Approach to Neuro Exam

Question 1

What 5 things are essential to a basic Neuro Exam?

Answer 1

1) mental status, speech, and language
2) cranial Nerves
3) Sensory Testing
4) Cerebellar/ Coordination Testing
5) Motor System

Question 2

Dysarthria

Answer 2

defective articulation, usu caused by defect in motor control of speech apparatus

Question 3

Aphasia

Answer 3

disorder in producing ot understanding language, usu by lesions in dominant hemisphere (left)

Question 4

A&O x 1

Answer 4

oriented to person

Question 5

A&O x 2

Answer 5

oriented to person and place

Question 6

A&O x3

Answer 6

oriented to person palce and thing

Question 7

A&O x 4

Answer 7

oriented to event

Question 8

Depression

Answer 8

“have you been feeling down, depressed, or hopeless?”

“have you felt little interest or pleasure in doing things?”

Question 9

Delirium

Answer 9

Reversible

• screen using CAM Diagnostic Algorithm
• common in older hospitalized patients

Question 10

Dementia

Answer 10

NOT reversible

• must eliminate depression and delirium before can diagnose
• meds can slow progression

Question 11

Ptosis

Answer 11

drooping of eyelid due to elevator palpable weakness (CN 3)

Question 12

Pupillary dilation/asymmetry

Answer 12

disruption of parasympathetic fibers on cn 3 , if severe = fixed and dilated

Question 13

compressive brainstem lesions

Answer 13

brain herniations
initially = compress pupiloconstrictor fibers of cn 3 -> fixed and dilated pupil
second : somatic efferent fibers = oculomotor palsy (external strabismus)

Question 14

CN IV LESIONS
trochlear nerve

(vulnerable to trauma)

Answer 14

1) extropia (eye drifts laterally)
2) weakness of downward gaze (weakness of SO)
3) vertical diplopia (increases when looking down)
4) Head tilting - to opposite side of lesion
- > CAN BE MISS DIAGNOSED AS IDIOPATHIC TORTICOLLIS

Question 15

CN VI LESIONS

ABDECENS NERVE

Answer 15

MOST COMMON ISOLATED
seen in subarachnoid hem, late syphilis, and trauma

lesions :
1) convergent (medial) strabismus (esotropia) -> inability to abduct the eye (LR weak)

2) horizontal diplopia - maximal separation of the images when looking toward the paretic LR muscle

Question 16

Nystagmus

definition

types

causes

Answer 16

rhythmic beating of the eyes, beat in the fast direction

1) horizontal
2) vertical
3) rotatory

causes:

• vision impairment at early age
• disorder of labyrinth or cerebellar systems
• drug toxicity

Question 17

CN V Lesions

Trigeminal N

Answer 17

• decreased sensation to face and mucous membranes
• loss of corneal reflex
• weakness of jaw muscles
• jaw deviation to weak side (unopposed action of pterygoid m.)

Question 18

Trigeminal Neuralgia

Answer 18

• recurrent brief episodes of unilateral shock like pain along one or more distributions of trigeminal n.
• debilitating
• innocuous stimuli

Question 19

CN VII LESIONS

facial n.

Answer 19

• paralysis of m. of facial expression ( Bells palsy)
• loss of corneal reflex
• hyperacusis (increase sensitivity to sound)
• crocodile tear syndrome - due to aberrant regeneration of n. after trauma - patient sheds tears when chewing

Question 20

Bell’s palsy

Answer 20

peripheral facial paralysis, caused by trauma or infection

Question 21

Bilateral facial Palsies

Answer 21

Miller-fisher variant of Gillian barre syndrome

Question 22

Suprenuclear (central) facial palsy

Answer 22

spares upper face, contralateral jaw droop and hemiplegia

*impt for det peripheral vs central palsy

Question 23

CN VIII

vestibulocochlear n.

Answer 23

• whisper test
• finger rub test
• Weber-Rinne testing

Question 24

CN VIII LESIONS

vestibular lesions result in?
cochlear lesions result in?

Answer 24

Dysequilibrium = imbalance
nystagmus = rapid involuntary and rhythmic movement of the eye 

Destructive = sensorineural hearing loss (acoustic neuroma)
irritative = tinnitus (ring in ears) ex: meds -> aspirin and antibiotics

Question 25

CN 9 and 10

Answer 25

- listen to voice for hoarseness (vocal cords), nasal tone(palatal weakness) - gag reflex - difficulty swallowing - "ah" -> symmetric elevation if intact - UNILATERAL LOSS INDICATED AND IPSILATERAL CN X LESION

Question 26

LESIONS IN CN 9 LEAD TO

Answer 26

- loss of gag reflex - los of sensation to pharynx and posterior 1/3 tongue - slight dysphagia

Question 27

CN 10 LESIONS RESULT IN

Answer 27

- dysphonia - dysphagia - dyspnea - loss of gag or cough reflex

Question 28

Testing CN 11 lesions testing? and result if lesion

Answer 28

testing: SCM = turn head against resistance (contraction of L SCM turn head to the R) trap = shrug shoulders against resistance if lesion SCM = paralysis results in difficulty turning head to opposite side trap : weakness results in unilateral shoulder droop

Question 29

CN 12 testing and lesion

Answer 29

testing : protrude tongue, and push tongue against cheeks as apply resistance lesions = tongue deviate to side of lesion and inability to push tongue to opposite side

Question 30

Dermatomes C2, 3, 4, 6, 7, 8 T 4,10 L 1,4,5 S1

Answer 30

auricle, earlobe, ant/post neck , top of shoulder, radial forearm and thumb, long finger, little finger nipple, belly button inguinal, patella/medial calf, anterolateral calf/great toe posterolateral calf/achilles/ little toe

Question 31

Testing sensory pain , temperature, vibration, proprioception

Answer 31

spinothalamic tract sharp wood depressor , spinothalamic hot and warm tubes water, 128 hx on bony prominence posterior columns, move toes up and down grabbing at sides posterior columns

Question 32

stereognosis

Answer 32

ability to ID shapes of objects, or recognizer placed in hand

Question 33

Graphestheisa

Answer 33

ability to ID numbers written on palm

Question 34

Two-point discrimination

Answer 34

ability to distinguish being touched by one or two points

Question 35

double silmutaneous stimulation (extinction)

Answer 35

ability to feel two locations being touched silmutanously

Question 36

Patterns of sensory loss 1) single nerve 2) root or roots 3) spinal Cord 4) brainstem

Answer 36

1) loss limited to distribution of single nerve 2) loss in different distributions - --> c5,6,7 in arms - -->L4,5, S1 in legs 3) complete, hemisection of SC, PC, anterior spinal syndrome 4) ipsilateral loss in face and contralateral body

Question 37

Patterns of sensory loss pt 2 1) thalamic 2) cortical loss 3) functional loss

Answer 37

1) hemisensory loss fo all modalities 2) intact primary sensations but loss of cortical sensations 3) non-anatomical distribution `

Question 38

Testing for cerebellar functions

Answer 38

-rapid alternating movements -finger to nose -heel to shin -gait (regular, hell to toe, hopping, shollow knee bend, get up and go) stance (Romberg, pronator drift)

Question 39

gait cycle

Answer 39

``` stance = entire time foot is on ground swing= entire time foot is in air ``` wide base = distance b/w feet is greater than normal

Question 40

Cerebellar ataxia gait

Answer 40

staggering, unsteady, feet wide apart

Question 41

Sensory ataxia gait

Answer 41

unsteady feet wide apart, feet thrown forward and clopped down on to ground, patient watches ground when walking

Question 42

Parkinsonian gait

Answer 42

stooped forward, short steps "shuffling", involves hesitation "festination", decrease arm swing

Question 43

Grading motor strength

Answer 43

``` 0 = no contraction 1= barely detectable flicker 2 = active movement of body with gravity eliminated 3= movement against gravity 4= movement against gravity and some resistance 5= active against full resistance w/o fatigue (normal) ```

Question 44

Reflex scale

Answer 44

``` 0= absent 1= somewhat diminished, low normal 2= average 3= brisker than avg 4= very brisk, hyper reflexive, with clonus ```

Question 45

Additional reflexes

Answer 45

1) abdominal t10-12 2) babinski L5,S1 3) anal reflex S2-4

Question 46

Meningeal Signs

Answer 46

1) nuchal rigidity : neck resistance to flexion - > most have bacterial infection - > less with subarachnoid hem 2) brudzinkis sign - > stretches femoral n. - > flex neck , + = flexion in hips and knees 3) kerning sign - > stretches sciatic - > flex hip and knee, slowly extend leg to straight - > + = pain or increased resistance to knee ext beyond 135 degrees