CNS exam

Question 1

Scope of the system

Answer 1

Narrow the picture as much as possible using a good history. Look to answer these questions:
Local or diffuse?
How has it developed over time?
Restricted to nervous system or include other systems?
CNS, PNS or Both?

Goal: Integrate History and PE
Get to WHERE the lesion is
Then you can develop a meaningful “WHAT the lesion is” differential. Don’t jump too fast

Question 2

CNS scope

Answer 2

Cortex
Basal Ganglion
Brain Stem
Cerebellum
Spinal Cord

Question 3

PNS scope

Answer 3

Cranial Nerves
Sensory Afferents
Motor Efferents
Neuromuscular Junction
Muscle itself

Question 4

Anxiety and depression

Answer 4

estimated to be 30% of primary care visits.

Question 5

Unexplained persistent symptoms frequent:

Answer 5

Headache, GI issues, insomnia, fatigue, chronic pain

Question 6

Mental Status Exam

Answer 6

1. Appearance and Behavior
		level of consciousness
		posture, motor behavior, hygiene
2. Mood/Affect   
3. Speech/Language
		articulation, relevance, word finding,
		rate, fluency
4. Thoughts/Perceptions
		logic, coherence, content,  insight, 	judgment
5. Cognitive/Executive Function
		orientation, memory, abstract thinking, 	performance

Question 7

1. Appearance and Behavior

Answer 7

Level of Consciousness: State of awareness of self and environment. Impaired by disease of the brainstem reticular activating system, or damage in parts of BOTH hemispheres

    ALERT: Awake, not sleepy or tired, responding 	appropriately to the environment 

LETHARGIC (sleepy): awake, but tending to fall asleep if not gently stimulated

    STUPOROUS: falling asleep unless vigorously 	stimulated

    COMATOSE: a sleep-like state from which the 	patient cannot be awakened

Question 8

Posture and Motor Activity:

Answer 8

Calm? Constant motion?
Depression with anxiety?
Side effect to neuroleptic medication?
thyroid medication?

Question 9

Hygiene

Answer 9

You think it is fine, They think they smell.

Delusion?

Question 10

. Affect/Mood

Answer 10

Observe expressions and affect

Appropriate for situation?
	Engaged?
	Angry?  Anxious?  	Indifferent?
	Detached?

Depression            Drugs 
Fatigue		       ETOH
Insomnia		       Meds
Concentration	Steroids
			       Endocrine

Anxiety:
   Palpitations      Breathless
   Tremors             Numbness
   Dry mouth  
   ETOH withdrawl?
   Hyperthyroid?

Fear
Paranoia?
Complex Partial Seizure?
Completely appropriate?

Question 11

Language

Answer 11

The clinical exam of language should include assessment of:
		Spontaneous Speech
		Naming
		Comprehension
		Repetition
		Reading
		Writing

You are evaluating for Aphasia: Disorder in producing or understanding language.

Spontaneous Speech: Look for

Articulation

Appropriate word finding.   Assess for  Paraphasia = Substituting similar sounding syllables or words; Paraphasic errors.  
		“pen”  for   “pencil”	
		 “plentil”  for  “pencil”

 Is there normal prosody: the melody or 	variable tone of speech?  

Spontaneous Speech:

Verbal Fluency:  do they maintain appropriate rate, flow, volume, content, meaning and melody (prosody)?

If your patient lacks meaning or fluency, evaluate for Aphasia: Disorder in understanding or producing language: spoken or written

Question 12

Testing for Aphasia:

Answer 12

Naming: test the ability to name objects
ANOMIA: loss of the ability to name common objects; the most common deficit in true aphasia

Comprehension: follow commands.
“Point to nose” Point to nose then knee”

Repetition: have the patient repeat some simple words or a phrase
“No if’s, and’s or but’s”

Reading and Writing: short exercises

Question 13

Aphasia

Answer 13

Disorder in understanding or producing language: spoken or written
Injury, Disease, Psychogenic

Question 14

Dysphasia

Answer 14

Impairment in use of speech that is clear “Dys-phasia”

Failure to arrange properly in sentence

Question 15

Dysarthria

Answer 15

Imperfect articulation due to lack of motor coordination; damaging event CNS or PNS. Language comprehension and use may be fine.

Question 16

More stuff on aphasia

Answer 16

Aphasia is due to a localized lesion of the dominant hemisphere of the brain:
The left cerebral hemisphere in 99% of all right-handed patients and probably 70% of left-handed patients

Most ambidextrous patients are also left hemisphere dominant

Aphasia may be the only sign of a new neurological disease, such as stroke, tumor or head trauma, or recent seizure

Question 17

Wernicke’s area

Answer 17

transforms sensory input into neural word representations to give a word meaning.

Question 18

Broca’s area

Answer 18

transforms these neural word representations into actual articulations that can be spoken.

Question 19

Aphasia

Answer 19

Loss of power of expression or the comprehension of spoken or written language

Damage to Broca’s or Wernicke’s or their interconnection causes aphasia

Question 20

the language of broca’s vs wernicke’s aphasia

Answer 20

Brocas Aphasia click to see video
“Expressive” Aphasia
understanding of spoken language mostly preserved

Wernicke’s Aphasia click to see video
“Receptive” Aphasia
fluent speech that makes no sense

Question 21

Thoughts and Perception

Answer 21

Brocas Aphasia click to see video
“Expressive” Aphasia
understanding of spoken language mostly preserved

Wernicke’s Aphasia click to see video
“Receptive” Aphasia
fluent speech that makes no sense

Question 22

Cognitive Function

Answer 22

Orientation: Person, Place, Time
Attention: Ability to concentrate
Memory: Recent and Remote

Executive Function
Abstract Thinking/Insight
Calculation
Constructional Ability

Question 23

Orientation

Answer 23

PERSON (name): seldom lost unless the patient has aphasia or schizophrenia

2. PLACE (location): often lost in some hospitalized patients, or delirious/extremely demented outpatients
3. TIME: most commonly lost of these three; include time of day, day of week, month, year if possible

Typically, physicians write “A&O x 3”

Question 24

Memory

Answer 24

RECENT Memory: the ability to store new information, up to a few days

REMOTE Memory: more distant memories. Includes autobiographical (dates of graduation, marriage, etc.) or historical (date of wars, elections, sports, etc.)

Can be the only sign or symptom of a brain disease

Alzheimer’s dementia almost always begins as a progressive loss of memory; first recent, and then distant memory

Question 25

Recent Memory

Answer 25

Testing recent memory: “Please listen to these 3 words, and then repeat them. I will ask you to remember them soon.” Ask them in approximately 3-5 minutes. Occasionally a normal patient will recall only 2/3, but recalling 0, or 1 words on two attempts is pathologic Also tested by: 1. “How long have you been in the hospital?” 2. Giving a patient a brief story to remember, perhaps three or four sentences long 3. “What did you have for breakfast (or lunch, dinner)?”

Question 26

Remote Memory

Answer 26

Less often tested, mostly for confirming a diagnosis of dementia Examples: 1. When did you graduate from high school? 2. When did you get married? 3. How many children do you have? 4. When did you retire? 5. When did the Vietnam War (or World War II) occur? 6. Can you name some recent presidents?

Question 27

Executive Function: Insight

Answer 27

Insight/Judgment, Reasoning Ability, Abstract thinking It tests the “higher abilities” that patients should possess, or had before they became ill Tests mostly for dementia, or any disease of the FRONTAL lobes and their connections Crucial in diagnosing Alzheimer’s Disease and the other common causes of dementia. Proverbs 1. “Look before you leap” 2. “People in glass houses shouldn’t throw stones” 3. “Still waters run deep” Situational questions for choice “What would you DO if you: 1. Found a closed envelope fully-addressed and stamped ? 2. Found a wallet on the street? Similarities can be tested; How are the following alike (or different)? 1. Apples and oranges 2. Tables and chairs 3. Californians and Texans 4. Shirts and dresses

Question 28

Delirium

Answer 28

acute confusion episode, may be due to infection, uremia, alcohol withdrawal. Disoriented, poor judgment, delusions common, attention poor, mood fluctuates “Everything’s an Emergency!”

Question 29

Dementia:

Answer 29

insidious, slowly progressive, affect often flat, maintains orientation and attention until late in process. Altzheimer’s, B12 deficiency, hypothyroid, head trauma. Can have acute angry, delusional episodes later in the course of disease.

Question 30

What's the best way to distinguish agitated dementia from delirium?

Answer 30

Attention testing typically the best exam to distinguish agitated dementia from delirium . Poor attention think delirium

Question 31

____ is often disturbed, but ___ is seldom disturbed

Answer 31

Language is often disturbed, but speech is seldom disturbed

Question 32

Executive Function: Calculation

Answer 32

Number span: normal patients should be able to repeat 5 or 6 numbers in correct order, or do 4 numbers in reverse order 2. Spelling a common word, backwards and forwards, ‘WORLD’ 3. Do the months of the year or the days of the week, forwards and backwards 4. Doubling a number; 9X9=81, 162, 324

Question 33

Executive Function: Constructional Ability

Answer 33

Constructional Ability: copy a figure or ask them to draw something simple Integration of Motor Activity: ask to perform a task, see if they can. Apraxia is the inability to perform the command. Can also be tested here.

Question 34

Mini Mental Status Exam:

Answer 34

Screening tool for mental status ``` 23-30= normal 19-23= borderline ```

Question 35

Mental Status Screening

Answer 35

Recent study found elderly well still able to visit their doctor alone for a routine PE rated their cognition equally good as those with known dementia. Yikes. Use cognitive screening tests like MMSE or Folstein ``` Refer to Neurophychologist for full evaluation, diagnosis and treatment options depression, dementia, concussion/TBI detect malingering determine competence cognitive rehabilitation (TBI) behavioral therapy (chronic pain ```

Question 36

cerebellum

Answer 36

The cerebellum receives sensory and motor input to coordinate motor activity, maintain equilibrium and control posture.

Question 37

cerebellar testing

Answer 37

``` Gait Regular walk Tandem: one foot in front of the other Heel/toe: away on heels, back on toes Heel to Knee and slide down shin (heel to shin) Bilateral smoothness, accuracy Repeat eyes closed for higher sensitivity Romberg/Pronator Drift: tested together ```

Question 38

tracts and the cerebellar testing

Answer 38

Posterior column = motor efferents Contralateral lesion in corticospinal tract because it decussates as it leaves the medulla; this tract is most responsible for motor signals to the hands, particularly fine movement. So drift in the right arm is a bad signal originating in the left corticospinal tract before it decussates. Tandem is one foot directly in front of the other, can go forward then backwards. Be there to catch them if needed Heel/Toe is walking forward on heels, then turning around and walking forward on toes. The order is not important

Question 39

Romberg

Answer 39

tests ataxia specific to posterior column function. While positioned and eyes open, balance is maintained. Closing eyes removes visual input and ataxia (falling over) occurs. Direction of the fall may indicate where the lesion is.

Question 40

Pronator drift:

Answer 40

in same stance as for Romberg, if the arm drifts downward (and occasionally lateral) when eyes are closed it is specific for a contralateral corticospinal tract lesion/disease Cerebellar ataxia is present with eyes open or closed, ie, not a function of proprioceptive input.

Question 41

Fingers to nose cerebellar testing

Answer 41

Finger-to-Nose Eyes Open (“your nose, my finger”) Make sure the patient extends his arm “completely” to reach your own index finger, this enhances any abnormality if present. Move finger up, down and cross midline Clumsy, vary in speed/force, past point = Dysmetria Finger to Nose Eyes Closed (drunk test) Standing, eyes closed, arms stretched out to side, bring each in to nose. Poor coordination worsens with eyes closed.

Question 42

voice dysmetria

Answer 42

Voice Dysmetria: Count to 10 as quickly as possible. Motor coordination

Question 43

dysdiadochokinesis and cerebellar testing

Answer 43

Rapid Alternating Movements Flip hand over in other palm rapid; must lift hand off palm Can also use the thigh DYSDIADOCHOKINESIS: one movement cannot be abruptly stopped and followed by the opposite movement: slow, irregular and clumsy

Question 44

what does the cranial nerve exam do?

Answer 44

Localizes pathologic processes specific to individual cranial nerves and can indicate where pathology is involved. This assists in diagnostic accuracy of neurologic disorders.

Question 45

Olfactory nerve

Answer 45

Olfactory is seldom tested, unless the patient complains of a loss of smell, or there is a frontal injury or possible frontal lobe tumor Usually tested only for presence/absence, with some coffee beans, or cinnamon Abnormalities seen with concussion(mild traumatic brain injury or TBI) Typically, physicians will write, “Cranial nerves 2 through 12 intact.” CN 2-12 intact But be sure to DO IT if you document this

Question 46

Optic nerve

Answer 46

Acuity Pupillary Reflex: Afferent is CN II, it senses the light. Efferent: CN III (Oculomotor) Visual field exam Ophthalmoscopic examination is direct visualization of retina including optic disc and vessels. Optic nerve exam is primarily functional

Question 47

CN III, IV, VI

Answer 47

Look at eyes in the primary position: esotropia (medial deviation) exotropia (lateral deviation) Efferent pupillary response to light (III Oculomotor: levator palpebrae, sup/inf rectus, inf oblique, medial rectus) Extraocular movements: Six cardinal directions Trochlear (IV Superior Oblique) moves the eye downward and out. Abducens (VI Lateral Rectus) move laterally Remember the cover/uncover test to check bilateral central focus; looking for strabismus

Question 48

CN VI palsy

Answer 48

Mild or total loss of lateral rectus function = horizontal diplopia Often without a localizing sign; INCREASED INTRACRANIAL PRESSURE ANYWHERE may cause a unilateral or bilateral CN VI palsy

Question 49

CN V: The Trigeminal Nerve

Answer 49

Sensory: for the face, 3 divisions Test sensation to each bilaterally: soft or temperature, and/or pinpick Motor: masseter and pterygoid: clench teeth, move jaw side to side Corneal Reflex: Gently touch lateral cornea w/ cotton or gauze Afferent: CN V senses the stimulus Efferent: CN VII motor to blink Both eyes should blink together There is sensory innervation from the cervical root in these same distributions. To localize Trigeminal distribution test across midline in these areas ONLY.

Question 50

CN VII: The Facial Nerve

Answer 50

Muscles of facial expression Upper face: closing the eyes, raising the eyebrows Lower face: smiling Taste of anterior 2/3 tongue Lacrimation Salivation Stapedius muscle of middle ear (dampens sound) CN VII can be affected either centrally or peripherally. Central: ­ Cortex or brainstem Muscles of lower face only Peripheral: muscles of unilateral, same side upper and lower face

Question 51

Facial nerve central lesions

Answer 51

1. Cerebral hemisphere lesion: signal must cross before it is manifested Lower facial weakness of the opposite side. Extremities on opposite side 2. Brainstem lesion: Lower facial weakness of the same side.

Question 52

facial nerve peripheral lesions

Answer 52

Peripheral Lesion: After leaving the brainstem Commonly compressed as it goes through the internal or external auditory canal by unknown, likely auto-immune processes (Bell’s palsy) or tumors, lacerations, infections (Lyme, etc.) In a PERIPHERAL CN VII lesion, the entire seventh nerve is likely damaged, so there is weakness of the upper AND lower facial muscles on that same side

Question 53

Facial nerve lesions: peripheral vs central recap

Answer 53

In peripheral VII nerve interruption you will see full, unilateral facial weakness or paralysis on the same side as the nerve problem. Bell’s Palsy is a common example In central (brainstem or cortex) interruption, only the lower face will be affected. The actual lesion will be on the opposite side if it originates in the cortex ( = cerebral hemisphere), and will be on the same side as the weakness if from the brain stem. Peripheral crossover innervation of upper motor facial nerves is intact.

Question 54

CN VIII: Vestibulocochlear

Answer 54

Hearing and Balance: The auditory portion of CN VIII is tested by the physician directly; most disorders of the vestibular portion are assumed from a history of positional vertigo Hearing can be determined subjectively by how well the patient seems to understand the physician’s words, or by the examiner rubbing her index and thumb together one inch lateral to each ear of the patient, or the patient’s hair can be rubbed about one inch lateral to each ear Injured in concussion (TBI): CN I, VII, VIII can be seen

Question 55

CN IX, X: Glossopharyngeal and Vagus nerves

Answer 55

CN IX is sensory to the soft palate, and CN X helps to raise the palate, so the Gag Reflex tests them both: GAG REFLEX: Afferent: CN IX Efferent: CN X Glossopharyngeal (IX) provides taste on the posterior 1/3 of tongue

Question 56

CN XI: Spinal Accessory Nerve

Answer 56

Innervation of the sternocleidomastoid and trapezius muscles Resist the patient shrug both shoulders simultaneously Resist a head tilting to each side

Question 57

CN XII: Hypoglossal

Answer 57

Purely motor to only the tongue Ask patient to stick out tongue (note if midline) and move side to side Look also for atrophy or fasiculations of the tongue In case of a CN XII peripheral lesion, the tongue deviates to the SAME SIDE

Question 58

summary of screening neuro exam

Answer 58

The exam should contain assessment of: Mental Status: alertness, appropriate responses, orientation to date and place Cranial Nerves: acuity, pupillary light reflex, eye motion, hearing, facial strength Motor: major muscle group strength upper and lower extremity, gait, coordination (finger to nose) Sensory: test toes/feet – one modality of light touch, pain, temp or proprioception Reflexes: DTR upper/lower, Babinski