NEURO DIAGNOSIS

Question 1

MENTAL STATUS EVALUATION

Answer 1

1 Orientation 2 Level of Alertness, Attention, and Cooperation 3 Memory 4 Language 5 Calculations 6 Apraxia 7 Sequencing tasks 8 Abstraction

Question 2

ORIENTATION

Answer 2

Ask the patient’s name, location, and date

Question 3

LEVEL OF ALERTNESS, ATTENTION, and COOPERATION

Answer 3

Ask the patient to spell a word forward and back ward Ask the patient to repeat a string of integers forward and backward Ask the patient to name the months forward and backward

Question 4

MEMORY

Answer 4

Recent - Ask patient to recall three items after 5 minute delay Remote - Ask patient to recall certain historical facts within patient’s memory (lifetime) ** “Where did you go to high school?”

Question 5

LANGUAGE

Answer 5

Object naming - Ask patient to name 3 objects/shapes Repetition - Ask patient to repeat words or a sentence Reading - Ask patient to read a sentence

Question 6

CALCULATIONS

Answer 6

Simple additions and subtractions, should be 2 or more steps - ask patient to do a calculation

Question 7

APRAXIA

Answer 7

Following a complex motor command like “pretend to comb your hair” or “pretend to brush your teeth”

Question 8

SEQUENCING TASKS

Answer 8

Ask the patient to tap the table with: fist, open palm, then side of open hand (rock, paper, scissors) perform as rapidly as possible

Question 9

ABSTRACTION

Answer 9

Ask patient to interpret a proverb or colloquialism “The early bird gets the worm”

Question 10

DIADOCHOKINESIA

Answer 10

Patting Test: Rapid, rhythmic, alternating movements. Have patient pat leg with each hand as fast as possible * Mostly testing cerebellum (coordination and gait)

Question 11

DIADOCHOKINESIA alt.

Answer 11

Supination - Pronation *Mostly testing cerebellum (coordination and gait)

Question 12

DYSMETRIA

Answer 12

Index finger test: Have patient touch your (doctor’s index finger) (while Dr. moves finger to all 4 quadrants) and then his/her nose alternately several times. (Note tremors or lack of coordination)

Question 13

GAIT

Answer 13

Gait- observe patient walking toward and away, note posture, stability, foot elevation, trajectory of leg swing, balance, and arm motions. Tandem gait- ask the patient to walk heel to toe (police DUI test, walk in a straight line) (cerebellum). Forced gait testing- ask the patient to walk on heels for 6 steps and then on toes for 6 steps (test lumbar roots).

Question 14

What are the 2 spinothalamic tract tests?

Answer 14

Crude touch and Pain (pinprick)

Question 15

CRUDE TOUCH

Answer 15

Ask the patient to identify when he or she is being touched with the dull end of the neurotip. (inability = spinothalamic tract involvement)

Question 16

PAIN (PINPRICK)

Answer 16

Ask the patient to identify when he or she is being touched with the pin or toothpick or the neurotrip (inability = spinothalamic tract involvement)

Question 17

What are the Dorsal Column Tests?

Answer 17

1 Vibration - Pallesthesia 2 Light Touch 3 Joint Position Sense 4 Romberg Test

Question 18

VIBRATION PALLESTHESIA

Answer 18

Place the handle of a vibrating 128 Hz tuning fork on the joint line of the upper and lower extremities. utilize 3 distal interphalangeal joints. If abnormal continue to evaluate proximally until a normal finding is achieved at the base of the 5th metacarpal or metatarsal, and the radial and ulnar styloid processes, or medial and lateral malleoli. Ask the patient to identify when he or she feels vibration and when the doctor has stopped the vibration (inability = dorsal column involvement)

Question 19

LIGHT TOUCH

Answer 19

ask the patient to identify when he or she is being touched with a cotton swab or brush. (inability = dorsal column involvement)

Question 20

JOINT POSITION SENSE

Answer 20

Dr. stabilizes lateral surface of fingers or toes and asks patient to identify if finger or toe is up or down. Start with DIP, if positive, then move to PIP, then MCP of the lower extremity and then proceed to the upper extremity. If negative at any time, then move to the next digit. (inability = dorsal column involvement)

Question 21

ROMBERG TEST

Answer 21

ask the patient to stand with the feet shoulder width apart, and with eyes closed, while doctor stands close to steady the patient. (swaying, or falling = dorsal column involvement)

Question 22

What does Discriminatory Sensation test?

Answer 22

Tests the integrity of the somatosensory cortex

Question 23

POINT LOCALIZATION (TOPOGNOSIS)

Answer 23

Ask the patient to identify multiple points the doctor touches with the dull end of the neurotip, a paperclip, or toothpick

Question 24

SHARP VS DULL DESCRIMINATION

Answer 24

Ask the patient to identify whether the sharp or dull end of the neurotip is being applied to multiple points on the skin of each extremity.

Question 25

STEREOGNOSIS

Answer 25

Ask the patient to identify familiar objects (keys, pencils, coins) by the sense of touch.

Question 26

GRAPHESTHESIA

Answer 26

Ask the patient to identify numbers or letters traced lightly on the skin.

Question 27

BAROGNOSIS

Answer 27

Ask the patient to identify the difference between two same sized objects of different weight.

Question 28

TWO POINT DISCRIMINATION

Answer 28

Determine the smallest area in which two points can be separately perceived on the hands. Touch the patient with a paperclip opened wide enough that two separate stimuli are felt, then bring the stimuli closer together until only one is felt. Repeat in three locations (fingertip, finger & palm). Compare bilaterally.

Question 29

What is the Westphal sign?

Answer 29

Absence of any DTR (especially patellar; LMNL)

Question 30

DIRECT LIGHT

Answer 30

RESPONSE: Ipsilateral pupillary constriction when light is shined in the eye AFFERENT: Optic N. II (ipsilateral to light source) INTEGRATING CENTER: Midbrain EFFERENT: Oculomotor Nerve III (ipsilateral to light source)

Question 31

INDIRECT LIGHT

Answer 31

RESPONSE: Contralateral pupillary constriction when light is shined in the eye AFFERENT: Optic N. II (Ipsilateral to light source) INTEGRATING CENTER: Midbrain EFFERENT: Oculomotor N. III (Contralateral to light source)

Question 32

ACCOMMODATION

Answer 32

RESPONSE: Convergence of the eyes with with pupillary constriction AFFERENT: Optic N. II INTEGRATING CENTER: Occipital Cortex EFFERENT: Oculomotor N III

Question 33

CAROTID SINUS

Answer 33

RESPONSE: Reduction in heart rate when examiner presses the carotid sinus AFFERENT: Glossopharyngeal N. IX INTEGRATING CENTER: Medulla EFFERENT: Vagus Nerve X

Question 34

OCULOCARDIAC

Answer 34

RESPONSE: Reduction in heart rate when examiner presses the eye AFFERENT: Trigeminal N. V INTEGRATING CENTER: Medulla EFFERENT: Vagus N. X

Question 35

CILLIOSPINAL

Answer 35

RESPONSE: Pupillary dilation when examiner pinched the base of the neck at the cervical sympathetic chain AFFERENT: Cervical Sympathetic Chain INTEGRATING CENTER: T1-T2 Spinal Cord EFFERENT: Cervical Sympathetic Chain

Question 36

CORNEAL

Answer 36

RESPONSE: Blinking and tearing of the eye upon touching the cornea with a cotton wasp AFFERENT: Trigeminal N. V INTEGRATING CENTER: Pons EFFERENT: Facial N VII

Question 37

GAG/PHARYNGEAL

Answer 37

RESPONSE: Gagging upon touching the back of the throat with a tongue depressor AFFERENT: Glossopharyngeal N. IX INTEGRATING CENTER: Medulla EFFERENT: Vagus N X

Question 38

UVULAR/PALATEAL

Answer 38

RESPONSE: Raising of the uvula upon phonation, or touching with a tongue depressor AFFERENT: Glossopharyngeal IX INTEGRATING CENTER: Medulla EFFERENT: Vagus N

Question 39

INTERSCAPULAR

Answer 39

RESPONSE: Drawing inward of scapular when skin or interscapular space is irritated AFFERENT: T2-T7 Spinal Nerves INTEGRATING CENTER: T2-T7 Spinal Cord EFFERENT: Dorsal Scapular Nerve

Question 40

ABDOMINAL

Answer 40

RESPONSE: Umbilicus deviation to the stroked side. Absence is normal only if bilateral (see Beevor sign) AFFERENT: Upper T7-10, Lower T11 - T12 INTEGRATING CENTER: Spinal Cord T7-T12 EFFERENT: Upper T7-10, Lower T11-T12

Question 41

PLANTAR

Answer 41

RESPONSE: Plantar flexion (curling) of toes upon stroking sole of foot AFFERENT: Tibial N INTEGRATING CENTER: Spinal Cord S1-S2 EFFERENT: Tibial N.

Question 42

GLABELLA aka MCCARTHY

Answer 42

Contraction of orbicularis occuli muscle upon percussion of supraorbital ridge (glabella)

Question 43

HOFFMAN

Answer 43

Clawing of the fingers and thumb (flexion and adduction of thumb with flexion of the fingers) upon flicking tip of index finger into extension

Question 44

TROMNER

Answer 44

Flexion of the fingers and thumb upon tapping palmar surface or tips of middle three fingers

Question 45

ANKLE CLONUS

Answer 45

Continued involuntary contraction (sustained plantar flexion) or foot upon quick forcible dorsiflexion of the foot

Question 46

BABINSKI

Answer 46

Dorsiflexion of the big toe and fanning or splaying of other toes upon stimulation of the plantar surface of the foot (lateral to medial) (Plantar Reflex)

Question 47

What are the alternate ways to elicit Babinski?

Answer 47

Oppenheim Sign Chaddock Sign Gordon Sign Schaefer Sign

Question 48

Oppenheim Sign

Answer 48

Application of pressure to anterior tibia stroking downward

Question 49

Chaddock Sign

Answer 49

Stroking down the lateral leg around the lateral malleolus

Question 50

Gordon Sign

Answer 50

Squeezing the calf

Question 51

Schaefer Sign

Answer 51

Squeezing the achilles tendon

Question 52

OLFACTORY NERVE (I)

Answer 52

a) Ask about disorders of sense of smell and of taste (will diminish with loss of smell) b) Using a penlight, make sure nostrils are not blocked. c) Occlude one nostril at a time (eyes should be closed) Have patient sniff familiar and non-irritating odors, use the milder scent first. Ask the patient: 1) Do you smell anything? 2) Can you identify the substance?

Question 53

OPTIC NERVE (II)

Answer 53

a) Inspect external structures of eye b) Inspect the optic fundi with ophthalmoscope c) Test visual acuity Screen by reading print Screen with shapes and/or colors d) Confrontation Test Examine directly in front and level with patient’s face Have patient cover one eye Bring object into view from eight different directions (P-A) per eye e) Direct light reflex- ipsilateral pupillary constriction f) Indirect light reflex (consensual reflex)- contralateral pupillary constriction g) Accommodation reflex Test ability of the eyes to adapt for near vision Instruct patient to follow object inward from a distance Convergence of the eyes, constriction of the pupil

Question 54

OCULOMOTOR (III), TROCHLEAR (IV), and ABDUCENS (VI)

Answer 54

The following four tests are for CN III specifically: a. Check for ptosis b. Direct light reflex c. Indirect light reflex d. Accommodation reflex The following will test CN III, IV, and VI combined: a) Extraocular movements with six cardinal fields of gaze. Observe patient’s eyes for normal conjugate, or parallel movements of the eyes and nystagmus as you have him/her follow your finger or pencil while it makes a wide “H” in the air: Trochlear = down and in Abducens = lateral Oculomotor all other fields.

Question 55

(V) Trigeminal Nerve (Ophthalmic, Maxillary, and Mandibular)

Answer 55

a) Oculocardiac Reflex: Take pulse, apply pressure over the patient’s closed eye, pulse rate should decrease 2-3 beats per 15 sec. b) Test corneal reflex with wisp of cotton, should see blinking and tearing c) Test pain (sharp pinprick) on face bilateral in all 3 divisions (3 places per division for a total of 18 touches) d) Test for light touch to the face with wisp of cotton or brush in all 3 divisions (3 places per division for a total of 18 touches) e) Light touch to anterior 2/3 of tongue, inside cheeks, and hard palate with toothpick. (Use a penlight to view the inside of the mouth) f) Have patient clench teeth, palpate masseter and temporalis muscles at rest & motion.

Question 56

FACIAL NERVE (VII)

Answer 56

a) Ask the patient about changes in taste sensations sweet, salty, and sour on the anterior two thirds of the tongue. b) Inspect face for asymmetry (at rest and during motion) Ask the patient to perform the following: Raise eyebrows Close eyes tightly Show teeth Puff out cheeks Smile Frown

Question 57

VESTIBULO-COCHLEAR NERVE (VIII)

Answer 57

Sensory-Cochlear Portion a) Screening tests to confirm side of hearing loss: Finger Rub Test: Assess hearing by rubbing fingers together near the EAM (external auditory meatus), find maximal distance sound can be heard. Whisper Test Have patient close his eyes (to prevent lip-reading) and cover the ear on the side not being tested. Place your head/mouth 2 feet from the ear being tested and whisper words to the patient and ask patient to repeat the words. You can also ask questions to the patient and have the patient answer yes or no to each question. b) Distinguish between perceptive and conductive hearing loss using a 512 Hz tuning fork by using Weber and Rinne tests. Weber Test Procedure: Place the handle of the vibrating tuning fork on the midline of the skull and ask the patient to compare the intensity of the sound in the two ears. Indicates: (-) Normal: sound is equal in both ears. (+) Conductive deafness: sound lateralizes to the bad ear. (+) Sensorineural deafness: sound lateralizes to the good ear. CLINICAL SCIENCES DIVISION 94 Rinne Test Procedure: Place the handle of a vibrating tuning fork against the mastoid bone for bone conduction. Begin counting or timing the interval with a watch. Ask the patient to tell you when the sound is no longer heard, noting the amount of time. Then quickly hold the vibrating fork near the external ear canal without touching the patient (.5 to 1”) for air conduction, and again have the patient indicate when the sound ceases. Again, note the amount of time. Indicates: Normal: air conduction persists twice as long as bone conduction Abnormal: Conduction deafness: air conduction is absent, equal to, or less than bone conduction. Abnormal: Sensorineural deafness: air conduction and bone conduction are both radically decreased or absent. Vestibular Portion Fukuda Step Test Procedure: Patient marches in place, eyes closed for 50 steps. Positive: A turning to one side Indicates: Vestibular lesion on the side of rotation Hallpike Dix Maneuver Procedure: Patient is seated with head turned 45º to the right or left. Examiner quickly brings the patient into the supine position with head extended off the table. Examiner notes any nystagmus. Patient is then brought to the seated position. Repeat with head turned to the opposite direction. Positive: Nystagmus starting 2-5 seconds after movement and stopping within 30 seconds. Indicates: Benign positional vertigo Barany Whirling Chair Test Procedure: Seated patient is spun in chair in one direction Indicates: Normal: fast component of nystagmus will be in the direction of the spin. Vestibulo-ocular Reflex Procedure: Dr. holds patient’s head and instructs patient to fix vision on the doctor’s face. Observe and note spontaneous nystagmus. Dr. then turns patient’s head into rotation, lateral flexion, and flexion and extension. Indicates: Normal patient should maintain eye contact eyes moving at the same speed in the opposite direction of head movement. Inability to maintain fixation or spontaneous nystagmus indicates a vestibular lesion.

Question 58

GLOSSOPHARYNGEAL AND VAGUS IX AND X

Answer 58

a) Note any hoarseness of the voice. b) Ask the patient about change in bitter taste sensation on the posterior third of the tongue. c) Uvula reflex = Patient says “ah” while doctor shines light in mouth and depresses tongue as necessary Watch for symmetrical rising of soft palate. Unilateral paralysis = One side of palate does not rise and uvula deviates to the normal side. d) Gag reflex. e) Have patient swallow while you palpate thyroid cartilage. f) Carotid sinus reflex.

Question 59

SPINAL ACCESSORY NERVE XI

Answer 59

a) Trapezius Muscle Inspect Palpate Muscle test b) Sternocleidomastoid Muscle Inspect Palpate Muscle test - Ask patient to rotate head to one side. Dr. instructs patient to hold, while Dr. attempts to return the head to neutral.

Question 60

HYPOGLOSSAL NERVE XII

Answer 60

a) Inspect tongue for: 1. Atrophy 2. Fasciculations 3. Deviation b) Have patient stick out tongue and test bilateral with tongue depressor, or use the tongue in cheek method Unilateral paralysis = Protruded tongue deviates to involved side.