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Physical Diagnosis > Neurologic Exam > Flashcards

Flashcards in Neurologic Exam Deck (53):
1

Common/Concerning NS Symptoms

(8)

  1. HA
  2. Dizziness/vertigo
  3. Weakness - generalized, proximal, or distal
  4. Numbness
  5. Abnormal/lack of sensation
  6. LOC, syncope, or near-syncope
  7. Seizure
  8. Tremors/involuntary movements

2

Principles for all Neuro Exam Components

(3)

  1. Mental status
  2. Symmetric or asymmetric findings
  3. In the event of asymmetry ,do causative lesions lie in CNS or PNS?

3

NS Eval Categories

(7)

Organize your thoughts into these categories

  1. Mental status
  2. Speech
  3. Language
  4. Cranial nerves
  5. Motor system
  6. Sensory system
  7. Reflexes 

4

Mental Status Exam (MSE)

(2 functions, 4 qualifications)

Function:  

  1. help identify neurological disease  
  2. distinguish focal deficits from difficuse processes

Qualifications: Make sure the pt is 

  1. Alert
  2. Cooperative
  3. Attentive
  4. Understands the language  

5

Level of Consciousness

Alertness or state of awareness of the environment 

6

Attention

The ability to focus or concentrate over time on one task or activity - an inattentive or distractable prson c impaired consciousness has difficulty giving a hx or responding to questions. 

7

Memory

The process of registering/recording info. Separated into two categories:

  1. Recent/short term - minutes, hours, days
  2. Remote/long term - intervals of years

Tested by asking for immediate repetition of material, followed by storage or retention of info

8

Orientation

Awareness of personal identitiy, place and time; requires both memory and attention 

9

Perceptions

Sensory awareness of objects in the environment and their interrelationships (external stimuli)

Also refers to internal stimuli such as dreams and hallucinations 

10

Thought processes 

The logic, coherence, and relevance of the patient's thought as it leads to selected goals, or how people think

11

Insight 

Awareness that symptoms or distrubed behaviors are normal or abnormal

Example - distinguishing b/w daydreams and hallucinations that seem real 

12

Judgement

Process of comparing and evaluating alternatives when deciding on a coiurse of action; reflects values that may or may  not be based on reality and social conventions or norms 

13

Mood

 

A more sustained emotion that may color a person's view of the world (mood is to affect as climate is to weather) 

14

Language

A complex symbolic system for expression, receiving, and comprehending words; as with consciousness, attention and memory

Language is essential for assessing other mental functions

15

Higher Cognitive Functions

Assessed by vocabulary, fund of information, abstract thinking, calculations, construction of objects that have two or three dimensions 

16

Mental Status Exam Components

(5)

  1. Appearance/behavior
  2. Speech/language
  3. Mood
  4. Thoughts/perceptions
  5. Cognitive function -
    • memory, attention
    • infromation
    • vocabulary
    • calculations
    • abstract thinking
    • constructional ability 

17

Level of Consciousness + Eval Techniques

(5 levels, techniques, and 4 abnormal responses)

See chart

A image thumb
18

Posture Evaluations

(3)

  1. Observe if pt is in bed or walking around
  2. Note body posture
  3. Observe pace, range, and character of movements

19

Personal Hygiene Observations

  1. Clothing - cleaned, pressed, fastened properly?
  2. Grooming - skin, hair, nails, teeth

20

Facial Expression Observations

  • Appropriateness for the topic
  • Face at rest
  • Symmetry 

21

Speech and Language Evaluation 

(5 aspects)

  1. Quality - talkative vs silent
  2. Rate - slow or fast
  3. Volume - appropriate/inappropriate, loud/soft
  4. Word articulation - spoken clearly and distinctly vs mumbling
  5. Fluency - rate, flow, and melody of speech/content
    • ​hesitancies/gaps in flow and rhythm
    • disturbed inflections or monotone
    • circumlocutions - phrases/sentences are substituted for a word ("what you write with" instead of "pen")
    • Paraphasias - malformed words ("I write with a den")

22

Mood Assessment Technique

"How are your spirits?"

23

Orientation Evaluation

Figure out knowledge of person, place, and time

For patients you know, preface this with the fact that you have to ask a lot of questions

24

Cognative Evaluation, Attention

(2 methods)

  • Serial 7's - "starting from a hundred, subtract 7, and keep subtracting 7 until I tell you to stop"
  • Spelling backward - you say a 5 letter word and spell it: W O R L D, ask the pt to spell it backward 

25

Cognitive Functions - Remote Memory

Ask pt about birthdays, anniversaries, SSN (ehh...), names of schools attended, job held, or past historical events

Only ask things you know the answer to

26

Cognitive Function Evaluation - Recent Memory

Ask the patient about today's weather, today's appointment time, how he/she got to the appointment, who is the current president 

27

Cognitive Function Evaluation - Short Term Memory

Three Word Recall - ask pt to remember 3 unrelaed terms and tell them you will re-ask in 5 minutes 

28

Cognitive Functions - Naming/Follwing Instructions

(2 tests)

  1. Ask pt to name 2 items found in room
  2. Ask pt to read this card and do what it says (card reads, "CLOSE YOUR EYES")

29

CN I (Olfactory) Exam

Occlude each nostril and test different smells

30

CN II (Optic) Eval

  1. Test visual acuity c Snellen eye chart or hand-held card
  2. Inspect fundi
  3. Screen visual fields by confrontation 

31

CN II-III (Optic, Oculomotor) Exam

  1. Inspect size and shape of pupils 
  2. Test reactions to light and accomodation 

32

CN III, IV, VI (Oculomotor, Trochlear, Abducens) Evaluation

  1. Test EOM c 6 cardinal directions of gaze
  2. Lid elevation
  3. Check convergence 

33

CN V (Trigeminal) Evaluation

  1. Palpate temporal and masseter muscles while pt clenches teeth
  2. Test forehead, cheeks, and jaw on each side for sharp/dull sensation 

34

CN VIII (Facial) Evaluation 

  1. Assess face or asymmetry, tics, abnormal movements
  2. Ask pt to raise eyebrows, frown, close eyes tightly, snow teeth (grimace), smile, puff both cheeks 

35

CN VIII (Acoustic) Evaluation 

Test hearing, lateralization, and air/bone conduction 

36

CN IX, X (glossopharyngeal, vagus) Evaluation 

  1. Assess if voice is hoarse
  2. Assess swallowing
  3. Assess palate movmenet as pt says "ah"
  4. Test gag reflex, warning pt first 

37

CN XI (spinal accessory) Evaluation

  • Assess strength as pt shrugs shoulders against your hands 
  • Note contraction of opposite SCM, and force as pt turns head against your hands

38

CN XII (Hypoglossal) Evaluation 

Ask pt to protrude tongue and move it side to side; assess symmetry, atrophy

39

Motor System Examination 

(3 aspects)

Position, movement, muscle bulk, tone

  • Observe 
    • Body position
    • Involuntary movements (tremors, tics, fasciculations)
  • Inspect muscle bulk, ntoe any atrophy
  • Assess muscle tone
    • Flex and extend the arm and lower leg for residual tension → slight resistance to passive stretch 

40

Tremor ID

(differentiate b/w real and fake)

Grab the limb unexpectedly 

Real - tremor continues

Fake - tremor will stop 

41

Muscle Strength Grading System 

(0-5 scale)

 

  • 0 - no muscular contraction
  • 1 - barely detectable flicker/trace of contraction
  • 2 - active movement of body part c gravity eliminated
  • 3 - active movement against gravity
  • 4 - active movement against gravity and some resistance 
  • 5 - active movement agaisnt full resistance s evident fatigue; normal muscle strength 

Ask pt to move actively against opposing resistance - if opposition resistance is evident then pt receives a grade 5

 If pt can only move against gravity assign grade 3

42

Muscular Strength Eval

(6 muscle groups, evals for each)

  1. Biceps/triceps, wrist - flexion + extension 
  2. Handgrip, finger - abduction/adduction + thumb opposition
  3. Trunk - flexion, extension, lateral bending
  4. Thorax - expansion, diaphragmatic excursion during respiration 
  5. Hip - flexion, extension, abduction, and adduction 
  6. Knee and ankle - flexion, extension 

43

Coordination Examination 

(4)

  • Rapidly alternating movements -
    • pt turns hand rapidly over and back on thigh
    • taps tip of index finger rapidly on distal thumb
    • taps ball of foot rapidly on your hand 
  • Point-to-point movements - 
    • Pt touches nose then your index finger as you move it to different positions
    • Pt moves heel from opposite knee down the shin to the big toe
  • Gait - watch pt do the following
    • Walk across the room
    • Walk heel/toe
    • Walk on toes then heels
    • Hops in place 
  • Stance
    • Romberg test - pt stand c feet together and eyes open, then eyes closed for 30-60 sec s support (positive if pt loses balance)
    • Pronator drift - pt stands for 20-30 sec c both arms straight forward, palms up, and eyes closed; tap arms briskly downward (pronation and downward drift of arm is a positive test)

44

General Principles, Sensory Examination

(3)

  1. Compare symetric areas on both sides of the body
  2. When testing pn, temp, and touch, compared distal c proximal extremities
  3. Map out boundaries of any area of sensory loss or hypersesitivity 

45

Sensory System Tests

(5, c procedures)

  1. Pain - have pt differentiate between sharp or dull or compare 2 sensations bilaterally on similar dermatomes (use a disposable object like cotton swab or pin)
  2. Light touch - cotton wisp 
  3. Vibration - tap 128 -hz tuning fork on your hand, then place it on the DIP joint of the pt's finger. ask pt if you feel a buxx, tell when it stops. Likewise test over the joint of the big toe 
  4. Proprioception - hold big toe by its sides b/w thumb and index finger, pull it away from the other toes and mov it up then down. Ask the pt to ID the direction of movement 
  5. Descrimative sensation - evaluated ability of sensory cortex to analyze and interpret sensations. Perform tests if pt struggles c proprioception 
    • ​Stereognosis
    • Graphesthesia
    • Two-point descrimination
    • Point localization
    • Extinction 

46

Stereognosis

Place a ey or familiar object in pt's hand and ask pt to ID it 

47

Number Identification (graphesthesia)

Outline a large number on the pt's hand and ask the pt to ID it

 

48

Two-Point Discrimination

Using two ends of an opened paper clip/pins, touch the finger pad in two places simultaneously. Ask pt to ID 1 vs 2 touches 

49

Point Localization

Lightly touch a point on the pt's skin and ask the pt to point to that spot 

50

Extinction 

Touch an area on both sides of teh body at the same time and ask if the pt feels 1 or 2 spots 

51

Deep Tendon Reflex Principles

(6)

  1. Select properly weighted hammer
  2. Encourage pt to relax; position limbs properly and symmetrically
  3. Hold reflex hammer loosely b/w thumb and index finger so that it swings freely in an arc
  4. Strike the tendon c a brisk direct movement; use the minimum force needed to obtain a response
  5. Use reinforcement when needed to distract pt
    • ​Upper body - clench teeth or push down on bed c thighs
    • Lower body - lock fingers and try to pull hands apart
  6. Grade the response 

52

Reflex Grading

(4+ to 0 system)

  • 4+ ; very brisk, hyperactive, c clonus (rhythmic oscillations b/w flexion and extension)
    • Clonus - usually elicited @ ankle
  • 3+ ; brisker than average; possibly but not necessary indicative of disease
  • 2+ ; average, normal
  • 1+ ; somewhat diminished, low normal
  • 0 ; no response 

53

Deep Tendon Reflexes

(6)

  1. Biceps reflex (C5-C6)
  2. Triceps reflex (C6, C7, C8)
  3. Supinator or brachioradialis (C5, C6)
  4. Knee reflex (L3-L4)
  5. Ankle reflex (Primarily S1-S2)
  6. Babinski's sign (L5-S1)