Neuro Exam Info Flashcards
Cranial nerves
I- olfactory
II- optic
III- oculomotor
IV- trochlear
V- trigeminal
VI- abducens
VII- facial motor
VIII- vestibulocochlear
IX- glossopharyngeal
X- vagus
XI- accessory
XII- hypoglossal
I olfactory nerve assessment
History questioning: any changes in sense of smell?
Think taste Vs smell
If testing req: use coffee, vanilla or peppermint on each nostril
If anosmia: inspect nose
General facial inspection prior to cranial Ass: x 4 items
Wasting of facial muscles
Facial asymmetry ptosis
Inability to close an eye
Endocrine facies: acromegaly, Paget’s, scars, vesicles, haemangiomas
II Optic nerve assessment: x 5 items
Snellen’s chart @ 6m - use glasses if normally worn (3m if difficult, closer 1m, no. of fingers, moving hand, light detection. AND 6/9 or pinhole needed)
Visual fields - confrontation or hands moving in (cover own eye, mirror image, to help detect peripheral margins)
Pupils - direct light each eye & swinging light test.
Fund us exam - fundoscopy
Colour vision test - coloured tests
III Oculomotor/IV Trochlear/VI Abducens
Pupils - size, shape, equality, regularity
Presence of any ptosis - dropping upper eyelid
Testing the light reflex - ? Already
Accommodation - look at wall, then adjust to pen closer to face… move pen even closer to face too.
Eye movements - following finger patterns to test full fields
Nystagmus - follow pen/finger from midline to sides & paper to each side & ask Pt to focus on wall behind it
Nystagmus terminology
Jerk (described by the direction of the quick phase, more common) or Pendular (slow pendulum like movement)
Horizontal/Vertical/Rotational
Frequency (how often they move back & forward - high/low) & Amplitude (distance eyes move - high/low)
Central Vs Peripheral Nystagmus
Central:
- low frequency, high amplitude
- vertical nystagmus
- gaze fixation does NOT affect nystagmus
- pendular & rotatory nystagmus
- does NOT get exhausted
Peripheral:
- high frequency, low amplitude
- horizontal nystagmus
- gaze fixation can suppress nystagmus
- quick phase & slow phase (unidirectional)
- can get exhausted
V Trigeminal (motor): x 4 points
Motor division:
- inspect for wasting of temporalis muscle
- clench teeth & palpate masseter muscle
- open mouth & hold open while examiner tries to close
- jaw jerk/masseter (exaggerated in UMN lesions: pseudobulbar palsy)
V Trigeminal (sensory)
Test divisions:
V1 - ophthalmic; forehead
V2 - maxillary; cheek
V3 - mandibular; chin
(Sharp before soft!!)
Test corneal reflex:
- lightly touch w cotton tip to edge of eye [afferent: sensory div of Trigem & efferent: facial for corneal reflex]
VII Facial nerve
Motor div:
- Facial asymmetry
- look up check: loss of wrinkling
- fell check: pushing down on each side
- ask Pt to frown
- shut eyes tightly: & try to open (look for Bell’s phenomenon: upward movement of eyeball)
- smile: ?loss of nasolabial folds
- puff out cheeks: test power by pushing against
VIII Vestibulocochlear nerve
Test for hearing: Rinne’s & Weber’s tests
? Dix-Hallpike manoeuvre if req
IX Glossopharangeal & X Vagas nerves
Ask Pt to open mouth & say ‘Ah’: inspect palate & uvula for any displacement (uvula displaced away from side of lesion)
Assess for:
- hoarseness of voice
- bovine cough
- any Hx of dysphagia
NOT gag reflex!!
XI Accessory nerve
Ask Pt to:
- shrug shoulders: feel bulk of traps & try to push shoulders down
- turn head to left against assessors resisting hand (checking R sternocleidomastoid) & vice versa
XII Hypoglossal nerve
Inspect tongue at rest: ? Wasting/fasciculations
[LMN lesions; weakness, wasting & fasciculations, UMN lesions; small immobile tongue]
Ask Pt to:
- stick out their tongue: look for deviations (towards side of lesion)
- check for any problems with speech articulation
Fasciculations: visible, spontaneous & intermittent contractions of muscle fibres.
Neuro Exam of limbs (gen insp & motor)
General inspection:
- asymmetry
- abnormal posture
- involuntary movements
- muscle wasting
- scars
- skin lesions
Motor System:
- R or L handed
- hands by sides: look for fasciculations (w wasting & weakness = LMN lesion)
Pronator drift
Ask Pt to:
Hold both arms out straight, palms up & eyes closed
Drifts:
- downward: pyramidal lesion
- upward: cerebellar lesion
- any direction: loss of proprioception (searching movements affecting fingers)
General Muscle assessment
Bulk:
- atrophy (distal/proximal, unilateral/bilateral, symmetrical/asymmetrical): best seen in hands & shoulders
- feel for muscle bulk
[atrophy & fasciculations present = LMN disease]
Tone:
- normal residual tension in relaxed muscle
- test by noting resistance to passive movement (support Pt’s limb w one hand & move passively w other)
Check flexion & extension: of all joints & passive range of motion of appropriate joints
Descriptions:
- flaccid/hypotonic: acute phases spinal cord injury, stroke & cerebellar lesions
- hypertonic: UMN or extrapyramidal lesions
- rigid (cogwheel/lead pipe rigidity): Parkinson’s Dx or clasp like in lesions of pyramidal tract.
Muscle strength: grading
Test joint by joint, one side at a time.
Grading:
0- no contraction/complete paralysis
1- flicker or trace contracted
2- active movement possible with gravity eliminated
3- active movement possible against gravity, but no further resistance added
4- slight/mod/submaximal movement against gravity & some resistance
5- active movement against full resistance without evident fatigue (normal power)
Remember:
- compare from side to side
- muscle strength is tested by gauging the examiner’s ability to overcome the Pt’s full voluntary muscle resistance
- all movement is released by the examiner unless the Pt is unable
Upper Limbs muscle testing: direction & nerve tracts involved
Shoulder:
- abduction C5, C6: abduct w elbows flexed against Ex
- adduction C6, C7, C8: adduct w elbows flexed against Ex
Elbows:
- flexion C5, C6: bend against Ex
- extension C7, C8: extend against Ex
Wrist:
- flexion C6, C7: make fist & flex, then resist Ex trying to extend
- extension C7, C8: (radial nerve) make fist & extend, then resist Ex trying to flex
Fingers:
- flexion C7, C8: grip strength
- extension C7, C8: straighten against Ex
- abduction C8, T1: spread against Ex
- adduction C8, T1: hold fingers together & prevent Ex abducting
Gait assessment
Ask Pt to:
-walk normally a few metres, turn around quickly & walk back
- walk heel to toe (exclude midline cerebellar lesion)
- walk on toes (ex. S1 lesion)
- walk in heels (ex. L4, L5 lesions or foot drop)
- perform Romberg test
Romberg test
Procedure:
- Pt standing feet together, warms crossed across chest
- 20-30secs eyes open
- repeat with eyes closed
Romberg Pos if: irregular sway or falling when eyes closed (Defective proprioception)
Lower Limb muscle testing: directions & nerves
Hip:
- flexion L2, L3: raise straight leg against Ex
- extension L5, S1, S2: Pt to keep leg down & prevent Ex pulling it up
- adduction L2, L3, L4: prevent abduct of knees
- abduction L4, L5, S1: prevent adduct of knees
Knee:
- extension L3, L4: knee slightly bent, ask Pt to extend against Ex
- flexion L5, S1: bend knee against Ex
Foot:
- dorsiflexion L4, L5: flex foot against Ex
- plantar flexion S1, S2: extend foot against Ex
(Also tested w Romberg test)
Ankle:
- extension/hallucis longus: (big toe L5 resistance) bring big toe towards Pt against Ex
- inversion L4: push foot In against Ex (w lower leg immobile)
- eversion L5, S1: push foot Out against Ex (w lower leg immobile)
Reflexes grading
Grading:
0 = absent
+ = present but reduced
++ = Normal
+++ = increased/brisk, poss normal
++++ = very brisk, hyperactive, poss w clonus
Remember:
- 0 or + is Normal in some people
- compare from side to side & comment on symmetry/asymmetry
- if reflex appears absent, always test again following reinforcement (distraction = get Pt to clench teeth for test)
- increased jerk = UMN lesion
- decreased/absent jerk = any part of reflex arc breached [muscle itself (myopathy), motor nerve (neuropathy), anterior spinal cord root (spondylosis), anterior horn cell (poliomyelitis), or sensory arc (sensory root or sensory nerve)
Upper limb Reflexes
Biceps (C5, C6):
- w Pt’s arm flexed, hand pronated, not overlapping: place finger on biceps tendon & strike finger w hammer
[watch for contraction of biceps tendon & flexion of forearm]
Triceps (C7, C8):
- w Pt’s arm supported & flexed @ elbow: strike triceps tendon directly w hammer [watch for triceps contraction & forearm extension]
Supinator/Brachioradialis (C5, C6):
- w Pt’s arm resting on thigh & partly pronates: strike yr finger over the radius 1-2 inches above the wrist [watch for flexion of elbow & supination of forearm]
Lower limb Reflexes: x 3 items
Knee jerk (L3, L4):
- w Pt seated legs dependant: strike patellar tendon [watch for contraction of quadriceps]
(Can be done supine w Ex supporting flexed knee)
Ankle jerk (S1, S2):
- w foot in mid- position, knee bent & thigh externally rotated (easier on bed) while maintaining dorsiflexion at ankle: strike Achilles tendon [watch for plantar flexion]
(Can be done sitting w foot held in dorsiflexion)
Plantar reflex (L5, S1, S2):
- w Pt supine or seated: stroke lateral surface of foot from heel to ball of foot w blunt object [watch for flexion of big toe]
Babibski’s response: extension of big toe & fanning of other toes. Normal in infants BUT = UMN lesion in adults.
Important Dermatomes for Sensory tests
C3- front of neck
T4- nipples
T7- xiphisternum
T10- umbilicus
L1- inguinal
L2- upper anterior thigh
L3- area around front of knee
L4- medial aspect of leg
L5- lateral aspect of leg
S1- heel & sole of foot
S2- posterior aspect of thigh
Testing Sensory function
Less is more
Start distally & work proximally
Sensory modalities:
- pain/temp (spinothalamic tract)
- position/vibration (posterior column)
- light tough (posterior column & spinothalamic tract)
Upper limb sensory testing
Pain:
- demonstrate first (sternum)
- arms In anatomical position
- compare L & R in same dermatomes
- ask if sharp or dull
- can be done eyes open or closed
Proprioception:
- demonstrate w little finger
- demo w eyes open
- test w eyes closed & get Pt to identify the random Up & Downs
- any abnormality distally, work more proximal to wrists or even elbow. [loss of position sense: posterior column Dx or lesion in peripheral nerve or root]
Vibration:
- 128Hz tuning fork
- demonstrate vibrating fork on sternum
- perform test w eyes closed
- place on DIP joint of thumb while vibrating & ask Pt to indicate when stopped
- abnormality distally, work proximally on bot prominences: head of ulna at wrist or olecranon process at elbow.
[first sensation lost in peripheral neuropathy, eg; diabetes]
Light touch:
- cotton wool
- demonstrate first
- test w eyes closed
- compare L & R & each dermatome
- do not Stroke
Temperature:
- not normally tested regularly
- can use metal object
- start distally & move proximally rapidly asking if temp changes
- better tolerated then Pain!!
Lower limb Sensory testing
Pain:
- demo on sternum
- legs in anatomical position
- compare L & R dermatomes
- ask if it feels sharp or dull
- eyes open or closed
- if sensation decreased peripherally: assess for ‘stocking’ sensory loss (rapid pricks from toes up tibia)
Proprioception:
- passively move Pt’s DIP of big toe
- demo eyes open
- test eyes closed & get Pt to identify random Up & Downs
- if abnormal distally, work proximally: ankle or even knee
Vibration:
- 128 Hz fork
- demo vibrating on sternum
- eyes closed, test on DIP of big toe: vibrating & when it stops
- compare L & R
- abnormality distally, work proximally: malleoli to patella.
Light touch:
- cotton wool
- tested last
- eyes closed & say Yes when touch felt
- compare L & R dermatomes
- do not Stroke
Temperature:
- not tested regularly
- distal to proximal rapidly & ask if temp changes
- better tolerated than Pain!!
Upper limbs Coordination (3)
Rapid alternating movements:
- ask Pt to supinate & pronate one hand on other palm as rapidly as possible
- Dysdiadochokinesis: slow, clumsy or irregular = cerebellar dysfunction, pyramidal or extrapyramidal tract abnormalities.
- DDK performance by Non-dominant hand can also be slow & inaccurate
Finger Nose Test:
- eyes open, ask Pt to touch finger to nose then Ex’s finger at nearly full extension range
- Ex moves finger to 2-3 diff locations
- eyes closed: look for past pointing & intention tremor [cerebellar dysfunction]
Rebound:
- ask Pt to lift arms rapidly from the sides & then stop
- hyptonia due to Cerebellar Dx can cause delay in stopping arms
Lower limb Coordination
Heel to Shin test:
- w Pt supine, heel of one foot on opposite knee & slide down shin to big toe, at moderate pace & as accurately as poss
- clumsy movements, or heel moving from side to side, over shoots position = cerebellar dysfunction
Toe-Finger test:
- ask Pt to lift foot & touch Ex’s finger
Foot-tapping test:
- ask Pt to tap foot on Ex’s hand as fast & as accurately as poss.
Rinne’s test
Bone Vs air conduction
- 512 Hz tuning fork
- vibration on mastoid process 2-3 secs Vs vibration of forks parallel & 1 cm from ear, 2-3 secs
Normal:
- air louder then bone: Rinne’s Positive
Conductive hearing loss:
- bone louder than air: Rinne’s Negative
Sensorineural hearing loss:
- air louder than bone (Rinne’s false pos)
Weber’s test
Comparison of L & R hearing
- 512 Hz fork
- place vibrating fork on cranial midline
- ask Pt if sound is louder in one ear than the other?
Normal:
- sound heard in midline/balanced
Conductive hearing loss:
- sound heard in Bad ear
Sensorineural hearing loss:
- sound heard in Good ear
SWIFT
Scars
Wasting of muscles
Involuntary movements
Fasciculations
Tremor
Vertigo causes: central/peripheral/systemic
Central- brainstem or cerebellum
Peripheral- vestibular apparatus or 8th cranial nerve
Systemic- psychogenic, cardiovascular, metabolic, trauma or toxicity aetiologies
Vertigo physical assessment: x 9 items
Check:
- general appearance
- vital signs
- ECG to rule out arrhythmias
- BGL to rule out hypo/hyper
- assess for gross neurological signs: facial palsy, hemiparesis, limb ataxia or gait issues
- cranial nerve assessment: esp. 2, 3, 4, 5, 6 & 7… w particular focus on 8th! (Rinne’s & Weber’s tests)
- assess Cerebellum & it’s connections: gait, coordination, reflexes, Romberg test, finger to nose test
- perform Ear exam
- perform positional nystagmus testing (Dix-Hallpike)
Vertigo investigations
May include:
- BGL
- Hb
- renal & liver function tests
- ECG +/- Halter monitoring
- audiometry
- rotational tests
- radiology eg; MRI
Vertigo intervention x 5 points
Explain & encourage: self-limiting in a few weeks
Rest from normal activities or triggers
For BPPV - Epley manoeuvre May assist
Labyrinthine sedatives: prochlorperazine in acute stage, for a few days Max. (Prolonged use can prevent compensation)
Consider: antihistamines or antiemetics to ameliorate vertigo
Vertigo red flags
- accompanying neurological signs
- ataxia out of proportion to vertigo
- nystagmus out of proportion to vertigo
- central nystagmus
- central eye movement abnormalities
Dix-Hallpike manoeuvre
- sit Pt on exam table & turn head to one side 45 degrees
- place Pt supine rapidly so head hangs over edge of bed (ask Pt to keep eyes open)
- keep Pt in this position for 30 secs or no nystagmus occurs
- return Pt to upright sitting position & observe of another 30 secs to see if nystagmus occurs
- Repeat with head turned to opposite side
Notes:
- will tend to aggravate paroxysmal vertigo & nystagmus if posterior canal dysfunction is present in inner ear
- nystagmus will appear after a latency of a few secs & generally last less than 30secs
- generally, eyes will beat toward the ground & then when repositioned they will beat towards the opposite direction
- this test may induce nausea & vomiting
Meniere’s Dx
Classic triad: vertigo, hearing loss & tinnitus
Dx: increased endolymph in cochlea & labyrinth, unknown pathogenesis
- usually 30-50yo w equal prevalence across genders
- usually unilateral, but may become bilateral across time
Symptoms:
- vertigo
- tinnitus
- nausea & vomiting
- sweating & pallor
- progressive hearing loss
- nystagmus observed only during an attack
Hx:
- abrupt onset
- variable ear pressure/fullness/decreased hearing & tinnitus
- episodes 30mins to hrs
- variable time interval between attacks
- may be prev Hx of same
Dix-Hallpike Contradictions
Any neck pathology:
- cervical instability
- # ondontoid peg
- recent cervical spine #
- Atlantic-axial subluxation
- cervical disc prolapse
- vertebra-basilar insufficiency
- recent neck trauma that restricts torsional movement
- cervical myelopathy
- recent neck surgery
- rheumatoid arthritis affecting neck
Carotid bruits!
Prior cerebrovascular Dx
- carotid sinus syncope
- cardiac bypass
Dix-Hallpike precautions: x 3 items
- severe neck pain
- severe back pain
- severe orthopnoea may restrict duration of test
Meniere’s Dx complications
May include:
- injury due to associated falls
- anxiety symptoms
- disability due to unpredictable vertigo
- progressive imbalance or deafness
- intractable tinnitus
Meniere’s Dx advice/Ed
- notify Pt about disease to reduce anxiety (often fear malignancy)
- avoid excessive intake: salt, caffeine, tobacco
- low salt diet <3gm per day
- stress management techniques
- ensure Pt has regular check ups w PC Phys
- advise Pt around further sources of info/Ed
Epley manoeuvre (posterior canal BPPV)
Ind: rotatory nystagmus
Prep: pillow under shoulders to give room for head support
Start:
- sitting & like Dix-Hallpike: 45 degree turn
- go supine, holding 45 d turn for 30-60secs
- turn head to other side (45 d angle opposite side) & Hold 30-60secs
- turn head a further 90 d (req Pt to roll onto side & keep head at same position) ?Hold
- assist to sitting
Lempert manoeuvre (lateral canal BPPV)
Ind: lateral nystagmus
Prep: lie so head supported by bed
Start:
- supine: turn head 90 d to one side, Hold 30-60secs
- turn a further 90 d, onto side, head facing down, Hold 30-60secs
- turn a further 90 d, onto front, head facing over shoulder, Hold 30-60secs
- turn final 90 d to original position & Hold 30-60secs
- assist to sitting
Deep head hanging manoeuvre (superior canal BPPV)
Ind: vertical nystagmus
Prep: edge of bed so head hangs down when supine
Start:
- supine on bed, shoulders on edge, head hanging as low as poss, Hold 30-60 secs
- lift chin to chest (probable support req!), Hold 30-60secs
- assist Pt to sitting
Migraine triggers & clinical focus points
Triggers:
- sound, odour, oestrogen fluctuations
- Foods: red wine, chocolate, ripe cheese, foods containing tyramine or tryptophan
- stress
Clin focus:
- no one Rx superior in all respects
- pharmacologic app: directed by severity, associated N&V, Rx setting & Pt specific factors (ie; vascular risk factors/drug preference)
- non-pharmacologic: Pt preference
- symptomatic Rx: more effective when given earlier & one dose, not repeat small doses
- oral agents: many are ineffective because of poor absorption 2nd to migraine-induced gastric stasis
Migraine pharmacological Rx (symptom focus; doses; stepwise; combo; alternates)
- simple analgesics: some Pt’s respond well to aspirin, NSAIDs, paracetamol
- anti-emetics: IV metoclopramide, chlorpromazine, & prochlorperazine - dopamine receptor antagonists & found to be effective in reducing pain
- opioids & barbiturates: Last resort Only!! (High risk & assoc w chronic migraine development)
- Triptans: selective 5-HT agonists that cause cranial vasoconstriction, peripheral inhibition & inhibition of transmission thru 2nd-order neurons of trigeminocervical complex: first line abortive therapy though effective w pain in migraines 15-80% of Pts. Onset: 10-120mins, some side effects tho: heat, tingling, chest discomfort & injection site reactions. (Check contraindications!)
- Crystalloid IV solution: rehydrate vomiting Pts.
Standard doses:
Aspirin - 300-900mg
Ibuprofen - 200-400mg
Naproxen - 750mg initial; 250-500mg after 1 hr if needed
Diclofenac - 75-150mg
Ketorolac - 10mg IM initial; then 10-30mg every 4-6hrs
Paracetamol - 1000mg
Antiemetics:
Metoclopramide - 10mg IV/IM
Prochlorperazine - 12.5mg IM
Ondansetron - 4-8mg IV/IM/wafer
Triptans:
Sumatriptan (most commonly used) 6mg SC.
Alternate: eletriptan, naratriptan, rizatriptan.
Mild-Mod:
- no N&V - simple analgesics
- w N&V - add antiemetic & consider parenteral/rectal routes
Mod-Severe:
- no N&V - oral options firstline, inc Triptans
- w N&V - parental routes for Triptans & antiemetics
Combo Rx:
- synergistic effect of Sumatriptan & Naproxen; significant improvement by 2hrs
Non-pharmacological:
- rest in quiet, darkened cool room
- cool packs to forehead/neck
- avoid: tea, coffee, orange juice
- avoid: moving around too much
- don’t read/watch TV
