H&P Neurology Exam

Question 1

Gait

Walk on toes and heels, tandem walking

Rising from chair

Answer 1

Balance and coordination - cerebellar disease

Tandem walking may reveal more mild ataxia due to cerebellar disease or corticospinal lesions

Distal strength (walking), proximal strength (rising from chair or getting on to exam table)

Abnl gait increases risks of falls

Question 2

Romberg Sign

Answer 2

Stand with feet together, pt closes eyes

Positive Romberg if pt has worse balance when they have their eye closed

Cerebellar function - poor balance with eyes open and closed

Proprioception - usually do worse with eyes closed (posterior columns)

Question 3

Pronator Drift

Answer 3

Positive if hands pronate

• indicates corticospinal tract lesion in contralateral hemisphere

If arms are tapped and fail to return to resting position, proprioception is impaired

• Posterior columns lesion

Question 4

Olfactory Nerve Exam

Answer 4

Usually only examined with specific complaint of anosmia

Don’t use noxious stimuli

Question 5

Optic Nerve

CN II

Answer 5

Visual Acuity

• Snellen Eye Chart

Peripheral Visual Fields - divided into quadrants

• evaluate by confrontation

Ocular fundoscopic exam

Question 6

III, IV, VI

(occulomotor, trochlear, abducens)

Answer 6

Extraocular Movements

• 6 cardinal fields (LR6 SO4 AO3)
• Ptosis - III nerve palsy

Pupillary Reflex (III)

• Assess symmetry
• Direct pupillary constriction
• Consensual pupillary constriction

Elevate Lid III

Closes Lid VII

Question 7

Trigeminal (V)

Answer 7

Facial Sensation

Corneal reflex

• touch side of cornea with wisp of cotton - pt should blink

Jaw movements/strength

• pt smiles/clench jaw, palpate masseter muscles

Question 8

Facial (VII)

Answer 8

Facial expressions/symmetry

• smile
• puff out cheeks

Close eyelids; keeps eyelids closed against resistance

Question 9

Vestibulocochlear (VIII)

Answer 9

Whisper test

Weber & Rinne

Hearing

Laterlalization & type of hearing loss (conduction vs. sensory)

Question 10

IX & X (glossopharyngeal & vagus)

Answer 10

swallowing

rise of soft palate

gag reflex

Question 11

Trigeminal, facial, vagus, hypoglossal

V, VII, X and XII

Answer 11

Voice and speech

Note grossly during hx

Question 12

Spinal Accessory - XI

Answer 12

Turns head against resistance

Elevates shoulders against resistance

(SCM and trapezius)

Question 13

Hypoglossal (XII)

Answer 13

Protrudes tongue

With disease with protrude toward the affected side

Question 14

Motor Examination

Muscle Tone and Strength

Answer 14

Muscle Tone

• Passive ROM - spasticity, flaccidity, clonus

Strength

• Graded 0-5
• Assess U&LE grossly for proximal and distal muscle weakness - looking for assymmetry, weakness
• Heel/toe walking, can also help with distal muscle strength of lower extremities
• getting up from chair also helps proximal muscle strength in LE

Question 15

Proprioception and Cerebellar Function

Accuracy of movements

Answer 15

• finger-to-finger test (overhead to examiner’s finger)
• Finger-to-nose test (examiner changes position)
• Heel-to-shin test

Coordination/accuracy is depend on intact motor system for strength, intact cerebellum for rhythmic movement and steady posture, vestibular system for coordinating eye, head and body movements, and intact sensory system for position sense

Question 16

Proprioception and Cerebellar Function

**Coordination **

Answer 16

• UE - rapid alternating movements
  
  • pronation/supination
  • thumb taps
• LE - toe taps on examiner’s hands

Evaluate speed, rhythm, smoothness of movements

Dysdiadochokinesis - inability to perform rapid alternating movements

Question 17

Sensory Function

Answer 17

Primary Sensory Function

• Superficial (light) Touch

If abnl move to discriminate between…

Spinothalamic tract

• Assess sharp vs. dull in several areas
• Temperature (hot vs. cold water)

Posterior columns

• Vibration - start at most distal joint, use tuning fork adn go proximally until pt can feel vibration
• Position of joints - pt says which way joint is moving
• Decreased in DM, EtOHer, tertiary syphilis, vit b deficiency, aging

Cortical Sensory function (tactile discrimination)

• sterognosis (name familiar objects)
• two-point discrimination (<6mm in finger pads is nl)
• Graphesthesia (# or letter on palm)
• Point location

Question 19

Reflexes

Answer 19

Biceps and Brachioradialis - C5-6
Triceps - C6-7
Patella - L2-3-4
Achilles - S1
Superficial planter (Babinski) L5-S1 (normal = great toe goes down)

Diminished reflexes - decreased sensory function, segmental damage to cord or muscle damage

Exaggerated - UMN disease

Clonus - rhythmic oscillations in the opposite direction muscle is stretched