Neuro

Question 1

List components of a full mental status exam and compare it to components of a Mini Mental State exam.

Answer 1

Mini Mental Status is brief - measuring orientation, registration, attention and calculation, recall, ability to follow commands, and language

Full Mental Status (MoCA) - Is much more broad and has higher sensitivity and specificity

Question 2

• Excessively energetic movements or constantly watchful eyes suggest

Answer 2

tension, mania, anxiety, a metabolic disorder, or the effects of recreational or prescription drug use (e.g., methamphetamine, amphetamine salts, cocaine, and steroids).

Question 3

• Slumped posture and a lack of facial expression may indicate

Answer 3

depression or a neurologic condition such as Parkinson disease.

Question 4

• Person disorientation results from

Answer 4

cerebral trauma, seizures, or amnesia.

Question 5

• Place disorientation occurs with

Answer 5

psychiatric disorders, delirium, and cognitive impairment.

Question 6

• Time disorientation is associated with

Answer 6

anxiety, delirium, depression, and cognitive impairment.

Question 7

The Glasgow Coma Scale is used to quantify the

Answer 7

level of consciousness after an acute brain injury or medical condition

Question 8

• Signs of possible cognitive impairment include the following

Answer 8

significant memory loss, confusion (impaired cognitive function with disorientation, attention and memory deficits, and difficulty answering questions or following multiple-step directions), impaired communication, inappropriate affect, personal care difficulties, hazardous behavior, agitation, and suspiciousness

Question 9

An inability to describe similarities or differences in analogies

Answer 9

may indicate a lesion of the left or dominant cerebral hemisphere.

Question 10

• Abstract reasoning: Ask the patient to tell you the meaning of a fable, proverb, or metaphor, such as the following:
• A stitch in time saves nine.
• When the patient has average intelligence, an adequate interpretation should be given.
• Inability to explain a phrase may indicate

Answer 10

poor cognition, dementia, brain damage, or schizophrenia.

Question 11

• Impairment of arithmetic skills may be associated with

Answer 11

depression, cognitive impairment, and diffuse brain disease.

Question 12

• Aphasia:

Answer 12

a speech disorder that can be receptive (understanding language) or expressive (speaking language), may be indicated by hesitations and other speech rhythm disturbances, omission of syllables or words, word transposition, circumlocutions, and neologisms.

• Aphasia can result from facial muscle or tongue weakness or from neurologic damage to brain regions controlling speech and language

Question 13

Immediate recall or new learning: Ask the patient to listen and then repeat a sentence or a series of numbers. Five to eight numbers forward or four to six numbers backward can usually be repeated.
- Loss of immediate and recent memory with retention of remote memory suggests

Answer 13

dementia.

3 word recall

Question 14

Recent memory: Give the patient a short time to view four or five test objects, telling him or her that you will ask about them in a few minutes. Ten minutes later, ask the patient to list the objects. All objects should be remembered.
- Loss of immediate and recent memory with retention of remote memory

Answer 14

suggests dementia

Question 15

Remote memory

Answer 15

: Ask the patient about verifiable past events or information such as sibling’s name, high school attended, or a subject of common knowledge.

Question 16

Distinguish between the following terms: confusion, lethargy, delirium, stupor, and coma.

Answer 16

Confusion: Inability to think or reason in a focused, clear manner.

Lethargy: falls asleep without repeated stimulation

Delirium: fluctuating acute confusion

Stupor: requires vigorous and/or painful physical stimulation to be awakened

Coma: not able to be aroused by any stimulus any sort and no response to the environment

Question 17

Aphasia

Answer 17

can result from facial muscle or tongue weakness or from neurologic damage to brain regions controlling speech and language.

Question 18

Question 19

List indications for using the Glasgow Coma Scale and explain the assessed behaviors, criteria for scoring, and maximum and minimum possible scores.

Answer 19

Max Points: 15; Min Points: 3

Question 20

Distinguish between the following types of abnormal posturing: decorticate, decerebrate, and hemiplegia, and discuss the clinical significance of each.

Answer 20

Decorticate Associated w/ injury to the corticospinal tracts above the brainstem.
Decerebrate Associated w/ injury to the brainstem.
Hemiplegia: Associated w/ damage to ICA, MCA, or ACA

Question 21

Distinguish between the following disorders of altered mental status: delirium, dementia, and depression.

Answer 21

Delirium: impaired cognition, arousal, consciousness, mood, and behavioral dysfx of acute onset
Dementia: A chronic, slowly progressive disorder of failing memory, cognitive impairment, behavioral abnormalities, and personality changes that often begins after age 60 years
Depression: Feelings of sadness, loss, anger, or frustration that interfere with everyday life for an extended period

Question 22

Distinguish between tests performed with a 128 Hz. tuning fork and those performed with a 512 Hz. tuning fork.

Answer 22

128 Hz. tuning fork (the larger tuning fork w/ a weighted end)
Vibratory sense in fingers and toes - testing proprioception of the posterior column
● Using the tuning fork start distally at DIP joints and move proximally, prn

512 Hz. tuning fork (the smaller tuning fork)
Tests for CN VIII, cochlear division - testing of a cranial nerve
● Weber test
● Rinne test

Question 23

· Identify the location of the following spinal nerve dermatomes: C3, C6, C7, C8, T4, T10, T12, L4, L5, and S1.

Answer 23

C3: Proximal neck
C6: Thumbs & index finger pads
C7: Middle finger pads
C8: Ring and pinkie finger pads
T4: Nipple level
T10: Umbilicus
T12: Inguinal
L4: Medial foot
L5: Mid-dorsum foot
S1: Lateral

Question 24

Question 25

· Discuss how to assess motor strength and using the Grade 0 to 5 scoring system to describe findings.

Answer 25

Grade 5/5 (normal): Full ROM against gravity and full resistance Grade 4/5 (good): Full ROM against gravity and some resistance Grade 3/5 (fair): Full ROM against gravity only Grade 2/5 (poor): Full ROM when gravity is eliminated Grade 1/5 (poor): Slight contractility, no movement Grade 0/5 (none): No contractility

Question 26

· Explain the use of and findings of normal/abnormal pronator drift test.

Answer 26

Arms held out with palms up and with eyes closed, positive if an arm falls down. - Abnormal indicated corticospinal tract dysfunction such as a lesion.

Question 27

· List and describe tests to assess posterior column function 6

Answer 27

Vibration deep pressure Joint position sense stereognosis point location 2 point discrimination

Question 28

2 point disrimination

Answer 28

2-point discrimination: Use two ends of a paper clip or sharp ends of a broken tongue blade, and alternate touching the patient's skin with one point or both points at various locations over the body. Ask the patient how many points are felt. On the fingertips and toes, two points are commonly felt when 2 to 8 mm apart. A greater distance is expected for discrimination of two points on other body parts, such as the back (40 to 70 mm) or chest and forearms (40 mm).

Question 29

· List and describe tests to assess cerebellar function (examination of coordination): | 6

Answer 29

1. Observe gait - heel-toe motion, smoothness, arm swing, level of hips, etc. 2. Heel-toe walking (tandem gait) - Walking in a straight line; like you are walking on a tightrope or the test police officers makes an individual do when they think they are intoxicated beyond repair 3. Point-to-point (nose-examiner’s finger-nose) testing - *must compare bilaterally 4. Heel-knee-shin test - repeatedly move heel up and down shin in a straight line to assess fluidity; *must compare bilaterally 5. Pick up 3 coins off the table - test each hand for fine motor coordination 6. Rapid alternating movements (RAM): *must compare bilaterally a. In upper extremities - Pronation/supination of hand (like making a pancake) b. In lower extremities - Pat feet on examiner’s hand

Question 30

# LATERAL · List and describe tests to assess spinothalamic tract function.

Answer 30

**- Superficial pain** - Alternating the sharp and smooth edges of a broken tongue blade or paper clip, touch the skin in an unpredictable pattern. Allow 2 seconds between each stimulus to avoid a summative effect (see Fig. 23.19, B). Ask the patient to identify each sensation as sharp or dull and where it is felt. - Evaluation of superficial pain and touch can be evaluated together. Alternate the use of the sharp and dull tongue blade edges with fingertip strokes to determine whether the patient can identify the change in sensation. **- Temperature** - To evaluate temperature sensation, roll test tubes of hot and cold water against the skin, alternating in an unpredictable pattern between the various sites. Ask the patient to indicate which temperature is perceived and where it is felt.

Question 31

# ANTERIOR · List and describe tests to assess spinothalamic tract function.

Answer 31

**- Superficial touch** - Touch the skin with a cotton wisp or with your fingertip, using light strokes. Do not depress the skin, and avoid stroking areas with hair. Have the patient point to the area touched or tell you when and where the sensation is felt. - **Deep pressure** - Squeeze the trapezius, calf, or biceps muscle to evaluate deep pressure sensation. The patient should experience discomfort.

Question 32

# POSTERIOR · List and describe tests to assess spinothalamic tract function.

Answer 32

- **Vibration** - Place the stem of a vibrating tuning fork (the tuning fork with lower Hz has slower reduction of vibration) against several bony prominences, beginning at toe and finger joints. The sternum, shoulder, elbow, wrist, shin, and ankle may also be tested. Ask the patient to tell you when and where the buzzing or tingling sensation is felt. Dampen the tines on occasion before application to determine whether the patient distinguishes a difference. - Deep pressure - Squeeze the trapezius, calf, or biceps muscle to evaluate deep pressure sensation. The patient should experience discomfort. **- Position sense** - Assess the great toe of each foot and a finger on each hand. Hold the joint to be tested (e.g., great toe or finger) by the lateral aspects to avoid giving a clue about the direction moved. Beginning with the joint in neutral position, raise or lower the digit, and ask the patient which way the joint was moved. Expect patients to identify the joint position. **- Stereognosis**- Hand the patient a familiar object (e.g., key, coin) to identify by touch and manipulation. Think about Pt’s hands behind back - Point location - Touch an area on the patient's skin and withdraw the stimulus. Ask the patient to point to the area touched. No difficulty localizing the stimulus should be noted. This procedure is often performed with superficial tactile sensation. **- 2-point discrimination** - Use two ends of a paper clip or sharp ends of a broken tongue blade, and alternate touching the patient's skin with one point or both points at various locations over the body. Ask the patient how many points are felt. On the fingertips and toes, two points are commonly felt when 2 to 8 mm apart. A greater distance is expected for discrimination of two points on other body parts, such as the back (40 to 70 mm) or chest and forearms (40 mm). - Proprioception did one want to add here?

Question 33

· List and describe tests to assess cerebral cortex sensory function.

Answer 33

Stereognosis 2 point disrcimination Graphesthesia extinction phenomenom: Simultaneously touch two areas on each side of the body (e.g., cheek, hand, or other area) with the sharp edge of a broken tongue blade. Ask the patient to tell you the number of stimuli and where they are felt. Expect similar sensations to be felt bilaterally.

Question 34

· Explain how to properly perform a Romberg test and discuss potential causes when a Romberg sign is elicited. Evaluates balance. Ask patient to close their eyes and stand feet together with arms at the sides. | Positive means?

Answer 34

Positive sign indicated cerebellar ataxia, vestibular dysfunction, or sensory loss.

Question 35

List the commonly tested deep tendon reflexes (DTRs), list the spinal nerves tested with each, and discuss conditions which may increase or decreased DTRs.

Answer 35

Biceps - C5 and C6 Brachioradialis - C5 and C6 Triceps - C6, C7 and C8 Patellar - L2, L3, and L4 Achilles - S1 and S2 *Absent reflexes may indicate neuropathy or LMN, whereas hyperactive reflexes indicate UMN

Question 36

· Explain how to properly grade deep tendon reflexes using the 0 to 4+ scale and when to assess for clonus.

Answer 36

Grading of DTRs: 0 - No response 1+ Sluggish or diminished 2+ Active or expected 3+ More brisk than expected, slightly hyperactive 4+ Brisk, hyperactive, with intermittent or transient clonus

Question 37

List the commonly tested superficial reflexes, and discuss conditions which may cause them to become decreased or absent.

Answer 37

Upper abdominal - Slight movement expected, diminished may be diminished in obese or pregnant women, absent on side of corticospinal tract lesion Lower abdominal - “ “ Cremasteric - Should rise Plantar - Babinski indicated pyramidal UMN lesion

Question 38

· Describe how to assess for the presence of meningeal signs using the Kernig and Brudzinski tests, and describe the appearance of and explain clinical significance of a positive Kernig or Brudzinski test.

Answer 38

Brudzinski - Flex neck and observe for involuntary flexion of hips and knees Kernig - Flex the leg at the knee & hip when the patient is supine, and then attempt to straighten the leg Positive Signs - Indicate meningeal irritation

Question 39

· Explain how to properly assess for intactness and symmetrical response of superficial pain sensation using sharp/dull testing, and explain the purpose of “dull” testing.

Answer 39

Tested in each branch of Trigeminal nerve → Sharp and rounded edge used in an unpredictable alternate pattern. Allow 2 seconds between each and ask patient to identify if sharp or dull, and where it is felt. Dull used to determine if patient can identify change in sensation.

Question 40

· Explain how to properly assess for intactness and symmetrical response of superficial (light) touch sensation using a cotton wisp.

Answer 40

Touch skin with a cotton wisp using light strokes, have patient point to area touched or tell you when and where sensation is felt.

Question 41

Discuss the significance of testing for point localization and extinction

Answer 41

Evaluates the posterior column of ascending tract and evaluates for LMN disorder

Question 42

Discuss the findings in positive Tinel’s and Phalen’s signs and their associated clinical condition.

Answer 42

Tinel's - Tapping nerve causes tingling sensation to radiate through that area → shows signs of damage to the median nerve, present in carpal tunnel Phalen's - Positive when flexing wrist to 90 degrees for 1 minute causes symptoms in the median nerve section and suggests carpal tunnel