2.3. Neuro Exam OSCE Flashcards
What is included in your general neuro assessment?
mental status
- level of alertness
- appropriateness of responses
- orientation to person, place, time
How is CN I tested?
smell -use familiar & non-irritating odors
Conditions associated with loss of smell
- sinus conditions
- head trauma
- smoking
- aging
- cocaine use
How is CN II tested?
- visual acuity w/ snellen eye chart
- visual fields by confrontation
- light reaction
when is a person considered legally blind?
20/200
how far should the patient be from the snellen’s eye chart during an exam?
20 ft
How is vision tested by confrontation?
wiggling fingers at edge of field asking pt if they see it
How is light reaction tested?
shining light into eye checking for direct reaction & consensual reaction in other eye (sensory II, constriction III)
How is CN III tested?
- Light Reaction Consensual pupillary dilatation/constriction (III)
- The Near Reaction: Pupillary constriction (III)
How would you perform a Near Reaction test? What does this test, specifically?
- Pt shift gaze from far object to near one, pupils constrict.
- Tests CN III and accommodation
- CNIII – Check eyelid for ptosis
How would you document a normal Cardinal Signs of Gaze test?
EOMI (extra-ocular muscles are intact)
Nystagmus
Eyes make repetitive, uncontrolled movements
How far in front on the patients face are you when performing the Cardinal Signs of Gaze test?
12-18 inches
How you would test CN V?
- MOTOR: masseter & temporal muscles
- SENSORY: ophthalmic (V1), maxillary (V2), mandibular (V3)
- CORNEAL REFLEX – Sensation is V, blinking is VII
How would you perform a motor test for CN V?
- Palpate the temporal & masseter m & ask pt to clench their teeth.
- Note the strength of m contraction.
- Ask pt to move jaw side to sided testing lateral pterygoids.
What would unilateral weakness indicate when testing for CN V motor?
CNS pontine lesion
What would bilateral weakness indicate when testing for CN V motor?
cerebral hemispheric disease since bilateral cortical innervation
How would you perform a sensory exam for CN V?
- Test forehead, cheeks, jaw on each side for pain sensation. Pt eyes should be closed.
- Use a broken long-tipped cotton swab occasionally substituting blunt end for point as stimulus. Ask pt if it is sharp or dull & be sure to compare sides.
-If abnormality found, confirm by temp sensation. Touch skin w/ either hot or cold stimuli & ask pt to report which they feel.
What would facial and body sensory loss on the same side during a CN V sensory exam indicate?
contralateral cortical or thalamic lesion
What would ipsilateral face but contralateral body sensory loss during a CN V sensory exam indicate?
Stroke in the brainstem
L brain stem lesion = L facial & R body sensory loss
What type of peripheral disorders would one see Isolated facial sensory loss?
trigeminal neuralgia
How would one test the corneal reflex for CN V?
Use a clean cotton swab to touch the cornea lateral to the iris, blinking of both eyes is the normal reaction to the stimulus
What would blinking absence in both eyes indicate with a corneal reflex test?
CN V lesions
What would blinking absence on the same side of weakness indicate with a corneal reflex test?
CN VII lesions
How would one test CN VII?
Facial muscles of expression:
-Inspect face during rest & conversation to note any asymmetry & observe any ticks or other abnormalities
-Raise both eyebrows, frown, close both eyes tight so that you cannot open them, test muscular strength by trying to open them, show both upper & lower teeth, smile, puff out both cheeks
What would be findings of Bell’s Palsy on exam?
affects both upper & lower face, loss of taste, hyperacusis, ↑ or ↓ tearing, CN7 lesion
How would a central lesion of CN VII appear on exam?
affects mainly lower face
How would one test the parasympathetics for CN VII?
secretion of saliva & tears
How would one test CN VII, sensory?
taste for salty, sweet, sour & bitter substances on the ant 2/3 tongue
How would you differentiate stroke from Bell’s palsy?
Unilateral lower face vs unilateral upper and lower face paralysis
How would one test CN VIII?
- Cochlear: Whisper, Weber, Rinne tests
- Vestibular: incorporated into cerebellar tests
How would you perform a whisper test? What is this testing?
CN VIII- Cochlear N
Check for hearing loss. If present, do Weber and Rinne tests.
-Stand 2 feet behind patient.
-Instruct patient to occlude ear not being tested.
-Exhale a full breath before whispering to ensure a quiet voice.
-Whisper a combination of three numbers and letters, such as 3-U-1. Use a different combination for the other ear.
-Abnormal Test= 4/6 numbers or letters are incorrect
What is considered an abnormal whisper test?
4/6 numbers or letters are incorrect
What do Weber and Rinne test’s assess? Which CN?
CN VIII
Tests for conductive or sensorineural hearing loss
How could one test the vestibular division specifically for CN VIII?
Balance- Rarely included in usual neuro exam
How would one test for CN IX? Include motor, sensory, and parasympathetics
- Gag reflex (CN IX, CN X)
1. Motor – Voluntary m for swallowing & phonation
2. Sensory – Sensation of nasopharynx, gag reflex & taste for post 1/3 tongue (taste and gag reflex rarely tested in PC setting)
3. Parasympathetic – Secretion of salivary glands & carotid reflex
What 4 tests can be performed to assess CN X?
- Inspect soft palate & uvula for symmetry
- Fails to rise w/ b/l lesion, deviate to normal side w/ u/l lesion - Observe for difficulties w/ swallowing
- Test for gag reflex – absence = lesion CN IX or perhaps X (rarely done in office setting)
- Evaluate for presence of nasal tone & hoarseness of voice (may be presenting sx)
What is the motor control of CN X?
Voluntary for swallowing & phonation
What is the sensory control of CN X?
Sensation behind ear & part of external ear canal
What does the parasympathetics for CN X do?
- Secretion of digestive enzymes
- peristalsis
- carotid reflex
- involuntary action of heart, lungs & digestive tract
What is the motor control of CN XI?
SCM and Trapezius- Head & shoulder movement & some actions for phonation
How would one test CN XI?
- Look from behind for fasiculations & compare side to side
- Check for trapezius m strength by shrugging shoulders against resistance
- Trap weakness w/ atrophy & fasciculations = peripheral n disorder. In paralysis, the shoulder droops, & scapula is displaced downward & laterally - Check SCM m strength by turning head to each side against resistance (Contraction of L SCM turns head to R).
What is the motor function of CN XII?
Tongue movement for lingual speech sound articulation (“L, T, D, N”)
How would one test CN XII?
- Inspect tongue for symmetry, tremors, & atrophy
- Check tongue movement towards nose & chin
- Check tongue strength when pressed against cheek
- Evaluate quality of lingual sounds
- CN XII lesion results in tongue deviation to the weak side (“licks its wounds”).
What aspects are included in a general motor neuro examination?
- Body position & gait
- Involuntary movement – tremors, tics or fasciculations
- Muscle bulk – wasting, atrophy
- Muscle tone – feeling the muscle resistance to passive stretch
When would you document a “0” for muscle strength?
0 = No muscle contraction
When would you document a “1” for muscle strength?
1 = Barely detectable flicker or trace of contraction
When would you document a “2” for muscle strength?
2 = Active movement w/ gravity eliminated
When would you document a “3” for muscle strength?
3 = Active movement against gravity
When would you document a “4” for muscle strength?
4 = Active movement against gravity & some resistance
When would you document a “5” for muscle strength?
5 = Active movement against full resistance w/o fatigue
What muscle & nerve is tested with a shoulder shrug?
trapezius (CNXI)
What muscle(s) & nerve(s) are tested with a flexion and extension at the elbow?
- Flexion (C5,6)
- extension (C6,7,8)
What muscle(s) & nerve(s) are tested with flexion and extension at wrist?
C6,7
What muscle(s) & nerve(s) are tested with hand grip?
C7,8,T1
What muscle(s) & nerve(s) are tested with finger abduction?
C8,T1
What muscle(s) & nerve(s) are tested with opposition of thumb?
C8,T1
What muscle(s) & nerve(s) are tested with flex, ext, add, abduction of hip?
Flex: (L2,3,4 – psoas and iliacus)
- ext: (S1 – glut max)
- adduction: (L2,3,4)
- abduction (L4,5,S1)
What muscle(s) & nerve(s) are tested with flex and ext of knee?
-Flexion (L4,5,S1,2 –hamstrings) -extension (L2,3,4 –quads)
What muscle(s) & nerve(s) are tested with plantar flexion and dorsiflexion of ankle?
- Plantar (S1 – gastrocnemius )
- dorsiflexion (L4,5 – tibialis anterior)
What part of the brain are you testing when looking for coordination?
cerebellum
What tests can be performed to test the cerebellum?
- Rapid alternating movements
- Finger-to-nose
- Finger-to-finger
- Heel-to-shin
How do you perform a finger-to-nose/finger-to-finger test for coordination?
- Pt touch doc index finger & then their nose alternating several times. Move doc finger about so pt has to alter directions & extend arm fully to reach it. Observe accuracy & smoothness of movement & watch for any tremor.
- Now hold in 1 place so pt can touch it w/ 1 arm & finger outstretched. Ask pt to raise arm overhead & lower it again to touch finger. After several times, ask pt to close eyes & try again. Repeat on other side.
*This tests position sense & functions of both labyrinth & cerebellum.
How do you perform a rapid alternating movements test for coordination?
- Arms – Strike 1 hand on thigh, raise hand, turn it over & then strike the back of hand down on same place. Urge pt to repeat these movement rapidly. Observe speed, rhythm, smoothness. Repeat w/ other hand. Non-dominate hand often slower.
- Tap the distal joint of thumb w/ tip of index finger as rapidly as possible. Observe same things & non dominate less well again.
- Legs – Tap doc hand as quick as possible w/ ball of each foot in turn. Note any slowness or awkwardness. Feet normally perform less well than hands.
How do you perform a heel-to-shin test for coordination?
Ask pt to place 1 heel on the opposite knee, & then run it down the shin to big toe. Note smoothness & accuracy of movement. Repetition w/ pt eye closed tests for position sense. Repeat w/ other side
What could an abnormal rapid alternating movements test called?
dysdiadochokinesis
How do you test for gait?
- Gait: Casual, tandem, toe & heel walking
- Hop in place on one leg
- Do shallow knee bend
- Alternative to hop/knee bend for frail: Rise from sitting position without arm support and step up on a steady stool
How do you perform a casual gait test?
Walk across room or down hall, turn & come back – observe posture, balance, swinging arms, movement of legs. Normal balance is easy & arms swing at sides & turns are accomplished smoothly
What is an abnormal casual gait test?
Lack coordination, instability = ataxic. May be due to cerebellar disease, loss of position sense or intoxication
How do you perform a tandem gait test?
Walking heel-to-toe in straight line, may reveal subtle ataxia
What does the “heel walk then toe walk” test for?
Sensitive tests, respectively, for plantarflexion & dorsiflexion of ankles, as well as balance
- May reveal distal m weakness in legs.
- Inability to heel-walk: sensitive test for CST damage
What does the “hop in place on one leg” test for?
Tests proximal and distal muscle strength, requires position sense and cerebellar function
What does the “shallow knee bend on each leg” test for?
May reveal weakness of hip extensors, quadriceps or both
What are the neuro tests for stance?
- Romberg test
- Test for pronator Drift
*These two tests can be performed at the same time – make sure to stand close enough to patient to prevent a fall
How do you perform a Romberg test? What is this testing for?
- test of proprioception.
- Patient stands with feet together and eyes open. Close both eyes for 30-60 seconds.
- Normal is minimal swaying.
- If patient loses balance with eyes open, it is cerebellar ataxia.
- If pt loses balance with eyes closed, it is a positive Romberg sign.
What is a positive Romberg sign?
pt loses balance with eyes closed
How do you test for pronator drift? What would a positive test be specific for?
Patient closes eyes for 20-30 seconds with both arms held forward, palm up.
- Pronator drift occurs when one forearm turns inward and down and is specific for corticospinal tract lesion.
- Next, tap the arms briskly downward. The arms normally return to the horizontal position, requiring muscle strength, coordination and good position strength.
What is considered a positive Pronator drift test?
Pronator drift occurs when one forearm turns inward and down and is specific for corticospinal tract lesion.
How do you test for pain and temperature? What part of the brain is this testing?
Spinothalamic tract
-Pain – Using safety pin or broken tongue depressor. Occasional use the blunt end for comparison
-Temp – Often omitted if pain sensation is normal. If indicated use test tubes filled w/ hot & cold water
How do you test for position and vibration? What part of the brain is this testing?
posterior columns
-Position (proprioception): Grasp sides of pt big toe between your thumb & index finger & move it w/ pt eyes closed ask for a response of up or down. Should sense big toe movement within 5 degrees and index finger within 1 degree of motion.
-Vibration: Use a relatively low-pitched tuning fork of 128Hz. Place vibrating for over IP joints, malleoli.
How do you test for light touch? What part of the brain is this testing?
Both Spinothalamic tract and posterior columns
Use a fine wisp of cotton. Compare 1 area w/ another & bilateral sides
What is the deep tendon reflex graded out of?
4+ = Very brisk, hyperactive, w/ clonus (rhythmic oscillation b/w F & E)
3+ = Brisker than average, possibly but not necessarily indicative of dz
2+ = Average, normal
1+ = Somewhat diminished, low normal
0 = No response
What could a hyperactive deep tendon reflex indicate?
CNS Lesion
What could a hypoactive deep tendon reflex indicate?
PNS Lesion
How would one test abdominal reflexes? What nerves are primarily tested here?
Use a broken tongue depressor or broken cotton tipped swab
(T10-T12) , stroke peripherally to toward the umbilius in each quadrant, normally should see contraction of abdominal m w/ deviation of umbilicus toward the stimulus
How would one test anal reflexes? What nerves are primarily tested here?
Use a broken tongue depressor or broken cotton tipped swab
(S2-S4), lightly scratch the anus on both sides, note reflex contraction of anal muscles, loss of this reflex arc can indicate cauda equina lesions
How would one test plantar response? What nerves are primarily tested here?
Use a broken tongue depressor or broken cotton tipped swab
(L5, S1) Stroke the plantar/lateral aspect of the foot from the heel to the ball of the foot. The normal response of the toe should be plantarflexion (downgoing great toe). Dorsiflexion of the hallux and fanning of the toes is pathologic* and suggests CNS lesion.
This is called the Babinski response, but to avoid confusion should be verbally reported and/or presented as an “upgoing” great toe.
(norm in newborns)
What are 3 classic meningeal signs?
Inflammation in the subarachnoid space causes resistance to movement that stretches the spinal nerves:
- neck flexion/nuchal rigidity
- the femoral nerve (Brudzinski’s sign)
- sciatic nerve (Kernig’s sign)
How do you perform a test for nuchal rigidity? What is a positive test? What is the specificity?
- Pt supine, place hands behind pt’s head & flex the neck forward. If neck is supple, pt can easily bend the head & neck forward;
- (+): neck stiffness with resistance to flexion found in ≈84% of pts with acute bacterial meningitis and 21-86% with subarachnoid hemorrhage.
- Low sensitivity in suspected/moderate cases; reliability with severe meningeal inflammation.
How do you perform a test for Brudzinski’s Sign? What is a positive test? What is the specificity?
- physician flexes pt’s neck, hips and knees should stay relaxed and motionless.
- (+) sign: hips and knees flex as pt’s neck is flexed.
- Low sensitivity.
How do you perform a test for Kernig’s Sign? What is a positive test? What is the specificity?
-Flex the pt’s leg at hip and knee, then straighten the knee.
Discomfort behind the knee during full extension occurs normally but this should not be painful
-(+) sign: pain and increased resistance to extending the knee.
-Low sensitivity.
What are the 5 best practice components when doing a neuro exam?
- mental status
- CN: vision, light reflex, eye move, hearing, facial strength
- motor systems: gait, strength, coordination
- sensory system: one modality at toes (light touch, pain, temp, proprioception)
- Reflexes
