Abnormal Neuro Exam

Question 1

Finding what’s abnormal

Answer 1

There is certainly value in finding normal results as part of the physical examination
But a clearly reproducible ABNORMAL finding is generally even more valuable
Always make an extra effort to find things that are abnormal
The slang term for this among physicians is “Great pick-up!” and is one of the highest compliments we give each other
As you gain experience and confidence, you will do this more and more frequently

Question 2

The Clinical Method of Neurology

Answer 2

As with any system examination, a complete history and examination is the way to begin with a patient

The neurological history, particularly in how the symptoms develop over time (minutes, days, weeks, years, etc.) helps determine the “WHAT” of diagnosis: stroke, infection, demyelination, tumor, seizure, trauma, etc.

The neurological examination helps to determine the “WHERE,” since we know so much about the FUNCTIONS of each segment of the central and peripheral neurological systems

Question 3

Neurological Examination: An Overview

Answer 3

A “top to bottom” approach: the cortex to the brainstem, the cerebellum, the spinal cord, and the peripheral nerves

Mental status examination
Cranial nerves
Cerebellum
Strengths
Deep tendon reflexes
Sensory testing, as needed
Gait, if possible

Question 4

Coma:

Answer 4

a sleep like state, from which patients cannot be awakened

Question 5

Aphasia:

Answer 5

decline in the use or understanding of speech

Question 6

Acute confusional state:

Answer 6

loss of awareness, understanding, orientation, judgement, and ability to pay attention and concentrate

Question 7

Delirium:

Answer 7

confusion with restlessness, perhaps combativeness, illusions and hallucinations, resistance to medical care

Question 8

Apraxia and Agnosia:

Answer 8

losses of cerebral cortical skills

Question 9

Dementia:

Answer 9

a more chronic decline in all cerebral functions

Question 10

Finding these abnormal conditions is far more helpful than

Answer 10

than simply concluding a patient has “altered mental status”

Question 11

Performing a mental status exam

Answer 11

Second and third year medical students may feel most patients will be offended by a mental status examination, or they will feel insulted
In reality, most patients do not have any objections to mental status examinations, unless they are physical uncomfortable or have significant psychiatric problems
However, it is always good to determine, tactfully, in advance, how much mental status testing can and should be done with each individual patient
Some mental status testing can be done as soon as the history is begun, in reality, as a student gains experience

Question 12

The MSE: LOL AMEN

Answer 12

1. Level of consciousness
2. Orientation
3. Language
   
   • -these may be sufficient in most cases
4. Attention
5. Memory
6. Executive/Intellectual function
7. Non-dominant hemisphere

Question 13

MSE: The Seven Components

Answer 13

1. Level of consciousness: fully alert, lethargic/sleepy, stuporous, comatose
2. Orientation: person, place, time
3. Language: spontaneous/fluent/articulation, comprehension/commands, naming, repetition
4. Attention: digit span, spelling, months/days forwards/backwards
5. Memory: anterograde (recent), retrograde (distant)
6. Executive/Intellectual function: verbal fluency, similarities, proverbs, estimates
7. Non-dominant hemisphere: visual-spatial and construction skills, neglect, music

Question 14

Level of consciousness

Answer 14

This is the subjective assessment of the physician:

ALERT: fully awake without stimulation, and able to cooperate in a history and physical examination

LETHARGIC: Patient prefers to sleep, but will stay awake with minimal verbal or physical stimulation

STUPOROUS: Patient requires repeated physical stimulation to stay awake

COMATOSE: A sleep like state in which the patient CANNOT be awakened: no further mental status testing is possible!

Question 15

Abnormal level of consciousness

Answer 15

A lowered level of consciousness is always significant
Finding a previously alert patient is stuporous or comatose means something is seriously wrong, and is often an early sign of either a new disorder or a worsening of a known one:

1. The patient has had a new problem such as a decline in the function of an organ system: CNS, heart, lungs, kidneys, liver
2. A new medication has produced an adverse effect
3. The bacterial infection has spread to the blood: sepsis
4. The patient’s hematocrit, glucose or partial pressure of oxygen has declined, or the partial pressure of carbon dioxide has risen

Question 16

Orientation

Answer 16

TEST FOR PERSON (NAME), PLACE , AND DATE(TIME)
Not always valuable in localizing brain disease, but traditionally tested in virtually all patients
May be affected by any of the medical conditions that cause confusion or dementia
Some physicians add a fourth factor: awareness of their reason for being in the hospital or the doctor’s office

Documentation, if a normal level of consciousness and orientation: AOX3, which is a minimum mental status examination for patients with no apparent neurological disease

Question 17

MSE: Abnormal Language

Answer 17

Aphasia is ALWAYS an indication that the patient’s DOMINANT HEMISPHERE is impaired: stroke, hemorrhage, seizure, or trauma, if it is a sudden result, or a tumor or dementia, if GRADUAL over many months or years

BROCA’S APHASIA: frontal lobe, usually accompanied by hemiplegia, retained understanding, brief “telegraphic” output

WERNICKE’S APHASIA: less common, superior temporal lobe, fluent, poor understanding

Both have ANOMIA, or inability to name objects, and inability to repeat
Both usually have limitations in writing, AGRAPHIA

DYSARTHRIA, or slurred or thick speech, may be due to disease of either hemisphere, and sometimes the brainstem, or may be due to a decline in consciousness or medication effect, or diseases of the larynx or mouth

Question 18

Aphasia

Answer 18

is ALWAYS an indication that the patient’s DOMINANT HEMISPHERE is impaired: stroke, hemorrhage, seizure, or trauma, if it is a sudden result, or a tumor or dementia, if GRADUAL over many months or years

Question 19

BROCA’S APHASIA

Answer 19

frontal lobe, usually accompanied by hemiplegia, retained understanding, brief “telegraphic” output

Question 20

WERNICKE’S APHASIA:

Answer 20

less common, superior temporal lobe, fluent, poor understanding

Question 21

Wernicke’s and Broca’s have these in common:

Answer 21

Both have ANOMIA, or inability to name objects, and inability to repeat
Both usually have limitations in writing, AGRAPHIA

Question 22

DYSARTHRIA,

Answer 22

or slurred or thick speech, may be due to disease of either hemisphere, and sometimes the brainstem, or may be due to a decline in consciousness or medication effect, or diseases of the larynx or mouth

Question 23

Testing language function

Answer 23

First of all, listen to patients, beginning with your history taking

Have patients REPEAT words or simple phrases

Have patients READ a paragraph

Have patients WRITE a sentence

Have patients carry out two or three step functions you read to them: “Close your eyes, stick out your tongue, and raise your right arm”
Have patients NAME some simple objects, such as a pen, a comb, a cup, etc. ($100 bill)

Question 24

MSE: Attention (Concentration)

Answer 24

The loss of attention may suggest the beginning of the acute confusional state

Attention can be evaluated by:

1. Do the months (or the days of the week) forward and then backwards
2. Serial sevens, subtracting seven starting from 100
3. Read a series of letters, asking the patient to raise his hand when he hears the letter “A”
4. Have the patient spell “WORLD” forwards and backwards

Question 25

Acute confusional state (ACS)

Answer 25

Can also be referred to as ENCEPHALOPATHY: it is due
to widespread, sometimes variable or fluctuating, dysfunction of the entire brain, with
disorientation, inattention, memory loss, poor reasoning; or

THE MIND IS NOT FUNCTIONING WITH ITS NORMAL SPEED OR CLARITY

A widespread “insult” to the brain caused by infections, drugs, alcohol withdrawal, loss of hepatic, renal or pulmonary function, electrolyte abnormalities; sometimes head trauma or encephalitis; usually a problem OUTSIDE OF THE BRAIN WHICH AFFECTS THE BRAIN

Patients with ACS can not reliably be tested for any later parts of the MSE beyond attention

DEMENTED PATIENTS ARE MORE PRONE TO ACS THAN OTHER PEOPLE

Question 26

Delirium: beyond ACS

Answer 26

There may be agitation (aggressive and dangerous behavior), sometimes hallucinations, tremors, wide fluctuations in blood pressure and pulse rate suggesting autonomic nervous system involvement
Usually there is hyper-reactivity to environmental stimulation, with restlessness, or at other times, extreme sleepiness
Delirium will limit the ability of patients to recover from other illnesses, or prolong their recovery from surgery, as patients become angry and uncooperative (agitated)
Antipsychotic drugs are often necessary for relief

Question 27

MSE: MEMORY

Answer 27

Usually due to BILATERAL medial temporal lobe damage, particularly the HIPPOCAMPUS, but the amygdala and the frontal lobes are essential for good memory function
Alzheimer’s disease almost always begins as a progressive loss of memory; first recent, and then distant memory; can also be a result of drugs, alcohol, or depression

ANTEROGRADE: recent memory, or the ability to store new information, up to a few days

RETROGRADE: more distant memories, including autobiographical (dates of graduation, marriage, etc.) or historical (date of wars, elections, sports, etc.)

Question 28

MSE: Anterograde Memory

Answer 28

Testing recent memory: “Please listen to these 3 words, and then repeat them. I will ask you to remember them soon.” Memorize your OWN 3 words, and ask them in approximately 3 – 10 minutes. Some patients deserve a second try.

Occasionally a normal patient will recall only 2/3, but recalling 0, or 1 words on two attempts is pathologic

Also tested by:

1. “How long have you been in the hospital?”
2. Giving a patient a brief story to remember, perhaps three or four sentences long
3. “What did you have for breakfast (or lunch, dinner)?”
4. Hide three objects in your examining room as the patient watches, and then ask the patient where they were hidden

Question 29

MSE: Retrograde Memory

Answer 29

Less often tested, mostly for confirming a diagnosis of dementia

Examples:

1. When did you graduate from high school?
2. When did you get married?
3. How many children do you have?*
4. When did you retire?
5. When did the Vietnam War (or World War II) occur?
6. Can you name some recent presidents?

Question 30

MSE: Executive function

Answer 30

These are the higher functions of the cerebral cortex
They can only be tested if the prior sections of the MSE show adequate function
Diagnostic of dementia if abnormal for an extended period

Can be tested in many ways: Recent news events, recalling recent Presidents or the current governor of the state, general fund of knowledge (distances, geography), determining similarities of two objects, the interpretation of common proverbs

Question 31

Executive function- VERBAL FLUENCY

Answer 31

: an excellent test of how the frontal lobes retrieve information from the temporal lobes:
1. Ask the patient to name as many members of a category as he can:
Examples: animals, girls’ or boys’ names, states in the United States, cities in Colorado, things you can buy in a grocery store or an apartment store, or words beginning with the letter A, F, S, etc.

Most healthy young patients can name 20 or more in one minute, while demented elderly patients will name less than
TWELVE in one minute

Question 32

Abnormal executive function

Answer 32

Along with possible amnesia, aphasia, apraxia, and decline in the functions of the nondominant hemisphere, the loss of executive function is diagnostic of DEMENTIA;
A more gradual, subtle loss of all of the higher cognitive abilities, which develops over months or years
Unlike delirium, dementia is usually irreversible

Patients will lose their memory in most types of dementia, their ability to do the activities of daily life, their social and occupational skills, and ultimately they will be unable to live independently
As dementias progress over years, the earlier aspects of the mental status exam will also suffer, such as orientation and attention, language, and finally even level of consciousness

Question 33

Apraxia

Answer 33

Loss of skilled movements and gestures

Partial damage to the dominant lobe, resulting in the loss of complex, multi-step actions, such as combing the hair, brushing the teeth, shaving or putting on makeup, or even getting dressed
Patients cannot carry out these tasks, even though they have sufficient motor and sensory functions to do them
Likely due to LOSS OF CONNECTIONS between different sites in the cerebral cortex
Common in stroke survivors and in severely demented people

Question 34

Agnosias

Answer 34

Recognition deficits

Hemispatial neglect: not appreciating that there are people or objects in the left side of the room or on the left side of a drawing or photograph, in spite of preserved vision

Anosognosia: the inability to recognize hemiparesis in a patient’s left arm or left leg; very common immediately after a stroke

Dressing agnosia: inability to button clothes or put an arm in a sleeve on the left side, or to shave or put on make up on the left side of the face

Question 35

MSE: Non-dominant (right) hemisphere

Answer 35

Functions partly/entirely localized to the right hemisphere
Parietal lobe: visual-spatial skills, constructions, awareness of one’s own body or the environment, especially to the left visual field
Abnormalities suggest a new tumor, stroke or trauma, or if chronic, dementia
Temporal lobe: loss of musical abilities and a tendency to psychiatric disturbances such as psychosis, depression and bipolar disorder, anxiety
Occipital lobe: left homonymous hemianopia and prosopagnosia, inability to recognize faces

Question 36

Lack of constructional skills

Answer 36

Again, a sign of nondominant (right) parietal lobe damage

Can be tested by having the patient draw, or copy, simple and then increasingly complicated figures, such as a circle, a square, a cube, a house, or a clock with all of the numbers

May also reveal hemispatial neglect

Very much impaired in dementias such as Alzheimer’s Disease

Question 37

Cranial nerve mnemonic; classical in a medical education

Answer 37

“On Old Olympus’ Towering Top, A Finn And German Viewed A Hop”

1. Olfactory
2. Optic
3. Oculomotor
4. Trochlear
5. Trigeminal
6. Abducens
7. Facial
8. Acoustic (Now called Vestibulo-Cochlear)
9. Glossopharyngeal
10. Vagus
11. Accessory
12. Hypoglossal

Question 38

Abnormal cranial nerves

Answer 38

Long known to be a way of localizing a disease to the brainstem, other portions of the head, including the face, or sometimes the neck and upper thorax
The brainstem and the face are especially vulnerable to seemingly small changes, seen with an abnormal cranial nerve examination finding
Widespread abnormalities of the brain stem lead to loss of consciousness, diffuse weakness of the arms and legs, loss of respiration, and eventually loss of cardiac function

Question 39

Abnormal CN II

Answer 39

Loss of vision is always a catastrophe for patients, even if it is “only” loss of distance vision or reading ability
Even more serious is the total loss of vision in one o both eyes, or a completely homonymous hemianopia
Tunnel vision, or bitemporal hemianopia, points to a lesion around the pituitary gland
The most important thing to check with CN II is the visual acuity
Pupillary reactivity and funduscopy are also important

Question 40

Abnormal pupillary reactions

Answer 40

Loss of the pupillary reflex indicates a problem with the afferent portion (CN II) and/or the efferent portion (CN III)
A pupil that does not react at all to light may be caused by blindness, optic neuritis (sometimes due to multiple sclerosis), an optic nerve tumor, or when it is dilated and unreactive, due to Adie’s pupil (polyneuropathy, especially in diabetics)
A unilateral significantly dilated pupil may be due to a lesion of CN III, including herniation of the ipsilateral cerebral hemisphere!

Question 41

Abnormal CN III

Answer 41

Occasionally due to strokes, diabetes, or even migraine

These disorders usually “spare the pupil,” so it still reacts to light and may be equal in diameter to the other pupil

The pupil is NOT spared in lesions from outside the midbrain: tumor, herniation of the ipsilateral cerebral hemisphere due to a large tumor or hemorrhage
May be caused by a life threatening aneurysm of the posterior communicating artery

Question 42

Ptosis

Answer 42

Droopiness of the upper eye lid , via the LEVATOR PALPEBRAE SUPERIORIS, may due to CN III lesions: tumor, aneurysm or diabetic infarction of the midbrain
May also be part of a neuromuscular disease such as myasthenia gravis
May be found in Horner’s Syndrome, due to weakness of Mueller’s muscle, from damage to the unilateral SYMPATHETIC NERVOUS SYSTEM
Sometimes from trauma or prior eye surgery

Question 43

Abnormal CN IV

Answer 43

CN IV, the trochlear nerve, is the only completely crossed cranial nerve, serving the contralateral superior oblique muscle, damaged by trauma or congenital disease

1. Tested by having the patient look DOWN AND IN
2. The eye is also minimally abducted by the superior oblique

Question 44

Abnormal CN VI

Answer 44

CN VI, the abducens nerve, serves the ipsilateral lateral rectus muscle, and can indicate localized disease of the pons or the skull, or increased intracranial pressure from tumors or trauma anywhere inside the skull

Question 45

CN VII: The Facial Nerve

Answer 45

Almost entirely motor, to the muscles of facial expression
But also taste of anterior tongue, lacrimation and salivation
Limitation of hearing damage from loud noise by contraction of the stapedius muscle

Tested by closing the eyes, raising the eyebrows, for the UPPER FACE

Tested by smiling or pursing the lips for the LOWER FACE

Many people have lower facial asymmetries, from incompletely-healed central or peripheral lesions

Question 46

Abnormal CN VII

Answer 46

YOU MUST KNOW Central versus peripheral seventh nerve palsies!!!

PERIPHERAL ; in the course of the facial nerve after it has left the pons; BOTH the upper and the lower facial muscles on that side are impaired: these are peripheral seventh nerve palsies
1. If truly idiopathic, it is called Bell’s Palsy

CENTRAL; the lesion is in the pons or upper brain stem, or far more commonly in the contralateral cerebral hemisphere, and ONLY the lower facial muscles are impaired
a. Still unclear why this occurs, perhaps because the lower facial muscles receive innervation from BOTH SIDES of the motor strip in the frontal lobes

Question 47

The Cerebellum

Answer 47

Important for COORDINATION OF MOVEMENTS ON THE SAME SIDE: this is due to the “double cross” of cerebellar efferents crossing over in the brainstem and going to the contralateral thalamus and contralateral motor cortex; descending corticospinal fibers will cross in the medulla oblongata

Patients have ATAXIA of many movements which require rapidity and precision, especially the limbs, but also extra-ocular movements

Ataxia actually means a lack of coordination due to cerebellar disease, and not simply trouble walking

Question 48

ways to test the cerebellum

Answer 48

There are many ways to test each cerebellar hemisphere
Remember that because of the “double cross,” CEREBELLAR DISEASE IN ONE LOBE ALWAYS PRODUCES ABNORMALITIES ON THE SAME SIDE OF THE BODY

Finger to nose, extending the patient’s arms completely
Rapid alternating movements
Knee to ankle movements of the opposite leg

Question 49

Strokes and hemorrhages, or expanding tumors of one cerebellar hemisphere may cause rapid death due to

Answer 49

BRAIN STEM DAMAGE AND BLOCKAGE OF THE FOURTH VENTRICLE’S CSF FLOW

Question 50

Abnormal cerebellum

Answer 50

One hemisphere may be damaged commonly in strokes, hemorrhages, primary and metastatic tumors, or trauma,

Acute cerebellar diseases, and chronic bilateral cerebellar diseases, are likely to affect the patient’s ability to walk

Ataxia means a lack of coordination due to diseases of the cerebellum: it DOES NOT mean “trouble walking”

Bilateral cerebellar diseases may be due to familial cerebellar degeneration, alcoholism, certain medications, mercury, multiple sclerosis

Question 51

Cerebellum: Romberg test

Answer 51

Actually, a better test of the POSTERIOR COLUMNS (gracile and cuneate fasciculi) than the cerebellum; best done after other cerebellar tests are completed
Patients are ask to stand with their eyes open, and then tested for falling when asked to close their eyes

Upright posture requires 3 functions:

1. Vision
2. Cerebellum
3. Posterior columns

Question 52

Testing of strengths

Answer 52

The numerical quantification of strengths has weaknesses (pun intended)
Strengths are numbered 0 to 5, with the most numbers for severe weakness ( 0 to 3), and only 4 and 5 for mild weakness

0/5: absolutely no movement in a group
1/5. minimal, or “flicker” of movement
2/5. minimal horizontal movement, but no movement against gravity
3/5. Some movement against gravity
4/5. Moderate strength against gravity and some resistance
5/5. Normal contraction

Question 53

Abnormal motor strengths

Answer 53

Very important to patients, of course, especially if it is a sudden weakness
Physicians commonly overlook subtle weaknesses
Patients who complain of being “weak all over” are often dismissed as hypochrondriacs
Weakness in multiple parts of the body CAN be due to a somatoform disorder, but can also be due to upper cervical spine diseases, neuromuscular diseases such as myasthenia gravis, myopathies or acute demyelinating polyneuropathy (the Guillain-Barre syndrome)

Question 54

Localized weakness

Answer 54

Quadriplegia: disease of the upper or mid cervical spine, or both of the corticospinal tracts of the brain stem
Hemiplegia: disease of one cerebral hemisphere or one side of the brainstem along the corticospinal tract
Paraplegia: disease of the spinal cord in the thoracic or high lumbar regions
Weakness of one arm: cervical spine disease or the brachial plexus, or some strokes
Weakness of one leg: lumbar spine disease or the lumbar sacral plexus, or, rarely a stroke (anterior cerebral artery infarct)

Question 55

Other muscle features

Answer 55

When testing strengths, it may be useful to note the BULK or size of certain important muscles
Also, the TONE of the arm or leg, which is resistance to stretch, increased in CNS causes of weakness
Look for evidence of FASCICULATIONS: quick muscle jerks or twitches, caused by peripheral nerve disorders, but sometimes idiopathic and benign

Question 56

Deep Tendon Reflexes

Answer 56

All DTRs are traditionally graded 0 – 4

0: no reflex
1: diminished reflex
2: average reflex
3. increased reflex, but only one beat
4. increased reflex with CLONUS: two or more beats

A reflex of 0 is usually pathologic, but a reflex of 4 is always pathologic

Question 57

Abnormal deep tendon reflexes

Answer 57

If decreased, may be due to diabetes mellitus, hypothyroidism, vitamin B12 deficiency, exposure to heavy metals or some organic chemicals, autoimmune diseases

If increased, may be due to lesions of the corticospinal tracts (upper motor neuron weakness) especially in the spinal cord or brain stem, less so in the cerebral hemispheres, or hyperthyroidism, or even with a normal pregnancy

Question 58

The Babinski SIGN

Answer 58

There is NO Babinski TEST!!!
There is a plantar reflex, in which the sole of each foot is quickly stroked from the heel to the toes

The Normal Plantar Reflex is FLEXION of the big toe
The Abnormal Plantar Reflex is EXTENSION of the big toe, sometimes with separation or “fanning out” of the smaller toes
This Abnormal response, with big toe extension, is called a:
BABINSKI SIGN

Question 59

Upper or lower motor neuron?

Answer 59

This can be a very helpful way of determining the cause of weakness, knowing there are two distinct categories

Upper motor neuron: brain or spinal cord:
- Increased reflexes, spasticity, only delayed atrophy of muscles, Babinski signs

Lower motor neuron: motor neuron, neuromuscular junction, muscle itself:
- Decreased reflexes, atrophy within weeks, sometimes fasciculations, no Babinski signs

Question 60

The Neurological Examination: Sensory Exam

Answer 60

Sensory loss can be due to disease at any level of the central or peripheral nervous systems:
Cerebral hemisphere 
Thalamus
Brainstem
Spinal cord 
Peripheral nerves or roots of nerves

By the time the physician gets to sensory testing, there should already be some sense of where the patient’s disease is located. If not, the sensory examination can still be very helpful. Direct your sensory examination based upon your suspicions, or the sensory examination may be time-consuming and useless. I recommend it be your final, or next-to-last area in the neurological examination

Question 61

Abnormal sensory testing

Answer 61

Sensory loss can be due to disease at any level of the central or peripheral nervous systems:

Cerebral hemisphere (sensory cortex or subcortical connecting fibers, including the thalamus): numbness of the entire contralateral face, arm or leg

Brainstem: numbness of the face, sometimes bilateral
Spinal cord: CAUSES A SENSORY LEVEL
Peripheral nerves or roots of nerves are commonly affected, as in radiculopathies: limited loss of fine touch within the limited distribution of a single nerve or DERMATOME

Question 62

Abnormal Gait

Answer 62

Not always necessary, but it can be very helpful:

Hemiplegic gait, with circumduction, inability to bring the leg all the way in
Spastic gait: Limited ability to bend at the hips and knees
Festinating gait: slow with the first steps, then faster and faster, and out of control, in Parkinson’s disease
Inability to stand or walk at all: spinal cord disease or an acute cerebellar lesion such as stroke or hemorrhage