neuro exam Flashcards
two ways of examining
gait –cranial nerves –upper
limbs –lower
limbs
cranial
nerves – upper
limbs –lower
limbs –gait
CN1 test?
Have you noticed a recent change in your sense of smell or taste?
* Use bedside products (orange, coffee, chocolate)
* Test each nostril separately
cn2 test?
visual acuity –visual
inattention –visual fields– light reflex accommodation– fundoscopy
how to test visual acuity
Test each eye separately
* (spectacles)
* Snellen chart
* Read newspaper / magazine / finger counting
how to test visual fields
Assessed by confrontation using
a red pin
* Test each eye separately
how to test light reflex
Direct and consensual
* Use a bright pen torch
how to test accomodation
Observed by watching the pupil
as gaze is shifted from a distant
object to a near object
LR6SO4
Lateral rectus - sixth nerve, abducens
Superior oblique- fourth nerve, trochlear
how to test cn5
Sensation to anterior 2/3 of tongue
* Motor fibres to muscles of mastication
* Jaw jerk
* Corneal reflex – not performed
cn7 test
Raise your eyebrows, shut your eyes tight and don’t let me open them,
puff out your cheeks, purse your lips and smile (show me your teeth)
cn8 test?
2 divisions - cochlear (hearing) and vestibular (balance)
* Test hearing- whisper a number on one ear whilst covering the other.
Ask them to repeat it.
* If a hearing abnormality is suspected, perform Rinne’s and Weber’s
tests (refer to handbook)
cn9 and cn10 test?
Open mouth wide and assess whether the uvula is in the midline at rest
* Say ‘aah’ and note any asymmetry of movement. The uvula will deviate
away from the side of a glossopharyngeal nerve palsy
* Ask whether any difficulty swallowing (gag reflex is not performed) – CN 9
afferent, CN 10 efferent
* (Ask to cough. A bovine (non-explosive) cough suggests a vagal nerve palsy)
* Note any hoarseness of the voice
cn11 test
Innervation to sternocleidomastoid and trapezius
* Sternocleidomastoid – ask to turn head again resistance and palpate
the contralateral sternomastoid muscle
Trapezius – ask to shrug shoulders against resistance
cn12 test?
- Inspection at rest
- Observe for tongue fasciculations
- Ask to push tongue inside mouth against cheek
- Move tongue side to side
- Tongue is deviated towards the side of the lesion
UMN weakness may exhibit
- Increased tone (spastic)
- Pyramidal weakness
- Brisk reflexes
LMN weakness may exhibit
- Muscle wasting and
fasciculations - Decreased tone
- Depressed or / absent reflexes
systematic approach to limb exam
Tone Power Reflexes Coordination Sensation
how to test tone
Passively move each joint
* Hypertonia, normal or hypotonia
* Hypertonia – spasticity or rigidity
Spasticity – velocity dependent, UMN lesion
Rigidity – same irrespective of speed of movement, parkinsonism
how to grade muscle power
0- no contraction,no movement
1- flicker or trace concentration
2- active movement with gravity eliminated
3- active movement with gravity
4- active movement against gravity and resistance
5- normal power
approach to limb weakness
- Unilateral or bilateral
- Proximal or distal or global
- Pyramidal weakness
- Isolated lesion of nerve root or nerve or muscle
how to test reflexes?
- Present or absent
- If present – depressed or increased (brisk)
- Reinforcement
- In lower limb examination – remember to examine the plantar reflex
(lateral border of foot towards big toe)
how to test limb coordination?
Upper limbs
Tremor and dysmetria
Finger-nose test
Fine motor skills
Rapid alternating hand movements (dysdiadochokinesis)
* Lower limbs
Heel-shin test
how to test sensation?
2 parts – dorsal column and spinothalamic tract
* Vibration and joint position test
128 Hz tuning fork
* Light touch and pinprick
Dermatomes
how to test gait?
- Walk normally, then heel to toe
(walk normally, then stand with feet together, then in tandem, then
heel to toe) - Posture, balance, stride, arm swing
- Pattern recognition
- Romberg’s test
types of gait patterns
Hemiplegic
* Spastic
* Ataxic
* Apraxic / Festinant / Shuffling
* High steppage
* Waddling
* Antalgic
how to undertake rombergs test?
- Stands with feet together, arms outstretched in front and hands
supinated
(If unable do this with the eyes open – cerebellar lesion) - If can maintain the position with the eyes open but loses balance
when eyes are closed - loss of proprioceptionvv
