Neuro Lecture Flashcards
Elements of complete neuro exam
Mental status CNs Motor and sensory DTRs Cerebellar Gait Special tests
What must first be established in neuro exam?
Patient’s dominant hand
R handed people are ___ brain for speech
Left
75% of L handed people are ___ brain for speech
Left
Mental status exam consists of:
- Level of consciousness
- Appearance (dress, affect, hygiene)
- Orientation (to person, date, place)
- Language (quality, comprehension)
- Concentration (serial 7s, WORLD backwards)
- Calculation (17+12)
- Recall (3 objects in 3 mins)
- Current events
What tool can be used for the mental status exam? What does it test?
Folstein MMSE
- Orientation
- Registration
- Calculation
- Recall
- Language
CN I testing:
- Patency of each nostril
- Odor test
CN II testing:
- VA then VF
- Funduscopic exam
- PERRLA
CN III, IV, VI testing:
EOMs with the H test
CN V testing:
- Pin and light touch on ophthalmic, maxillary and mandiublar divisions
- Motor test (jaw jerk should be absent, ask patient to chew to test masseter and temporalis muscles)
CN VII testing:
- Show teeth
- Squeeze eyes shut
- Wrinkle forehead
What is Bells phenomena?
Patient closes eyes and the eye on the SAME side as the peripheral facial weakness will NOT close (but eye rolls superiorly)
Central facial weakness occurs with what disorder?
Stroke
Peripheral facial weakness occurs with what disorder?
Bell’s palsy, acoustic neuromas
Central facial weakness spares:
Forehead and eye closing
CN VIII testing:
Hearing, Weber and Rinne
CN IX and X testing:
- Say ahh watch uvula (deviates to strong side)
- Test gag reflex
CN XI testing:
- Shrug shoulders (trap)
- Turn head against resistance (SCM)
CN XII testing:
Stick out tongue (deviates to weak side)
What is upper motor neuron weakness characterized by?
- Increased tone/spasticity
- Increased reflexes
- Minimal or no atrophy
- No fasciculations
- Positive Babinski
What is lower motor neuron weakness characterized by?
- Decreased tone
- Flaccidity
- Absent or hyporeflexia
- Atrophy and fasciculations
- Absent Babinski
What is upper motor neuron disease often a result of?
Stroke or brain injury
What does lower motor neuron disease involve?
Can involve spinal cord, peripheral nerve, or muscle
UE motor testing:
- Pronator drift
- Deltoids (C5)
- Biceps (C5, C6)
- Triceps (C6, C7)
- Wrist extensors (C6, C7 stop traffic)
- Wrist flexors (C6, C7)
LE motor testing:
- Hip flexion (L2, 3)
- Adduction (L2-4)
- Abduction (L4, 5)
- Knee extension (L3, 4)
- Knee flexion (L5, S1)
- Dorsiflex foot (L4, 5)
- Plantar flex (S1)
- Extension of great toe (L5)
- Extension of remaining toes (L5, S1)
Strength grading system of motor exam
0 = no movement 1 = trace/flicker of movement 2 = able to move when gravity is eliminated 3 = able to move against gravity 4 = some weakness against resistance 5 = normal strength (able to move against resistance)
What strength grades are considered functional movement?
Above 3/5
so 4/5 is weakness but some function preserved
Sensory exam consists of which tracts?
- Spinothalamic tract (pain and temperature)
- Dorsal (posterior) column (position sense and vibration)
L5 sensory =
Lateral portion of lower leg and great toe
S1 sensory =
Lateral portion of top and sole of foot
Dermatome of the shoulders
C5, C6
T1
Dermatome of inner upper arms
T1
Dermatome of nipple level
T4
Dermatome of umbilicus
T10
Dermatome of groin
L1, L2
Dermatome of knee
L4
Dermatome of posterolateral thigh
S1
Dermatome of upper anterior thigh
L3
Dermatome of lateral thigh crossing to anterior lower leg
L5
Dermatome of great toe
L5
Dermatome of little toe
S1
Dermatome of posteromedial thigh
S2
Describe position (proprioception) test
- Test distal most portion of an extremity (finger or toe)
- Move up and down with lateral contact points
How to test vibration sense?
- Use 128 tuning fork
- Test over bony prominences
Define graphesthesia
- Test of discriminatory sense
- Draw number in patient’s palm and have them identify
Define stereognosis
- Ability to identify touch alone
- Put an item in palm of pt’s hand and ask them to identify (e.g. key, coin, paper clip)
Define 2 point discrimination
- Ability to identify 2 separate stimuli that are close together
- Use EKG calipers
- Ask pt if 1 or 2 pins
Define extinction and what may cause it
- Patient “extinguishes” 1 of 2 simultaneous contralateral stimuli
- Lesions in sensory cortex
What does the Romberg test assess?
Position sense NOT cerebellar function
Define ataxia
Loss of coordination
What 3 senses are required to keep us upright and balanced?
- Vision
- Equilibrium (semicircular canals)
- Proprioception (position sense)
How many of the 3 senses required for balance do you need to maintain balance?
2 of the 3 need to work
remove 2 of the 3 and you will fall over - vision, equilibrium, proprioception
What symptom will patients with disequilibrium complain of?
Vertigo/dizziness
If a patient “passes” the Romberg test, what is it called?
ABSENT Romberg (NOT negative)
What do the deep tendon reflexes test?
Simple spinal reflex (even deeply comatose pts may have preserved DTRs)
Grading of DTRs
0 = no reflex 1 = hyporeflexia 2 = normoreflexia 3 = hyperreflexia 4 = marked hyperreflexia (clonus)
Reinforcement techniques of DTRs
- Used to “coax” diminished reflexes
- For LE, pt curls fingertips together in front of themselves and pulls in oppo directions
- For UE, pt clenches jaw
How to use reflex hammer for DTRs?
- UE use pointy portion (smaller tendon target)
- LE use wider portion (wider tendon target)
UE DTRs
- Biceps
- Triceps
- Brachioradialis
LE DTRs
- Patellar
- Achilles
What else do we check when doing LE DTRs?
Babinski
- Stroke along lateral aspect of sole and then across
- POSITIVE (abnormal) is if great toe moves upward
- ABSENT (normal) is if great toe moves down
What are the superficial reflexes?
- Superficial abdominal
- Cremasteric (men only)
Describe superficial abdominal reflexes
Stroke 4 quadrants lightly and umbilicus will move toward the stimulus
Describe cremasteric reflex
- Men only
- Stroke inner upper thigh and ipsilateral testicle will move rostrally (superiorly)
What does cerebellar testing assess and what does it consist of?
- Tests coordination
- Rapid alternating movements (RAMs)
- Finger nose finger (FNF)
- Heel knee shin (HKS)
How to assess gait?
- Normal walking
- Heels (brings out AT)
- Toes (brings out gastroc)
- Tandem
Glabellar sign
- Tap between eyebrows
- Pt eyes blink rhythmically (abnormal)
Grasp reflex
Just like babies reflex but is pathological in adults
Palmomental reflex
Scratch palm and patient will purse lips (may be very subtle)
Snout reflex
Tap mouth and pt will purse lips
Asterixis
Flapping tremor of the hands seen in liver disease
Kernig’s sign
- Flex hip and knee
- Straighten knee
- Pt will resist and note pain behind knee
- Pain is the telling sign
Brudzinski sign
Flex neck and patient will draw up hips and knees
Describe Babinski reflex
- Briskly stroke lateral surface of sole and go across MT heads
- Absent (normal) is great toe to flex (move down)
- Positive (abnormal) is great toe to extend (move up)
What are you looking at to assess Babinski reflex?
Only the FIRST motion of the big toe determines absent or positive Babinski
