Neuro 1 Flashcards by Casey Hamilton

Components of neurological examination

Assessment of awareness/level of consciousness
Posturing
Mental Status
Speech Assessment
Cranial Nerve Examination
Cerebellar/Coordination Testing
Gait Examination
Motor and Strength Examination
Reflex Testing
Sensory Examination

How well did you know this?

Not at all

Perfectly

Components of the Mental Status Exam (MSE)

General appearance, behavior, and attitude
Level of consciousness and orientation
Speech and language
Mood and affect
Thought process, Content, and Perceptions
Memory and cognition
Judgment and insight

How well did you know this?

Not at all

Perfectly

What level of consciousness?

Patient is able to open eyes, look at you, and responds fully and appropriately

Alert

How well did you know this?

Not at all

Perfectly

What level of consciousness?

Patient is drowsy, but can open eyes, look at examiner, and respond. Falls back to sleep easily.

Lethargic

How well did you know this?

Not at all

Perfectly

What level of consciousness?

Patient opens eyes and looks at you, offers confused responses, has lack of interest in environment

Obtunded

How well did you know this?

Not at all

Perfectly

What level of consciousness?

Patient wakens only with painful stimuli. Verbal responses slow or absent. Falls back into unresponsive state when stimuli ceases

Stuporous

How well did you know this?

Not at all

Perfectly

What level of consciousness?

Patient is unarousable to any stimuli

Comatose

How well did you know this?

Not at all

Perfectly

What posture is this?

–Upper extremities flexed at the elbows and held closely to the body

–Lower extremities are internally rotated and extended

Decorticate posture

___________

–Thought to occur when the brain stem is not inhibited by the motor function of the cerebral cortex.

How well did you know this?

Not at all

Perfectly

Decorticate posture is thought to occur when…..

–Thought to occur when the brain stem is not inhibited by the motor function of the cerebral cortex.

How well did you know this?

Not at all

Perfectly

What posture is this?

Rigid flexion;
upper arms held tightly to side of body;
elbows, wrists, and fingers flexed;
feet are plantar flexed
legs extended and internally rotated;
may have fine tremors or intense stiffness

Decorticate

How well did you know this?

Not at all

Perfectly

What is the site of lesion for decorticate posture?

corticospinal tracts, above the brainstem

How well did you know this?

Not at all

Perfectly

What posture is this?

–Seen in persons with extensive brain stem damage to the pons and lesions that compress the lower thalamus and midbrain

Decerebrate Posture

How well did you know this?

Not at all

Perfectly

What posture is this?

Rigid extension
arms fully extended
forearms pronated
wrists and fingers flexed
jaws clenched
neck extended
back may be arched
feet plantar flexed
may occur spontaneously, intermittently, or in response to a stimulus

Decerebrate

How well did you know this?

Not at all

Perfectly

What is the site of lesion for the decerebrate position?

brainstem

How well did you know this?

Not at all

Perfectly

3 questions of Orientation?

Name
Day or date
Where are we?

How well did you know this?

Not at all

Perfectly

Assessing speech and language. You are assessing:

Talkative or silent?
Does the patient speak spontaneously or only when directly questioned?

What aspect of speech and language is that?

Quantity

How well did you know this?

Not at all

Perfectly

Assessing speech and language. You are assessing:

Is the speech too fast, too slow, or just right?

What aspect of speech and language is that?

Rate

How well did you know this?

Not at all

Perfectly

Assessing speech and language. You are assessing:

Is the speech too loud, too quiet, or just right?

What aspect of speech and language is that?

Volume

How well did you know this?

Not at all

Perfectly

Assessing speech and language. You are assessing:

Can you understand what the patient is saying physically? If not, why not?

What aspect of speech and language is that?

Articulation

How well did you know this?

Not at all

Perfectly

Assessing speech and language. You are assessing:

Is the rate, flow, melody, and content of speech within normal limits?

What aspect of speech and language is that?

Fluency

How well did you know this?

Not at all

Perfectly

Assessing speech and language:

If the rate, flow, melody, and content of speech are not within normal limits, what should you suspect?

If not, suspect an aphasia.

How well did you know this?

Not at all

Perfectly

Speech and Language/Fluency

What are you testing?

Ask patient to follow one or two step command

Word comprehension

How well did you know this?

Not at all

Perfectly

Speech and Language/Fluency

What are you testing?

Ask patient to repeat, “No ifs, ands, or buts”

Repetition

How well did you know this?

Not at all

Perfectly

Speech and Language/Fluency

What are you testing?

Ask patient to name the parts of a watch

Naming

How well did you know this?

Not at all

Perfectly

**_Speech and Language/Fluency_** What are you testing? * Ask patient to read a paragraph out loud

Reading

**_Speech and Language/Fluency_** What are you testing? * Ask patient to write a sentence

Writing

\_\_\_\_\_\_\_\_ is the external expression of emotion visible to the clinician

Affect

What are you assessing? •Are the pts responses and body language devoid of emotion?

Affect

What are you assessing? •Are their responses hyper-emotional?

Affect

What are you assessing? •Do the pts responses change dramatically through the interview?

Affect

What are you assessing? •Are the responses appropriate to the patient’s situation or what they are saying?

Affect

What are you assessing? •Does the pt have poor eye contact?

Affect

Mood tends to alter quickly and spontaneously; unstable. This is called \_\_\_\_\_\_

Labile mood

How do you assess the patient's mood?

To assess mood, you need to ask the patients how they are feeling

**_Assessment of Thought Process_** Identify: – speech shifts from one topic to another that is not clearly related to the first topic without the patient realizing that the topics are unrelated.

Derailment or loose associations

**_Assessment of Thought Process_** Identify: •– only partially relevant or irrelevant responses to questioning

Tangentiality

**_Assessment of Thought Process_** Identify: •– Patient speaks more and more quickly than would be ordinarily expected. Patient gives long answers to brief questions and may not finish one thought before starting another.

Pressured speech

**_Assessment of Thought Process_** Identify: •– speech makes no sense at all (aka “word salad”)

Incoherence

**_Assessment of Thought Process_** Identify: •– speech is delayed in reaching goal because of unnecessary detail, however components are properly related

Circumstantiality

**_Assessment of Thought Process_** Identify: •– During the course of a discussion, pt changes subject in response to something unrelated in the environment.

Distractable speech

**_Assessment of Thought Process_** Identify: •– persistent repetition of specific words or ideas

Perseveration

**_Assessment of Thought Process_** Identify: •– word choice doesn’t make any sense because words are chosen based on the sound they make (often rhyming), not their meaning.

Clanging

**_Assessment of Thought Process_** Identify: •– Fabrication of facts to fill in gaps of memory

Confabulation

**_Assessment of Thought Content_** Identify: •– Recurrent, uncontrollable thoughts or images that are unwanted and unpleasant to the pt.

Obsessions

**_Assessment of Thought Content_** Identify: •Repetitive behaviors or mental acts that the pt. feels driven to perform to produce relief or to prevent some future consequence (although that consequence is unlikely)

Compulsions

**_Assessment of Thought Content_** Identify: •– False, fixed personal beliefs that are not shared by others in the pts community

Delusions

**_Assessment of Thought Content_** Identify: •– Persistent, irrational fears accompanied by desire to avoid the stimulus

Phobias

**_Assessment of Thought Content_** The below are all examples of \_\_\_\_\_\_\_: –Persecution –Grandiosity –Delusion of being controlled externally –Somatic delusions –Jealousy

Delusions

**_Assessment of Thought Content_** Identify: •– A sense that things in the environment are unreal, strange or remote

Feelings of Unreality

**_Assessment of Thought Content_** Identify: •– A sense that the inner self has become detached from the mind or body

Feelings of Depersonalization

**_Assessment of Thought Content_** Identify: •– Fears, tensions, or uneasiness that may be focused or free-floating

Anxiety

**_Assessment of Perceptions_** Identify: •– misperception of real external stimuli

Illusions

**_Assessment of Perceptions_** Identify: •– false perceptions. Pt hears, sees, smells or feels something others cannot.

Hallucinations

**_Assessment of Memory_** Identify: * Can pt. learn something new and repeat it back?

Registration

**_Assessment of Memory_** Identify: •Can the patient correctly remember things that happened today?

Recent Memory

**_Assessment of Memory_** Identify: •Can the patient correctly remember things that happened or information from long ago?

Remote Memory

**_Assessment of Cognition_** Identify: •Can the patient focus enough to be able to perform tasks?

Attention

**_Assessment of Cognition_** Identify: •Assess patient’s apparent intelligence by assessing the degree to which they are informed and the complexity of their vocabulary

Information and vocabulary

**_Assessment of Cognition_** Identify: •– Ask the patient to interpret a commonly used proverb

Abstract Thinking: Proverbs

**_Assessment of Cognition_** Identify: –Ask the patient to tell you how two things are alike

Abstract Thinking: Similarities

**_Assessment of Judgment_** What are the two ways to assess judgment?

–Ask patients to propose a solution to their current problems: “How will you get follow up care after you leave here today?” –Ask patients to propose a solution to a hypothetical problem: “What would you do if you found a stamped, addressed letter on the ground?”

\_\_\_\_\_\_\_\_\_\_\_ is the ability to evaluate a situation and form an appropriate response

Judgment

\_\_\_\_\_\_\_\_ is the ability of patients to understand and acknowledge their illness or situation.

insight

Standardized way to test mental status that is: ## Footnote * Validated many times * Easy to administer * Results reproducible across examiners * Brief and well-tolerated by patients

Mini Mental State Exam (MMSE)/ “Folstein” test

How do you score MMSE?

* 27 – 30 = Normal * 20 – 26 = Mild Dementia * 10 – 19 = Moderate Dementia * \< 10 = Severe Dementia \*\*For pts \> 80 years old, 25 or more is normal. \*\*Patients with low levels of education (less than 8th grade) will score lower from the start

**_Assessment of Speech Disorders_** Identify: •– loss of ability to speak because of damage to larynx or throat

Aphonia

**_Assessment of Speech Disorders_** Identify: – Difficulty speaking due to abnormalities of the oral and facial muscles that produce speech. Cause can be central or peripheral. Speech sounds “sloppy”.

Dysarthria

**_Assessment of Speech Disorders_** Identify: •– loss of comprehension or power of expression of speech.

Aphasia

**_Assessment of Speech Disorders_** Identify: –Pt can comprehend perfectly, but not speak fluently. You know that they understand because they can nod or shake head appropriately.

Broca’s aphasia – is an expressive aphasia.

**_Assessment of Speech Disorders_** Identify: – Pt cannot comprehend language, but is able to speak fluently. Patient usually speaks gibberish.

Wernicke’s aphasia – is a receptive aphasia.

Cranial nerves are _____ nerves

Peripheral

Cranial Nerve I Exam

•I = OLFACTORY –One nostril at a time!!! –Don’t Use A Noxious Stimulus –Coffee, Cinammon, Mint

Cranial Nerve II Exam

* II = OPTIC NERVE * Evaluation: –Visual Acuity Test –Visual Fields by Confrontation –Funduscopic Exam

Cranial Nerve III/IV/VI Exam

•III = OCULOMOTOR –Observe lids for ptosis –Pupillary response to light (CN II & III) and accommodation (PERRLA)\* –Extraoccular movements (EOMs) * CARDINAL POSITIONS * IV = TROCHLEAR – superior oblique muscle * VI = ABDUCENS – lateral rectus muscle

Ptosis is which cranial nerve?

CN III (three) oculomotor

Cranial nerves and eye muscles: what statement to remember?

•“LR VI, SO IV, all else III”

Assessing Pupillary Response To Light. Which CNs?

•Assesses CN II & III

Cranial Nerve V Exam

•V = TRIGEMINAL MOTOR : –Masseter & Temporalis –movement & strength SENSORY : –Light touch and sharp /dull – all 3 divisions bilaterally –Corneal Reflex

Cranial Nerve VII Exam

VII = FACIAL Observe for: –Facial asymmetry –Strength of facial muscles * Raise eyebrows * Smile * Show teeth * “Puff out cheeks and don’t let me push them in” * Purse lips * Close eyes against resistance

Identify: ## Footnote –Forehead wrinkling preserved –Mild weakness of eye closure –Flat nasolabial fold –Most common cause is stroke

Central Seventh Nerve Paralysis

Identify: ## Footnote –Entire side of face affected –Forehead not wrinkled on affected side –Severe weakness of eye closure on affected side –Flat nasolabial fold on affected side –Cause: cranial neuropathies. Most commonly, Bell’s Palsy

Peripheral Seventh Nerve Paralysis

Cranial Nerve VIII Exam

VIII = VESTIBULOCOCHLEAR –Auditory Acuity •Document stimulus used (Weber, Rinne, hair rub, whisper)

Cranial Nerve IX/X Exam

•IX = GLOSSOPHARYNGEAL –Gag reflex and ability to swallow –Can the pt taste sour and bitter tastes? X = VAGUS –Say “ahhh” - uvula elevates symmetrically /deviates AWAY from side of lesion –Observe ability to swallow

Cranial Nerve XI Exam

XI = ACCESSORY • Assessment of muscle strength bilaterally • Trapezius: –Shoulder shrug against resistance • Sternocleidomastoid: –Left/right rotation of neck against resistance

Cranial Nerve XII Exam

XII = HYPOGLOSSAL •Observe tongue at rest, then protruded. In both: –Inspect for fasciculations –Tongue should be in midline –Unilateral paralysis-the tongue deviates _TOWARD_ the affected side. •Press tongue against inside of cheek and you attempt to push it away to assess strength. –

**_Coordination / Cerebellar Testing_** Testing assesses integration of: Cerebellar system:

–rhythmic movements and posture

**_Coordination / Cerebellar Testing_** Testing assesses integration of: Vestibular system

––balance, & eye, head & body movements

**_Coordination / Cerebellar Testing_** Testing assesses integration of: Sensory system

––position sense (aka proprioception)

What does the below test? ## Footnote •Rapid Alternating Movements (RAM)

Coordination testing

What does the below test? ## Footnote •Point-to-point Testing (Finger to Nose and Heel-Knee-Shin)

Coordination testing

What does the below test? ## Footnote •Romberg testing

Coordination testing

What does the below test? ## Footnote •Pronator Drift

Coordination testing

Rapid movement testing results in non-fluid movements or inability to keep track of the order. What is this called? (i.e. abnormal rapid movement testing)

Dysdiadochokinesis

Point to point testing results in inability to find the finger /nose, or to smoothly run down leg . What is this called? (i.e. abnormal point to point testing)

Dysmetria

What are the two tests for point-to-point testing?

1. –Finger-to-nose 2. –Heel-knee-shin

What does the ROMBERG TEST assess?

–CEREBELLAR FUNCTION –PROPRIOCEPTION (position sense)

What is a positive ROMBERG TEST?

•pt stands well with eyes open but loses balance with eyes CLOSED --this result is abnormal--

What does PRONATOR DRIFT test? * Part 1: Holding up a pizza box with eyes closed ONLY

–Upper Motor Neuron Function –PROPRIOCEPTION (position sense)

If you do the PRONATOR DRIFT test, what is a clear indication a patient is faking?

•Patients who are faking will let their arm fall, but will not pronate

If you do the PRONATOR DRIFT test, what is a clear indication of upper extremity weakness?

•the arm will begin to pronate and fall

What does PRONATOR DRIFT test? * Part 2: Tapping the arms and watching recoil

–PROPRIOCEPTION (position sense) only

What does PRONATOR DRIFT test? * Part 2: Tapping the arms and watching recoil What's a normal response? Abnormal response?

–PROPRIOCEPTION (position sense) only * Normal = rapid return to baseline position * Abn = unable to quickly return to baseline position

**_Gait Assessment_** What does the below test? * Walk casually across room and include turns

gait abnormalities

**_Gait Assessment_** What does the below test? * Walk On toes

distal muscle weakness

**_Gait Assessment_** What does the below test? * Walk On heels

–distal muscle weakness

**_Gait Assessment_** What does the below test? * Rise from sitting position

–proximal muscle weakness

6 assessments of Gait

1. Casually walk across room and include turns 2. On toes 3. On heels 4. Tandem 5. Hopping on one foot in place 6. Rise from sitting position

**_Gait Abnormalities_** Identify: –Shuffling gait with leg extended and held stiff

•Spastic Gait –Unilateral corticospinal tract injury such as stroke or traumatic brain injury

**_Gait Abnormalities_** Identify

•Spastic Gait ## Footnote –Unilateral corticospinal tract injury such as stroke or traumatic brain injury –Shuffling gait with leg extended and held stiff

**_Gait Abnormalities_** Identify

•Scissors Gait ## Footnote –Bilateral corticospinal tract injury –Adductor spasm, knees pulled together, knees and thighs hit each other –Seen in cerebral palsy, MS

**_Gait Abnormalities_** Identify: –Adductor spasm, knees pulled together, knees and thighs hit each other

•Scissors Gait ## Footnote –Bilateral corticospinal tract injury –Seen in cerebral palsy, MS

**_Gait Abnormalities_** Identify: –Hip and knee are elevated excessively high to lift the foot off the ground. The foot is brought down to the floor with a slap. –Patient cannot walk on heels

•Steppage Gait –Cause: Loss of ability to dorsiflex ankle –Seen in neuropathies/ radiculopathies

**_Gait Abnormalities_** Identify:

•Steppage Gait ## Footnote –Cause: Loss of ability to dorsiflex ankle –Hip and knee are elevated excessively high to lift the foot off the ground. The foot is brought down to the floor with a slap. –Patient cannot walk on heels –Seen in neuropathies/ radiculopathies

**_Gait Abnormalities_** Identify:

•Cerebellar Gait ## Footnote –Feet set wide apart and steps are unsteady, uncertain and of variable length –Indicator of cerebellum damage (including severe alcohol intoxication)

**_Gait Abnormalities_** Identify: –Feet set wide apart and steps are unsteady, uncertain and of variable length

•Cerebellar Gait ## Footnote –Indicator of cerebellum damage (including severe alcohol intoxication)

**_Gait Abnormalities_** Identify: –Small steps and is decreased arm swing when walking –Head and body are flexed and arms are semi-flexed and abducted

•Basal Ganglia Gait (Parkinson’s or Festination gait)

**_Gait Abnormalities_** Identify:

•Basal Ganglia Gait (Parkinson’s or Festination gait) ## Footnote –Small steps and is decreased arm swing when walking –Head and body are flexed and arms are semi-flexed and abducted

**_Gait Abnormalities_** What does this indicate? •Spastic Gait

–Unilateral corticospinal tract injury such as stroke or traumatic brain injury

**_Gait Abnormalities_** What does this indicate? •Scissors Gait

–Bilateral corticospinal tract injury –Seen in cerebral palsy, MS

**_Gait Abnormalities_** What does this indicate? •Steppage Gait

–Cause: Loss of ability to dorsiflex ankle –Seen in neuropathies/ radiculopathies

**_Gait Abnormalities_** What does this indicate? •Cerebellar Gait

–Indicator of cerebellum damage (including severe alcohol intoxication)

**_Gait Abnormalities_** What does this indicate? •Basal Ganglia Gait

–Indicator of Parkinson’s or Festination gait

**_Gait Abnormalities_** A person with **Steppage Gait** cannot walk on \_\_\_\_\_

heels ## Footnote –Loss of ability to dorsiflex ankle

Neuro 1 Flashcards

(123 cards)