Neuromusculoskeletal examination

BASELINE NEUROLOGICAL EXAM:

Joint position sense:

Vibration sense:

Pathological reflexes

            Oppenheim’s (stroke blunted end of reflex hammer down the anterolateral leg from below the patella to the lateral malleolus):

            Gordon’s (squeeze the calf muscles):

            Schaefer’s (apply deep pressure to the Achilles tendon):

            Chaddock’s (briskly stroke the blunted end of the reflex hammer on the lateral side of the foot, starting at the level of the lateral malleolus area of the heel to the little toe):

            Babinski:

            Hoffman’s/Tromner’s:

Cortical combined testing

            Stereognosis (identify an object):

            Topesthesia (state where they are being touched):

            Graphesthesia (trace 8 or 4):

            Double simultaneous stimulation (state whether they feel one or two arms being touched):

Signs of hypocalcemia

            Chvostek’s sign (tapping over the facial nerve just anterior to the ear causes contraction of the facial muscles):

Frontal release reflexes

            Sucking reflex (touching the lips or corner of the mouth causes a sucking movement):

            Grasp reflex (stroking the palm of the hand causes the hand to reflexively grasp):

            Rooting reflex (stroking the corner of the mouth or cheek elicits reflexive turning of the head toward the stimulus):

            Palmomental reflex (tapping or scraping the thenar eminence of the hand causes the hand muscles to contract):

            Glabellar reflex (tapping on the forehead causes repeated uncontrollable blinking):

            Snout reflex (tapping or touching the upper lip causes marked contraction of the lips):

Ulnar neuropathy (should be documented by EMG and nerve conduction studies)

            Point tenderness:

                        Guyon’s tunnel

                        Flexor carpi ulnaris

                        Cubital tunnel

                        Medial brachium (arcade of Struthers)

                        Subscapularis

            MMT:

                        Adductor pollicis

                        Opponens digiti minimi

                        Flexor carpi ulnaris

                        Flexor digitorum profundus (4th and 5th digits)

Radial neuropathy (should be documented by EMG and nerve conduction studies)

            Point tenderness:

                        Superficial radial nerve

                        Supinator

                        Spiral groove

                        Triceps brachii

                        Subscapularis

            MMT:

                        Abductor pollicis longus

                        Supinator

                        3rd digit extension

Median neuropathy (should be documented by EMG and nerve conduction studies)

            Point tenderness:

                        Transverse carpal ligament (and 2-3 cm below TCL)

                        Pronator teres (and flexor digitorum superficialis)

                        Common flexor origin (lacertus fibrosus, ligament of Struthers)

                        Subscapularis

                        Pectoralis minor

            MMT:

                        Abductor pollicis brevis

                        Opponens pollicis

                        Pronator teres

                        Flexor digitorum profundus (2nd and 3rd digits)

Equilibrium

            Observation (gait, station, repose): Ambulation fluid; patient able to change positions during exam without distress. No decomposition of movement during gait, station, or repose. No nystagmus or difficulty with expressive language noted. Girth of extremities grossly appears bilaterally symmetrical.

            Swaying of body

            Balance problems

            Increase base width stance

Loud cadence

            Hypotonia

            Dysmetria

            Dyssynergia (irregular movement)

            Dysarthria

            Nystagmus

            Pendular, normoreflexia, hyporeflexia

            Hyperkinesia or hypokinesia

            Romberg test:

            Rapid alternating movements:

            Finger-nose-finger:

            Heel-shin:

            Check reflex:

            Position holding:

            Fukuda’s marching-in-place test (Have the patient march in place, raising the ipsilateral arm as each leg is elevated. After a few cycles, have the patient close his eyes and continue for 30 seconds. Rotation of the body to one side indicates a lesion on that side.):

            Tremor assessment (arms extended then flexed and brought into body)

            Rigidity or hypokinesia assessment (passively move patient’s arms/legs)

Peripheral nerve injury

            Femoral neuropathy

            Lateral femoral cutaneous neuropathy

                        Meralgia paresthetica: numbness or tingling in the anterolateral thigh; corresponding history of prolonged sitting, diabetes or other condition involving dysglycemia, overweight/obesity, keys/other objects in front pockets, tight-fitting pants

                        Anterior pelvic tilt

                        Point tenderness

                                    One inch inferior to ASIS (where the lateral femoral cutaneous nerve is most superficial)

                                    At/around the inguinal ligament

                                    Hip flexor myofascial triggering/hypertonicity

                                    Other myofascial triggering/hypertonicty may be present in the lower quarter

                                    Pelvic obliquity; joint restriction at the low back/pelvis, pubes, T/L junction, hip and/or feet

                        ROM

                                    Passive hip extension or forced hip flexion may increase symptoms

                                    L/S ROM typically normal

                        MMT

                                    Iliopsoas

                                    Quadriceps

                        Reflexes

                                    Adductor reflex

                                    Cremasteric reflex

            Sciatic neuropathy

            Tibial neuropathy

                        Point tenderness

                                               Medial calcaneal tubercle (behind medial malleolus, inferior to navicular and/or medial arch)

                                               Soleus

                                    MMT

                                                Dorsiflexion and eversion combined painful

                                                Abduction of toes painful

            Common peroneal neuropathy

            Superficial peroneal neuropathy

            Sural neuropathy

            Medial plantar neuropathy

            Lateral plantar neuropathy

MENTAL STATUS EVALUATION:

Affect and mood

Orientation

Memory

Language/speech

Consciousness/alertness

Calculation

Judgment

Comprehension/abstraction

The patient presented alert and oriented X3. Depressed affect, tearful, disheveled. Patient had difficulty in expressive language but was able to comprehend instructions during the history and physical exam. Abnormal articulation, including slow utterances and imperfect pronunciation of words. Normal voice quality and pitch. Speech had no unnatural separation of syllables.

Adapted from my QME template.