1.3 The Detailed Neurologic Examination in Adults Flashcards
What would you check to exam the Metal status of a patient?
Alert, oriented to person, place, time ( patient gives a cogent medical history).
What is apraxia?
- Ex. Idiomotor apraxia
- Can’t do a simple task when asked, but can do it involuntarily.
What is visual spatial perception?
- Relative when patient has difficulty losing objects (getting lost)
- copy/draw (a clock, overlapping pentagons, etc.).
How do yo check executive function?
Goal directed behavior- a complex set of activities (involves, volition, planning, purpose, action, and effective performance). Activities of daily living affected. Depends on working memory, mental flexibility, design fluency, motor programming, ability to inhibit responses
How do you check Mood an thought content?
Eye contact, blunting, spontaneous speech, (ask family members for help here).
How would you check speech of the patient?
fluent, normal syntax, comprehension, repetition.
How would you check the (in general) cranial nerves for?
visual fields, extra ocular movements, fundoscopic exam, facial symmetry and facial sensation, and hearing is normal.
How would you check motor function for?
Mass, tone, and strength
How would you check a patients sensory for?
light touch, pin prick and double simultaneous stimulation.
How would you check a patients giant for?
- Stepping, toe-heel walking, turning; be observant.
How would you check the patients cerebrallar for?
Finger nose finger, no involuntary movements
Where would you check the patients reflex
upper and lower extremities, toes planter bilaterally
What would you check for a patient’s cerebrovascular?
Carotid, orbital or cranial bruits
What are the general things you would look at during the musculo-skeletal exam?
range of motion axial and appendicular structures, normal Osteopathic exam.
What would you check to access the level of consciousness for a patient?
- Arousal (alert, attentive, sleepy, lethargic, unresponsive)
- Able to focus and direct cognitive processes, resist distraction, sustain attention (attention affects other areas including memory and executive functioning).
What would you do to check a patients short term memory?
Immediate: (short term; read a sentence and comprehend, digit span recall).
What would you do to check a patients long term memory?
i. Recent (new material as remembering three words in 5 minutes)
ii. Remote (Memories of TV shows, news events)
iii. Episodic (dates, events, personal experiences) vs. Semantic (word meaning, phrases, facts).
What is implicit memory?
-Implicit memory (aka, non declarative, unconscious
What is explicit memory?
Declarative, factual
What is acalculia?
inability to calculate
What is agraphia?
inability to write; couldn’t write name
What is Gerstmann syndrome?
Left posterior hemispheric lesion
What is Finger agnosia?
Inability to recognize fingers, pinky? Index
What are examples of visuospatial issues?
R-L confusion, fingers
What areas do the clock drawing test cover?
- single task- covers multiple cognitive domains)
- level of consciousness (alert), visual spatial perception, praxis.
What is the name of Cr N II?
Optic Nerve
What is the first step after finding a patient has asymmetric pupils?
Finding which one is abnormal
What is anisocoria?
- Is a condition characterized by an unequal size of the eyes’ pupils.
- Normal in 10-20% of the population
What are issues that can cause anisocoria?
1) Due to efferent pupillary defect (parasympathetics) carried in Cr N lll
2) Defect in sympathetics (carried in brainstem> upper cervical spinal cord then outside the CNS in cervical ganglion to eye).
What is Horner’s syndrome?
- droopy eyelid (ptosis)
- Constriction of pupil of eye
- SMALL pupil is the abnormal one and due to a lesion of Sympathetic tract.
What is a pancoast tumor?
- Apical lung mass
- Can cause anisocoria on small pupil side with droopy eyelid (ptosis)
- this is part of what is called Horner’s Syndrome. (small pupil with ptosis)
Who is most likely to get a Pancoast tumor?
-Most common with smokers
What cranial nerves are involved in eye movement?
Cr N III,IV, VI
What is internuclear Opthalmoplegia?
Produced by lesion of the medial longitudinal fasciculus (MLF); this pathway connects Cr. N. VI nucleus on one side with Cr.N. III nucleus on the other, allowing for conjugate horizontal gaze. A MLF lesion is manifest by impaired adduction on affected side, accompanied by nystagmus in the other, abducting eye.
What cranial nerve is involved with facial sensation?
Cr N V
How do you test Cr N V?
Touch with cotton, corneal reflex with cotton wisp when feasible,
What are the three branches of facial sensation?
-three braches; ophthalmic, maxillary and mandibular;
What is Bell’s palsy?
Peripheral weakness or paralysis of one side of the face causing a facial droop; drooling, eye issues with tearing (excessive, dry eye); loss of taste, pain behind ear a facial nerve (Cr N VII) lesion.
What cranial nerve is involved with facial strength?
Cr N VII
How do you test facial strength?
-close eyes tight, wrinkle forehead, smile
What is the name of CN1?
Olfactory
What is the name of CN2?
Optic
What is the name of CN3?
Oculomotor
What is the name of CN4?
Trochlear
What is the name of CN5?
Trigeminal
What is the name of CN6?
Abducens
What is the name of CN7?
Facial
What is the name of CN8?
Vestibulocochlear
What is the name of CN9?
Glossopharyngal
What is the name of CN10?
Vagus
What is the name of CN11?
Accessory
What is the name of CN12?
Hypoglossal
Which cranial nerves are sensory only?
CN 1, 2, 8
Which cranial nerves are motor only?
CN 3, 4, 6, 11, 12
Which cranial nerves are mixed actions?
CN 5, 7, 9, 10
What is the function of CN1?
- Olfactory
- Smells
What is the function of CN2?
- Optic
- Sees
What is the function of CN 3, 4, and 6?
- Moves eyes
- CN3 Constricts pupils
- Accommodates
- CN3: Oculomotor
- CN4: Trochlear
- CN6: Abducens
What is the function of CN5?
- Chews and feels front of head
- Trigeminal
What is the function of CN7?
- Moves the face, tastes, salivates, cries
- Facial
What is the function of CN8?
- Hears, regulates balance
- Vestibulocochlear
What is the function of CN9?
- Tastes, salivates, swallows, monitors carotid body and sinus.
- Glossopharyngeal
What is the function of CN10?
- Tastes swallows, lifts palate, talks, communication and from thoraco-abdominal viscera
- Vagus
What is the function of CN11?
- Turns head, lifts shoulders
- Acessory
What is the function of CN12?
- Moves tongue
- Hypoglossal
What Cranial nerve is involved with the gag reflex?
- Vagus (Cr N 10)
- 20% of patients do not have gag reflex.
What tests do you do to check Cr N VII?
- Hearing (finger rub)
- Weber/ Rinne for conduction vs. sensorineural hearing loss
What is dysarthria?
Articulation errors
What nerves are involved in dysarthria?
Cr N VII, IX, X, XII
What nerve causes tongue weakness?
CN XII- Hypoglossal Nerve
- Atrophy and fasciculations are often prominent with peripheral lesions.
- Tongue deviates to the side of the peripheral nerve lesion
What is the grading system for muscle strength created by?
MRC- Medical Research Council
What is the 0/5 on the muscle strength grading system?
no discernable muscle or muscle fiber contraction
What is the 1/5 on the muscle strength grading system?
flicker/twitch of muscle fiber movements without movement of joint/limb
What is the 2/5 on the muscle strength grading system?
weak contraction (cannot overcome gravity
What is the 3/5 on the muscle strength grading system?
weak contraction (able to overcome gravity but no additional resistence)
What is the 4/5 on the muscle strength grading system?
weak contraction (able to overcome minimal resistence
What is the 5/5 on the muscle strength grading system?
Full Strength
What are the limitations of the muscle grading system?
i. Difficult to conventionally assess large muscle groups or exceptionally powerful individuals
ii. Subjectivity between 4/5 and 5/5
What muscles have deep tendon reflexes?
i. biceps C5-6
ii. triceps C 6-7
iii. brachioradialis C5-6
iv. knee (patellar) L3-4
v. ankle (gastrocsoleus
or Achilles) S1
vi. hamstrings L5
What is clonus?
rhythmic series of contractions elicited by stretching the tendon
What is the DTR grading system positive tests?
Asymmetry and sustained clonus ; the most important positives
On the DTR grading system what is a 0/4?
0 or 0/4 = absent
On the DTR grading system what is a 1/4?
1/4 = reduced (hypoactive)
On the DTR grading system what is a 2/4?
2/4 = normal DTR
On the DTR grading system what is a 3/4?
3/4= hyperactive
On the DTR grading system what is a 4/4?
4/4= clonus (sustained or several beats)
What cervical nerve goes to the thumb?
C6
What cervical nerve goes to the pinky?
C8
What lumbar nerve goes to the large toe and lateral thigh?
L5
What sacral nerve goes to the small toe and sole?
S1
What is Dysmetria?
inibility to perform point to point movements
What is Dysdiadochokinesis?
an inability to perform rapid alternating movements slow or irregular: movement disorder
What test do you do to check cerebellar/coordination?
- Evaluate by testing patient’s ability to perform:
- Rapid alternating movements (hands on thighs and rapidly supinate- pronate hands for 10 seconds).
- Heel down Shin- slide down from knee to top of foot.
What is the Romberg test?
- Patient stands still, feet together, then ask patient to close eyes
- Positive test-If significant and immediate loss of balance
What are false positives for cerebrovascular brutus?
Anemia, hypermetabolic state or pressing too hard with stethoscope
What are the false negatives for cerebrovascular bruits?
Total occlusions
What is the grading system for Cerebrovascular bruits?
1/4 low grade, 2/4 more, 3/4 more, 4/4; if there’s an associated diastolic component
