Neurological Examination

Gait (Cerebral function)

- walk: obverve posture, balance, arm swing - heel to toe: tandem walkem - walks on toes, then on heels: observe balance - can u walk on toes and heels

When would u see fasciculations

- ALS

CN VI

- Abducens - movement of lateral rectus muscle - "away from the nose" - impaired abduction .... cranial nerve six makes the eyes do tricks!

Level of Consciousness

- Alert: OE spontaneously, or awake and alert - lethargy: drowsy, responds slowly - stupor: arouses only after painful stimulation. Minimal awareness of self - Coma: Remains unarousable. No response

Outpatient mental status exam

- Attention - memory testing - perseverance - Apraxia

Cerebellopontine Angle Tumor

- CN V (VA): corneal - CN VII: taste anterior 2/3 - CN VIII: hearing loss

how to test CN VII

- COTTON BALL - can u feel this? - where is the cotton ball?

COMA

- Coma signals a potential life- threatening event effecting the two hemispheres, brainstem or both

CN VII

- Facial nerve - motor funciton - parasympathetic - sensory function - upper motor neuron vs lower motor neuron... neuron facial palsy?... bells palsy

Vibration sense (sensory)

- tap tuning fork, place vibrating instrument onto DIP - do you feel a buzz?? tell me when it stops!

two point discrimination

- touch pt finger pad in two places, alternate double stimulus irregularly - normal < 5 mm - not for testing purpose!

CN V

- trigeminal - Supplies sensation to face, nasal/ buccal mucosa, teeth

Fasciculations

- twitches of the muscles at rest

Discriminative senses

- two point discrimination - test- point localization

Broca's aphasia

- usually stroke patient - typically called motor aphasia or non-fluent aphasia - patients have marked impairment in fluency (compared to wernickes) - little or no fluency - unable to name and repeat - lesion in the frontal operculum .... ie u show a patient a pencil and they claim its a knife

5- normal (muscle strength)

movement against gravity with full resistance

2- weak ( muscle strength)

movement with gravity eliminated

How to test cerebellar system

- Fingers (FFM)- dysdiadokinesia (abnormal alternating movements - Finger-Nose-Finger (FNF)- past pointing - Heel-to- shin- Ataxia (abnormal trajectory and oscillatory movements to target)

LOC

- ICU mostly - awake and alert - lethargy - stupor - coma

Brain Death Exam

- Oculocephalic reflex: dolls eyes - cold caloric stimulation (stimuli of cold water hitting the tympanic membrane is very irritating. the person SHOULD look towards the stimulus or move... bread dead wont)

CN III

- Oculumotor - Pupillary constriction and Accommodation - Vertical and Horizontal movements of the eye - Muscle innervated include medial, superior, inferior rectus, inferior oblique

CN- 1

- Olfactory - test each nostril with eyes closed - use strong, easily identified odors - rare disorders cause this (large meningioma of the frontal lobe on the cribriform plate)

CN-II

- Optic - vital sign of the eye - what the eye does not see, the mind does not know. - Acuity- Snellen chart - Visual fields- confrontation - Fundoscopic Exam

Reflexes

- Superficial - Deep tendon

Romberg Test

- The patient stands with feet together and the arms at sides. Note any swaying (Slight swaying is okay). Ask the patient to close eyes for additional testing. - MAKE SURE FEET ARE TOGETHER

Diseases involving Trigeminal nerve (pearls)

- Tic Doloureaux (Trigeminal Neuralgia) affects V2 and V3 territory - Cavernous sinus lesions (Rare) - Herpes Zoster infection of the nerve

CN IV

- Trochlear - move superior oblique muscle - medial rotation "down and in"

CN- X

- Vagus - motor fibers to the pharynx and larynx - testing with CN IX - Midline uvula - use tongue blade. - to ensure its intact, make sure uvula is midline.

CN VIII

- Vestibulacochlear - responsible for hearing, balance, and awareness of position - auditory testing - rhine/ webe test

Superficial reflexes

- abdominal (umbilical response) - Cremasteric (testicular response) - corneal - anal reflex

Naming

- able to identify common objects as well as more complex parts of objects

Comprehension

- able to perform a series of action that are asked of patient -ie... take your right hand and touch your left ear? - HEY point to the ceiling after you point to the floor.

CN XI

- accessory - Spinal accessory - Supplies the SCM and trapezius muscles - Shrug shoulders - turn head side-to side

Wernicke's Aphasia

- also called fluent or sensory aphasia or receptive aphasia - associate with alcoholic - chronic thymine deficiency, or acute - additionally, difficult with naming and repetition - Paraphasic errors (production of unintended syllables, words, or phrases during the effort to speak) - Lesion is in posterior superior temporal lobe ie... cooking the other day and put cereal in the oven.

Muscle Bulk (motor exam)

- assess for atrophy, fasciculations (small muscle twitches) - compare: contours of symmetry

Deep tendon reflexes

- biceps C5 - Brachioradialis C6 - Triceps C7 - Patellar L4 - Achilles S1

Test- point localization

- briefly touch a point on pt skin (eyes closed). - - open eyes, and touch place previously touched

light touch (Sensory)

- compare bilaterally - start distally - work proximally if abnormal or absent (start with most distal... like start with end of toes. then work to bottom of shin, mid shin, etc)

Weber test

- conductive hearing loss: tone is louder on affected side - sensorineural hearing loss: tone is louder on normal side

A patient with ___ has acute onset of impaired recent memory, clouded thoughts, an are at risk for injury

- delirium

herpes zoster loves to live in

- dermatomes - follow the dermotonal pattern... can include the trigeminal nerve

Confrontation

- different ways - cover unaffected eye- test if they can see in the various field'; do the other then

Perseverance (Outpatient mental status exam)

- difficulty holding attention - see it in Alzheimers and Cognitive decline -... ie, be in front of tv and cant hold attention- walks away...

Dysphagia

- difficulty with swallowing

Dysarthria

- disturbance in motor control of pseech

Graphesthesia

- draw number on hand - eye closed - make sure number is facing the pt (upside to u

Speech difficulties

- dysarthria - dysphonia - dysphagia - aphasia

Components of language exam

- fluency - comprehension - naming - repetition - reading - writing

CN- IX

- glossopharyngeal - supplies sensation to: pharynx, posterior 1/3 of tongue, tympanic membrane - gag reflex - symmetrical elevation of soft palate

CN XII

- hypoglossal - supplies the motor fibers of the tongue - can they stick out their tongue - is it midline

Mental Status Examination

- important to put into context of the type of neurological patient you are examining - be aware of your audience and setting... for example... your mental status exam for a patient comatose in the ICU vs dementia in the clinic should be different - There is no one size fits all mental status exam for each patient and many observations can be made during history taking.

Apraxia

- inability to perform a complex motor task - ie. show me how you would hammer a nail with your hands

Rigidity

- increased muscle tone of flexors and extensors - resistance to passive movement does not have increased reflexes

Meningeal signs

- inflammation of the CNS - SAH (space occupied by blood that shouldnt be)

Hypotonicity

- loss of normal tone with flabby and soft muscle

Components of the neuro exam

- mental status - cranial nerves (objective way to find whats wrong) - motor - sensory - reflexes - cerebellar .... systematic approach

Memory testing (Outpatient mental status exam)

- mini-mental status - screening device for a high suspicion of Dementia - use other tests in conjunction with this; rule out other reasons for cognitive decline

4 areas of nervous system involved in coordination

- motor- strength - cerebellum - vestibular - sensory system

3- fair (muscle strength)

- movement against gravity

4- good (muscle strength)

- movement against gravity with some resistance

The motor exam

- muscle bulk - muscle tone

Motor function of CN VII

- muscles of facial expression (stapedius and part of digastric muscle)

Rhine test/ Weber test

- normally air conduction is > bone conduction bilaterally - conduction diseases involve the bone, auditory canal, tympanic membrane - sensorineural affects the nerve itself

Subarachnoid Hemorrhage

- on examination patient requires sternal rub to open his eyes and to attend to the examine - undergoes angiography and found to have

3 major divisions of CN V

- ophthalmic (V1) - maxillary (V2) - mandibular (V3)

Stereognosis

- place object in hand (key)... what is it? - eyes are closed

Propricoeption

- position sense - close your eyes - not socks or shoes - take great toe up, down up, and ask them what direction their toe is pointing!

Pronator drift

- put hands out like im about to put a pizza box in your hands - close eyes; hold out hands. - when one of the hands falls or moves - indicates a lesion .. somewhere. dont know where.

Fluency

- rate an accuracy of expression of thoughts - best done by having a patient describe a pictures (what is going on in this pictures... if they are able to describe it, that is their fluency)

Muscle tone (motor exam)

- resistance to passive movement (move arm up and down) - spasticity (resistance to movement of arm etc) - hyperreflexia (rapid; strong reflexes) - clonus (example of hyperreflexia.) - cogwheeling (associated with parkinsons.. spastic, slow type of movement... when they reach for a coffee mug. very slow and deliberate process)

Spasticity

- resistance varies with speed and direction of passive movement has increased reflexes .... increased muscle tone/ DTRs

Pain (sensory)

- sharp or dull - compare the two sensations

Attention (Outpatient Mental Status Exam)

- should be assessed early in the exam - have a patient recall random digits - should be able to recall 7 forward digit span

Trigeminal neuralgia

- significnt pain - issue with V3

1- Trace (muscle strength)

- slight contraction

Scanning speech

- some MS patients - completing their thoughts/ expression, but not at the rate that you would expect someone to give their speech.

Sensory Exam

1) light touch 2) pain 3) vibration sense 4) proprioception 5) tactile localization 6) discriminative sensations

Deep tendon reflexes response

1+) diminished 2+) normal 3+) increased 4+) hyperactive (can be a normal variant)

Grading Muscle Strength

1- trace 2- weak 3- fair 4- good 5- normal

Gently flexing the neck toward the cehst, with patient in supine position; there is pain and resistance; patient flexes knees in response suggesting meningeal irritation.

Brudzinski's sign

Repetition

able to repeat a sentence such as " no ifs ands or buts"

Sensory function of CN VII

anterior 2/3 of the tongue

If BC > AC

conductive hearing loss

Aphasia

difficulty with language broken into sensory and motor

Dysphonia

difficulty with phonation (hoarseness)

Parasympathetic function of CN VII

lacrimal, submaxillary, submandibular glands

lethargy

requires a loud verbal stimulus to arouse

stupor

requires tactile stimulation to arouse

if AC> BC w/ hearing loss

sensorineural hearing loss

coma

unable to arouse with noxious stimulus