Exam 4: Neuro Flashcards
How to assess in infant:
CN XI
Spinal Accessory
- Observe symmetry of shoulders
Which gender has a lower age-specific stroke incidence rate but higher lifetime risk for stroke?
Women
(b/c live longer then men)
The Biceps Reflex:
What spinal nerve roots are involved?
How do you test?
What is a normal reaction?
C5, C6
- The pt’s elbow should be partially flexed and the forearm pronated with palm down.
- Place your thumb/finger firmly on the biceps tendon.
- Aim the strike with the reflex hammer directly through your digit toward the biceps tendon.
Observe flexion at the elbow, and watch for and feel the contraction of the biceps muscle.
How to assess in infant:
CN XII
Hypoglossal
- Observe coordination of sucking, swallowing, and tongue thrusting
- Pinch nostrils; observe reflex opening of mouth w/ tip of tongue to midline.
The Anal Reflex
What spinal nerve roots are involved?
How do you test?
What is a normal reaction?
What does abnormal indicate?
S2-4
- Using a broken applicator stick or pinprick, lightly scratch the anus on both sides.
- Watch for reflex contraction of the external anal sphincter by placing a gloved finger in the anus during testing.
Loss of the anal reflex suggests a lesion in the S2–3–4 reflex arc, seen in cauda equina lesions.
How do you test neck Brudzinski Sign?
What do positive results indicate?
As you flex the neck, watch the hips and knees in reaction to your maneuver. Normally they should remain relaxed and motionless.
+ test: Flexion of both the hips and knees.
Suggests meningeal inflammation from meningitis or subarachnoid hemorrhage.
Cranial Nerve IX
What is the name?
How to perform test?
Abnormal finding indicates
Glossopharyngeal
- Listen to voice (hoarse, nasal?)
- Difficulty swallowing?
- Pt say “ah”- observe mvmt of soft palate/pharynx.
- Gag reflex
Hoarseness-vocal cord paralysis
Dysphagia-pharyngeal or palatal weakness
What are the corresponding clinical finding(s) to a stroke in the Subcortical circulationa— lenticulostriate deep penetrating branches of MCA
Contralateral motor or sensory deficit without cortical signs
Occlusion of the middle cerebral artery (MCA) has what clinical finding?
- Visual field cuts
- Contralateral hemiparesis
- Sensory deficits
The Brachioradialis Reflex
What spinal nerve roots are involved?
How do you test?
What is a normal reaction?
C5, C6
- The pt’s hand should rest on the abdomen or the lap, with the forearm partly pronated.
- Strike the radius with the point or flat edge of the reflex hammer, about 1-2in. above the wrist.
Watch for flexion and supination of the forearm.
How to assess sensory function in the infant?
What would abnormal findings indicate?
- Test for pain sensation by flicking the infant’s palm or sole with your finger.
- Observe for withdrawal, arousal, and change in facial expression.
If changes in facial expression or cry follow a painful stimulus but no withdrawal occurs, weakness or paralysis may be present.
How to assess in infant:
CN II
Visual acuity
Have infant regard your face & look for facial response & tracking.
How to assess in infant:
CN II, III
Response to light
- Darken room, raise infant to sitting position to open eyes.
- Use light & test for optic blink reflex (blink in response to light).
- Use the otoscope’s light (w/o speculum) to assess pupillary responses.
Positive Support Reflex
What age?
How to assess?
What would abnormal findings indicate?
Birth or 2 mo until 6 mo
- Hold infant around the trunk & lower until feet touch flat surface.
- The hips, knees, & ankles will extend, the infant will stand up, partially bearing weight, sagging after 20-30 seconds.
Lack of reflex suggests hypotonia or flaccidity.
Fixed extension & adduction of legs (scissoring) suggests spasticity from neurologic disease (CP).
How is muscle strength graded?
0 —No muscular contraction detected
1 —A barely detectable flicker or trace of contraction
2 —Active movement of the body part w/ gravity eliminated
3 —Active movement against gravity
4 —Active movement against gravity and some resistance
5 — Active movement against full resistance w/o evident fatigue (normal muscle strength)
Cranial Nerve X
What is the name?
How to perform test?
Vagus
- Listen to voice (hoarse, nasal?)
- Difficulty swallowing?
- Pt say “ah”- observe mvmt of soft palate/pharynx.
- Gag reflex
The Abdominal Reflexes
How do you test?
What is a normal reaction?
- Lightly but briskly stroke each side of the abdomen, above (T8, T9, T10) and below (T10, T11, T12) the umbilicus towards the center.
- Use a key, the wooden end of a cottontipped applicator, or a tongue blade twisted and split longitudinally.
- If obese or previous abd surgery, retract pt’s umbilicus away from the side being tested with your finger and feel for the muscular contraction.
Note the contraction of the abdominal muscles and movement of the umbilicus toward the stimulus.
Abdominal reflexes may be absent in both central and peripheral nerve disorders.
What are some common or concerning symptoms that the FNP should assess for as part of the neurological history?
- Headache
- Dizziness or vertigo
- Weakness (generalized, proximal, or distal)
- Numbness, abnormal or absent sensation
- Fainting and blacking out (near syncope and syncope)
- Seizures
- Tremors or involuntary movements
Cranial Nerve I
What is the name?
How to perform test?
Abnormal finding indicates
Olfactory
- Present pt w/ familiar non-irritating odors (cloves, coffee, soap, vanilla)
- Compress 1 side of nose & sniff thru other
- Close both eyes, occlude 1 nostril & test smell in other w/ substance.
- Repeat on the other side.
Loss of smell occurs in sinus conditions, head trauma, smoking, aging, use of cocaine, and Parkinson disease.
Asymmetric Tonic Neck Reflex
What age?
How to assess?
What would abnormal findings indicate?
Birth to 2 mo
- With the infant supine, turn head to one side, holding jaw over shoulder.
- The arms/legs on side to which head is turned will extend while the opposite arm/leg will flex.
- Repeat on other side.
Persistence > 2 mo suggests asymmetric CNS development & sometimes predicts development of CP.
How do you test Stereognosis? What could abnormal findings indicate?
- The ability to identify an object by feeling it.
- Place a familiar object (coin, paper clip, key) in pt’s hand and ask the patient to tell you what it is.
- Normally a patient will manipulate it skillfully and identify it correctly w/in 5 sec.
- Astereognosis refers to the inability to recognize objects placed in the hand.
Parachute Reflex
What age?
How to assess?
What would abnormal findings indicate?
8 mo & does not disappear
- Suspend infant prone & slowly lower head toward a surface.
- The arms & legs will extend in a protective fashion.
Delay in appearance may predict future delays in voluntary motor development.
What are the five categories of the neurological exam?
1. Mental status
2. CNs I-XII
3. Motor system: muscle bulk, tone, strength, coordination, gait, stance
4. Sensory system: pain, temperature, position, vibration, light touch, discriminative sensation
5. Deep tendon, abdominal, plantar reflexes
Rooting Reflex
What age?
How to assess?
What would abnormal findings indicate?
Birth to 3-4 mo
- Stroke the perioral skin at the corners of the mouth.
- The mouth will open & the infant will turn head toward the stimulated side & suck.
Absence of rooting indicates severe generalized or CNS disease.
Moro Reflex (Startle Reflex)
What age?
How to assess?
What would abnormal findings indicate?
Birth to 4 mo
- Hold the infant supine, supporting the head, back, & legs.
- Abruptly lower the entire body about 2 ft.
- The arms will abduct & extend, hands will open, & legs will flex. Infant may cry.
Persistence > 4 mo suggests neurologic disease (e.g., CP); > 6 mo strongly suggests it.
Asymmetric response suggests fracture of clavicle or humerus or brachial plexus injury.
What presents with severe headache and stiff neck?
Meningitis
Cranial Nerve XII
What is the name?
How to perform test?
Abnormal finding indicates
Hypoglossal
Tongue symmetry, position, & movement
- Listen to word articulation
- Inspect tongue lying on floor of mouth (atrophy, fasciculations)
- Protrude tongue (asymmetry, atrophy, deviation from midline?)
- Tongue side to side (symmetry of mvmt)
Tongue atrophy and fasciculations are present in ALS and past polio.
In a unilateral cortical lesion, the protruded tongue deviates away from the side of the cortical lesion. In CN XII lesions, the tongue deviates to the weak side.
The Achilles (Ankle) Reflex
What spinal nerve roots are involved?
How do you test?
What is a normal reaction?
Primarily S1
- If pt is sitting: partially dorsiflex the foot at the ankle. Patient relax. Strike the Achilles tendon.
- If pt is lying down: flex 1 leg at both hip and knee and rotate it externally so that the lower leg rests across the opposite shin. Then dorsiflex the foot at the ankle and strike the Achilles tendon.
Watch and feel for plantar flexion at the ankle and note the speed of relaxation after muscular contraction.
What exam findings would be present in the newborn that has been exposed to maternal substance abuse or the infant experiencing neonatal abstinence syndrome?
Subtle neonatal behaviors may indicate withdrawal from nicotine if the mother smoked during pregnancy such as:
- fine tremors
- persistent irritability
- poor self-regulation
What are Resting (Static) Tremors? Give example.
Are most prominent at rest and may decrease/disappear w/ voluntary movement.
Common relatively slow, fine pill-rolling tremor of parkinsonism, about 5/second.
What are stroke risk factors for women?
- Autoimmune collagen vascular disease
- History of preeclampsia
- Gestational diabetes
- Pregnancy-induced HTN
How do you test neck Kernig Sign?
What do positive results indicate?
- Flex the pt’s leg at both the hip and the knee
- Then slowly extend the leg and straighten the knee.
Discomfort behind the knee during full extension is normal but should not produce pain.
+ test: Pain and increased resistance to knee extension.
Suggests meningeal inflammation from meningitis or subarachnoid hemorrhage.
The Plantar Response
What spinal nerve roots are involved?
How do you test?
What is a normal reaction?
What does abnormal indicate?
L5, S1
- With a key or the wooden end of an applicator stick, stroke the lateral aspect of the sole from the heel to the ball of the foot, curving medially across the ball.
- Closely observe movement of the big toe, normally plantar flexion.
- Some pts withdraw from this stimulus by flexing the hip and the knee.
Dorsiflexion of the big toe is a positive Babinski response, arising from a CNS lesion affecting the corticospinal tract. The Babinski response can be transiently positive in unconscious states from drug or alcohol intoxication and during the postictal period following a seizure.
A marked Babinski response is occasionally accompanied by reflex flexion at hip and knee.
What presents as dull headache increased by coughing and sneezing, especially when recurring in the same location
Mass lesions (brain tumors, abscess)
Individuals with TIA have a 1-year mortality of ___%.
10-year risks for stroke from cardiovascular disease are ___%.
10-year risks for death from cardiovascular disease are ___%.
1 year: ∼12%
10 year stroke: 19%
10 year death: 43%
Plantar Grasp Reflex
What age?
How to assess?
What would abnormal findings indicate?
Birth to 6-8 mo
- Touch the sole at the base of the toes.
- Toes will curl.
Persistence of reflex > 8 mo suggests pyramidal tract dysfunction.
Cranial Nerve III
What is the name?
How to perform test?
Abnormal finding indicates
Oculomotor
- Pupillary reactions to light
- Near response (constriction and accommodation)
- EOM
- Convergence of the eyes
- Identify any nystagmus, diplopia, ptosis
Abnormalities: Anisocoria, abnormal constriction-CN III palsy, ptosis + opthomoplegia – intracranial aneurysm (awake), transtentorial herniation (comatose); if anisocoria worsens in darkness, the small pupil has abnormal dilation-Horner syndrome (unequal pupils and worsens in darkness, nothing to do for it, just monitor by optho) and simple anisocoria
Cranial Nerve VIII
What is the name?
How to perform test?
Abnormal finding indicates
Acoustic
- Whispered voice test
- If fail whisper test:
- Rinne (air & bone conduction)
- Weber (lateralization)
Excess cerumen, otosclerosis, and otitis media cause conductive hearing loss.
Presbyacusis from aging from sensorineural hearing loss.
Vertigo with hearing loss and nystagmus –Meniere disease.
Placing & Stepping Reflexes
What age?
How to assess?
What would abnormal findings indicate?
Birth (best after 4 days; variable age to disappear)
- Hold infant upright.
- One sole touch tabletop.
- The hip & knee of that foot will flex & the other foot will step forward.
- Alternate stepping will occur.
Absence of placing may indicate paralysis.
Newborns born by breech delivery may not have a placing reflex.
Cranial Nerve V
What is the name?
How to perform test?
Abnormal finding indicates
Trigeminal
- Corneal reflexes
- Touch cornea w/ cotton.
- Jaw movements
- Clench teeth
- Open & move jaw side to side
- Facial sensation
- Pain on forehead, cheeks, & chin. Eyes closed.
- If detect sensory loss, confirm using temperature sensation.
Unilateral jaw weakness: pontine lesions
Bilateral weakness: bilateral hermispheric dz
Stroke: ipsilateral facial and body sensory loss from contralateral cortical or thatlmic lesions
Blinking absent on both side with CN V lesions
Trunk Incurvation (Galant Reflex)
What age?
How to assess?
What would abnormal findings indicate?
Birth to 2 mo
- Support the infant prone w/ one hand & stroke one side of the back 1cm from midline, from shoulder to buttocks.
- The spine will curve toward the stimulated side.
Absence suggests a transverse spinal cord lesion or injury.
Persistence may indicate delayed development.
What are Intention Tremors? Give example.
Are absent at rest, appear with movement and often get worse as the target gets closer.
- Cerebellar disorders (multiple sclerosis)
Cranial Nerve II
What is the name?
How to perform test?
Abnormal finding indicates
Optic
- Visual acuity
- Inspect the optic fundi and discs
- Visual fields by confrontation- each eye separately then both together
- Pupillary reactions to light
- Near response
Stroke: partial loss of vision, visual field defect
Cranial Nerve VII
What is the name?
How to perform test?
Abnormal finding indicates
- Raise both eyebrows.
- Frown.
- Close both eyes tightly so you can’t open them. Test muscular strength by trying to open them.
- Show both upper and lower teeth.
- Smile.
- Puff out both cheeks.
Blinking absent one the side of weakness in lesions of CN VII.
Flattening of the nasolabial fold and drooping of the lower eyelid suggest facial weakness
Bells palsy (upper & lower face)
Cranial Nerve VI
What is the name?
How to perform test?
Abnormal finding indicates
Abducens
- EOM
- Convergence of the eyes
Identify any nystagmus (may be associated with cerebellar dz), diplopia, ptosis
Landau Reflex
What age?
How to assess?
What would abnormal findings indicate?
Birth to 6 mo
- Suspend the infant prone w/ one hand.
- The head will lift up, & the spine will straighten.
Persistence may indicate delayed development.
Palmar Grasp Reflex
What age?
How to assess?
What would abnormal findings indicate?
Birth to 3-4 mo
- Place your fingers into the infant’s hands & press against the palmar surfaces.
- The infant will flex all fingers to grasp your fingers.
Persistence of palmar grasp reflex >4 mo suggests pyramidal tract dysfunction.
Persistence of clenched hand >2 mo suggests CNS damage (esp if fingers overlap the thumb)
The Triceps Reflex:
What spinal nerve roots are involved?
How do you test?
What is a normal reaction?
C6, C7
- Pt sitting or supine.
- Flex the pt’s arm at the elbow, w/ palm toward the body, and pull it slightly across the chest.
- Strike the triceps tendon w/ a direct blow directly behind and just above the elbow.
- If difficult for the pt to relax, support the upper arm and ask the pt to let the arm go limp (“hung up to dry”). Then strike the triceps tendon.
Watch for contraction of the triceps muscle and extension at the elbow.
What is reinforcement?
How can it be used to assess reflexes?
If the pt’s reflexes are symmetrically diminished or absent, use reinforcement, a technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity.
Ex: To reinforce the arm reflexes, ask pt to clench teeth or squeeze both knees together. If leg reflexes are diminished or absent, ask the pt to lock fingers and pull one hand against the other. Tell the pt to pull just before you strike the patellar or Achilles tendon.
Clonus
Why would you test?
How do you test?
What is a normal reaction?
What does abnormal indicate?
If the reflexes seem hyperactive, test for ankle clonus.
- Support the knee in a partly flexed position. With your other hand, dorsiflex and plantar flex the foot a few times while encouraging the pt to relax, then sharply dorsiflex the foot and maintain it in dorsiflexion.
Look and feel for rhythmic oscillations between dorsiflexion and plantar flexion.
Normally the ankle does not react to this stimulus. There may be a few clonic beats if the patient is tense or has exercised.
Sustained clonus points to CNS disease. The ankle plantar flexes and dorsiflexes repetitively and rhythmically. Clonus must be present for a reflex to be graded 4.
Cranial Nerve IV
What is the name?
How to perform test?
Abnormal finding indicates
Trochlear
- EOM
- Convergence of the eyes
- Identify any nystagmus, diplopia, ptosis
Binocular diplopia in CN IV neuropathy-MG, trauma, thyroid ophthalmopathy
Cranial Nerve XI
What is the name?
How to perform test?
Abnormal finding indicates
Spinal Accessory
- Look for atrophy or fasiculations
- Shrug shoulders against hands
- Turn head to side against hand
Trapezius weakness w/ atrophy & fasciculations points to a peripheral nerve disorder.
In trapezius muscle paralysis, the shoulder droops, & scapula is displaced downward & laterally.
Observe the contraction of the opposite SCM muscle & note the force of the mvmt against hand. A supine patient w/ bilat. weakness of the SCM has difficulty raising head off pillow.
How do you test Two-point discrimination? What could abnormal findings indicate?
- Using the 2 ends of an opened paper clip, or 2 pins, touch a finger pad in 2 places simultaneously.
- Alternate the double stimulus irregularly with a one-point touch.
- Find the minimal distance at which the patient can discriminate one from two points (normally <5 mm on the finger pads).
- Lesions of the sensory cortex increase the distance between two recognizable points.
The Quadriceps (Patellar) Reflex
What spinal nerve roots are involved?
How do you test?
What is a normal reaction?
L2, L3, L4
- Patient may sit or lie down to flex knee.
- Briskly tap the patellar tendon just below the patella.
Note contraction of the quadriceps with extension at the knee. Placing your hand on the patient’s anterior thigh lets you feel this reflex.
What are Postural Tremors? Give examples.
They appear when the affected part is actively maintaining a posture.
- fine rapid tremor of hyperthyroidism
- the tremors of anxiety and fatigue
- benign essential (and often familial) tremor
How do you test graphesthesia? What could abnormal findings indicate?
- With the blunt end of a pen or pencil, draw a large number in the patient’s palm.
- A normally abled person can identify most numbers.
- Graphanesthesia = The inability to recognize numbers, indicates a lesion in the sensory cortex.
