Neuro Exam 2 Flashcards
What 2 tests do we do for Cranial Nerves 2 and 3?
- Inspect size and shape of pupils
2. Test pupillary reactions to light
What is Anisocoria? Percentage?
Difference of >0.4mm in diameter of compared pupils; seen in up to 38% of healthy adults
If there is no or decreased pupil reaction to light, what does this indicate?
Abnormality of cranial nerve 2 or 3
What could also be observed for a malfunction of Cranial Nerve 3?
Ptosis and ophthalmoplegia
What is ophthalmopleiga?
Paralysis of the muscles within or surrounding the eye
What is seen in Horner’s syndrome?
- Ptosis
- Anhydrosis
- Miosis
How do we check “Near Response”?
By asking the patient to follow our finger with their eyes, then bring the finger in close to their nose so they go cross eyed
How do we test Cranial Nerves 3, 4, and 6?
Having the patient follow our fingers; we test the extraocular movements and look for loss of conjugate movements
What does loss of conjugate eye movements in any of the 6 directions cause?
Diplopia (seeing 2 images)
What is Nystagmus? How is it named?
Involuntary eye movements; for the direction of the quick component
What 3 things is Nystagmus seen in?
- Cerebellar disease
- Vestibular disorders
- Internuclear ophthalmoplegia
What is Ptosis?
Drooping of eyelid
Can a slight difference in the width of the palpebral fissures be normal?
Yes in approximately 1/3 of people
How do we test motor and sensory for cranial nerve 5?
- Palpate the temporal and masseter muscles and ask the patient to clench the teeth
- Touch the forehead, cheeks, and jaw on each side with the patient’s eyes closed
Explain the Corneal Reflex origin
Sensory is Cranial Nerve 5 and motor is Cranial nerve 7
Explain Bell’s Palsy
Peripheral injury that affects both the upper and lower face from injury to Cranial Nerve 7
Name 3 other side effects that can be seen in Bell’s Palsy
- Hyperacusis
- Increased or decreased tearing
- Loss of taste
What affects mainly just the lower face?
Central lesion of Cranial Nerve 7
How do we test Cranial Nerve 8?
Whispered voice test
What is the sensitivity and specificity of the Whispered Voice Test?
> 90% and >80%
What should we determine if there is hearing loss present?
Whether it is conductive (impaired “air through ear” transmission) or sensorineural (damage to cochlear branch of CN 8)
What other technique can be used for HENT?
Weber and Rinne
How do test CN 9 and 10?
- Hoarseness in vocal cord paralysis
- Nasal voice in paralysis of the palate
- Ask the patient to say “ah” as you observe movements of the soft palate and the pharynx
- Gag reflex
Do normally healthy people sometimes have a diminished gag reflex?
Yes
How do we test CN 11?
- Look for atrophy or fasciculations in the traps
- Ask the patient to shrug both shoulders upward against your hands
- Ask the patient to turn his or her head with resistance to observe the sternocleidomastoid
How do we test CN 12?
- Listen to the articulation of the patient’s words
- Inspect the patient’s tongue and look for atrophy or fasciculations
- Observe the tongue protruded and look for asymmetry, atrophy, or deviation from midline
What 4 things do we look at for the Motor System?
- Body position
- Involuntary movements
- Characteristics of the muscles
- Coordination
What could abnormal body positions alert us to?
Stroke resulting in mono/hemiparesis
What are 3 types of involuntary movements?
- Tremors
- Tics
- Fasciculations
What are tremors?
Rhythmic oscillatory movements
What are 3 types of tremors?
- Resting (static) tremors
- Postural tremors
- Intention tremors
What is seen in resting Tremors?
Pill rolling tremor of Parkinsonsism, about 5 per second
Are intention tremors seen at rest?
No, only when getting close to target (possible multiple sclerosis)
Where can we see postural tremors?
Hyperthyroidism
What is Oral-Facial Dyskinesias?
Rhythmic, repetitive, bizarre movements that chiefly involved the face, mouth, jaw, and tongue (old man with odd tongue and face)
What are Tics?
Brief, repetitive, stereotyped, coordinated movements (woman winking)
What is Dystonia?
Similar to athetoid movements, but often involve larger portions of the body (woman turning neck looking forward)
What is Athetosis?
Slower and more twisting and writhing that choreiform movements (hands in weird positions)
What is Chorea?
Brief, rapid, jerky, irregular, and unpredictable movements
What is different in Chorea than Tics?
The movements seldom repeat in Chorea
What is Pseudohypertrophy?
Increased muscle bulk with diminished strength
If fasciculations in atrophic muscles are absent, what do we do?
Tap on the muscle with a reflex hammer to try to stimulate them
What does fasciculations with atrophy and muscle weakness suggest?
Peripheral motor unit damage
How do we assess muscle ton?
Feeling the muscle’s resistance to passive stretch
What 4 things do we look for in the passive stretch?
- Jerkiness in the resistance
- Spasticity (worsens at the extremes of range)
- Rigidity (increased resistance throughout the range, not range dependent)
- Decreased resistance
What does decreased resistance suggest?
Disease of the peripheral nervous system or acute stages of spinal cord injury
Do normal people vary widely in strength?
Yes
Define paresis
Impaired strength (weakness)
Define paralysis (plegia)
Absence of strength
Define Hemiparesis (paralysis)
Weakness of one-half of the body
Define Paraplegia (paralysis)
Paralysis of the legs
Define Quadriplegia
Paralysis to all 4 limbs
What 3 things could be associated with muscle weakness?
- Peripheral nerve disease
- CNS disease
- Muscular abnormalities
What is a 3 on the muscle strength scale?
Active movement AGAINST gravity
What is a 5 on the muscle strength scale?
5 (0 is no muscular strength detected)
Nerves and their roots for the UE
- Musculocutaneous: C5-C6
- Axillary: C5-C6
- Radial: C7-C8
- Median: C8-T1
- Ulnar: C8-T1
Nerves and their roots for the LE
- Sciatic: L5-S2
- Obturator: L2-L4
- Deep Peroneal Nerve: L5-S1
What 4 things are required for Coordination?
- Muscle strength (motor system)
- Cerebellar system (rhythmic movement and steady posture)
- Vestibular system (balance and coordinate eye, head, and body movements)
- Sensory system (position sense)
What 6 tests do we use for assessing coordination?
- Rapid alternating movements
- Point to point movements
- Gait
- Romberg test
- Pronator drift
- Sensory system test
What is the abnormality in rapid alternating movements called and it occurs in what?
Dysdiadochokinesis; cerebellar disease
Define Dysmetria
Finger initially overshooting its mark but reaches its target fairly well in point-to-point movements
Define Ataxic Gait
A gait that lacks coordination with reeling and instability
What does tandem walking mean and what might it reveal?
Walking heel-to-toe; ataxia not previously present
Define the Romberg Test
Patient standing with feet together and eyes closed to test position sense, normally only minimal swaying occurs
What is a positive Romberg Test and what could it be from?
Patient loses balance with eyes closed; dorsal column disease
What happens in cerebellar ataxia?
Patient has difficulty standing with feet together whether the eyes are open or closed
How do you test for pronator drift?
Patient stands for 20-30 seconds with both arms straight forward, palms up, and with eyes closed
What is pronator drift?
Pronation of one forearm and is both sensitive and specific for a corticospinal lesion
What is tested when we tap the arms briskly downward and the patient smoothly returns it?
Coordination
What 4 things do we test for the Sensory System?
- Pain and temperature (spinothalmic tracts)
- Position and vibration (posterior columns)
- Light touch (both pathways)
- Discrimination sensations (also involves cortext)
How do we assess pain?
Alternating a sharp and blunt end and asking the patient if it feels sharp or dull
Define Analgesia, Hypalgesia, and Hyperalgesia
- Absence of pain sensation
- Decreased sensitivity to pain
- Increased sensitivity to pain
If pain sensation is normal, what do we often omit?
Testing of temp
How do we assess light touch?
Touch the skin lightly with a wisp of cotton, avoiding pressure
Define anesthesia, hypesthesia, and hyperesthesia
- Absence of touch sensation
- Decreased
- Increased
How do we test vibration?
Use a low-pitched tuning fork of 128Hz and place it firmly over bony prominences
Vibration is often what? Common causes include what?
First sensation to be lost in peripheral neuropathy; diabetes and alcoholism
How do we assess proprioception? (position)
Grasping the patient’s big toe holding it by its SIDES
What could a loss of proprioception be from?
B12 deficiency from posterior column disease or diabetes in peripheral neuropathy
What is Discriminative Sensations?
Ability of the sensory cortex to correlate, analyze, and interpest sensations
When are discriminative sensations useful?
When touch and position sense are either intact or only slightly impaired
What is stereognosis?
Ability to identify an object by feeling it
When do we test for stereognosis?
For discriminatory senses
What is Astereognosis?
Inability to recognize objects placed in the hand occurring in the sensory cortext
What is number identification called?
Graphesthesia
Define hyperreflexia?
Hyperactive reflexes seen in CNS lesions along the descending corticospinal tract
What do we look for in deep tendon reflexes?
Associated upper motor neuron findings of weakness, spasticity, or a positive Babinski sign
Do we always compare the response of one side with the other for tendon reflexes? How are they grades?
Yes; 0-4+ scale
What is the number for the average reflexes?
2
Define Hyporflexia?
Hypoactive or absent reflexes seen in diseases of spinal nerve roots, spinal nerves, plexuses, or peripheral nerves (aka LMNS)
Can symmetrically diminished or even absent reflexes be found in normal people? What do we use if so?
Yes; reinforcement that involved isometric contractive of other muscles for up to 10 seconds that may increase reflex activity
Describe the Plantar Response
Levels L5-S1; positive Babinski response from a CNS lesion in the corticospinal tract means the toes stay straight as you scrape down
When do we test for Meningeal Signs?
If we suspect meningeal inflammation from meningitis or subarachnoid hemorrhage
What could inflammation in the subarachnoid space cause?
Resistance to movement that stretches the spinal nerves (neck flexion), the femoral nerve (Brudzinski’a sign), or the sciatic nerve (Kernig’s sign)
If reflexes seem hyperactive what do we test for? What could sustained clonus indicate?
Ankle clonus; CNS disease
What is normal 2-point discrimination? What could increase these detectable points?
<5mm on the finger pads; lesions of the sensory cortext
What is point localization? What could impair normal ability?
Briefly touching the patient and asking them to point out where you are touching; lesion in sensory cortex
What is extinction? What may happen in there is a lesion of the sensory cortex?
Simultaneously stimulate corresponding areas on both sides of the body; only 1 stimulus may be recognized
What are we testing for in a Straight-Leg Raise?
Lumbosacral radiculopathy
Describe a painful radiculopathy?
Compression of the spinal nerve root as it passes through the vertebral foramen and causes a painul sensation with associated muscle weakness and dermatomal sensory loss usually from a herniated disc
What is the sensitivity and specificity in an ipsilateral straight-leg raise?
95%, 25%
What is the S&S for crossed straight-leg raise?
40%, 90%
What is a positive straight leg test for lumbosacral radiculopathy?
Pain RADIATING into ipsilateral leg
Describe Asterixis
Ask the pt to “stop traffic” by extending both arms with hands cocked up and fingers spread. Watch 1-2 min
What does a sudden, brief, non-rhytmic flexion of the hands and fingers indicate?
Asterixis in metabolic encephalopathy
