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Flashcards in Neuro 1 Deck (123):
1

Components of neurological examination

  1. Assessment of awareness/level of consciousness
  2. Posturing
  3. Mental Status
  4. Speech Assessment
  5. Cranial Nerve Examination
  6. Cerebellar/Coordination Testing
  7. Gait Examination
  8. Motor and Strength Examination
  9. Reflex Testing
  10. Sensory Examination

2

Components of the Mental Status Exam (MSE)

  1. General appearance, behavior, and attitude
  2. Level of consciousness and orientation
  3. Speech and language
  4. Mood and affect
  5. Thought process, Content, and Perceptions
  6. Memory and cognition
  7. Judgment and insight

3

What level of consciousness?

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

Alert

4

What level of consciousness?

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

Lethargic

5

What level of consciousness?

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

Obtunded

6

What level of consciousness?

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

Stuporous

7

What level of consciousness?

  • Patient is unarousable to any stimuli

Comatose

8

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.

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9

Decorticate posture is thought to occur when.....

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

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10

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

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11

What is the site of lesion for decorticate posture?

corticospinal tracts, above the brainstem

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12

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

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13

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

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14

What is the site of lesion for the decerebrate position?

brainstem

15

3 questions of Orientation?

  • Name
  • Day or date
  • Where are we?

16

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

17

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

18

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

19

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

20

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

21

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.

22

Speech and Language/Fluency

What are you testing?

  • Ask patient to follow one or two step command

Word comprehension

23

Speech and Language/Fluency

What are you testing?

  • Ask patient to repeat, "No ifs, ands, or buts"

Repetition

24

Speech and Language/Fluency

What are you testing?

  • Ask patient to name the parts of a watch

Naming

25

Speech and Language/Fluency

What are you testing?

  • Ask patient to read a paragraph out loud

Reading

26

Speech and Language/Fluency

What are you testing?

  • Ask patient to write a sentence

Writing

27

________ is the external expression of emotion visible to the clinician

Affect

28

What are you assessing?

•Are the pts responses  and body language devoid of emotion?

 

Affect

29

What are you assessing?

•Are their responses hyper-emotional?

 

Affect

30

What are you assessing?

•Do the pts responses change dramatically through the interview?

 

Affect

31

What are you assessing?

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

 

Affect

32

What are you assessing?

•Does the pt have poor eye contact?

 

Affect

33

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

Labile mood

34

How do you assess the patient's mood?

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

35

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

36

Assessment of Thought Process

Identify:

•– only partially relevant or irrelevant responses to questioning

Tangentiality

37

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

38

Assessment of Thought Process

Identify:

•– speech makes no sense at all  (aka “word salad”)

Incoherence

39

Assessment of Thought Process

Identify:

•– speech is delayed in reaching goal because of unnecessary detail, however components are properly related

Circumstantiality

40

Assessment of Thought Process

Identify:

•– During the course of a discussion, pt changes subject in response to something unrelated in the environment.

Distractable speech

41

Assessment of Thought Process

Identify:

•– persistent repetition of specific words or ideas

Perseveration

42

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

43

Assessment of Thought Process

Identify:

•– Fabrication of facts to fill in gaps of memory

Confabulation

44

Assessment of Thought Content

Identify:

•– Recurrent, uncontrollable thoughts or images that are unwanted and unpleasant  to the pt.

Obsessions

45

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

46

Assessment of Thought Content

Identify:

•– False, fixed personal beliefs that are not shared by others in the pts community

Delusions

47

Assessment of Thought Content

Identify:

•– Persistent, irrational fears accompanied by desire to avoid the stimulus

Phobias

48

Assessment of Thought Content

The below are all examples of _______:

–Persecution

–Grandiosity

–Delusion of being controlled externally

–Somatic delusions

–Jealousy

Delusions

49

Assessment of Thought Content

Identify:

•– A sense that things in the environment are unreal, strange or remote

Feelings of Unreality

50

Assessment of Thought Content

Identify:

•– A sense that the inner self has become detached from the mind or body

Feelings of Depersonalization

51

Assessment of Thought Content

Identify:

•– Fears, tensions, or uneasiness that may be focused or free-floating

Anxiety

52

Assessment of Perceptions

Identify:

•– misperception of real external stimuli

Illusions

53

Assessment of Perceptions

Identify:

•– false perceptions.  Pt hears, sees, smells or feels something others cannot.

Hallucinations

54

Assessment of Memory

Identify:

  • Can pt. learn something new and repeat it back?

Registration

55

Assessment of Memory

Identify:

•Can the patient correctly remember things that happened today?

Recent Memory

56

Assessment of Memory

Identify:

•Can the patient correctly remember things that happened or information from long ago?

Remote Memory

57

Assessment of Cognition

Identify:

•Can the patient focus enough to be able to perform tasks?

Attention

58

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

59

Assessment of Cognition

Identify:

•– Ask the patient to interpret a commonly used proverb

Abstract Thinking: Proverbs

60

Assessment of Cognition

Identify:

–Ask the patient to tell you how two things are alike

Abstract Thinking: Similarities

61

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?”

62

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

Judgment

63

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

insight

64

Standardized way to test mental status that is:

•Validated many times

•Easy to administer

•Results reproducible across examiners

•Brief and well-tolerated by patients

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

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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

66

Assessment of Speech Disorders

Identify:

•– loss of ability to speak because of damage to larynx or throat

Aphonia

67

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

68

Assessment of Speech Disorders

Identify:

•– loss of comprehension or power of expression of speech.

Aphasia

69

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. 

70

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. 

71

Cranial nerves are _____ nerves

Peripheral

72

Cranial Nerve I Exam

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

73

Cranial Nerve II Exam

•II = OPTIC NERVE

•Evaluation:

–Visual Acuity Test

–Visual Fields by Confrontation

–Funduscopic Exam

74

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

75

Ptosis is which cranial nerve?

CN III (three) oculomotor

76

Cranial nerves and eye muscles: what statement to remember?

•“LR VI, SO IV, all else III”

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77

Assessing Pupillary Response To Light. Which CNs?

•Assesses CN II & III

78

Cranial Nerve V Exam

•V = TRIGEMINAL

MOTOR :

–Masseter & Temporalis
–movement & strength

SENSORY :

–Light touch  and sharp /dull – all 3 divisions bilaterally
–Corneal Reflex

79

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

80

Identify:

–Forehead wrinkling preserved

–Mild weakness of eye closure

–Flat nasolabial fold

–Most common cause is stroke

Central Seventh Nerve Paralysis

81

Identify:

–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

82

Cranial Nerve VIII Exam

VIII = VESTIBULOCOCHLEAR

–Auditory Acuity

•Document stimulus used (Weber, Rinne, hair rub, whisper)

83

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

84

Cranial Nerve XI Exam

XI = ACCESSORY

• Assessment of muscle

    strength bilaterally

• Trapezius:
–Shoulder shrug against resistance
•  Sternocleidomastoid: 
–Left/right rotation of neck against resistance

85

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.

86

Coordination / Cerebellar Testing

Testing assesses integration of:

Cerebellar system:

–rhythmic movements and posture

87

Coordination / Cerebellar Testing

Testing assesses integration of:

Vestibular system

––balance, & eye, head & body movements

88

Coordination / Cerebellar Testing

Testing assesses integration of:

Sensory system

––position sense (aka proprioception)

89

What does the below test?

•Rapid Alternating Movements (RAM)

Coordination testing

90

What does the below test?

•Point-to-point Testing (Finger to Nose and Heel-Knee-Shin)

Coordination testing

91

What does the below test?

•Romberg testing

Coordination testing

92

What does the below test?

•Pronator Drift

Coordination testing

93

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

94

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

95

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

  1. –Finger-to-nose
  2. –Heel-knee-shin

96

What does the ROMBERG TEST assess?

–CEREBELLAR FUNCTION

–PROPRIOCEPTION (position sense)

97

What is a positive ROMBERG TEST?

•pt stands well with eyes open but loses balance with eyes CLOSED

--this result is abnormal--

98

What does PRONATOR DRIFT test?

  • Part 1: Holding up a pizza box with eyes closed ONLY

–Upper Motor Neuron Function

–PROPRIOCEPTION (position sense)

99

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

100

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

•the arm will begin to pronate and fall

101

What does PRONATOR DRIFT test?

  • Part 2: Tapping the arms and watching recoil

–PROPRIOCEPTION (position sense) only

102

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

103

Gait Assessment

What does the below test?

  • Walk casually across room and include turns

gait abnormalities

104

Gait Assessment

What does the below test?

  • Walk On toes

distal muscle weakness

105

Gait Assessment

What does the below test?

  • Walk On heels

–distal muscle weakness

106

Gait Assessment

What does the below test?

  • Rise from sitting position

–proximal muscle weakness

107

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

108

Gait Abnormalities

Identify:

–Shuffling gait with leg extended and held stiff

•Spastic Gait

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

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109

Gait Abnormalities

Identify

 

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•Spastic Gait

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

–Shuffling gait with leg extended and held stiff

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110

Gait Abnormalities

Identify

 

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•Scissors Gait

–Bilateral corticospinal tract injury

–Adductor spasm, knees pulled together, knees and thighs hit each other

–Seen in cerebral palsy, MS

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111

Gait Abnormalities

Identify:

–Adductor spasm, knees pulled together, knees and thighs hit each other

 

 

•Scissors Gait

–Bilateral corticospinal tract injury

–Seen in cerebral palsy, MS

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112

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

 

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113

Gait Abnormalities

Identify:

 

 

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•Steppage Gait

–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

 

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114

Gait Abnormalities

Identify:

 

 

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•Cerebellar Gait

–Feet set wide apart and steps are unsteady, uncertain and of variable length

–Indicator of cerebellum damage (including severe alcohol intoxication)

 

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115

Gait Abnormalities

Identify:

–Feet set wide apart and steps are unsteady, uncertain and of variable length

 

 

 

•Cerebellar Gait

 

–Indicator of cerebellum damage (including severe alcohol intoxication)

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116

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)

 

 

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117

Gait Abnormalities

Identify:

 

 

 

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

–Small steps and is decreased arm swing when walking

–Head and body are flexed and arms are semi-flexed and abducted

 

 

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118

Gait Abnormalities

What does this indicate?

•Spastic Gait

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

119

Gait Abnormalities

What does this indicate?

•Scissors Gait

–Bilateral corticospinal tract injury

–Seen in cerebral palsy, MS

 

120

Gait Abnormalities

What does this indicate?

•Steppage Gait

–Cause:  Loss of ability to dorsiflex ankle

–Seen in neuropathies/ radiculopathies

 

121

Gait Abnormalities

What does this indicate?

•Cerebellar Gait

–Indicator of cerebellum damage (including severe alcohol intoxication)

 

122

Gait Abnormalities

What does this indicate?

•Basal Ganglia Gait

–Indicator of Parkinson’s or Festination gait

 

123

Gait Abnormalities

A person with Steppage Gait cannot walk on _____

heels

–Loss of ability to dorsiflex ankle