Examination (WM) Flashcards
What are the four features of Gerstmann’s syndrome? (and how do you test them)
Left right dissociation (cross hands and ask which is which)
Finger Agnosia (point to left index, point to left ring)
Acalculia (serial 7s)
Agraphia (can’t write)
What are the 6 things to examine common to both parietal lobes?
3-2-1 (3 somatosensory, 2 hands, 1 eyes) 3 somatosensory:- Two point discrimination Tactile location Tactile extinction (sensory inattention) 2 hands:- Sensory perception (write on hand - graphaesthesia) Stereognosis (coin and key) 1 eyes:- Visual fields
How do you specifically examine the dominant parietal lobe?
4 Gerstmann items \+ Motor dyspraxia (three hand test) \+ Ideomotor dyspraxia (show me how to slice a loaf of bread)
How do you examine specifically the non-dominant parietal lobe?
Spatial apraxia (clock face, five pointed star)
Dressing apraxia
Geographical apraxia
Put the whole parietal exam together (schematic)
Right or left handed?
Both lobe exam
Dominant or non-dominant specific exams as indicated
Examine this patient’s speech
Assess this patients speech
Observation: Scars, trachy, peg
Ask if right or left handed
Dyphasia
- “Describe your journey here today” Long sentence (expressive speech, ?frontal operculum)
- “What’s this?” (pen, coin) - nominal (dominant frontal operculum)
- “Name as many animals as you can in 10 seconds” - (dominant frontal operculum)
- “when I clap my hands left hand on nose right hand on knee” Complex task (receptive speech, posterior-superior temporal gyrus, wernicke’s)
- “Repeat this sentence “a stitch in time saves 9”” (conductive- arcuate)
Dysarthria
- Repeat “British constitution”, “west register street”, “baby hippopotamus”
Dysphonia
- Cough
- Say “eeeee”
- “aaaaaa”
Dyslexia
- Read aloud
Dysgraphia
- Write down this phrase “
If dysarthric then lower cranial nerves +/- cerebellar exam
Examine this patient’s gait
Inspect - Shoes and aids Walking Heel toe walk Walk on toes and heels Romberg
Examine this patient for Parkinson’s
Bradykinesia \+ Rigidity Tremor Postural instability;gait
Observation
- Spontaneous movements - Eye blink (lack of blink)
Bradykinesia - do they get slower over time or smaller over fime (speed and amplitude)
Observation - mask facies, reduction in spontaneous movements
1) Bradkyinesia - finger tapping as big and as fast as you can Fist open close Toe tapping Heel tapping 2) Rigidity - wrist, elbow (do activation manouvre - tap with contralateral hand) Ankle, knee (can activate with contralateral hand still) ?couch Tremor within rigidity is cogwheel rigidity 3) Tremor. Resting, postural (arms outstretched), kinetic tremor (finger-nose) 4) Gait and balance. Standing from chair (arms crossed), walk (turns, step length, heel strike, arm swing). Pull test (should correct in 1 or 2 steps)
Examine this patient’s upper limbs
To Do
Expose Inspection (scars including neck) Tone Power C5-T1 Reflexes Biceps, triceps, supinator Finger jerks, (?pectoral (C5), ?deltoid (C5),?scapulohumeral) Sensation Fine touch and pin prick
Other tests
Myelopathy - hoffman’s - hold middle finger and flick distal phalanx towards palm
Median - pinprick. Does it feel sharp
OK sign. Tinel and phalen
Ulnar - sensory mapping. Tinel and elbow and guyon’s canal.
Fromment’s -ulnar. Wasting first dorsal interosseous
Joint position sense - finger, wrist, elbow, shoulder
vibration
Sensory - Fine touch - Pinprick Then go on to do temperature vibration 2 point discrimination
Examine this patient’s lower limbs
Walk Heel walk Toe walk Rombergs Expose Surroundings (I see a stick at the bedside) Back for deformity or scars Tone "is there any pain". Clonus Power Reflexes - knee, ankle, babinski
Examine this patient’s hands
Place hands on lap or pillow
Compare both sids
Describe e.g. wasting and weakness
Gross movements
Functional - buttons
Examine for ulnar
Power abductor digiti minimi
Abductor pollicis (froment’s sign)
Flexor digitorum profundis
Median nerve:
Pope can’t make a fist - hand of benediction (high)
Ape hand at rest
Test is OK sign
Radial
Finger drop and partial wrist just below elbow
Distal forerm sensory only
Go on to do phalen’s, tinel’s
OK sign - flexor polices longs and flexor digitorum profundis
Examine this patients Vth cranial nerve
V 3 areas Corneal Feel temporalis and masseter Pterygoids primarily pull jaw in - if right is weak, jaw deviates to right
Examine this patients eyes
CN II - Can you see well with both eyes? Do you wear glasses?
Snellen chart 6 metres first (if not available then reading)
Fields
Fundoscopy - examine the red reflex, then look at back of eye (describe what you’re doing as you do it - discs, vessels, scan rest of retina)
CN III, IV, VI-
Inspect
Direct and consensual
RAPD
Accomodation (constriction when looks more closely)
Movements Saccades and pursuit
IV palsy on looking downwards and inwards
Children with Ivth will try to tilt away (run away from problem) from bad eye
Pupil reaction (direct, consensual, swinging light) + accomodation
Examine this child
Feel fontanelle Measure head circ + map Ask parents about milestones Examine scars, shunts etc Midline defects
Age appropriate neurological exam
Infant coma scale Eyes - same as adult Verbal - 5 coos, 4 irritable, cries 3 moans, 1 none Motor - 6 is normal spontaneous, 5 is withdraws touch
Examine this patient’s spine
Inspect
Tenderness
Movements c, t, l
Completeness - neurological exam
Examine this patient’s swallow
CN IX, X, XII +/- dysarthria
Examine this patient’s frontal lobe
Right or left handed
Any unusual behaviour? change in sense of smell, change in urinary function?
Orientation (time, place, person)
Attention (repeat a set of numbers)
Abstract thought - “a stitch in time saves nine”?
Planning - “describe the steps involved in making a cheese sandwich” (also checks long expressive speech)
Speech - nominal (objects, animals)
Motor - facial asymmetry, pronator drift
Eye fields - (lesion classically deviates ipilaterally). Resting position, pursuit, saccades
Primitive reflexes (frontal release signs)
- Glabellar tap (blinking doesn’t extinguish) - Grasp (stroke across palm towards thumb) - bilat - Palmar mental - palm is stroked from base of thenar eminence to thumb and elicits ipsilateral mentalis twitch - bilat
(Inspect for scar)
Gait (esp magnetic)
Handedness Screening Orientation Attention Abstract Planning Speech Motor Eyes Reflexes Gait
Examine this patient’s parietal lobe
Right or left handed
Both lobes
3-2-1 (3 somatosenosry, 2 hands, 1 in eyes)
Two point discrimination Tactile location Tactile extinction (sensory inattention)
Sensory perception (write on hand - graphaesthesia) Stereognosis (coin and key)
Visual fields
Dominant
4 (gerstman) and 2
Gerstmanns
Left right dissociation - cross hands and ask which is right and left
Finger agnosia - (point to left index, point to left ring)
Acalculia - serial 7s
Agraphia - can’t write
Dyspraxia (motor) - three hand test
Ideomotor dypraxia - show me how you would slice a loaf of bread
Non-dominant
2 and 1
Spatial
Clock face
Five-pointed star
Dressing apraxia
Geographical dyspraxia
Examine this patient’s temporal lobe
Memory
Name and address (them to repeat + in 5 mins)
Speech
When I clap my hand pat your head and stick out your tongue
Fields
And can you remember that address I told you earlier
Examine this patients occipital lobe
Fields
Examine this patient’s cerebellum
DANISH
Ataxia - (cross arms for trunk and stand and walk (broad gait tend to fall towards illness - flocculonodular lobe does trunk) - [can also do run heel down shin and up to kick hand]
Dysdiadochokinesesis
Nystagmus (fast phase towards side of lesion, can also get downbeat)
Intention Tremor
Scanning speech(individual syllables enunciated)
Hypotonia
Examine this patient’s foot drop
Walk Inspect Tone Power Reflexes Sensation
Peroneal, L5, paramedian motor strip
Gait
Lower limb
Inversion - L5 but tibial
What cutaneous signs are there in neurocutaneous syndromes
TS - facial angiofibromas, ungual fibromas, shagreen patch
(cortical tubors, subependymal nodules, SEGA)
NF1
Skin - café au lait spots (6 of more)|, neurofibromas, axillary or groin freckling,
Eyes - lisch nodues
Head - optic pathway glioma, sphenoid wing dysplasia
NF2 - bilat VS or 1st degree relative and unilateral or several other tumours
VHL - retinal angiomas, haemoangioblastomas, renal cell carcinoma , phaeochromocytomas
Sturge Weber - pot wine stain, localised cortical atrophy and calcification
Examine this patient with acromegaly
Inspection
Look at the face
Open mouth, stick tongue out and say ‘ah’
Examine hearing (conductive hearing loss)
Hands
Large fingers, tinel and phalen
Examine ulnar nerve
BP and pulse, fields, test for glucose
Examine VIIth nerve
VII Raise eyebrows Obicularis oculi (try to open eyes) Smile Buccinator (press gently)
(also could test taste and hearing and ask about lacrimation)
Examine VIIIth nerve
VIII
Cover one ear (whisper a number in other)
If deficit then Rinne and weber (with weber if left ear is bad then if it hears better it is conductive, if hears worse it is sensorineural)
Examine lower cranial nerves
IX,X
Assess voice for hoarseness
Ask patient to swallow and cough
Examine palate (say ‘ah’ - deviates away from palsy)
Gag reflex - posterior pharyngeal wall on each side
XI
Atrophy of trapezius
Shrug
Turn head against resistance
XII
Listen to articulation
Inspect for wasting or fasciculations
Protrude tongue (will deviate to the affected side)
What are the features of essential tremor?
Bilateral upper limb action tremor (later intention tremor)
8-12 Hz
Lower limb possible
Head possible
Can affect voice
Rarely chin or jaw
Improves with EtOH
Handwriting normal size or macrographic
What is the difference between intention tremor and action tremor?
Intention tremor = increased amplitude as target is neared
Features of parkinson’s tremor?
Resting Unilateral or bilateral 3-5Hz Frequently involves mouth, tongue, jaw, leg Relieved by activity Handwriting micrographic and decrimating
Features of dystonic tremor?
Action tremor
Unilateral or bilateral but always asymmqetrical
Can affect neck, voice or jaw
When do you get lead pipe rigidity?
Parkinsons
What causes cogwheeling?
Rigidity + Tremor
What is in the AMTS?
Personal - Age Date of birth Orienting- Time Year Name of this place Recognise two people Prime minister Memory- Address and repeat WW2 Maths - Count back 20 to 1
