Basic Neuro Exam Flashcards
A&O x4
alert to person, place, situation, and time
Dysarthria vs. Aphasia
Dysarthria- defective articulation, maybe stuttering, or difficulty physically forming words due to poor motor control of speech apparatus
Aphasia- disorder in speech caused by cortical defects (stoke) affecting Broca’s and Wernikes areas
What do you need to rule out before diagnosing dementia?
Depression and Delirium
Cranial Nerve Confrontation: how to you document?
Cranial nerves II-VII intact to confrontation (or testing)
If nerves are not directly tested but you hav spoken with the patient long enough to notice they are grossly intact, you may document “Cranial Nerves grossly intact
Deficits seen in CN III lesion
Ptosis, Pupillary dilation or asymmetry, Down and out gaze with compressive brainstem lesions
Deficits seen in CN IV lesions
CN IV is particularly susceptible to trauma given its long track around the brainstem
Extropia (lateral drifting of eye), weakened downward gaze, vertical diplopia increased when looking down, head tilting towards opposite side of the lesion (due to decreased ability to maintain eye torsion)
Deficits seen in CN VI lesions
The MOST COMMONLY isolated nerve palsy seen in pts with subarachnoid hemorrhage, late syphilis, and trauma Convergent strabismus (estropia) due to inability to abduct the eye) and Horizontal diplopia with maximal separation of images when looking towards the paretic lateral rectus muscle
Deficits seen in CN V lesions
decreased sensation to areas of face associated with specific divisions, weak muscles of mastication, loss or corneal reflex, jaw deviation towards weak side (due to unopposed action of opposite lateral pterygoid muscles)
Trigeminal Neuralgia
Recurren breif episodes of unilateral shock-like painful sensations to disctributions of the Trigeminal Nerve (CN V)
Deficits seen in CN VII lesions
Loss or corneal reflex, Bells Palsy, hyperacusis, crocodile tears syndrome, loss of taste in anterior 2/3 of tongue, decreased salivation
When do you see bilateral facial palsies?
In the Miller-Fischer variant of Guillan-Barre Syndrome
Supranuclear Facial Palsy
AKA Central Seven Palsy
Only lower part of affected side of the face is paralyzed, can still move eyebrows and orbilcularis oculi muscles
Often associated with contralateral hemiplegia
Important in differentiating between a peripheral and a central lesion
Deficits seen in CN VIII lesion
Tested with Whisper Test, Finger Rub, and Weber-Rinne
Lesion of the vestibular division results in disequilibrium (vertigo) and nystagmus
Lesions of the cochlear division results in either sensorineural hearing loss or (if only irritated) tinnitus
Deficits in CN IX
Loss of gag reflex, loss of sensation in pharynx and posterior 1/3 of tongue, slight dysphagia
Deficits in CN X
Dysphonia (irregular, hoarse voice), dysphagia, dyspnea, loss of cough reflex
Deficits in CN XI
Weakness in elevating shoulders or turning head against resistance (due to Trapezius and Sternocleidomastoid muscles respectively) Will see unilateral shoulder droop
Deficits in CN XII
A protruded tongue to deviate to the side of the lesions, patient will be unable to press tongue to the cheek of the non-affected side
What sensory dermatome is associated with the following nerve roots? C2 C3 C4 T4 T10 L1 L5 S1
C2- Auricle of ear C3- Earlobe C4 lateral neck/top of shoulders T4 nipple line T10 umbilicus L1 inguinal area L5 great toes S1 pink toes and posterolateral calf
How do you test pain/temperature?
Broken tongue depressor/ test tubes filled with warm/cold water
Testing Spinothalamic tract
How to test vibratory sense/ proprioception?
Vibratory sense- use a 128HX tuning fork on bony prominences of extremities
Proprioception- pt closes eyes and you move toes up or down and ask them to idenify the direction. Be sure to hold toes on the lateral aspects so as not to give palpatory clues
Stereognosis
Ability to identify the shaped of objects or name objects placed in the hand
Graphesthesia
Ability to identify numbers written on the palm
What pattern of sensory loss would you expect to see in a…
thalamic lesion?
Cortical lesion?
Thalamic lesion would result in a hemisensory loss of all modalities of sensation
Cortical lesion: intact primary sensation but loss of cortical sensation (unconsciously aware of the sensation, but unable to consciously perceive it)- think cortical blindness
How to test cerebellar function?
Rapid alternating movements, Finger to nose, Heel to shin, gait assessment (will be wide and unstable), Romberg, Test, Pronator drift, hopping on one leg, shallow knee bend
Gait seen in Sensory Ataxia
Unsteady, feet wide, feet thrown forward and slapped down on heels when walking, patient watches the ground
Patient cannot sense the usual proprioception and pressure associated with walking so make exaggerated movements to feel compensatory sensations higher up in the leg
Parkinsonian Gait
Stooped forward, narrow base, shuffling steps, decreased arm swing, festination (involuntary hesitation)
Causes of loss of small (anosmia)
Parkinson’s disease, trauma, sinus infection, smoking, aging, and use of cocaine
How do you test CN II?
Snellen Eye chart for visual acuity, Visual field confrontation test, pupillary light reaction (sensed by CN II, reaction CN III)
Test CN III?
H test with Near reflex test, watch for nystagmus
Testing CN V?
Sensation testing, palpated muscles of mastication.
Unilateral weakness is due to a Pontine lesion
Bilateral weakness is due to some Cerebral Hemispheric Disease since that would require bilateral cortical innervation deficits
Stoke Patterns for sensory loss
Cortical/Thalamic Lesion?
Brain stem lesion?
Cortical/thalamic lesion causes contralateral sensory loss over the ENTIRE body, both face and body
Brain stem lesion: Ispilateral loss of sensation in face and contralateral loss of sensation in the body ex. Left brainstem lesion= Left facial deficits and Right body deficits
Whisper Test
Tests CN VIII, stand 2 feet behind patient and instruct them to occlude ear not being tested. Whisper 3 numbers/letters and ask the pt to repeat it
Positive Test: When patient incorrectly names 4/6 letters
What does an abnormal Rapid Alternative Movements Test indicate?
Disdiadochokinesis
How to assess gait?
Casual Gait- patient walks normally, if unstable, called ataxic
Tandem Gait- walking heel to toe, may reveal a more subtly ataxia
Heel/Toe walk- balance as well as distal strength in dorsi and plantar flexion
Hop in place on one leg- requires position sense and cerebellar function
Shallow knee bend on one leg- ay reveal weakness of hip extensors/quads, or both
Romberg Test
Pt stands with feet together and eyes open. If unable to maintain balance with eyes open- it is a cerebellar ataxia
If able to do so with eyes open, but not when eyes are closed- it is a positive Romberg Sign
Abdominal Reflex
Testing T10-12, stroke towards umbilicus in each quadrant and one should see contraction of muscles with subtle deviation of umbilicus towards the stimulus (area just stroked)
Anal Reflex
Very important when suspicious of spinal cord injury
Test S2-4: Lightly stimulate the anus on either side, should see contraction of anal muscles “anal wink”
Commonly lost in Cauda Equina syndromes
Plantar response
Stoke the bottom of the foot from heel to toe along the lateral aspect. Adults should curl their toes in towards stimulus. Infants 4mo and younger might express the Babinski reflex where the fan their toes instead. Adults that display the Babinski reflex have some CNS lesion
What must you ABSOLUTELY do during a regular neuro exam?
Assess mental status, visual field, pupillary response, fundoscopic exam, H test, hearing, facial strength, shoulder shrugging, distal strength testing, gait assessment, coordination assessment (finger-nose), sensation testing, DTRs, and plantar response
