swallowing (CN XII) Pinch infant’s nose.	EXPECTED: Mouth will open, and tip of tongue will rise in midline position.
Evaluate primitive reflexes in infant
• Palmar grasp (present at birth) Making sure infant’s head is in midline, touch palm of infant’s hand from ulnar side (opposite thumb)	EXPECTED: Strong grasp of your finger. Sucking facilitates grasp. Grasp should be strongest between 1 and 2 months of age and disappear by 3 months.
• Plantar grasp (present at birth) Touch plantar surface of infant’s feet at the base of toes.	EXPECTED: Toes should curl downward. Reflex should be strong up to 8 months of age.
• Moro reflex (present at birth) With infant supported in semisitting position, allow head and trunk to drop back to a 30-degree angle.	EXPECTED: Symmetric abduction and extension of arms. Fingers fan out, and thumb and index finger form a C. Arms then adduct in an embracing motion followed by relaxed flexion. Reflex diminishes in strength by 3–4 months and disappears by 6 months.
• Placing (4 days of age) Hold infant upright under axilla next to a table or chair. Touch dorsal side of foot to table or chair edge.	EXPECTED: Flexion of hip and knee, lifting of foot as if stepping up on table. Age of disappearance varies.
• Stepping (between birth and 8 weeks) Hold infant upright under axilla and allow soles of feet to touch surface of table.	EXPECTED: Alternate flexion and extension of legs, simulating walking. Disappears before voluntary walking.
• Asymmetric tonic neck or “fencing” (by 2–3 months) With infant lying supine and relaxed or sleeping, turn infant’s head to one side so jaw is over shoulder. Then turn infant’s head to other side.	EXPECTED: Extension of arm and leg on side to which head is turned and flexion of opposite arm and leg. Reversal of extremities’ positions with head turned opposite way. Reflex diminishes by 3–4 months of age and disappears by 6 months.
	UNEXPECTED: Be concerned if infant never exhibits reflex or seems locked in fencing position.

Sample Documentation

Subjective

A 48-year-old man presents for his annual physical examination. No concerns about poor balance, loss of sensation, unsteady gait. History of diabetes mellitus type 1 for 30 years, well controlled.

Objective

CNs II to XII grossly intact. Gait is coordinated and even. Romberg negative. Rapid alternating movements coordinated and smooth. Superficial touch, pain, vibratory sensation are intact bilaterally. Deep tendon reflexes 2+ bilaterally in all extremities. Plantar reflex produces expected plantar flexion of toes. No ankle clonus. Monofilament test reveals decreased sensation on plantar surfaces of both feet.