Neurological Examination

Question 1

Neurological Examination

Answer 1

A neurological examination is a series of tests conducted by a neurologist to evaluate the integrity of the nervous system for many reasons, including (but not limited to):
1. Following trauma or stroke
2. When there are suspected neurodegenerative changes
3. Following exposure to a neurotoxic agent

Question 2

When do we use neurological examination?

Answer 2

Aging, trauma, meningitis

Global assessment on how the person is doing
Mental status exams that show basic problems with attention of executive control

Question 3

Neurological damage

Localization

Answer 3

Neurological damage can be located virtually everywhere, some can be much easier to identify

Question 4

Peripheral Nervous System and localization

Answer 4

Sensory disturbance- more global effect, bilateral dysfunction

Question 5

Localization

Internal Capsule

Answer 5

a two-way tract for the transmission of information to and from the cerebral cortex

Cuts through between basal ganglia and thalamus→ has both A&E axons→ Number of strokes can damage this

Damage: motor and sensory impairments, damage in spinal cord, brain stem until cranial nerves, can be at neuromuscular junctions itself (musuclar reflexes)

Question 6

Basic components of neurological exam

Answer 6

1. Patient history
2. Cranial nerve function
3. Motor function (e.g., reflexes)
4. Somatosensory function
5. Coordination
6. Mental status (sophisticated cog functions)

Question 7

What are things that are considered for patient history

Answer 7

1. Age
2. Education (predictor of number of later life decline problems)
3. Handedness
4. Past medical history
5. Use of recreational drugs
6. Family medical history

Question 8

Patient History

Handedness

Answer 8

Brain has some lateralization (language is typically left hemisphere dominant, attention is right) → Matters because it can somehow predict handedness,
- Over 95% Right handed, left hemisphere is dominant for language (always sure)
- 10% Left handed, 3/4 are still hemisphere dominant for language, but ¼- ½ bilateral dominance (equal ), ½ right hemisphere dominance

Question 9

Patient History

Past medical history

Answer 9

matter in terms of the dysfunction as a complication of a previous surgery

Question 10

Cranial Nerves

Sensory, motor, or both (Mnemonic)

Answer 10

Some say Money Matters, but my brother says big brain matters more

Question 11

Cranial Nerves

Answer 11

set of 12 nerves that send electrical signals between your brain and different parts of your head, face, neck and torso

Question 12

What are the 12 Cranial Nerves?

Answer 12

I. Olfactory
II. Optic
III. Oculomotor
IV. Trochlear
V. Trigeminal
VI. Abducens
VII. Facial
VIII. Vestibulocochlear
IX. Glossopharyngeal
X. Vagus
XI. Accessory
XII. Hypoglossal

Question 13

Mnemonic for cranial nerves

Question 14

I

Olfactory

Answer 14

The ethmoid ridge (sensory axons) and cribriform plate (spongy bone, has holes where axons come in from) support sensory axons connecting to cranial nerve I. Impact can easily shear these axons, causing loss of smell.

Damaged from mild head injury (mild tbi)

Question 15

I

Testing Olfactory

Answer 15

Cover one nostril and have the patient close their eyes, then ask them to identify a common scent (e.g., coffee or vanilla). The olfactory nerve can be damaged by mild head injuries, such as mild traumatic brain injury (TBI).

Question 16

II

Optic Nerve

Answer 16

• Standard visual acuity tests
• Visual field confrontation
• Papilledema and intracranial pressure

Question 17

Testing sensory nerve vs. motor nerve

Answer 17

if test vision, test eyes; if motor, have to test motor control, muscle integrity (atrophy)

Question 18

Atrophy

Answer 18

a process where a body part partially or completely wastes away

muscles can atrophy one side or another, damage to one of the cranial nerves, tend to atrophy ; can either look or touch muscle (to test)

Question 19

II

Standard Visual Activity

Answer 19

Snellen chart- visual acuity one eye at a time, read from a distance usually at 10 feet

Question 20

II

Visual field confrontation

Answer 20

Fundoscopy is an examination of the fundus, the inside back of the eye. To perform it, the lights are dimmed to enlarge the pupil. Focuses on a specific point, and the examiner observes the macula, which is the center of vision.

Question 21

II

Papilledema and intercranial pressure

Answer 21

Papilledema is the swelling of the optic disc due to increased intracranial pressure, which pushes the optic nerve forward into the eye. This condition often indicates elevated pressure within the skull, which can have various underlying causes.

Question 22

Which cranial nerves are associated to eye movement?

Answer 22

III- Oculomotor
IV- Trochlear
VI- Abducens

Question 23

III

Oculomotor

Answer 23

controls four of the six muscles responsible for eye movement

Question 24

III

What to check for oculomotor?

Answer 24

check for ptosis- drooping of the upper eyelid

Question 25

# IV Trochlear

Answer 25

smallest of all cranial nerve, controls 1 single eye muscle

Question 26

# VI Abducens

Answer 26

Controls only 1 nerve in the eye

Question 27

Testing Abducens, Oculomotor, and Trochlear

Answer 27

To test the abducens nerve (cranial nerve VI), have the patient fixate on a pen and move it through all directions. If there is an issue with cranial nerve III or VI, the **affected eye may struggle to follow in certain directions, leading to gaze restriction**. This misalignment can cause double or blurry vision, as one eye cannot keep up with the other.

Question 28

# V Trigeminal

Answer 28

- Facial somatosensation - Motor function The trigeminal nerve **branches into three divisions**, each responsible for sensation in different facial areas: the jaw, cheeks, and forehead.

Question 29

# V Testing Trigeminal- Motor or Sensory?

Answer 29

When testing, different facial areas are touched to assess sensation, as each area has distinct types of touch receptors. These receptors send sensory information via **afferent pathways** to the brain, covering various touch sensations. 1. hold the patient’s chin and apply resistance as they attempt to open or close their mouth. 2. palpate the jaw muscles to assess their condition, checking for signs of atrophy or good muscle tone.

Question 30

# VII Facial

Answer 30

* Facial asymmetries The facial nerve is responsible for both facial sensation and movement, including expressions. Facial nerve dysfunction can significantly impact these abilities, often visibly.

Question 31

# VII Testing Facial nerves

Answer 31

To test the motor function, ask the patient to smile, look up, and wrinkle their forehead, checking for symmetry in these movements. Asymmetry may indicate facial nerve issues.

Question 32

# VII Bell’s palsy

Answer 32

condition caused by facial nerve dysfunction, leading to drooping on one side of the face. It typically resolves on its own over time.

Question 33

# VIII Vestibulocochlear

Answer 33

Auditory perception

Question 34

# VIII Testing Vestibulocochlear

Answer 34

test hearing by covering one ear and whispering a word or phrase into the other ear at varying distances, then switch ears. Additionally, evaluate balance, as this nerve is responsible for both hearing and equilibrium.

Question 35

# IX Glossopharyngeal

Answer 35

glosso-tongue, pharyn- pharynx - responsible for taste at front of tongue

Question 36

# X Vagus

Answer 36

* Swallowing and voice * Gag reflex

Question 37

# XI Accessory nerve

Answer 37

* Shrugging of shoulders * Head resistance

Question 38

# X How to test the Vagus

Answer 38

assessed by evaluating the ability to speak and swallow. Issues with voice quality can indicate dysfunction. Gag reflex can be tested to assess nerve function and the integrity of the throat muscles.

Question 39

# XI How to test accessory nerve

Answer 39

apply some pressure against head and force down on shoulders

Question 40

# XII Hypoglossal

Answer 40

* Stick out the tongue, lateral movement

Question 41

# XII How to test the Hypoglossal nerve

Answer 41

ask the patient to stick out their tongue and move it laterally. You can also have them push their tongue against their cheek. Asymmetry in the tongue's position or movement may indicate a problem with the nerve.

Question 42

Motor Function Features

Answer 42

Key features to examine: - **Gross appearance** of muscle -**Muscle tone**, strength ## Footnote Lots of neurons considered motor neuron→ brain to brain stem, brain stem down to spinal cord, out of spinal cord to muscle themselves→ any damage along this pathway cause probs with motor control

Question 43

# Motor Function Upper vs lower motor lesions

Answer 43

**Upper motor neuron lesions** (in the cerebral cortex or spinal cord) result in **exaggerated movements and hyperreflexia**, which are heightened reflex responses. In contrast, **lower motor neuron lesions** (from the spinal cord to the muscles) lead to **hyporeflexia** , characterized by diminished reflexes and weakened muscle responses.

Question 44

Somatosensory function

Answer 44

* Pain * Light touch and proprioception * Testing for astereognosis * Testing for agraphesthesia

Question 45

# Somatosensory function Proprioception

Answer 45

Proprioception refers to the body’s ability to sense its position and movement in space. During a test of proprioception, the doctor will have the patient close their eyes and then guide one hand to touch another body part. The patient is then asked if they can identify the position of their hand, assessing their awareness of spatial awareness and body positioning.

Question 46

# Somatosensory function Testing for **astereognosis**

Answer 46

Testing for **astereognosis** involves assessing a person's ability to **identify objects through touch alone**, without visual input. During the test, the patient can feel the texture (hard, soft, long, cold) of the object

Question 47

# Somatosensory function Testing for **agraphesthesia**

Answer 47

Testing for **agraphesthesia** involves the doctor writing a number on the patient's skin (typically on the palm or back) using a finger or stylus. The patient is then asked to identify the number without looking.

Question 48

Coordination

Answer 48

* Quick, alternating movements * Point-to-point movement * Heel-to-shin test * Standing/sitting * Gait * Romberg test

Question 49

# Coordination Point-to-Point Movement

Answer 49

Task: Touch the index finger to the nose, then touch the examiner’s finger.

Question 50

# Coordination Heel-to-Shin Test

Answer 50

Position: Lie on side. Task: Place one heel on the opposite knee and slide it down to the shin back and forth. Difficulty indicates potential cerebellum problems.

Question 51

# Coordination Standing/Sitting

Answer 51

Assess posture and stability in standing and sitting positions.

Question 52

# Coordination Gait

Answer 52

Observe the patient's walking pattern. An unusual gait may suggest cerebellar issues.

Question 53

# Coordination Romberg Test

Answer 53

Task: Ask the patient to close their eyes and extend their arms out. Balance relies on three sources of information: **visual input, cerebellar function, and vestibular input**. To maintain balance, only two out of these three criteria need to be functional.