Neurologic Exam

Meningeal signs

- Nuchal Rigidity - Brudzinski sign - Kernig sign

What is Hoover's sign?

- healthy pt flexes the right hip they will automatically extend the left hip - no movement of the opposite leg may suggest functional weakness

Plantar respones/reflex aka Baninksi

- stroke the lateral aspect of the sole of the foot from heel to ball - dorsiflexion of the great toe is positive Babinksi response

Romberg test

- test position sense - pt stand w/ feet together and eyes open - close their eyes - observe pts ability to maintain upright posture w/ minimal or no swaying

What is the arm rapid alternating movement test?

- w/ the pt seated demonstrate hitting the thigh w/ one hand, raise it up, and turn it over, and strike the thigh w/ the back of the hand - tap distal joint of the thumb w/ the tip of the index finger

Muscle strength scale

0/5 No detection of muscular contraction 1/5 A barely detectable flicker or trace of contraction with observation or palpation 2/5 Active movement of body part with elimination of gravity 3/5 Active movement against gravity only and not against resistance 4/5 Active movement against gravity and some resistance 5/5 Active movement against full resistance without evident fatigue (normal muscle strength)

grading scale for deep tendon reflexes:

0= no response 2+ normal 4+ very brisk; hyper; clonus

5 components of a neurologic exam

1. mental status 2. CN exam 3. reflexes 4. motor system 5. sensory system

Parkinsonian gait

A gait pattern marked by increased forward flexion of the trunk and knees; gait is shuffling with quick and small steps; festinating may occur.

Deep tendon reflex testing what nerve roots? Know how to check each one Biceps reflex Brachioradialis Triceps Knee (patellar) Ankle (achilles)

Biceps: C5,C6 Brach: C5, C6 Tri: C6, C7 Knee: L2-L4 Ankle S1

Intentional tremor can be caused by what?

Cerebellar disease (stroke/tumors), and MS

steppage gait foot drop

lift the leg high off the floor and slap the foot down

an abnormal DTR could help

locate the pathologic lesion

hemisensory loss

loss of sensation on one side of the body (opposite of the cerebral hemisphere)

Dystonia

medical side effects or torticollis

gait tests

tandem walking (heel to toe) walk on toes, heels(distal) hop in place, shallow knee bend (proximal) stand up, sit down watch patient walk

ataxia

the loss of full control of bodily movements

effort of muscle strength testing depends on

the patient (pain, understanding instructions)

Hyperreflexia

Exaggerated reflex responses; sign of UMN, clonus

spastic hemiparesis

Flexed arm held close to body while client drags toe of leg or circles it stiffly outward and forward

flaccidity

GBS or LMN lesion, spinal shock

Parkinsonism, cerebellar stroke/tumor ***

Normal to hyporeflexic; just because an exam is normal does NOT mean neuro issue can be ruled out

sensory system tests

Pain Light touch Temperature Position Vibration Discrimination test limbs and extremities first and symmetrically

Gait evaluation

Reveals effects of impairments on functional activities. high risk for fall or have other findings

Oral-Facial Dyskinesias

Rhythmic, repetitive, bizarre movements Face, mouth, jaw, and tongue *complications with psychotropic drugs*

scissors gait

Stiff, short gait; thighs overlap each other with each step

Tics

Tourette's syndrome

Graphesthesia

ability to "read" a number by having it traced on the skin

analgesia

absence of pain

paralysis/plegia

absence of strength

anesthesia

absence of touch sensation

Parkinson tremors are present

at resting or static movement

rigidity associations **

basal ganglia lesion (lead pipe or Cogwheel Parkinsonism)

incoordination can be a sign of

cerebellar disease

athetosis

cerebral palsy

hypoalgesia

decreased pain sensation

sensory level

diminished sensation in all dermatomes below the level of the lesion

polyneuropathy

disease of many nerves; symmetrical distal sensory loss

What are the indications for a neurologic exam?

dizziness/vertigo, headache, weakness, syncope, numbness/tingling, seizures, tremors/ataxia, stroke symptoms, head injury, behavioral changes

point to point tests

finger to nose, heel to shin you can take away gravity and have them heel to shin lying down observe for smoothness and coordination

vibration tests in

fingers and toes first

vibration loss

first senstion lost in peripheral neuropathy

Asterixis

help identify metabolic encephalopathy

Cortical stroke, spinal cord compressions:

hyperreflexia

Postural tremors can be caused from what?

hyperthyroid, anxiety, fatigue, benign essential tremor

Polio, ALS, peripheral neuropathy:

hyporeflexic

Stereogenesis

identify an object without sight

Dysdiadochokinesia

impaired ability to perform rapid alternating movements

paresis is ___ ___

impaired strength

Dysmetria

inability to control the distance, power, and speed of a muscular action ex. pt may overshoot mark on finger-to-nose test

Hyperalgesia

increased sensitivity to pain

hyperesthesia

increased sensitivity to stimulation such as touch or pain

Pronator drift

involuntary turning or lowering of forearm when outstretched sign of cortiospinal lesions from contralateral side

questions to answer with sensory tests

is the lesion central vs peripheral, bilateral or unilateral, dermatomal, poly or spinal cord syndrome?

grading of a DTR is based on:

level of muscle contraction

DTR's are _____

monosynaptic

deep tendon reflexes

muscle contraction in response to a stretch caused by striking the muscle tendon with a reflex hammer

evaluating the motor system:

position, movements, bulk, atrophy, tone, strength, coordination, gait

Reflex asymmetry

should be somewhat equal focal deficits- nerve roots, peripheral nerve lesions loss of bilateral distal tendon reflexes--> polyneuropathies

areflexia

sign of LMN lesion (spinal nerves, peripheral nerves)

Hypothyroidism causes

slow relaxation phase on reflex testing

cerebellar ataxia

staggering, wide-based gait; difficulty with turns

Lumbosacral radiculopathy

straight leg raise

Test the patients coordination

strength, movements, balance, position sense tests: rapid movements, point to point movements, gait and standing

chorea

sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face Sydenham's chorea with rheumatic fever, Huntingtons disease

loss of position sense

tabes dorsalis, MS, B12 deficiency, diabetic neuropathy

What are distracting maneuvers?

to make sure the patient doesn't help you or fake the reflex; Jendrassik- pull apart their fingers Clench another muscle to distract

what is normal in muscle strength testing?

wide variation is normal (dominant hand should be taken into consideration)