Assess mental status General appearance/presentation Orientation x 4 Test cranial nerves Assess motor system Inspection Muscle strength Assess sensory system Light touch, superficial pain, vibratory sense, proprioception Check deep tendon reflexes (DTRs) Test cerebellar function Rapid alternating movements, point-to-point movements, gait Special tests, if indicated (by PE or ROS)

CA powerpoints Flashcards by Sasha Bonney

7 Major components of the Neurological exam

Mental Status
Cranial Nerves (I-XII)
Motor System
Cerebellar Function
Sensory System
Deep Tendon Reflexes (DTRs)
Special Tests, if indicated

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Is the mental status intact?
Are your findings symmetric?
Where is the lesion? If findings are asymmetric or abnormal, is the lesion in the central nervous system or in the peripheral nervous system?

what are these questions?

questions to really think about when seeing a pt

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brain, brainstem, spinal cord

CNS

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12 CNs and peripheral nerves (including spinal nerves – 8 cervical, 12 thoracic, 5 lumbar, 5 sacral and 1 coccygeal)

PNS

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Organization of Exam

Assess mental status
- General appearance/presentation
- Orientation x 4
Test cranial nerves
Assess motor system
- Inspection
- Muscle strength
Assess sensory system
- Light touch, superficial pain, vibratory sense, proprioception
Check deep tendon reflexes (DTRs)
Test cerebellar function
- Rapid alternating movements, point-to-point movements, gait
Special tests, if indicated (by PE or ROS)

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Reflects the patient’s capacity for arousal or wakefulness; determined by level of activity that patient can be aroused to perform in response to stimuli from examiner

Level of Consciousness

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–Do NOT dilate pupils

–Do NOT flex neck if there is any question of trauma to head or neck (x-ray first)

patient in stupor or coma…

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using normal tone of voice, patient’s arousal intact; responds fully & appropriately

Alert

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using loud tone of voice, patient appears drowsy but opens eyes and responds then falls asleep

Lethargic

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shake patient gently; patient opens eyes but responds slowly, somewhat confused (ie drunk)

Obtunded

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apply painful stimulus to arouse patient from sleep, verbal responses slow/absent, unresponsive when stimulus ceases

Stuporous

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unarousable w/ eyes closed after repeated painful stimuli, no response to environment

…painful stimuli with no response….

Comatose

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Explain the 3 main aspects of the glasgow coma scale and then the ratings under each main componenet

I know this is a long flashcard but this is important to known… i can see her explaining a pt and asking us to assess what their glasgow coma scale is. At least those are questions they would do in my EMT class who knows…..

•Eye opening

–None (1) Even to supraorbital pressure

–To pain (2) Pain from sternum/limb/supraorbital pressure

–To speech (3) Nonspecific response, not necessarily to command

–Spontaneous (4) Eyes open, not necessarily aware

•Motor response

–None (1) To any pain; limbs remain flaccid

–Extension (2) Shoulder adducted and shoulder and forearm internally rotated

–Flexor response (3) Withdrawal response or assumption of hemiplegic posture

–Withdrawal (4) Arm withdraws to pain, shoulder abducts

–Localizes pain (5) Arm attempts to remove supraorbital/chest pressure

–Obeys commands (6) Follows simple commands

•Verbal response

–None (1) No verbalization of any type

–Incomprehensible (2) Moans/groans, no speech

–Inappropriate (3) Intelligible, no sustained sentences

–Confused (4) Converses but confused, disoriented

–Orientated (5) Converses and is oriented

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hIghest grade you can get on glasgow coma scale

and lowest

Lowest 3

Higherst 15

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patients w/ scores of 3-8

usually are considered to be in a coma

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no pupillary reaction to light

probably mid brain issue

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Midposition fixed pupils
One large pupil
Small or pinpoint pupils
Large pupils

Pupils in Comatose Patients

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When testing if meningeal inflammation first, make sure there is NO

injury to cervical vertebrae or spinal cord (if trauma, x-ray first)

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with patient supine place hand behind the patient’s head flex neck forward, chin to chest (check for nuchal rigidity)

•Test if meningeal inflammation suspected (eg, meningitis or subarachnoid hemorrhage)

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•Positive if flexion of both hips & knees is noted when neck is flexed

Brudzinski’s Sign

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•Positive if pain & increased resistance is noted to straightening the knee after hip & knee are flexed

Kernig’s Sign

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Fever, headache and altered level of concisouness

with menengitis

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Test if mental function is impaired; may indicate

metabolic encephalopathy

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Ask patient to “stop traffic” by extending both arms w/ hands cocked up – watch for 1 to 2 minutes
Positive if sudden, brief, nonrhythmic flexion of hands and fingers

Asterixis

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CN I

smell

CN II

– visual acuity, visual fields, funduscopic exam

CN II, III

– pupillary reactions (direct and consensual)

CN III, IV, VI

extraocular movements (including convergence)

CN V

corneal reflexes, facial sensation (3 areas), clinch teeth

CN VII

facial movements (raise eyebrows, close eyes, smile, frown, show upper/lower teeth, puff out cheeks)

CN VIII

hearing (whispered voice) (sensory/neuro or cognitive loss)

CN IX, X

swallow, say “ah,” gag reflex

CN V, VII, X, XII

voice and speech

CN XI

shoulder and neck movements

CN XII

tongue symmetry and position

with excessive brain swelling you may see _____________ so look in daaa eye

papillary edema (swelling around disc)

Weber is testing for? if conductive loss? If sensorineural hearing loss?

* Test for lateralization * If conductive hearing loss, lateralizes to impaired ear * If sensorineural hearing loss, lateralizes to good ear

impaired “air through ear” transmission

loss is conduction

from damage to cochlear branch of CN VIII

sensorineural

Rinne testing for what? if sensorineural hearing loss? if conductive hearing loss?

* Test for air and bone conduction * If sensorineural hearing loss, AC\>BC * If conductive hearing loss, BC=AC or BC\>AC AC: air conduction BC: Bone conduction

sinusitis, smoking, aging, cocaine use, Parkinson’s disease

CN I

papilloedema, glaucoma, stroke, retinal emboli, optic neuritis, pituitary tumor

CN II

\***anisocoria (unequal pupils)**, intracranial hemorrhage, transtentorial herniation, Horner’s syndrome \*anisocoria can be a normal variant in a percentage of people

CN II, III

**nystagmus** (involuntary jerking movement of eyes), **\*ptosis** (drooping of upper eyelids), **diplopia**, astigmatism, myasthenia gravis, Grave’s disease, Horner’s syndrome, cerebellar disease

CN III, IV, VI

stroke, CNS lesions, trigeminal neuralgia, acoustic neuroma

CN V

Stoke, Bell's Palsy

CN VII

cerumen impaction, otitis media, Meniere’s disease, aging

CN VIII

pharyngeal weakness, CN X lesion

CN IX, X

**aphonia** (loss of voice) due to vocal cord paralysis, **dysarthria** (poor articulation) due to cerebellar disease, **aphasia** (disorder in producing or understanding language) such as Wernicke’s aphasia or Broca’s aphasia

CN V, VII, X, XII

trapezius atrophy due to peripheral nerve disorder, bilateral weakness of sternomastoids

CN XI

cortical lesion, amyotrophic lateral sclerosis, polio

CN XII

–Body position –Involuntary movements –Characteristics of muscles (bulk, tone, & strength) –Coordination (includes cerebellar function)

Things to focus on in motor system

3 types of tremors

1. resting 2. postural 3. intention

pill-rolling tremor of parkinsonism

resting tremor

, benign essential/familial tremor

Postural tremor

cerebellar disease, multiple sclerosis

Intention tremor

–Oral-facial dyskinesias (eg, tardive dyskinesia) –Tics (eg, Tourette’s syndrome) –Dystonia (eg, torticollis) –Athetosis (eg, cerebral palsy) --Chorea (eg, Huntington’s disease)

•Involuntary movements

increased tone; rate-dependent, increasing w/ rapid movement(eg, stroke)

Spasticity

– increased resistance throughout ROM; it is not rate-dependent; “lead pipe rigidity.”

Rigidity

marked floppiness (eg, Guillain-Barre & spinal shock)

Flaccidity

sudden changes in tone w/ passive ROM (eg, dementia)

Paratonia

* 0 = No contraction noted * 1 = Barely detectable contraction * 2 = Active movement with gravity eliminated * 3 = Active movement against gravity * 4 = Active movement against gravity & some resistance * 5 = Active movement against full resistance w/o evident fatigue – This is NORMAL strength

Scale for Grading Muscle Strength

dermatones

Dermatomes of cervical spine

for C4-C5, its the ______ nerve thats affected but for T4-T5, it would be ______ affected because of that extra C8 nerve

that like for C4-C5, its the C5 nerve thats affected but for T4-T5, it would be T4 affected because of that extra C8 nerve

Deltoid and biceps (shoulder abduction and elbow flexion)

Biceps flexion and wrist extensors

Triceps, wrist flexors and finger extensors

:Finger flexors and interossei muscles (aB and aD duction of the fingers)

Interossei muscles ONLY

head

C1-C2

Diaphragm, breathing

C3-C4

Go back to the ppt and look at the cool images from slide 28-32... the pictures are not copying over well to brain scape

fhdusiagvidsoabvisdba neuro hdiasbgjdsabvjdabvdja

Dermatomes of Lumbar Spine

Hip flexion

Knee extension

Ankle dorsiflexion

Great toe extension

AnkIe plantar flexion, ankle eversion, hip extension

Knee flexion

again look at the cool pictures about L roots from slide 35-37

or dont... doesnt really matter haha

If shoulder muscles seem weak or atrophic, look for

winging

•Ask patient to extend both arms and push against a wall

looking for winging of scapula

\_\_\_\_\_\_\_\_\_\_\_ if medial border of scapula juts backward, suggesting weakness of serratus anterior muscle, seen in muscular dystrophy or injury to long thoracic nerve

winging

If patient has low back pain w/ lumbosacral radiculopathy (sciatica if in S1 distribution), test

Straight-leg raise on each side

•Positive for lumbosacral radiculopathy if pain radiates into ipsilateral leg (foot dorsiflexion can further increase leg pain)

Straight-Leg Raise

3 types of Cerebellar Function Tests

**•Rapid alternating movements** –In cerebellar disease, dysdiadochokinesis is noted **•Point-to-point movements** **•Gait** –In cerebellar disease, ataxia is noted

balance disorder

Cerebellar dysfunction

•Stand w/ feet together and eyes open, then close eyes for 30-60 seconds, only minimal sway should occur

Romberg Test

•Stand for 30 seconds w/ arms straight forward, palms up and eyes closed. Then, tap arms briskly downward at the same time

Test for Pronator Drift

Abnormalities in gait Spastic Hemiparesis

Spastic gait scissors gait

Abnormalities in gait Parkinsonian Gain

Propulsive gait Steppage gait

cerebellar ataxia

wide and unsteady gait

sensory ataxia

wide, unsteady AND heel strikes first

Sensory Sytsem 4 exam tests

* Light touch * Pain (dull + sharp) * Vibration * Proprioception

•If touch and position sense are intact, you can proceed to testing the sensory cortex w/ \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

discriminative sensations

–Stereognosis –Graphesthesia –Two-point discrimination –Point localization –Extinction

discriminative sensations (testing of sensory cortext)

Ankle reflex

primary S1

Knee reflex

L2, L3, L4

Brachioradialis reflex

C5, C6

Biceps reflex

C5, C6

Triceps reflex

C6, C7

If DTRs (deep tendon reflexes) seem hyperactive (4+), test for \_\_\_\_\_

clonus

•Dorsiflex and plantar flex foot a few times then sharply dorsiflex foot and hold – look/feel for rhythmic oscillations between dorsiflexion and plantar flexion

testing for Clonus

•If clonus present, may indicate

central nervous system disease

Cutaneous Stimulation Reflexes •Briskly stroke each side of abdomen above (T8, T9, T10) & below (T10, T11, T12) umbilicus w/ wooden end of cotton-tipped applicator

Abdominal Reflexes

if Abdominal Reflexes absent

may indicate central or peripheral nerve disorders

* Stroke lateral aspect of sole from heel to ball of foot, curving medially across the ball – note movement of great toe * Positive if **dorsiflexion of great toe**

Babinski Response (L5, S1)

dorsiflexion of great toe in Babinski response may indicate:

–CNS lesion in corticospinal tract –Unconscious states from drugs/alcohol intoxication –Postictal period after seizure

•Using dull object (eg, cotton swab), stroke outward in 4 quadrants from anus

Anal reflex

If loss of anal reflex contraction, may indicate

cauda equina lesions (S2-3-4)

so what are the 4 relfexes we jsut learned?

–assessing DTRs (like we have always done) –Clonus –Abdominal Reflexes –Babinski Response

* Used to diagnose stroke, determine location and size of tumor, aneurysm, or vascular formation * Dye injected via capsule placed via catheter * Serial x-rays taken * Negative side effects; warmth, slight discomfort

Cerebral Angiogram

used to diagnose neuromuscular disorders (may also confirm carrier status for genetic disorders)

Muscle and/or nerve biopsies

are used to determine tumor type

•Brain biopsies

* the removal of small amount of spinal fluid via bedside sterile procedure * \*\*Common after affect is a headache – helped by having the patient lie flat * Diagnostic of infections such as meningitis, helps in diagnosis of MS, measure of intracranial pressure

Lumbar Puncture - “Spinal Tap” Cerebrospinal Fluid Analysis

3 contraindications for LP

* Increased Intracranial Pressure * Coagulopathy * Brain Abscess

* Age \> 60 * Immunocompromised * Known CNS Lesions * Seizure in last week * Altered Consciousness * Focal findings on Neurological Exam * Papilledema on Physical Exam

Perform a Brain CT Prior to LP….

Lab Studies Performed on Cerebrospinal Fluid

* Cell Count and differential * Glucose and protein levels * Gram stain, culture and sensitivity * Viral titers, VDRL tests, Crytococcus Antigen, ACE levels, others

Position for LP

* Noninvasive, Painless * Detect bone and vascular, certain brain tumors, cysts, herniated discs, spinal stenosis, encephalitis, blood accumulation, intracranial bleeding in stroke, tissue damage in trauma * Drawbacks – some radiation (avoid in pregnancy), dye sensitivities when dye used, claustrophobic patients

CT Scan

* Small amount of dye injected via x-ray guidance into the spinal disc, CT then completed * May cause some residual discomfort requiring short term pain medication

Discography

* Used to detect problems with spine and spinal nerve roots * Lumbar Puncture – fluid is mixed with contrast dye and injected into spinal sac. * Allows for clearer image of spinal canal and nerve roots * Patient may have post procedure headache, residual pain

Cisternography – Intrathecal contrast-enhanced CT Scan

* Monitors brain activity through the skull * Assists in diagnosis of seizure disorders, tumor, tissue damage post TBI, inflammation of the brain/spinal cord, psychiatric disorders, sleep disorders * Pre procedure – patients should avoid caffeine and rx/non rx drugs that impact nervous system

Electroencephalography (EEG)

* Diagnoses nerve and muscle dysfunction and spinal cord disease * Measures electrical activity from brain and/or spinal cord to a peripheral nerve root * Usually completed in conjunction with a Nerve Conduction Velocity (NCV) test – which measures electrical energy by assessing the nerve’s ability to send a signal

Electromyography (EMG)

* A group of tests used to diagnose disorders such as involuntary eye movement, dizziness and balance disorders * Involved electrode taped around eyes to record eye movements * Infrared photography may also be used to evaluate eye movements

Electronystagmography (ENG)

* Measure the electrical signals to the brain generated by hearing, touch, and sight. * Used to evaluate sensory nerve problems, confirm MS, brain tumor, acoustic neuroma, spinal cord injury

Evoked Potentials (also called Evoked Response)

•acoustic issues

Auditory evoked potentials

detect loss of vision from optic nerve nerve damage

Visual evoked potentials

evaluate for nerve damage or degeneration from cord injury or deg. disease

Somatosensory EP

* Used extensively – assists in diagnosis of brain and spinal cord tumor, eye disease, inflammation, infections, vascular irregularities that can lead to stroke * May also be used to monitor degenerative disease * Used to quantify brain trauma

MRI

* Injection of a water or oil based contrast dye into the spinal cord to enhance x-ray imaging of the spine * Used to diagnose spinal nerve injury, herniated discs, fractures, back or leg pain, and spinal tumors * Again – patients may experience headache post lumbar puncture

Myelography

* Provides 2 and 3 dimensional pictures of brain activity by measuring radioactive isotopes that are injected into the bloodstream. * Used to detect or highlight tumors, diseased tissue, measure cellular and/or tissue metabolism, monitor blood flow, determine brain injury post trauma, substance abuse

Positron Emission Tomography (PET Scan)

* Measures brain and body activity during sleep * Used to detect sleep disorders, restless leg syndrome, insomnia, obstructive sleep apnea * Painless, noninvasive, risk-free

Polysomnogram

* Evaluates blood flow to tissue * Follow up test to MRI to diagnose tumors, infections, degenerative spinal disorders, stress fractures. * Same theory as PET utilizing radioactive isotope, a rotating camera and production of a detailed 3 dimensional image of blood flow and activity in the brain

Single Photon Emission CT (SPECT)

* Analysis blood flow to the brain and can diagnose stroke, brain tumors, hydrocephalus and vascular problems * Fetal Ultrasound to Determine Pathology prior to birth

Neurosonography (Ultrasound of Brain and Spinal Cord)

used to view arteries and blood vessels in neck, determine risk of stroke

Transcranial Doppler US

* Uses infrared sensing devices to measure small temperature changes between the two sides of the body or within a certain organ * Used to detect vascular disease of head and neck, soft tissue injury, nerve root compression, some degenerative disorders * Generates a 2 dimensional picture, is safe, risk-free

Thermography (Infrared Thermal Imaging)