Lectures 3 + 4 - Neurological Exam Flashcards
What is assessed in a neurologic examination?
MCMRCS
- Mental State
- Cranial Nerves
- Motor Exam
- Reflexes
- Coordination and Gait
- Sensory Exam
What is assessed in the mental state exam?
- Glasgow coma scale
- level of alertness, attention
- orientation - check if they know where they are
- memory - anterograde, retrograde
- language
- delusions and hallucinations
- mood
What is the glasgow coma scale?
Asks three questions:
- Opening of eyelids
- Motor responses
- Verbal responses
max score = 15
concerning score = 8 and below
What could cause a deficit in levels of alertness, attention and cooperation?
- assess by digit span, or spelling short words backwards
- damage to BRAINSTEM, bilateral lesions of THALAMI or CEREBRAL HEMISPHERES impaires CONSCIOUSNESS
- different focal brain lesions, diffuse abnormalities, dementias and encephalitis, behavioural and mood disorder
What would cause a loss of short term memory?
damage to LIMBIC STRUCTURES
What causes problems in language?
Lesions in BROCA’S AREA and WERNICKE’S AREA - dominant frontal lobe, left temporal and parietal lobes.
Thalamus also indicated
What causes neglect?
Test for extinction on double simultaneous stimulation
- lesion on right parietal lobe
- lesion on right thalamic or basal ganglia
both causes neglect on left side.
What can delusions and hallcucinations implicate in a neurological examination?
- toxic or metabolic abnormalities
- psychiatric disorder
- focal lesions or seizures in visual, somatosensory auditory cortex.
- lesions in association cortex or limbic system
What can mood problems implicate in neurological examination?
disorder of neurotransmitters
possibly lesion in thyroid
How do we examine CN I?
- smell - peanut butter, coffee, soap
- closed head TBI
- olfactory groove meningioma
- etc
How do we examine CN II
- using an opthalmoscope to check retinas
- Visual acuity using eye chart one eye at a time
- map visual field using fingers
- visual extinction - can they see out of each eye
Where in the eye mostly has cones?
Fovea
this is where colour vision occurs
fovea has a big representation in brain
What is the optic cup?
This is the blind spot, and is where all the nerves converge.
Raised intercranial pressure will show cupping out of blind spot- it will become CONCAVE
What are the different lesions that can occur to CN II, and how will it present?
In front of the optic chiasm - will affect the ipsilateral eye
Behind the optic chiasm - will affect the contralateral visual FIELD in both eyes
How do we examine CN II and III
- Pupillary responses
Note size at rest, then see if they constrict in light, and accomodate (eyeballs move inwards when looking at something moving closer) - check for consensual puppilary response - other eye pupil also responding.
PERRLA
What would cause problems in the pupillary response or consensual response?
ipsilateral optic nerve lesions, ipsilateral parasympathetics travelling in the CN III, or problems in pupillary constrictor muscle or iris
contralateral optic nerve for consensual response
How do we examine CN III, IV, VI?
convergent eye movements
smooth eye movements in all directions
abnormalities in individiual eye muscles, or specific cranial nerves
indicates lesions of cerebellum
How do we examine CN V
trigeminal nerve
facial sensation and muscles of mastication
use cotton swab or safety pin
How do we examine CN VII
can be seen in weaknesses or asymmetry between sides of face
can also ask them to smile, frown etc.
taste
lesions in UMN in contralateral motor cortex, descending motor pathways, LMN in ipsilateral facial nerve nucleus, faicla muscles.
eg. stroke - UMN
How do we examine CN VIII
hearing and vestibular sense
- gently rub fingers outside ear
vestibular sense is generally not tested unless patients have vertigo etc.
problems with hearing can result from lesions in the acoustic nerve, or neural elements in the ear, such as cochlea
How do we examine CN IX AND X
palate elevation and gag reflex
does the palate elevate evenly when they say ‘aah’
- gag reflex is only tested in patients with suspected brainstem lesions, impaired consciousness or impaired swallowing.
How do we examine VI, VII, IX, X and XII
muscles of articulation
- just listen to the patient speak.
have there been changes?
slurred, hoarse, nasal, low or high, breathy etc.
speech articulation can be affected in lesions of muscles of articulation, neuromuscular junction, or peripheral or central portions of V, VII, IX, X and XII.
How do we examine CN XI
- Sternocleidomastoid and trapezoid muscles
- assessed by asking to shrug shoulders, turn head side to side etc
- weakness can be caused by lesions in muscles, neuromuscular junction, LMN of the CN XI
check back on slide
How do we examine CN XII
- tongue muscles - are there any fasciculations?
- ask to stick tongue out and move it around.
Fasciculations - LMN damage.
