Nervous System Exam

Question 1

With your patient’s eyes closed, you place a key in their right hand and ask them to identify the object by feeling it.

Answer 1

Stereogenosis - discriminative sensations assessment

Question 2

Inability to recognize numbers drawn on the palm

Answer 2

Graphanesthesia - indicates a lesion in the sensory cortex - also impaired in posterior column diseae

Question 3

You see unequal pupil size of >0.4 mm (anisocoria) and stosis of the left eye (OS). you know this CN is impacted:

a) II
b) III
c) IV
d) VI

Answer 3

b) III - Oculomotor

Question 4

Five components of the neurologic exam

Answer 4

1) Mental status 2) Cranial nerves 3) Motor system 4) Sensory system 5) Deep tendon, abdominal and plantar reflexes

Question 5

Two ways to test coordination

Answer 5

1) Rapid alternating movements (palms and back of hands on thighs) 2) Point-to-point movement (touch nose, then touch your finger as you move it around) **Slow or clumsy movements during these test suggest cerebellar disease**

Question 6

With your patient’s eyes closed, you draw a large number on the patient’s palm

Answer 6

graphestheia: number identification - discriminative sensations assessment

Question 7

Part of the diabeteic foot exam includes all except:

a) Monofilament testing
b) Vibratory perception
c) Romberg
d) Visual Inspection

(Bates pg 731)

Answer 7

c) Romberg

The Romberg test is a test of positive sense. The pt should first stand with feet together and eyes oopen and then close both eyes for 30 to 60 seconds without support. Note the pt’s ability to maintain an upright posture. Normally any swaying is minimum.

Ataxia from dorsal column disease causes loss of position sense

Question 8

During the two-point discrimination exam, and increase in the distance between two recognizable points indicates:

Answer 8

Lesions of the sensory cortex - also impaired in posterior column disease

Question 9

You patient exhibits clonus during your DTR exam. You would document this as:

a) 1+
b) 2+
c) 3+
d) 4+

Answer 9

d) 4+

Very brisk, hyperactive, with clonus (rhythmic oscillations between flexion and extension)

Question 10

All are part of a neurological sensory exam except:

a) Proprioception
b) Finger-to-nose test
c) 2-point discrimination
d) Stereognosis

Answer 10

b) Finger-to-nose test

Finger-to-nose test is a test for coordination - clumsy, unsteady, and inappropriately variable in speed, force, and direction is seen in cerebellar disease.

Question 11

When assessing this common symptom, it is important to clarify what the patient means – fatigue, apathy, drowsiness, or actual loss of strength

Answer 11

Weakness - paresis

Question 12

In a comatose patient with absent doll’s eye movements (oculocephalic reflex) you would observe:

a) extreme bilateral nystagmus when you turn the patient’s head
b) dilation of left eye when headis turned to the right
c) dilation of right eye when head is turned to right
d) eyes do not move when the head is turned to left or right

Answer 12

d) eyes do not move when the head is turned to left or right

In a comatose patient with absent doll’s eye movements, the ability to move both eyes to one side is lost, suspicious for a lesion of the midbrain or pons.

Question 13

With your patient’s eyes closed while using a paper clip or two pins, touch a finger pad simultaneously, find the minimal distance at which a person can discriminate the two points - normal is <5mm.

Answer 13

Two-Point discrimination - discriminative sensations assessment

Question 14

Inability to recognize objects placed in the hand

Answer 14

Astereognosism - indicates a lesion in the sensory cortex - also impaired in posterior column disease

Question 15

What patterns should you identify about weakness?

Answer 15

• Proximal - in the should and/or hip girdle, for example - Distal - in the hands and/or feet - Symmetric - in the same areas on both sides of the body - Asymmetric - Includes: - Focal - in a portion of the face or extremity - Monoparesis - in an extremity - Paraparesis - in both lower extremities, for example - Hemiparesis - in one side of the body

Question 16

To assess the integrity of nerve pathway C 5-6, you would assess DTRs (or muscle stretch response) at these 2 locations:

a) Brachioradialis (a.k.a. supinator)
b) Biceps
c) Triceps
d) Sensory cervical reflex

Answer 16

a) Brachioradialis/Supinator
b) Biceps

Question 17

The two most common symptoms in neurologic disorders

Answer 17

Headaches and dizziness

Question 18

You flex the patient’s leg at the hip and knee, then slowly straighten the knee. Your patient complains of pain and there is increased resistance to knee extension. This is a positive finding for what sign of meningeal inflammation?

Answer 18

Kernig Sign

Question 19

What are the four parts of the neurologic diabetic exam?

Answer 19

1) pin-prick sensation 2) ankle reflexes 3) vibration perception 4) plantar light touch sensation (Semmes-Weinstein monofilament)

Question 20

Feeling light-headed, weak in the legs, or about to fait that may be caused by vasovagal stimulation, orthostatic hypotension, arrhythmia, or side effects from blood pressure or other medications

Answer 20

Pre-syncope

Question 21

The most common, slowly progressive risk factor for ulcerations, arthropathy, and amputation in patients who are diabetic - it is often asymptomatic, but as the condition progresses, it leads to burning electrical pain the the lower extremities, often at night

Answer 21

Distal symmetric polyneuropathy

Question 22

During this assessment, you flex the patient’s neck while watching the hips and knees - normally, they remain relaxed and motionless.

Answer 22

Brudzinski sign - flexion of both the hips and knees is a positive sign for meningeal inflammation/irritation

Question 23

Weakness of the face, arm, and leg on the same side of the body due to a lesion in the opposite hemisphere

Answer 23

Hemiparesis

Question 24

Testing proprioception, muscle strength, and coordination are assessing for:

Answer 24

Cerebellar function

Question 25

The patient stands for 20 to 30 seconds with eyes closed and both arms held straight forward with palms up. When one forearm and palm turn inward and down, this is know as what?

Answer 25

Pronator drift

Question 26

In this neurologic sensory exam technique, you pull then great to away from the other toes and then move the toe in upward and downward directions while the patient’s eyes are closed, asking the patient to identify the direction (“up” or “down”) that you are moving the toe.

Answer 26

Proprioception (joint position sense)

Loss of position sense, like loss of vibration sense, is seen in tabes dorsalis, MS, or B12 deficiency from posterior column disease, and in diabetic neuropathy.