Flashcards in Neuro Lecture Deck (75)
Elements of complete neuro exam
Motor and sensory
What must first be established in neuro exam?
Patient's dominant hand
R handed people are ___ brain for speech
75% of L handed people are ___ brain for speech
Mental status exam consists of:
-Level of consciousness
-Appearance (dress, affect, hygiene)
-Orientation (to person, date, place)
-Language (quality, comprehension)
-Concentration (serial 7s, WORLD backwards)
-Recall (3 objects in 3 mins)
What tool can be used for the mental status exam? What does it test?
CN I testing:
-Patency of each nostril
CN II testing:
-VA then VF
CN III, IV, VI testing:
EOMs with the H test
CN V testing:
-Pin and light touch on ophthalmic, maxillary and mandiublar divisions
-Motor test (jaw jerk should be absent, ask patient to chew to test masseter and temporalis muscles)
CN VII testing:
-Squeeze eyes shut
What is Bells phenomena?
Patient closes eyes and the eye on the SAME side as the peripheral facial weakness will NOT close (but eye rolls superiorly)
Central facial weakness occurs with what disorder?
Peripheral facial weakness occurs with what disorder?
Bell's palsy, acoustic neuromas
Central facial weakness spares:
Forehead and eye closing
CN VIII testing:
Hearing, Weber and Rinne
CN IX and X testing:
-Say ahh watch uvula (deviates to strong side)
-Test gag reflex
CN XI testing:
-Shrug shoulders (trap)
-Turn head against resistance (SCM)
CN XII testing:
Stick out tongue (deviates to weak side)
What is upper motor neuron weakness characterized by?
-Minimal or no atrophy
What is lower motor neuron weakness characterized by?
-Absent or hyporeflexia
-Atrophy and fasciculations
What is upper motor neuron disease often a result of?
Stroke or brain injury
What does lower motor neuron disease involve?
Can involve spinal cord, peripheral nerve, or muscle
UE motor testing:
-Biceps (C5, C6)
-Triceps (C6, C7)
-Wrist extensors (C6, C7 stop traffic)
-Wrist flexors (C6, C7)
LE motor testing:
-Hip flexion (L2, 3)
-Abduction (L4, 5)
-Knee extension (L3, 4)
-Knee flexion (L5, S1)
-Dorsiflex foot (L4, 5)
-Plantar flex (S1)
-Extension of great toe (L5)
-Extension of remaining toes (L5, S1)
Strength grading system of motor exam
0 = no movement
1 = trace/flicker of movement
2 = able to move when gravity is eliminated
3 = able to move against gravity
4 = some weakness against resistance
5 = normal strength (able to move against resistance)
What strength grades are considered functional movement?
(so 4/5 is weakness but some function preserved)
Sensory exam consists of which tracts?
-Spinothalamic tract (pain and temperature)
-Dorsal (posterior) column (position sense and vibration)
L5 sensory =
Lateral portion of lower leg and great toe
S1 sensory =
Lateral portion of top and sole of foot
Dermatome of the shoulders
Dermatome of inner upper arms
Dermatome of nipple level
Dermatome of umbilicus
Dermatome of groin
Dermatome of knee
Dermatome of posterolateral thigh
Dermatome of upper anterior thigh
Dermatome of lateral thigh crossing to anterior lower leg
Dermatome of great toe
Dermatome of little toe
Dermatome of posteromedial thigh
Describe position (proprioception) test
-Test distal most portion of an extremity (finger or toe)
-Move up and down with lateral contact points
How to test vibration sense?
-Use 128 tuning fork
-Test over bony prominences
-Test of discriminatory sense
-Draw number in patient's palm and have them identify
-Ability to identify touch alone
-Put an item in palm of pt's hand and ask them to identify (e.g. key, coin, paper clip)
Define 2 point discrimination
-Ability to identify 2 separate stimuli that are close together
-Use EKG calipers
-Ask pt if 1 or 2 pins
Define extinction and what may cause it
-Patient "extinguishes" 1 of 2 simultaneous contralateral stimuli
-Lesions in sensory cortex
What does the Romberg test assess?
Position sense NOT cerebellar function
Loss of coordination
What 3 senses are required to keep us upright and balanced?
-Equilibrium (semicircular canals)
-Proprioception (position sense)
How many of the 3 senses required for balance do you need to maintain balance?
2 of the 3 need to work
(remove 2 of the 3 and you will fall over - vision, equilibrium, proprioception)
What symptom will patients with disequilibrium complain of?
If a patient "passes" the Romberg test, what is it called?
ABSENT Romberg (NOT negative)
What do the deep tendon reflexes test?
Simple spinal reflex (even deeply comatose pts may have preserved DTRs)
Grading of DTRs
0 = no reflex
1 = hyporeflexia
2 = normoreflexia
3 = hyperreflexia
4 = marked hyperreflexia (clonus)
Reinforcement techniques of DTRs
-Used to "coax" diminished reflexes
-For LE, pt curls fingertips together in front of themselves and pulls in oppo directions
-For UE, pt clenches jaw
How to use reflex hammer for DTRs?
-UE use pointy portion (smaller tendon target)
-LE use wider portion (wider tendon target)
What else do we check when doing LE DTRs?
-Stroke along lateral aspect of sole and then across
-POSITIVE (abnormal) is if great toe moves upward
-ABSENT (normal) is if great toe moves down
What are the superficial reflexes?
-Cremasteric (men only)
Describe superficial abdominal reflexes
Stroke 4 quadrants lightly and umbilicus will move toward the stimulus
Describe cremasteric reflex
-Stroke inner upper thigh and ipsilateral testicle will move rostrally (superiorly)
What does cerebellar testing assess and what does it consist of?
-Rapid alternating movements (RAMs)
-Finger nose finger (FNF)
-Heel knee shin (HKS)
How to assess gait?
-Heels (brings out AT)
-Toes (brings out gastroc)
-Tap between eyebrows
-Pt eyes blink rhythmically (abnormal)
Just like babies reflex but is pathological in adults
Scratch palm and patient will purse lips (may be very subtle)
Tap mouth and pt will purse lips
Flapping tremor of the hands seen in liver disease
-Flex hip and knee
-Pt will resist and note pain behind knee
-Pain is the telling sign
Flex neck and patient will draw up hips and knees
Describe Babinski reflex
-Briskly stroke lateral surface of sole and go across MT heads
-Absent (normal) is great toe to flex (move down)
-Positive (abnormal) is great toe to extend (move up)