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)