Neurologic Exam Flashcards
1
Q
Neurologic Exam Components
A
- Mental Status
- Cranial Nerves
- Motor Examination
- Reflexes (DTRs, Pathological)
- Coordination and Gait
- Sensory Examination
2
Q
Neurologic Exam Descriptions
A
• Tests function
• Each part is used to titrate the patient’s level of function
• Flexible and SHOULD be tailored to clinical situation
• May be done in greater or less detail depending on the clinical suspicion
• Certain parts can be combined or performed in a slightly different order to minimize the number of times the patient needs to change positions
• Screen for unsuspected lesions and to test hypotheses for localization
3
Q
Mental Status =
A
Cerebral Examination
4
Q
3 global brain function which determines how well we can perform the neurologic exam
A
-Level of alertness
-Attention
-Cooperation
5
Q
Other components of mental status
A
• General behavior and appearance
• Orientation
• Memory
• Language
(left hemisphere dominant)
• Calculation
• Neglect and constructions (parietal obe)
• Sequencing tasks and frontal release signs frontal lobe)
6
Q
Language is dominant on
A
Left hemisphere
7
Q
Neglect and constructions is dominant on
A
Parietal lobe
8
Q
Sequencing tasks and frontal release signs are dominant on
A
Frontal lobe
9
Q
MMSE - P Description & Components
A
- Mini-Mental Status Examination -PH
- Over 30, 1pt each
- DSP - <27
Components
- Orientation to time and place
- Registration
- Attention & Calculation
- Delayed Recall
- Language
—Naming, Repetition, 3-step command, reading comp, writing, copying, & vision-spatial function
-for cerebrum capacity
10
Q
MOCA-P
A
- Montreal Cognitive Assessment - Philippines
• TOTAL SCORE: Sum of all subscores listed on the righthand side. Add one point for an individual who has 12 years or fewer of formal education, for a possible maximum of 30 points.
• A final total score of 26 and above is considered normal
DSP - 21
11
Q
Testing for the level of alertness, attention, and cooperation
A
Focus on a simple task
• Spelling a short word forward then backward
• Repeat a string of numbers forward and backward (digit span)
• Normal digit span is 6 or more forward and four or more backward
• Naming months forward and backward
• Twice a long to recite months backwards
12
Q
Usual cause for problem with the level of alertness, attention, and cooperation
A
• Brainstem reticular formation
• Bilateral lesions in thalami or cerebral hemispheres
• May be mildly impaired in unilateral cortical or thalamic lesions
• Encephalopathies
— Hepatic Encelopathies
• Behavioral and mood disorders
13
Q
Test for orientation
A
• Person
• Place
• Time
• Document specifically the questions they were asked and how they were answered
• Detect changes throughout time
• Tests recent and longer-term memory
14
Q
giving the patient several words to remember and testing for recall 4-5 mins later
A
Recent memory
15
Q
verifiable personal information
A
Remote memory
16
Q
Testing the recent memory
A
• Recall 3 items after a delay of 3-5
mins
• Make sure there is registration by asking to repeat it immediately before initiating the delay
• Provide distractions during the delay to prevent from rehearsing
17
Q
Testing remote memory
A
• Historical or verifiable personal events
18
Q
Impaired registration / immediate recall =
A
Impaired attention = impaired reticular formation or cerebrum
19
Q
Impaired delayed recall =
A
Impaired medial temporal lobes and medial diencephalon
20
Q
Composition of language
A
Spontaneous speech
Thinking
Comprehension
Naming
Repetition
Reading
Writing
21
Q
Fluency, abundance, content, tonal modulation, grammar
A
Spontaneous speech
** cerebellum for tonal modulation and grammar
22
Q
inappropriate substitution of words or syllables
A
Paraphrased errors
23
Q
form and content
A
Thinking
24
Q
Simple questions and commands
A
Comprehension
25
Easy and hard to name objects
Naming
26
Repeat single words and sentences
Repetition
27
Read and test for comprehension
Reading
28
Broca’s area and wernicke’s area are dominant on
Left cerebral hemisphere
29
Broca’s area is responsible for
Motor speech
Speech production
30
Wernicke’s area is responsible for
- speech comprehension
31
prevents a person from producing speech
person can understand language
words are not properly formed
speech is slow and slurred.
Broca’s aphasia
32
loss of the ability to understand language
person can speak clearly, but the words that are put together make no sense. This way of speaking has been called "word salad" because it appears that the words are all mixed up like the vegetables in a salad.
Wernicke’s aphasia
33
Connection between broca’s and wernicke’s
Arcuate fasciculus
34
Inability
carry
out an action in response to verbal command, in the absence of any comprehension deficit, motor weakness or incoordination (an activity that can be performed well spontaneously)
• Inability to formulate the correct movement sequence
• Pretend to comb your hair, brush your teeth, strike a match and blow it out
• Lesion in dominant
temporoparietooccipital area
Ideomotor apraxia
35
Ideomotor apraxia is a lesion dominant on
Temporoparietooccipital area
36
abnormality in attention to one side that is not due to a primary or secondary sensory or motor disturbance
• Extinction on simultaneous double extinction
• Prone to injury and falls
Hemineglect
37
L hemineglect is a lesion on the
R parietal lobe
38
Test for hemineglect
-Neglect drawing test
-Visual Extinction
-Tactile Extinction
-Copy drawing
39
difficulty in changing from one action to the next when asked to perform repeated sequence of actions
Preservation
40
tap table with fist, open palm, side of open hand then repeat
Luria manual sequencing tasks
41
Frontal release signs
Grasp
Snout
Rooting reflex
42
Motor execution is dominant on
Precentral gyrus
43
Planning is dominant on
Premotor cortex
44
Abstract reasoning, judgement, and logic is a dysfunction on
Frontal lobe
45
Fixed belief
Delusions
46
Fixed belief
Delusions
47
Inability to understand meaning, import or symbolic significance of ordinary sensory stimuli even though the sensory pathway and sensorium are relatively impact
Agnosia
48
Inability to recognize letters/numbers traced on the palm
Agraphesthesia
Agraphognosia
49
Inability to recognize face but recognize the voice and can describe the parts
Prosopagnosia
50
Lack of awareness of body defect
Anosognosis
51
Abnormal perceptions
Hallucinations
52
Diffuse brain dysfunction
• Psychiatric disorders
Delusions and Hallucinations
53
Disturbance in neurotransmitters
Mood
54
Signs of depression, anxiety, mania
• Congruence
• Psychiatric in origin
• Biochemical/neurotransmitter imbalances
• Somatization and conversion disorders
Mood
55
Nonexistent words
Neologism
56
Testing the CN 1
- Olfactory n./ Olfaction
- coffee grounds
beans
-Noxious odors may stimulate pain fibers of CN V
- One nostril at a time
57
Problem may be d/t
Nasal obstruction, damage to olfactory nerves in the mucosa, as they cross the cribriform plate, or intracranial lesions affecting the olfactory pathway
Parkinson's disease
- anosmia is one of the nonmotor symptoms
58
Visualization of the retina, retinal vessels, optic nerve atrophic changes, papilledema
Opthalmoscopy
59
Test for visual acuity
Snellen Chart
- test one eye at a time
60
Test for color vision
Ishihara test
61
Test of visual fields
fixate on the
examiner's nose and report when a finger can be seen moving in each quadrant or how many fingers are held up
- Blink to threat for stroke
- Perimetry - blinking lights machine
62
double simultaneous stimulation
Visual extinction/hemineglect
63
Visual hemineglect
contralateral parietal lesion: more robust when on the right
64
Pupillary Light Reflex (PLR)
CN II (Optic Nerve) and CN III (Oculomotor
Nerve)
65
Pupillary Light Reflex (PLR) Types
Direct pupillary light reflex
—ipsila cn ii
Consensual pupillary light reflex
—contralat cn iii
66
Near response
Accomodation
67
Accommodation is the convergence by
Medial recti
68
Pupillary constriction by
pupillary constrictor muscles of the iris
Iris sphincter
69
Lens thickening by contraction of the
Ciliary muscles
70
Testing for for cn iii, iv, vi
-Extraocular muscles
• Observe for dysconjugate gaze, spontaneous nystagmus
• Look in all directions without moving head
• Ask for double vision
71
check full range of horizontal and vertical eye movement
Smooth pursuit
72
Rapid fixation
Saccades
73
Cn v general sensation
- Facial Sensation and Muscles of Mastication
-light touch, pinprick on all divisions of trigeminal nerve
74
Tactile extinction
R parietal lesion
75
Afferent corneal reflex
Cn v
76
Efferent corneal reflex
Cn vii
77
What to inspect and palpate for cn v
Masseter and temporalis
78
Jaw jerk reflex
• Sign of hyperreflexia associated with UMN lesion to trigeminal motor nucleus
• Afferent and efferent limbs: CN V
79
Impaired facial sensation and muscles of mastication
lesions of CN V, trigeminal nuclear complex in brainstem, thalamus, somatosensory cortex
lesions of the UMN
That synapses with trigeminal motor nucleus,
LMN of trigeminal motor nucleus to peripheral nerve, NMJ, muscle
80
Cn vii observation
Asymmetry, depth of nasolabial fold (NLF), spontaneous facial expressions, blinking
• Compare with old photo
• Smile, puff cheeks, close eyes tightly, wrinkle eyebrows
• Taste in(anterior 2/3)of tongue
81
Screening for cn viii
Finger rubbing
• Whispered words
• Ticking of watch
• Weber's
• Rinne's
82
Benign paroxysmal positional vertigo
Dix-Hallpike Maneuver
83
unilateral hearing loss is d/tv
lesions in the ear, cochlea, CN VIIII
• Enter the brainstem and cross over at multiple levels and ascend bilaterally to thalamus and auditory cortex
84
Weber’s test
- Place a vibrating tuning fork (256Hz or 512Hz) on the vertex of the skull in the midline
• N: pitch heard equally on both ears
Conductive: louder on affected side (conduction through skull louder)
• Sensorineural: softer on affected side
85
Rinne’s test
Vibrating tuning fork placed on patient's mastoid then next to the
ear
• Air conduction is compared to bone conduction in each ear
• N: sound next to ear should be louder because it takes advantage of the middle ear bone amplification
• АС>ВС
Conductive: middle ear bones are not working normally or sound cannot access the middle
ear = softer next to ear
• ВС>АС
• Sensorineural: AC>BC but decreased in affected ear
86
Palatal Elevation and Gag Reflex
Cn ix & x
87
Impaired palatial elevation and gag reflex
Lesions of cn ix, x, nmj, pharyngeal muscles
88
Palatial elevation observation
Symmetrical palatal elevation when the patient says "aah"
89
Gag reflex observation
Gag when posterior pharynx is brushed - only tested in suspected brainstem pathology, impaired consciousness or impaired swallowing
90
Muscles of articulation cn
CN V, VII, IX, X, XII
91
CN V, VII, IX, X, XII
Listen to patient spontaneous speech - hoarse, slurred, nasal, rhythm, volume
• Change from baseline
• Dysarthria - abnormal pronunciation of speech (Slurred speech)
• Aphasia - abnormality in language comprehension or production
92
Impaired articulation
Lesions in muscles of
articulation, NMJ, peripheral or central portions of CCN V, VII, IX, X or XII
• Lesions in cerebellun
motor cortex sasal ganglia
93
Cn xi test
Shrug shoulders, turn head both sides
94
Can xii observation
Observe at rest - muscle bulk, presence of fasciculations (spontaneous, quivering)
• Tongue protrusion - deviations, movement side to side
• Tongue strength - push against inside of cheek
95
Signs of lmn lesions of the tongue
Fasciculations and atrophy
96
Unilateral tongue weakness
deviate towards weak side
• LMN - ipsilateral
• UMN - contralateral
97
Motor examination Components
1. Observation
2. Inspection
3. Palpation
4. Muscle tone testing
5. Functional testing
6. Strength testing
7. Presence of involuntary movements
98
Supraspinal neurons and their tracts
UMN
99
Anterior horn motor neuron send axons to innervate the skeletal muscles through the anterior roots of the spinal nerves
LMN
100
Components of LMN
• Anterior horn cell
• Peripheral nerve
• Neuromuscular junction
• Muscle
101
Observation for motor exam
Muscle bulk
• Presence of involuntary movements / paucity of movement
• Posture
102
Motor exam inspection and palpation
Muscle wasting, hypertrophy, fasciculations
103
abnormal muscle twitching due to spontaneous activity in groups of muscle cells
Fasciculations
104
Lmn disorder inspection and palpation
intrinsic hand muscles, shoulder girdle, thigh in patients
105
Inspection and palpation tenderness
Myositis
106
Amount of tension (or resistance to movement) in muscles
• Partial state of contraction at rest
Passive movement of the joints
Muscle tone
107
Lmn muscle tone
Discontinuation of the afferent or
efferent reflex pathways = loss of muscle
tone = flaccid
• Atrophy, reduced muscle volume
108
Umm muscle tone
High resistance to stretch due to
hyperactive stretch reflexes = hypertonic =
spastic
109
Detect subtle abnormalities
Drift
110
Test fine movements
- finger tapping
- rapid foot tapping
111
Muscle strength description
Patterns of weakness help localize a lesion
• Compare with contralateral counterpart
• Note pattern of weakness
112
DTR Testing
• Limbs relaxed and symmetrical position
• Compare with contralateral side to detect asymmetries
113
DTR Reinforcement procedures
- pull method of jendrassik
-counterpressure
114
Other signs of hyperreflexia
- Spread of reflexes to other muscles not directly tested
• Crossed adduction of opposite leg when medial aspect of knee is tapped
-hoffman’s and tromner’s
115
- babinski
downward contraction of toes
116
+ babinski sign
upgoing big toe and fanning of other toes with or without triple flexion reflex (ankle dorsiflexion, hip and knee flexion) = umn
Silent/mute compare w/ contralat side
117
Move an object along the lateral aspect of the sole
Plantar toe reflex
Babinski
118
Move an object in the lateral side of the foot
Chaddock
119
Squeeze hard on the Achilles tendon
Achilles toe reflex
Schaeffer
120
Press your knuckles on the pt’s shin and move them downward
Shin-toe reflex
Oppenheim
121
Squeeze the calf muscle momentarily
Calf toe reflex
Gordon
122
Make multiple light pinpricks on the dorsolat surface of the foot
Pinprici toe reflex
Bing
123
Pull the 4th toe outward and downward for a brief time and release suddenly
Toe-pull reflex
Honda, stransky
124
Primitive reflexes
Glabellar blink/tap
Snout reflex
Suck reflex
Grasp reflex
Palmomental reflex
125
Glabellar blink/tap
• taps glabella rapidly 10x
• N: lid remains open
• Abn: continuous reflex blinking with or without lid closure (orbicularis oculi)
126
Snout reflex
With patient's eyes closed, tap the philtrum
compressing the uppettp ainst the gum
• N: no response
• Abn: puckering or pursing of the lips (orbicularis oris)
127
Suck reflex
With patient's eyes closed, stroke the patient's lips from center of the crevice to the sides
• N: no response
• Abn: Pursing or sucking motion
128
Grasp reflex
Ex uses Index and middle finger to stroke patient's palm from the hypothenar eminence towards the junction of the index finger and thumb
• N: no response
• Abn: grasping Ex fingers
129
Palmomental reflex
• Stroke the patient's hypothenar eminence
• N: no contraction of mentalis muscle
• Abn: ipsilateral or bilateral mentalis contraction
130
Superficial Reflex
Bulbocavernosus
Anocutaneous
Cremasteric
Abdominal/bervor’s
131
pricking the glans bulbocavernosus muscle, detected by
pressing a finger against the perineum
Bulbocavernosus
132
pricking or scratching the perianal skin causes a quick constriction of the anal sphincter
Anocutaneous (anal wink)
133
elevation of the ipsilateral testicle in relation to thigh stimulation
Cremasteric
134
normal. response is the umbilicus twitches toward the quadrant stimulated
Abdominal/ beevor’s
135
Ataxia
Lack of order
abnormal movements in coordination disorders
• Appendicular ataxia
-ipsilat cerebellum
• Truncal ataxia
- cerebellum vermis
136
Test for appendicular ataxia
• Rapid alternating movements = dysdiadochokinesia
• Finger-to-nose test = dysmetria
• Overshoot
• Finger tapping test
• Heel-shin test
• Foot tapping
• Ipsilateral limb intention tremor
• Ipsilateral limb ataxia
137
cerebellar vermis
• Wide based, unsteady, drunk like gait
• May have difficulty sitting up without support
Truncal ataxia
138
Stand with feet together, eyes closed
Vision, proprioception, vestibular senses
• Eyes closed, instability due to proprioceptive and vestibular systems
Romberg Test
139
Coordination and gait observation
Stance, posture, stability, how high the feet are raised off the floor, trajectory of leg swing, circumduction, leg stiffness, arm swing, tendency to fall, rate and speed, difficulty initiating or stopping gait, involuntary movements
140
walk in straight line while touching the heel of one foot to toe of the other with each step
Tandem gait
- cerebellum= ipsilat
- vermis = any of the side
141
Sensations
Light touch -
• Pain - pinprick
• Temperature - cool piece of metal ie tuning fork
• 5-10C and 40-45C
• Vibration sense
• Joint position sense
• Two-point discrimination
142
Sensory exam
• Performed in all extremities including face and trunk
• Eyes closed
• Reproducible
• Correlate and recheck to improve objectivity
143
Light touch
Cotton tipped swab or fine light touch
• Anterior spinothalamic tract
144
Pain
Sharp or dull end of a safety pin or broken wooden swab
• Ask patient to identify sharp or dull
• Lateral spinothalamic tract
145
Temperature sense
Cold metal ie end of tuning fork
• Lateral spinothalamic tract
146
Vibration sense
Low frequency tuning fork 128 Hz on the ball of the large toe or fingers
• Posterior column-Medial
Lemniscal pathway
147
Joint position sense
Moving toe or finger up or down
• Posterior column-Medial
Lemniscal pathway
148
Two point discrimination
Special calipers or bent paper clip
• Alternately touching with one or two points
• Posterior column-Medial
Lemniscal pathway
149
neither patient nor examiner can flex the patient head because of reflex spasm of nuchal (extensor)
muscles
Nuchal rigidity
150
adduction and flexion of the legs as the head is flexed
• Flexion of the neck places tension on the entire cord and roots.
Flexion of the legs reduces stretch on nerve roots
Brudzinski sign
151
bent knee leg raising test; knees cannot extend due to pain
Kerning sign
152
Approach to neurologic deficit
History, Physical and Neurologic Examination
Is this a neurologic problem?
• Focal neurologic deficits
• Increased intracranial pressure
• Meningeal Irritation
Where is the lesion?
What is the lesion?
153
Set of symptoms or signs in which causation can be localized to an anatomic site in the CNS or PNS
Focal Neurologic Deficits
154
disturbance in higher intellectual functions
Cerebrum
155
cranial nerve deficits
Brainstem
156
weakness or paralysis of extremities
Motor pathway
157
incoordination, poor balance
Cerebellum
158
asymmetry in DTRs, pathological reflexes
Reflexes
159
sensory impairment
Somesthetic system
160
autonomic disturbances (bowel, bladder, sex)
Ans
161
autonomic disturbances (bowel, bladder, sex)
Ans
162
Intracranial pressure 3 volumes
1. Brain parenchyma
2. CSF
3. Blood volume
163
Sum of volumes of brain, CSF and intracranial blood is constant.
An increase in one should cause a decrease in one or both of the remaining 2.
Monroe kelly doctrine
164
• Blurred or elevated optic papillae (optic nerve head or disc) resulting from edematous fluid in the nerve fibers as they cross the disc to perforate the cribriform plate and enter the optic nerve
• Transmission of increased ICP into the eye via the subarachnoid space, which extends out along the optic nerve
Papilledema
165
Acute + trauma
Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage
Parenchymal hemorrhage
166
Acute - trauma + fever
Acute meningitis
167
Acute - trauma - fever
Cerebral infarction
Cerebral hemorrhage
Sah
168
Chronic
Mass lesion
Chronic meningitis
Hydrocephalus
169
Inc intracranial pressure sx
Headache/vomiting with:
a. Papilledema
b. Diplopia with internal squint (lateral rectus palsy secondary to abducens nerve lesion)
c. Decreased level of consciousness
d. Bulging fontanel, separation of sutures, rapidly enlarging head
170
Meningeal irritation
Headache/Vomiting with
• Nuchal rigidity
• Brudzinski sign
• Kernig sign
171
Where is the Neurologic Problem?
Levelize
• Localize
• Lateralize
172
Seizure
• Language problem (dysphasia/aphasia)
- dominant hemisphere
• Behavioral, personality and mental changes (delirium, dementia)
• Contralateral hemiparesis with Babinski
• Contralateral hemisensory deficit
• Contralateral homonymous hemianopia/quadrantanopsia (visual
field deficit)
Cerebral lesion
173
CROSSED MOTOR/SENSORY
SYNDROME
• Ipsilateral cranial nerve deficit
• Do not decussate from the brainstem to the structures that they innervate
• Contralateral hemiplegia with Babinski
• Contralateral hemisensory deficit
Brainstem lesion
174
Cn exit
Cerebral - CN I and Il
Midbrain - CN Ill and IV
Pons - CN V, VI, VII and VIII Medulla - CN IX, X, XI, XII
175
Central facial palsy
Paralysis of lower half of face
• Lesion in the contralateral motor cortex or corticobulbar tract
176
• Spastic gait disorder
• Bilateral corticospinal signs, with or without bladder symptoms
• Cutaneous sensory loss / sensory
level
Spinal cord lesion
177
Plexus roots
Brachial Plexus - C5-1 roots
• Lumbosacral Plexus - L1-S2
178
Peripheral n. Lesion
Weakness
Distal, symmetrical
Sensory deficits
Distal, symmetrical
Autonomic disturbances
May be present
Reflexes
Areflexia
179
Muscle dysfunction
Weakness
Proximal, symmetrical
Objective sensory deficits
None
Autonomic disturbances
None
Reflexes
Depending on severity of weakness
180
Nmj dysfunction
Motor dysfunction
Predilection for motor cranial nerves
Proximal
fluctuating weaknes
Sensory dysfunction
None
Autonomic dysfunction
None
Reflexes
Normal
181
The most frequent neurologic disease with sudden onset and rapid course of neurologic deficit:
Cerebrovascular disease
182
The most frequent neurologic disease with insidious onset and slowly progressive course of neurologic deficits:
Mass lesion
Degenerative disease
183
Neurologic disease that may be acute, subacute or chronic:
A. Infection
B. Metabolic/endocrine
C. Intoxication
D. Demyelinating disease
184
Increased tone -
Rigidity
185
Abnormal involuntary movements
Dyskinesia
186
Clasp-knife phenomenon in hemiplegic, quadriplegic, monoplegic, or paraplegic distribution
The examiner elicits the clasp-knife phenomenon, a catch-and-yiekl sensation, by a quick jerk of the resting extremity
Clonus and hyperactive MSRs
Extensor toe sign
Tends to predominate in one set of muscles, such as flexors of the upper extremity, the extensors of the knee, and plantar flexors of the ankle
EMG inactive with the muscle at complete rest
Spasticity
Pyramidal
187
Lead-pipe phenomenon, often with cogwheeling and tremor at rest; usually in all four extremities but may have a "hemi" distribution The examiner elicits the lead-pipe phenomenon of rigidity by making a relatively slow movement of the patient's resting extremity
No clonus; MSRs not necessarily altered
Normal plantar reflexes
Tends to affect antagonistic pairs of muscles about equally
EMG tends to show electrical activity with the muscle as relaxed as the patient can make it
Rigidity
Extrapyramidal
188
Ipsilateral limb ataxia
• Intention tremor
• Dysmetria
• Dysdiadochokinesia
Cerebellar hemisphere lesion
189
Truncal ataxia
• No limb ataxia
Cerebellar vermis ataxia
