ECR 11.12.12 Neurological Exam Flashcards
Guiding principle for Neuro Exam (3)
- IS mental status intact (able to answer questions)
- IS my patient able to partner with me to complete an accurate and reliable exam?
- Deficients may be transient/fluctuating (frustrating b/c answers may be different later in time)
Framework
Are findings symmetric
Is process generalized or focal (localized)
Is lesion in PNS or CNS (where are the lesion? what are the lesions?)
What is the nature of the lesion/process (infectious? sudden?)
Common presentations for neuro
Headach
Dizziness, vertigo, imbalance, clumsiness
Weakness
Sensory complaints
Loss of consciousness, syncope, near-syncope
Seizures
Tremors, involuntary movements, gait distrubance
Memory Changes, confusion
What are common neurological illnesses?
Strokes Seizures Headaches eoplams Neuromuscular disorders Nerve disorders Movement disorders Neurodegenerative disorders
What else could cuase headache
hypetension
Dizziness
inner ear infection
confusion-
dementia, por oxygenation, pneumonia, pulmonary embolism
loss of consciousness
hypokalemia
arrhthymia
What are the components of a the Neuro Exam (7)
Mental Status Cranial Nerves Motor Exam Sensory Exam Reflexes Coordination Gait and Stance
What do you look for doring Motor Exam (4)
Involuntary movements
Bulk
Tone
Power/Strength
What type of involuntary movements are you looking for
Tremor Tics Dystonia Athetosis Chorea
note location, quality, rate, rhythm, amplitude, relation to posture
Tremor
can happen at rest (Parkinsons)
when trying to grab soething you might be able to see it
Dystonia
twisted posture
Athetosis
writhing movements;greater amplitude with movement
Chorea
quick movement; often not purposeful but
may try to cover it up with a seemignly purposeful gesture
Chorea happens then pat pretnes like tried to make hand out gout like that
Bulk
mass of bulk- is it waht you expect
INspect and palpate
- shape/size/mass
- symmetry
- hypertrophy
Pseudohypertropphy
muscle tissue is degenerating
show false enalrgement
Muscle dystrophy (boy on swing with hugeeee calves b/c muscle infiltrated with iprprer tissue)
Atrophy
lower motor neuron- wasting disease
Tone
tension detected in muslce
normally slight residual maintained even at rest
palpate resitsnce ith movmeent through ROM
What are different tone
normal
hypertonic- inc tone
hypotonic- dec dtone
flaccid- complete absence of toen
Spasticity vs rigidity
Spastic- resistance at extremems/end of motion
Rigidity- same resistance ENTIRE motion
What is grading scale for Strength?
0-5
0- no muscle contrction
1- barely detectable flicker/trace of contraction
2- movement with gravity eliminated
3. movement with gravity, no resisitance
4. movement with gravity, with resistance
5. Normal muscle strenght** active
What is the grade for NORMAL Strength
5
What is paresis
IMPAIRED strength/weakness
What is plegia
ABSENCE of strength/paralysis
what are the different types of plegias?
hemiparesis
hemiplegia
paraplegia
quadriplegia
what is a parapleegia? Quadirplegia?
paraplegia- both legs paralyzed
Quadriplegia- all four limbs paralyzed (often spinal cord injury)
What are the primary modalities that you check for sensory exam?
pain (spinal) Temp (spinal) Proprioception (position) (Dorsal) vibration (Dorsal) light touch *Distcriminateive sensation
How do you assess pain
sharp object
how do you assess temp
cool side of tunign fork
Howdo ou assess postion/proprioception
moving digit
How d oyu assess vibration
128 Hz tunign fork
How do you assess light touch
cotton swab or fingers
What dermatone is T10
umbilicas
dermatome for T4
Nipple
Dermatome for C7
middle finger
Dermatome for L5
big toe
what is a dermatome
band of skin innervated by sensory root of a single spinal nerve
What is a reflex?
involuntary stereoteypical repsonse
Predictable reaction to standardized stimulus
What are the three types of reflexes
DTR- deep tendon reflex
Cutaneious stimulous reflexes
Primitive reflexes (beydong tis class)
Describe DTR
Deep Tendon Reflex
simplest of relfexes- monosynaptic, strike tendon with reflex hammer
Strike tendo
What are the DTR (5)
S1- Achilles L 2,3,4- Patellar C5,6- Brachioradialis C5,6- Biceps C7- Triceps
What is the grading for DTR
0-4+
0 = no response 1+ somewhat diminished, low normal 2+ average; noraml 3+ Brisker than avg (possibly, but not necessarily indicative of disease) 4+ Very brisk, hyperactive with Clonus
What is normal grading for DTR
2+
What is clonus
sustained rhythmic beating between flexion and extension
What are the superficial Cutaneous reflexes (4)
Abdominal Reflexes (T8-T12) Cremasteric Reflex (L1-L2) Babinski Reflex/ extensor plantar response (L5, S1) Anal REflex (S2-S4)
Abdominal Reflex
T8-T12
polysynaptic, more complicated
Strok outer quadrant, umbilicus mucles pulltoward stimulated area
May not respond (pregnant, surgery),
Cremasteric Reflex
L1-L2
stroke inner thigh and testes raises
Babsinki Response
L5,S1
Extensor platnar reposne
Normal: great toe plantarflex
Abnormal” Great toe dorsiflex, toes fan
Upper motor neuron defet! Stroke lateral aspect of foot; then cross-
babies hav+ Babinski till 6 months
Superficial Cutaneous Grading
Not graded!
Either present or absent!
Asymmetry is important to note
UMN or LMN lesion
What does Coordination require integration of fucntion of
- Cerebellarsystem (rhythmic, smooth, sequential movment)
- Motor System
3 Vestibular System: balance and coordinating eye - Sensory system : position sense
How do you test Coordination
1 Rapid Alternating Movements (RAM)
- Point to point movements
- Gait
- Stance
Cerebellar system
rhtymic, smooth, sequential movment and steady psoture
Motor system
strength
Vestibular system
balance and coordinating eye, head, body movements
sensory system
position sense
How do you test RAM coordination
Rapid Alternating Motion
Upper Extremity- Hands alternate palm and dorsum of hand on the thigh rapidly
Lower extremity- Tap foot against examiners hand
Dysdidiadochokinesis
What is Dysdiadochokinesis
slow, irregular, slumspy movements in response to attempt to alternately contract and relax agonist and antagonist muscles or muscle groups
Slow, irregular; lack of coordination
Can’t do RAM
Coordination : Point to Point
Finger-to-nose (F–> N)
Heel to shin (H–>S)
Dymetria
What is Dysmetria
difficulty with F–>N and H–>S (Point to Point)
inability to control muscle action required to move a body part smothly in a specific direaction or along aaprticular course
What is ataxia
lack of muscle coordinatino during voluntary movement
usually gait; but any voluntary movmvent
What is gait
process of recruiting and coordinating activity of various mucle groups of LE, UE, andn trunk to rpoduce at of walking
How do you test gait?
Normal gait across room
Tandem gait (drunk test)
Walk on toes; walk on heels
How do you test stance/station
measure of postural control
observe patietn standing
Romberg tst
Pronatory drift
What is romberg test
tests mainly for posiition sese
take aw ay vision, stay in one place with eyes closed
Pronator drift
detects subtle weakness (cerebellar disease)
arms out with eyes closed
if weakness in one arm, might drop/ pronate
What is the neurologic ROS
chagnes in mood, attention, or speech; changes in orientation, memory, insight, or judgemnt;
headache, dizziness, vergito; fainting, balckouts, seizures, weakness, paralysis, numbess of loss of snestiano, tingling or pins and needles’ termors or othe ronvlntary movments seizsures
What is the neurologic ROS
chagnes in mood, attention, or speech; changes in orientation, memory, insight, or judgemnt;
headache, dizziness, vergito; fainting, balckouts, seizures, weakness, paralysis, numbess of loss of snestiano, tingling or pins and needles’ termors or othe ronvlntary movments seizsures
