Neuro exam Flashcards
Exam flow
Patient interview
Level of consciousness
Cognitive function
Speech and communication
CN
Vital signs
CNS infection or meningeal irritation
increased intracranial pressure secondary to cerebral edema and brain herniation
ANS function
Sensory function
Perceptual function
Motor function
Medical record for diagnostic procedures/results
Levels of consciousness
O x3
Determine response to stimuli
- purposefull, nonpurposeful, no response
- verbal, tactile, simple commands
- painful stimuli: pinch, pinprick
Levels of arousal:
- alertness
- lethargy:
- obtundation:
- stupor
- coma
- unresponsive vigilance (vegetative) state
- minimally conscious state (MCS)
Lethargy=
appears drowsy, can respond but falls asleep easily
Obtundation=
patient can open eyes, lock at examiner, but responds slowly and is confused; demonstrates decreased alertness and interest in environment
Stupor=
patient can be aroused from sleep only with painful stimuli
verbal responses are slow or absent
patient returns to unresponsive state when stimuli are removed
demonstrates minimal awareness of self and environment
Coma=
a state of unconsciousness from which patient can’t be aroused, eyes remain closed; no response to external stimuli or environment
unresponsive vigilance (vegetative) state=
a state characterized by the return of sleep/wake cycles, normalization of vegetative functions (respiration, HR, BP, digestion) and lack of cognitive responsiveness (can be aroused but is unaware).
Persistent vegetative state: a state lasting >1 year for TBI and >3 months for anoxic brain injury
minimally conscious state (MCS)=
a state characterized by severely altered consciousness with minimal but definite evidence of self or environmental awareness
Glascow coma scale
relates consciousness to 3 elements of response:
1- eye opening
2- motor response
3-verbal response
scoring 3-15
- severe brain injury: 1-8
- moderate brain injury: 9-12
- minor brain injury: 13-15
Cognitive function exam:
1- memory
- immediate recall
- recent memory
- remote memory (long term)
2- attention
- length of attention span
- sustained attention: ability to attend to task w/o redirection (determine time on task, frequency of redirection)
- divided attention: ability to shift attention from 1 task to another (assess ability of dual task control; getting stuck on a task
- focused attention: ability to stay on task in presence of detractors
- ability to follow commons: single vs. 2 steps
3-emotional responses/behaviors
- safety/judgement; impulsive, lack of inhibition
- affect, mood: irritability, agitation, depression, withdrawal
- frutration tolerance
- self-centeredness
- insight into disability
- ability to follow rules of social conduct
- ability to tolerate criticism
4-higher level cognitive abilities
- judgement, problem solving
- abstract reasoning
- fund of general knowledge
- calculation
- sequencing
5- mini-mental state exam (MMSE) -includes screening items for orientation, registration, attention and calculation, recall and language -max score=30 -21-24=mild cognitive impairment -16-20=moderate impairment -
Speech and communication exam
1- expressive function
- examine fluency of speech, speech production
- nonfluent/Broca’s aphasia
- verbal apraxia
- dysarthria
2- receptive function
- examine comprehension
- fluent/Wernicke’s/receptive aphasia
3- global aphasia
- severe aphasia
- examine for marked impairments in comprehension and production of language
4- nonverbal communication
- examine ability to read/write
- use of gestures, symbols and pictures
Nonfluent aphasia
“Broca’s motor aphasia” “expressive aphasia”
a central language disorder in which speech is typically awkward, restricted, interrupted and produced with effort
result of a lesion involving the 3rd frontal convolution of the L hemisphere (Broca’s area))
Verbal apraxia
impairment of volitional articulatory control secondary to a cortical, dominant hemisphere lesion
Dysarthria
impairment of speech production resulting from damage to the central or peripheral NS
causes weakness, paralysis or incoordination of the motor-speech system (respiration, articulation, phonation and movements of the jaw and tongue)
Fluent aphasia
“Wernicke’s aphasia”
“receptive aphasia”
a central language disorder in which spontaneous speech is preserved and flows smoothly, while auditory comprehension is impaired
the result of a lesion in the posterior 1st temporal gyrus of the L hemisphere (Wernicke’s area)
Cheyne stokes respiration
a period of apnea lasting 10-60 seconds followed by gradually increasing depth and frequency of respirations
accompanies depression of frontal lobe and diencephalic dysfunction
hyperventilation
increased rate and depth of respirations
accompanies dysfunction of lower midbrain and pons
apneustic breathing
abnormal respiration marked by prolonged inspiration
accompanies damage to upper pons
CNS infection or meningeal irritation exam
*signs are global, not focal
1- neck mobility
- in supine: neck pain with flexion limitation and guarding due to spasm of posterior neck muscles
- can result from meningeal inflammation, arthritis or neck injury
2-Kernig’s sign
- in supine; flex hip and knee to chest, then extend knee
- positive sign= causes pain and increased resistance to extend the knee due to spasm of hamstring; when bilateral, suggests meningeal irritation
3- Brudzinski’s sign
- in supine, flex neck to chest
- Positive sign= causes flexion of hips and knees (drawing up)– suggests meningeal irritation
4- irritability
5- slowed mental function
- persistent headache, increased in head down position
- may progress to delirium, lethargy and coma
6- altered VS
-increased HR and RR, fever, fluctuating BP
7- generalized weakness
examine for increased intracranial pressure secondary to cerebral edema and brain herniation
1- altered level of consciousness
-progresses from restless and confused to decreasing level of consciousness, unresponsiveness and coma
2-altered VS
- increased BP
- widening pulse pressure and slowing pulse
- irregular respirations- periods of apnea, cheyne-stokes respirations
- elevated temp
3- headache
4- vomiting- secondary to irritation of vagal nuclei
5- pupillary changes (CN III signs)
-examine for ipsilateral dilation of pupil, slowed reaction to light progressing to fixed, dilated pupils (poor prognostic sign)
6- papulledema at entrance to eye
7- progressive impairment of motor function
-examine for weakness, hemiplegia, positive Babinski, decorticate or decerebrate rigidity
8- seizure activity
superficial sensations
pain
temp
touch
proprioceptive (deep) sensations
joint position sense kinesthesia (movement sense) vibration sense (pallesthesia)
combined (cortical) sensations
stereognosis= identify familiar objects placed in hand
tactile localization
2 point discrimination
barognosis: identify similar size/shaped objects
graphesthesia: identify numbers, letters traced on skin
bilateral simultaneous stimulation
Examine perceptual function
suspect perceptual dysfunction if patient has difficulty with functional mobility skills/ADLs for reasons that can’t be accounted for by specific sensory, motor or comprehension deficits
1- homonymous hemianopsia
2- examine for body scheme or image disorders (“somatognosia”)
- visual spatial neglect (unilateral neglect)
- R/L discrimination disorder
- Anosognosia: unawareness/denial of impairment
3- spatial relations syndrome
- figure-ground discrimination: pick out specific object from an array of object
- form constancy: pick out a large block from a group of blocks (same shape, different size)
- spatial relations: duplicate a pattern of 2 or 3 blocks
- position in space: demo different limb positions
- topographical disorientation: navigate a familiar route
- depth and distance imperceptions
- vertical disorientation: accurately identify when something is upright/vertical
4- examine for agnosia
5- examine for apraxia
homonymous hemianopsia
loss of half of visual field in each eye, contralateral to the side of the cerebral hemisphere lesion
Anosognosia=
severe denial, neglect or lack of awareness of severity of condition;
agnosia=
inability to recognize familiar objects with one sensory modality while retaining ability to recognize same object with other sensory modalities
apraxia=
inability to perform voluntary, learned movements in the absence of loss of sensation, straight, coordination, attention or comprehension
represents a breakdown in the conceptual system or motor production system or both
ideomotor vs. ideational
Ideomotor apraxia=
patient can’t perform task on command, but can do the task when left on own
ideational apraxia=
patient can’t perform the task at all, either on command or on own
examine motor function
muscle bulk/firmness
- determine whether atrophy is due to denervation, disuse or primary atrophy
- presence of persistent fasciculations suggests neurogenic injury
muscle tone
reflexes
muscle performance: strength, power, endurance
fatigue
voluntary movement control
coordination balance
gait and locomotion
Flaccidity and hypotonia
seen in segmental/LMN lesions: nerve roots and peripheral nerve injury
seen initially after suprasegmental/UMN lesions (brief period of spinal shock in SCI, cerebral shock in stroke)
decreased or no resistance to PROM
spasticity (spastic hypertonia)
seen in suprasegmental/UMN lesions
increased resistance to PROM; determine whether increasing the speed increases the resistance
spasticity is velocity-dependent
Additional signs:
- Clasp knife response: marked resistance to PROM suddenly gives way
- Clonus: maintained stretch stimulus produces a cyclical, spasmodic contraction; common in PF
- Hyperactive cutaneous reflexes, +Babinski: DF of great toe in response to stroking up the lateral side of the sole; indicative of corticospinal tract disruption
- Hyperreflexia: increased DTRs
- some degree of muscle weakness is usually present
Measured by modified Ashworth scale
Modified Ashworth scale
grading spasticity
0= no increase in muscle tone
1= slight increase in muscle tone, minimal resistance at end of ROM
1+ =slight increase in muscle tone, minimal resistance through less than 1/2 ROM
2= more marked increase in muscle tone, through most of ROM, affected part easily moved
3= considerable increase in muscle tone, passive movement difficult
4= affected part rigid in flexion or extension
Rigidity
increased resistance to PROM that is INDEPENDENT of the velocity of movement
seen in basal ganglia/nigrostriatal disorders: increased resistance to passive movement in agonist and antagonist muscle
Leadpipe: uniform t/o the range
Cogwheel: interrupted by a series of jerks
associated with Parkinson’s disease, resting tremor, bradykinesia; strength and reflexes are not affected
Decerebrate rigidity/posturing
seen in comatose patients with brainstem lesions between superior colliculus and vestibular nucleus
results in increased tone and sustained posturing of all limbs; trunk/neck in rigid extension
Decorticate rigidity/posturing
seen in comatose patients with lesions above superior colliculus
results in increased tone and sustained positioning of UE in flexion and the LEs in extension
Opisthotonos
prolonged, severe spasm of muscles, causing the head, back and heels to arch backward; arms and hands are held rigidly flexed
seen in severe meningitis, tetanus, epilepsy and strychnine poisoning
examine reflexes
DTR: normally occurring reflexes in response to stretch of muscle
Superficial cutaneous reflexes: normally occurring reflexes in response to noxious stimulus (light scratch) applied to skin
Primitive spinal reflexes
Midbrain/cortical reactions
Reflex scoring for primitive/spinal and tonic/brainstem reflexes:
0= absent
1+ tone change; no visible movement of extremities
2+ visible movement of extremities
3+ exaggerated, full movement of extremities
4+ obligatory and sustained movement, >30 seconds
characteristics of UMN syndromes
Location: CNS
Structures: cortex, brainstem, corticospinal tracts, SC
Disorders: stroke, TBI, SCI
Tone: increased, velocity-dependent (spastic)
Reflexes: increased, clonus; exaggerated cutaneous and autonomic reflexes; +Babinski
Involuntary movements: muscle spasms
Strength:
- stroke: weakness of paralysis on one side
- corticospinal lesion: contralateral if above decussation in medulla, ipsilateral if below
- SC lesion: bilateral loss below level of lesion
Muscle bulk: variable, disuse atrophy
Voluntary movements: impaired or absent: dyssynergic patterns, obligatory synergies
LMN syndrome characteristics
Location of lesion: PNS
Structures involved:
- SC: anterior horn cells, spinal roots, peripheral nerves
- CN: cranial nerves
Disorders: polio, Guillian-barre, PNI, peripheral neuropathy, radiculopathy
Tone:
- decreased or absent; hypotonia, flaccidity
- not velocity dependent
Reflexes:
- hyporeflexia
- cutaneous reflexes decreased or absent
Involuntary movements: with denervation: fasciculations
Strength: limited distribution; segmental or focal pattern, root innervated pattern
Muscle bulk: neurogenic atrophy; rapid, focal, severe wasting
Voluntary movements: weak or absent if nerve interrupted
Clinical issues with strength testing patients with CNS & UMN lesions:
passive restraint: soft tissue changes restrict ability to move (contractures)
Active restraint: spastic muscles restrict ability to move
Abnormal synergistic activity, inappropriate coactivation of muscles
Recruitment problems: abnormal type II fiber recruitment
Abnormal reflex activity: restricts ability to move
Isokinetic dynamometry: patients with UMN syndrome typically demonstrate decreased torque development with increased problems at high speeds, decreased limb excursion, extended time to peak torque development, extended time peak torque held, increased time intervals between reciprocal contractions and changes on “normal” extremities
Clinical issues with strength testing patients with PNS and LMN lesions
With myopathies: see proximal weakness of extremities
With neuropathies: see distal weakness of extremities
some conditions produce decremental strength losses (myasthenia gravis)
examine for presence of involuntary movements
Extrapyramidal disorders, BG dysfunction:
- Tics
- Chorea
- Athetosis
- Tremor
- Myoclonus
Cerebellar disorders: intention tremor occurring when voluntary movement is attempted
Cortical disorders: epileptic seizures, tonic/clonic convulsive movements
Tics=
spasmodic contractions of specific muscles
commonly involving face, head, neck or shoulder muscles
Chorea=
relatively quick twitches or “dancing” movements
Athetosis=
slow, irregular, twisting, sinuous movements, occurring especially in UEs
Tremor=
continuous quivering movements; rhythmic, oscillatory movement observed at rest (resting tremor)
Myoclonus=
single, quick jerk
Examine coordination
gross motor coordination: body posture, balance and extremity movements involving large muscle groups
- UE tests: finger to nose, alternating movements, supination/pronation, Bilateral symmetrical movements (clapping), bilateral asymmetrical movements (alternate touch knee/shoulder), bilateral unrelated movements (knee pat/elbow extension)
- LE tests: unilateral (heel to shin, foot tapping), etc..
- Postural/trunk tests: whole body movements
Fine motor coordination: extremity movements concerned with use of small muscle groups
- thumb/finger opposition (unilateral, bilateral)
- manual/finger dexterity: grasp and release
Evaluate/document:
- speed/rate control
- control
- steadiness/consistency
- response orientation
- reaction time
- descriptive comments
- –scoring: o=unable –> severe, mod, min, 4=normal
Dyssynergia=
impaired ability to associate muscles together for complex movement
Dysmetria=
impaired ability to judge the distance or ROM
Dysdiadochokinesia=
impaired ability to perform rapid alternating movements
sensory elements of balance
1- vision
2- somatosensory
3- vestibular
postural synergies (strategies) used to preserve balance
1- ankle strategy: DF and PF maintain balance by shifting COM forward//back using a long axis of motion
2-hip strategy: hip and lower trunk muscles shift COM with flexion/ext
3- stepping strategy: rapid steps are taken to realign COM within BOS
Functional balance grades
Normal:
- Static: able to maintain steady balance w/o hand held support
- Dynamic: accepts max challenge and can shift weight easily at full range in all directions
Good
- Static: able to maintain balance without hand held support, limited postural sway
- Dynamic: accepts moderate challenge; able to maintain balance while picking object off floor
Fair:
- static: able to maintain balance with hand hold support; may require occasional min assistance
- dynamic: accepts min challenge; able to maintain balance while turning head/trunk
Poor:
- static: requires hand hold support and mod-max assistance to maintain position
- dynamic: unable to accept challenge or move without LOB
Absent
ventriculography
x-rays of skill after injection of air into lateral ventricles
- delineates ventricals, helps localize tumors
- useful with increased intracranial pressures
myelography
x-rays of spine after injection of air or dye into spinal subarachnoid space
- delineates abnormalities impinging on subarachnoid space
- complications: dye may result in meningeal irritation
Cerebral angiography
x rays of skill after injection of dye into carotid and/or vertebral arteries
- largely been replaced my MRA
complications: invasive technique; may cause meningeal irritation, hemorrhage, vasospasm or anaphylactic reaction to dye
Computed tomography
neuroimaging technique in which narrow X-ray beams are transmitted through tissues of carrying densities and precisely measured
- allows cross sections (slices) of the brain to be visualized with 3D localization
- can use contrast agents
- useful for showing presence of abnormal changes in tissue density: areas of acute bleeding, cerebral edema, and cerebral infarction
spontaneous, ongoing EMG activity
1- Fibrillations: spontaneous, independent contractions of individual muscle fibers; evident with denervation for 1-3 weeks after losing nerve
2- Fasciculations: spontaneous contractions of all or most of the fibers in a motor unit; muscle twitches that can be observed or palpated
-present with LMN disorders and denervation
Complete LMN lesions show only fibrillation potentionals
Partial LMN lesions show fibrillation and fasciculation potentials
nerve conduction velocity
conduction velocities are obtained by stimulating peripheral nerves through the skin and recording muscle and sensory nerve action potentials
decreased conduction velocities are seen in peripheral neuropathies characterized by demyelination (Guillian-Barre, chronic demyelinating polyneuropathy, Charcot-Marie-Tooth disease)
slowed conduction velocities seen with focal compression of peripheral nerve
