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What are four questions to ask when evaulating pt. neuro system?

•Local or diffuse?
•How has it developed over time?
•Restricted to nervous system or include other systems?
•CNS, PNS or Both?


What are the six tests we use for the neuro examination?

1.Mental Status Examination (MSE)
2.Cranial nerves
6.Deep Tendon Reflexes 


What are the five components of the mental status exam?

  1. Appearance and behavior
  2. mood/affect
  3. speech/language
  4. thoughts/perceptions
  5. cognitive/executive function


What percent of Primary care visits are due to depression?



What does alert and oriented x3 mean?

Person, place and time


What is the definition of lethargic?

(sleepy): awake, but tending to fall asleep if   not gently stimulated


What is the definition of stupor?

Falling asleep unless vigorously stimulated


When observing a patients affect and expressions what are some things you might want to key in on?

  1. Appropriate forsituation?
  2.   Engaged?
  3.   Angry? 
  4. Anxious?
  5. Indifferent?
  6.   Detached?
  7.     Fearful?


What are some sypmtoms of anxiety?





dry mouth



What should the clinical exam of language include? (6)

  1. Spontaneous Speech
  2.   Naming
  3.   Comprehension
  4.   Repetition
  5.   Reading
  6.   Writing


When checking a patients language capacity you are testing aphasia, what is this?

Disorder in producing or understanding language


When testing spontaneous speech what should you look for?

  1. Articulation (dysarthria)
  2. Appropriate word finding
  3. Is there normal prosody (melody or variable tone of speech)
  4. Verbal fluency (rate, flow, volume, content, meaning and melody)


What should you do to test for aphasia?

  1. Naming: Test the ability to name objects
  2. Comprehension: Follow commands
  3. Repetition: have patient repeat some simple words or a phrase.  
  4. Reading and writing with short exercises


What does anomia mean?

Inability to name common objects.


What is the most common deficit in true aphasia?



What does dysphasia mean?


  1. Impairment in use of speech that is clear “Dys-phasia”

                            -Failure to arrange properly in sentence


What is dysarthria?

Imperfect articulation due to lack of motor coordination; damaging event CNS or PNS.  Language comprehension and use may be fine


Aphasia may be the only sign of a new neurological disease such as?



head trauma

recent seizure


What is the role of Wernike's area?

transforms sensory input into neural word representations to give a word meaning.


What is the role of Broca's area?

 transforms these neural word representations into actual articulations that can be spoken.


What is Broca's Aphasia?

“Expressive” Aphasia, understanding of spoken language mostly preserved.


What is Wernicke's Aphasia?

“Receptive” Aphasia, fluent speech that makes no sense


What is Apraxia?

Inability to turn verbal request into   motor performance 


What do apraxic patients have difficulty with?

•complex yet familiar activities, such as dressing or taking a shower, writing with a pen or pencil, using a comb or toothbrush, mimicking an examiner


What components of thoughts and perception should be assessed?

  1.    Process: assess logic, relevance and organization.
    1.   Are they coherent?
  2.    Content: phobias, anxieties, obsessions, delusions,              hallucinations
  3.    Insight:  The ability to understand their own problem.   
    1. “What brings you in today?”
    2.  “What do you think is wrong?”
  4.    Judgment: Appropriate decisions/actions to a      situation.
    1. “How will you manage if you lose   your job?”


What are the four components of cognitive function we should evaluate?

  1. Orientation
  2. Attention
  3. Memory
  4. Executive function


How do you establish orientation?

•1. PERSON (name): seldom lost unless the patient has aphasia or schizophrenia
•2. PLACE (location): often lost in some hospitalized patients, or delirious/extremely demented outpatients
•3. TIME: most commonly lost of these three; include time of day, day of week, month, year if possible


What are the two types of memory?

Recent memory

Remote memory


What is recent memory?

•the ability to store new information, up to a few days


What is remote memory?

•Memory: more distant memories.  Includes autobiographical (dates of graduation, marriage, etc.) or historical (date of wars, elections, sports, etc.)
(Long term memory)


How does Alzheimer's diseas usually begin?

•progressive loss of memory; first recent, and then distant memory


How would we test recent memory?

•“Please listen to these 3 words, and then repeat them.  I will ask you to remember them soon.” Ask them in approximately 3-5 minutes.  

•Occasionally a normal patient will recall only 2/3, but recalling 0, or 1 words on two attempts is pathologic

•Also tested by:

  1. “How long have you been in the hospital?”

  2. Giving a patient a brief story to remember, perhaps three or four sentences long

  3. “What did you have for breakfast (or lunch,   dinner)?”


REmote memory is less often tested but is used to confirm a diagnosis of?



Testing of executive function evaluates insight, judgement, reasoning, and abstract thinking.  This is used to test for?

•Tests mostly for dementia, or any disease of the FRONTAL lobes and their connections

•Crucial in diagnosing Alzheimer’s Disease and the other common causes of dementia.


How can executive function be tested?

•1. “Look before you leap”
•2. “People in glass houses shouldn’t throw stones”*
•3. “Still waters run deep”

•Insight can be tested by asking “What would you DO if you:
•1. Found an envelope fully-addressed and stamped letter?
•2. Found a wallet on the street?

•Similarities can be tested;  How are the following alike (or different)?
•1. Apples and oranges
•2. Tables and chairs
•3. Californians and Texans
•4. Shirts and dresses


What is the definition of delirium?

•acute confusion episode, may be due to infection, uremia, alcohol withdrawal.  Disoriented, poor judgment, delusions common, attention poor, mood fluctuates


What is the definition of dementia?

•insidious, slowly progressive, mood often flat, maintains orientation and attention until late in process.  Altzheimers, B12 deficiency, hypothyroid, head trauma.  Can have acute angry, delusional episodes later in the course of disease.


How do you test executive function calculation?

•1. Number span: normal patients should be able to repeat 5 or 6 numbers in correct order, or do 4 numbers in reverse order

•2. Spelling a common word, backwards and forwards, ‘WORLD’

•3. Do the months of the year or the days of the week, forwards and backwards

•4. Doubling a number; 9X9=81, 162, 324


How do you test executive function constructional ability?

•Constructional Ability: copy a figure or ask them to draw something simple

•Integration of Motor Activity:  ask to perform a task, see if they can.  Apraxia is the inability to perform the command.  Can also be tested here.


What are the ranges for normal, borderline and impaired mental status on the MMSE?

Normal = 23 - 30

Borderline = 19 - 23

Impaired = < 19


What is the role of the cerebellum?

receives sensory and motor input to coordinate motor activity, maintain equilibrium and control posture.


What are the components of cerebellar testing? (6)

  1. Gait
  2. Heel to knee and slide down shin
  3. Romberg/pronator drift:  (two tests in one)
  4. Finger to nose, eyes open
  5. Finger to nose, eyes closed
  6. Rapid alternating movements


How is gait assessed?

Regular walk, tandem, heel/toe


What do we look for with heel to knee and slide down shin?

Bilateral smoothness and accuracy


How is the Romberg/pronator drift test done?  

What is a positive Romberg test?  

Positive pronator drift?

  1.   Standing, feet together, arms straight out,   palms   up(supinated), fingers spread (decrease fine   proprioception), hold 20-30 seconds
  2. Positive Romberg = loses balance, Watch!
  3. + Pronator Drift = one arm pronates and may drift down


How do you perform the finger to nose tests?


Make sure the patient extends his arm “completely” to         reach your own index finger, this enhances any abnormality if present. Move finger up, down and cross midline. 


Standing, eyes closed, arms stretched out to side, bring each in to nose. Poor coordination worsens with eyes closed.


What is dysmetria?

 a lack of coordination of movement typified by the undershoot or overshoot of intended position with the hand, arm


How do you test rapid alternating movements?

What is the failure to do these actions called?

  1. Flip hand over in other palm rapidly; must lift hand off palm
  2. Rapid, bilateral, sequential touching of       each finger by the patient’s own thumb




How would you test voice dysmetria?  What does this reveal?

Count to ten as quickly as possible.  Reveals motor coordination


•Olfactory is seldom tested, unless the patient complains of a loss of smell, or?

there is a frontal injury or possible frontal lobe tumor


How do you test CN I?

•Usually tested only for presence/absence, with some coffee beans, or cinnamon


If you test all but CN I, and all are normal, what should you write?

CN 2-12 intact


How do we test the optic nerve?

  1. Acuity - visual chart
  2. Visual field exam
  3. Opthalmoscopic examination of the retina (not the nerve)
  4. Afferent component of the pupillary reflex


How do you test CN III, IV and VI?

  1. Efferent component of the pupillary reflex
  2. H - test for extraocular movements
  3. Inspect for congenital esotropia (medial deviation) or exotropia (lateral deviation) of each eye
  4. Cover/uncover test for bilateral central focus 


What does the cover test detect?



What does the Trochlear nerve do?

•Superior Oblique muscle: moves the eye downward and out.


What does the abducens do?

Lateral rectus - move eyes laterally


Fill in the blanks!


Identify muscles used in each eye in each picture


What is this?

IV palsy

Can’t pull globe to central position missing

Superior Oblique


What is this?

Right sixth nerve (VI) palsy

Cannot pull eye laterally without lateral rectus


What visual defect does CN VI palsy present with?  What can cause this?

Horizontal diplopia

•Often without a localizing sign; INCREASED INTRACRANIAL PRESSURE ANYWHERE may cause a unilateral or bilateral CN VI palsy


How do you test the three divisions of V for sense?

Test sensation to each bilaterally: soft or temperature, and/or  pinpick


How do you test the motor component of V?

masseter and pterygoid:  clench teeth, move jaw side to side


How do you test the corneal reflex?

Gently touch lateral cornea w/ cotton or gauze

     Afferent:  CN V senses the stimulus

    Efferent: CN VII motor to blink

     Both eyes should blink together


What does a cerebral hemisphere lesion of VII present with?

•Most of the control of facial muscles by the cerebral hemispheres is of THE LOWER FACE, so a lesion of one cerebral hemisphere causes only lower facial weakness of the opposite side.  


What does a brainstem lesion of CN VII present with?

•If the CN VII is damaged in a brainstem lesion, it is going to cause lower facial weakness of the same side.   

•Since the CN VII nucleus is above the decussation of the corticospinal tracts in the medulla oblongata, the extremities of the opposite side are also weakened in large lesion


How does a peripheral lesion of VII present?

•In a PERIPHERAL CN VII lesion, the entire seventh nerve is likely damaged, so there is weakness of the upper AND lower facial muscles on that same side


What is this?


What is this?


What is this?

Left-sided peripheral CN VII


How do you test CN VIII?

•Hearing and Balance: The auditory portion of CN VIII is tested by the physician directly; most disorders of the vestibular portion are assumed from a history of positional vertigo

•Hearing can be determined subjectively by how well the patient seems to understand the physician’s words, or by the examiner rubbing her index and thumb together one inch lateral to each ear of the patient, or the patient’s hair can be rubbed about one inch lateral to each ear


How do you test IX and X?

•CN IX is sensory to the soft palate, and CN X helps to raise the palate, so the Gag Reflex tests them both:

     Afferent: CN IX

       Efferent: CN X


How can you test IX with the tongue?

Taste on posterior 1/3 of tongue


What is the problem here?

Weakness of left-sided palatal contraction; CN X Vagus

Note the difference in height of the soft palate on both sides, and the deviation of the uvula to the right.  = Right sided lesion


How do we test CN XI?

•Resist the patient shrug both shoulders simultaneously

•Resist a head tilting to each side


How do we test CN XII?

•Ask patient to stick out tongue (note if midline) and move side to side

•Look also for atrophy or fasiculations of the tongue


In a case of a XII peripheral lesion, to what side does the tongue deviate?

Same side


The neuro screening exam should contain assessment of what 5 things?

1.Mental Status:  alertness, appropriate responses, orientation to date and place
2.Cranial Nerves:  acuity, pupillary light reflex, eye motion, hearing, facial strength
3.Motor: major muscle group strength upper and lower extremity, gait, coordination (finger to nose)
4.Sensory: test toes/feet – one modality of light touch, pain, temp or proprioception
5.Reflexes: DTR upper/lower, Babinski