Approach to Neuro Complaint

Question 1

What is the first thing you check within the neuro exam?

Answer 1

mental status, speech, and language

Question 2

defective articulation with speech, usually caused by defect in motor control of speech apparatus

Answer 2

dysarthria

Question 3

a disorder in producing or understanding language, usually caused by lesions in the dominant hemisphere (usually the left)

Answer 3

aphasia

Question 4

How do you report mental status in soap note and what section does it belong in?

Answer 4

• mental status: patient is alert and oriented x4 (to person, place, time, and event)
• belongs in objective section

Question 5

What is the difference between delirium and dementia?

What is the correlation between these two conditions and depression?

Answer 5

• delirium is REVERSIBLE (common in older adults during hospitalization) while dementia is NOT REVERSIBLE (depression/delirium must be treated before dx, meds can slow progression)
• depression can enchance symptoms of both delirium and dementia

Question 6

CN I function?

Answer 6

olfactory nerve (smell)

Question 7

CN II function?

Answer 7

visual acuity

Question 8

CN III function?

Answer 8

raise eyelids, pupillary constriction, most extraocular movements

Question 9

CN IV function?

Answer 9

downward, internal rotation of the eyes (looking toward nose)

*high yield*

Question 10

CN V function?

Answer 10

sensory dermatomes (V1, V2, V3), motor function of mastication, corneal reflex (sensory)

Question 11

CN VI function?

Answer 11

lateral deviation of the eye

*high yield*

Question 12

CN VII function?

Answer 12

motor: facial movements (expression, closing eyes, mouth); sensory: taste of anterior 2/3 tongue

*high yield*

Question 13

CN VIII function?

Answer 13

hearing (test using soft rub finger test, whisper test, or tuning fork)

Question 14

CN IX function?

Answer 14

motor: phonation; sensory: posterior 1/3 taste, gag reflex arc

Question 15

CN X function?

Answer 15

raise palate, motor function of pharynx

Question 16

CN XI function?

Answer 16

shrug shoulders against resistance (traps), turn head L and R against resistance (SCM)

Question 17

CN XII function?

Answer 17

motor function of tongue

(make sure it’s midline)

Question 18

What are the cardinal gaze signs and their innervations?

Answer 18

• inferior oblique (up and in), medial rectus (inward), superior rectus (up and out), inferior rectus (down and out): oculomotor N. (CN III)
• superior oblique (down and in): trochlear N. (CN IV)
• lateral rectus (outward): abducens N. (CN VI)

Question 19

What are the associated symptoms and presentation of CN III lesions?

Answer 19

• symptoms: ptosis (drooping of eyelid due to levator palpebrae weakness), pupillary dilation/asymmetry (due to disruption of ciliary plexus within parasympathetic innervation of pupil), ophthalmoplegia (denervation of extraocular muscles causing “down and out”)
• presentation: sudden, unilat ptosis and ophthalmoplegia (diplopia can be masked by severe ptosis)

Question 20

What are the symptoms and presentation associated with CN IV lesions?

Answer 20

• symptoms: hypertropia (eye drifts medially), weakness of downward gaze (due to superior oblique, eye drifts upwards), vertical diplopia (dbl vision increases w/ downward gaze), head tilting (to oppo side of lesion)
• presentation: vertical diplopia, difficulty reading/walking downstairs, torticollis secondary to head tilting

Question 21

What are the associated symptoms of CN VI lesions?

Answer 21

(most common isolated CN palsy, seen often in subarachnoid hemorrhage, syphilis, trauma)

• symptoms: convergent (medial) strabismus (esotropia) (inability to abduct eye due to lateral rectus weakness) and horizontal diplopia (esp when looking toward affected lateral rectus)

Question 22

What are the symptoms and presentation a/w CN V lesions?

Answer 22

• symptoms: decreased sensation, loss of corneal reflex, weakness of muscles of mastication, jaw deviation (toward weak side)
• presentation: recurrent brief episodes of unilat shock-like pain, can be triggered by innocuous stim, can be reprod on exam by stroking dermatome w/ light touch

(90% of cases caused by aberrant vein or artery compression of N.)

Question 23

What are the symptoms a/w CN VII lesions?

Answer 23

• paralysis of muscles of facial expression of upper/lower facial portions: presents as widened palpebral fissure and increased nasolabial fold (Bell’s palsy)
• loss of corneal reflex (efferent limb of CN VII)

Question 24

What is the difference between Bell’s palsy and supranuclear (central) facial palsy?

Answer 24

• Bell’s palsy (peripheral): etiology usually unknown, can be caused by trauma or infection
• supranuclear facial palsy (central): spares upper face, usually a/w hemiplegia (important for determining if weakness is central or peripheral)
• DIFFERENCE: Bell’s palsy is a peripheral nerve lesion on the unilat side of facial weakness, the entire affected side of the face shows weakness; supranuclear palsy is a central lesion on the contralat side of weakness, only affects lower muscles of face because unilat nerve fibers make up for lost innervation

Question 25

What are the symptoms a/w CN VIII lesions?

Answer 25

- vestibular division: **disequilibrium** and **nystagmus** - cochlear division: **destructive** (sensorineural hearing loss) and **irritative** (can cause tinnitus)

Question 26

What is nystagmus, what are the 3 types, and what are potential causes?

Answer 26

- **nystagmus**: rhythmic oscillation of eyes (2 phases, 1 is slow drift away from object, 2 is **saccade** phase quick rxn back), named for **saccade phase** - **types**: horizontal, vertical, rotatory - **causes**: vision impairment at early age, labyrinth or cerebellar disorder, drug tox (1-2 beats of nystagmus is nml physiologically, however sustained beats is abnormal/pathological)

Question 27

What are symptoms a/w CN IX lesion?

Answer 27

- loss of gag reflex - loss of sensation in pharynx and posterior 1/3 of tongue - mild dysphagia

Question 28

What are symptoms a/w CN X lesions?

Answer 28

- dysphonia (difficulty speaking) - dysphagia (difficulty swallowing) - dyspnea (difficulty breathing) - loss of gag or cough reflex

Question 29

What are symptoms a/w CN XI lesions?

Answer 29

- **in SCM**: paralysis of muscle, difficulty turning head to opposite side of affected muscle - **in trap**: weakness results in unilat shoulder droop (testing for these is against mild resistance)

Question 30

What are symptoms a/w CN XII lesions?

Answer 30

tongue **deviates** to **weak or affected side** and patient is unable to push tongue to opposite side (testing: patient protrudes tongue while physician applies mild resistance against cheeks)

Question 31

How do you document that you tested cranial nerves?

Answer 31

- **never** just put "cranial nerves are intact" - if you did a **partial test**: "cranial nerves are grossly intact" - if you did a **thorough test**: "cranial nerves II-XII are intact to testing" (CN I is usually not tested unless in special circumstances)

Question 32

dermatome of auricle of ear?

Answer 32

C2

Question 33

dermatome of earlobe, ant/post neck?

Answer 33

C3

Question 34

dermatome of superior shoulder?

Answer 34

C4

Question 35

dermatome of radial aspect of forearm?

Answer 35

C6

Question 36

dermatome of middle finger?

Answer 36

C7

Question 37

dermatome of little finger?

Answer 37

C8

Question 38

dermatome of nipple?

Answer 38

T4

Question 39

dermatome of umbilicus?

Answer 39

T10

Question 40

dermatome of inguinal region?

Answer 40

L1

Question 41

dermatome of patella and medial calf?

Answer 41

L4 (this is what we test w/ the patellar reflex)

Question 42

dermatome of anterolateral calf and great toe?

Answer 42

L5

Question 43

dermatome of posterolateral calf and little toe?

Answer 43

S1 (this is what we test w/ Achilles reflex)

Question 44

What are the primary sensations and how do we test them?

Answer 44

- **pain**: sharp object and gently touch patient (spinothalamic tract) - **temp**: often omitted if pain is nml, use cold metal object or test tubes w/ water (spinothalamic tract) - **vibration**: use tuning fork on bony prominence (posterior column) - **proprioception**: big toe positioning test w/ patient's eyes closed (posterior column)

Question 45

What are the discriminative (cortical) sensations?

Answer 45

- **stereogenesis**: ability to identify shapes of objects - **graphesthesia**: ability to identify numbers/letters written on palm - **two-point discrimination** - **double simultaneous stimulation**

Question 46

What are the 7 different patterns of sensory loss?

Answer 46

- **single nerve** - **root or roots**: loss in nerve distributions w/ single root (ex: C5-7 common in arms, L4, L5, S1 common in legs) - **spinal cord**: complete transection, hemi-section, posterior column, or anterior spinal syndrome - **brainstem**: crossed findings, ipsilat loss in face and contralat loss in body - **thalamic**: hemisensory loss of all modalities - **cortical**: intact primary sensations, loss of cortical sensations (i.e. graphesthesia and stereogenesis) - **functional**: non-anatomical (i.e. psychosomatic)

Question 47

What are the different types of cerebellar/coordination testing?

Answer 47

- rapid alternating movements, finger-to-nose, heel-to-shin - gait: regular, heel-toe, toe-heel, hopping, shallow knee bend, get-up-and-go - stance: pronator drift test (ability to maintain body position w/ eyes closed)

Question 48

- test that has patient stand with feet together and eyes closed - **(+) test**: patient is not able to stand upright - tests **proprioception, vestibular system**, and vision (you must have 2/3 of these functioning properly to stand upright, so this tests takes away vision and is focusing on proprioception and vestibular aspects) - best for testing **proprioception** b/c dysfunction w/ vestibular system presents more obviously w/ dizziness and loss of balance

Answer 48

**Romberg test** (did not include this w/ cerebellar testing b/c Dr. Pence said if you had an issue w/ cerebellar system you would not be able to stand w/ feet together even w/ eyes open)

Question 49

What aspects of the motor system can you observe during a physical exam?

Answer 49

- gait - body position - involuntary movements - muscle bulk: hypertrophy or atrophy - muscle tone

Question 50

How do you grade DTR's?

Answer 50

- 0-4/4 - 1-3 are not indicative of disease - 0/4: reflex absent - 4/4: issue w/ UMN

Question 51

How do you grade strength?

Answer 51

0-5/5 | (see chart for further info)

Question 52

Review of gait cycle:

Answer 52

Question 53

- abnormal gait pattern - staggering, unsteady, feet wide apart, other cerebellar signs usually present - staggering will be toward side of lesion/damage

Answer 53

cerebellar ataxia

Question 54

- abnormal gait pattern - unsteady, feet wide apart, feet thrown forward and slapped down first on heels then forefoot, patients watch ground when walking

Answer 54

sensory ataxia

Question 55

- abnormal gait pattern - stooped forward, short steps commonly called "shuffling gait" w/ festination (involuntary hesitation), decreased arm swinging

Answer 55

Parkinsonian gait

Question 56

What are the 3 common cutaneous or superficial reflexes?

Answer 56

- **abdominal reflex**: stroke skin of abd and look for involuntary reflex of abd muscles - **plantar response**: move from lateral portion of posterior foot and move anteriorly toward toes, intact reflex is toes curling down, non-intact reflex (**Babinski sign**) toes curl up which is nml in infants - **anal reflex**: stroke edge of anus w/ Q-tip, anus should wink, usually patients w/ non-intact reflex present w/ fecal incontinence

Question 57

What are signs of meningeal infection? \*high yield\*

Answer 57

**nuchal rigidity**: neck stiffness w/ resistance to flexion - occurs in ~84% of patients w/ acute bacterial meningitis and 21-86% of patients w/ meningeal irritation due to subarachnoid hemorrhage - most reliable presentation in meningeal irritation (but diagnostic accuracy is low) - must be sure no concern for vertebral fx before testing - important to use imaging to r/o presence of trauma

Question 58

What are the 2 physical exam tests for meningeal infection?

Answer 58

- **Brudsinski sign**: patient is supine while physician slowly flexes patient's neck; **(+) test** if patient involuntary flexes their hips and knees in response - **Kernig sign**: physician flexes patient's hip and knee then slowly extends knee straight keeping hip flexed; **(+) test**: pain or increased resistance to knee ext, also can cause passive flexion of neck