Lecture 7.3 Neuro PE (14% of final)

Question 1

1) Initial neuro survey should include visual inspection of what?
2) The last thing you should visually inspect involves what in particular?

Answer 1

1) Asymmetry, involuntary motion, muscular atrophy
2) Motor innervation

Question 2

When is strength tested?

Answer 2

When ROM is resisted

Question 3

What is the Scale for Grading Muscle Strength? (0-5 scale)

Answer 3

0-No muscular contraction detected
1-A barely detectable flicker or trace of contraction
2-Active movement of the body part with gravity eliminated
3-Active movement against gravity
4-Active movement against gravity and some resistance
5-Active movement against full resistance without evident fatigue. This is normal muscle strength.

Question 4

Sensation should be tested ___________, noting any _____________ or ___________ changes

Answer 4

bilaterally; decreases or one-sided

Question 5

1) What is the easiest sensation to test?
2) How is it done?
3) Where should this be done?

Answer 5

1) Light touch
2) Stroking the patient: “Can you feel me touching you, is it the same on both sides”
3) CNV, upper and lower extremities, and trunk

Question 6

How is vibration tested? Where?

Answer 6

Using large tuning fork, test distal vibration sense on bilat hands and feet

Question 7

How should you test proprioception?

Answer 7

Move distal extremity, have patent report its direction
“up, down, in out”

Question 8

1) What sensation test is often omitted?
2) How would it be tested?

Answer 8

1) Temperature
2) Test tubes of warm water can be used

Question 9

1) How do you test stereognosis?
2) Are the pt’s eyes open or closed?

Answer 9

1) Can they identify a common object that you place in their hand
2) Performed with eyes closed

Question 10

How do you test number identification?

Answer 10

Can they discern what number you are drawing on their hand?

Question 11

How do you test two-point discrimination?

Answer 11

Using sharp object, have them identify whether you are lightly poking them in “one” or “two” places at the same time

Question 12

What are the 3 discriminative sensations?

Answer 12

1) Two-point discrimination
2) Stereognosis
3) Number identification

Question 13

What are the 7 sensations you should test?

Answer 13

1) Light Touch
2) Vibration
3) Proprioception
4) Temperature
5) Two-point discrimination
6) Stereognosis
7) Number identification

Question 14

1) What is the C2 dermatome?
2) What is the C3 dermatome?

Answer 14

1) Ear and upper neck
2) Bottom of neck and clavicle to shoulder both anterior and posterior

Question 15

What is the T10 dermatome?

Answer 15

Umbilical

Question 16

What is the L1 dermatome?

Answer 16

Inguinal (“bikini” line)

Question 17

What is the C6 dermatome?

Answer 17

Lateral forearm and distal lat bicep, plus thumb and pointer finger

Question 18

What is the C8 dermatome?

Answer 18

Medial arm and ring and little fingers + part of wrist

Question 19

1) What is the L4 dermatome?
2) What is the L5 dermatome?

Answer 19

1) Anterior knee and thigh from lateral to medial side going downward
2) Anterior shin from lateral to medial, plus ankle and big toe + toe next to it both anterior and posterior

Question 20

1) Hyperactive reflexes are seen in what?
2) Hypoactive or absent reflexes occur in what?

Answer 20

1) CNS lesions
2) Lesions of spinal nerve roots, spinal nerves, plexuses, or peripheral nerves (i.e. not central)

Question 21

What is the scale for grading reflexes?

Answer 21

4) Very brisk, hyperactive, with clonus (rhythmic oscillations between flexion and extension)
3) Brisker than average; possibly but not necessarily indicative of disease
2) Average; normal
1) Somewhat diminished; low normal
0) Reflex absent

Question 22

1) Impaired strength is referred to as what?
2) What are fasciculations?
3) When do fasciculations suggest peripheral motor neuron disease?

Answer 22

1) Paresis
2) Rapid and light movements of the muscle
3) With atrophy and weakness

Question 23

1) Floppiness is “______________” or “_________” and suggests ___________ neuron disease.
2) What is spasticity?

Answer 23

1) “hypertonia” or “flaccidity”; peripheral
2) Increased tone that worsens at extremes of range

Question 24

1) What is spasticity seen in?
2) How is rigidity seen?

Answer 24

1) Central neuron disease
2) Through full range of motion

Question 25

1) Where is the biceps reflex?
2) How is it tested?

Answer 25

1) C5,C6
2) Elbow flexed, forearm pronated, thumb or finger over biceps tendon

Question 26

1) Where is the triceps reflex?
2) Where is the brachioradialis reflex?
2) How is the brachioradialis tested?

Answer 26

1) C6,C7
2) C5,C6
3) Rest hand on abdomen or lap, forearm slightly pronated, strike 1-2 in above the wrist

Question 27

1) Where are the quadriceps or patellar reflexes?
2) Where are the Achilles or ankle reflexes?
3) How are Achilles/ ankle reflexes tested?

Answer 27

1) L2 - L4
2) Primarily S1
3) Dorsiflex the foot and strike

Question 28

1) How do you do a heel to shin test?
2) Is this done bilaterally? When is it positive and in what condition?

Answer 28

1) Have patient either sitting or lying down and ask them to stroke shin with heel of opposite leg, from just below the knee down to the ankle
2) Bilat; movement will be clumsy in cerebellar disease

Question 29

1) How do you do a finger to nose test?
2) When is it positive and in what condition? What may also become apparent?

Answer 29

1) Patient touches nose, then your outstretched finger – several times
2) Movements are clumsy in cerebellar disease; intentional tremor may become apparent at the end of the movement as well

Question 30

1) How do you do a nuchal rigidity test?
2) Neck stiffness with resistance to flexion is found in ____% of pts with bacterial meningitis
3) Is this an accurate test?

Answer 30

1) Bend neck forward in the supine patient
2) 84%
3) Diagnostic accuracy is low

Question 31

What is the Brudzinski special test?

Answer 31

Flexion of neck = hips and knees react in pain

Question 32

How is the Kernig special test done? What is positive?

Answer 32

1) Flex at hip and knee
2) Pain at knee extension = positive

Question 33

1) When is the Clonus test positive?
2) How is this test done?
3) What are you feeling for? Why?

Answer 33

1) Hyperreflexia
2) Support the flexed knee and “loosen” the patient’s ankle with light dorsiflexion and plantar flexion. Then sharply dorsiflex and maintain pressure.
3) Rhythmic oscillations; these are abnormal and suggest CNS disease

Question 34

When may a Clonus test give a false positive?

Answer 34

May be a few “light” beats if the patient is tense or has exercised

Question 35

1) Asterixis is suggestive of what?
2) What pathologies should you think of?
3) What should you ask the pt to do to test it?
4) What is positive?

Answer 35

1) Metabolic encephalopathy
2) Advanced liver disease and high ammonia levels
3) “Stop traffic” holding for 1-2 minutes
4) Sudden, brief, nonrhythmic flexion of the hands

Question 36

1) How do you perform the Babinski reflex?
2) How do you achieve response?
3) When may it be transiently positive?

Answer 36

1) Using sharp object, stroke lateral aspect of sole from heel to ball of foot, curving medially across the ball.
2) Use lightest stimulus to achieve response.
3) If pt is unconscious from drug or ETOH and during postictal state of seizure

Question 37

1) What is a positive Babinski test? What does it indicate?
2) What is the sensitivity and specificity of this test?

Answer 37

1) Dorsiflexion of the big toe; CNS lesion of corticospinal tract
2) 50% sensitive
3) 99% specific

Question 38

1) What is the Romberg test?
2) How is it done? What should the pt be able to do?

Answer 38

1) Test of position sense, can be impaired in cerebellar ataxia
2) Stand with feet together and eyes open, then close if still stable.
-Pt should be able to self-correct any loss of balance

Question 39

1) How is the pronator drift test done?
2) What should the result be?
3) What are the two ways a test can be positive? What is it positive for?

Answer 39

1) Stand with eyes closed and both arms forward with palms up, tap the arms briskly downward
2) Arms should return smoothly to horizontal position
3) Failure to return or demonstration of spontaneous pronation; for contralateral corticospinal tract lesion

Question 40

1) How do you test rapid alternating movements of the arms?
2) When is this ability impaired? (3 conditions)

Answer 40

1) Have patient “pat” thighs with dorsal and palmar surfaces of hands in rapid succession
2) In cerebellar disease, impairment of the basal ganglia, and upper motor neuron disease

Question 41

1) How do you test rapid alternating movements of the fingers?
2) When will it be disturbed? (3 conditions)

Answer 41

1) As pt to “play piano” on thumb
2) In cerebellar disease, impairment of the basal ganglia, and upper motor neuron disease

Question 42

1) How is the anal reflex tested? What should occur and how is it detected?
2) What would a positive result suggest?

Answer 42

1) Using sharp object like applicator stick, scratch anus on either side. Reflexive contraction should occur and is detected with gloved finger inserted into the anus.
2) Suggests lesion in S2-S4, and is seen in cauda equina