Neurologic Evaluation w/Mental Status

Question 1

Purpose of Glasgow Coma Scale

Answer 1

Assess level of consciousness

in patients with TBI and to define broad categories of head injury

Question 2

Grading for Glasgow coma scale is based on what

Answer 2

3 parameters:

1. E: Eye opening (graded 1-4; no eye opening - spontaneous)

· 2 = opens to pain

· 3 = opens to verbal command

2. V: Best verbal response (1-5; no verbal response – oriented)
3. M: Best motor response (1-6; no motor response – obeys command)

Question 3

Nl level of consciousness =

Answer 3

alert

Question 4

1. hyperalert level of consciousness
2. drowsy, but easily aroused\
3. arousable, but responds slowly and is somewhat confused
4. difficult to arouse
5. unarousable

Answer 4

1. vigilant
2. lethargic
3. obtunded
4. stupor
5. coma

Question 5

how to conduct GSC

Answer 5

• 1. Ask to open eyes
• 2. squeeze trapezium and score response
• 3. apply pressure on supra-orbital ridge
• 4. firm-nail bed pressure

Question 6

CAM diagnosis

what is it used for?

Who is it scored?

Answer 6

• CAM = used to diagnosis delirium
  
  • diagnosis requires presence of 1 AND 2; either 3 OR 4
    
    • 1. Acute onset of fluctuating course: acute change from BL?
    • 2. Inattention
    • 3. Disorganized thinking: is pts thinking disorganized or incoherent
    • 4. Altered level of consciouness

Question 7

PE for patients with acute change in MS

Answer 7

1. First, ABCs to make patient is stable
2. Full head => toe exam, making sure to pay atn to
   
   1. CN
   2. Fundascopic exam
   3. Strength
   4. Sensation
   5. DTR

Question 8

Tests for meningeal irritation

Answer 8

1. Nuchal rigidity
2. Brudzinki
3. Kernig

Question 9

Nuchal rigidity

Answer 9

Patient is unable to touch chin to chest either actively or passively.

Dx = meningeal irritation

Question 10

Brudzinki’s Test

Answer 10

Patient lies supine. When the head is elevated, the knees involuntary flexing the knees and hips in an attempt to relieve the pain caused by meningeal irritation.

Dx: Meningeal Irritation

Question 11

Kernig test

Answer 11

1. Patient is supine.
2. Hip and knee begin in the flexed position.
3. When the knee is extended ==> back pain=> meningeal irritation.
4. Returning to knee flexion relieves the pain.

Dx: Meningeal irritation

Question 12

Decorticate posturing

Answer 12

Flexed posture

1. Upper arms are held tightly to side of body
2. Elbows, wrists, fingers = flexed
3. Feet = plantar flexed
4. Legs = extended and IR
5. Fine tremors or intense stiffness may be present

Question 13

Decerebrate posturing

Answer 13

1. Arms are fully extended
2. Forearms pronated.
3. Wrists and fingers are flexed and jaw is clenched.
4. Neck is extended and back may be arched.
5. Feet are plantar flexed

Question 14

Babinski reflex

Answer 14

Stimulation of the plantar aspect of the foot

• NL=> big toe plantarflexion of the big toe.
• • babinksi => big toe dorsiflexes

Indicates= CNS lesion affecting the corticospinal tract.

Question 15

Pronator Drift

Answer 15

1. Patient extends arm , palms up and closes their eyes for 20 – 30 seconds.
2. Close eyes and try to maintain arm positions.
3. (+) sign = one arm drifts downward.

Tests for lesions in corticospinal tract lesions in the contralateral hemisphere. (upper motor neuron)

Dx: Mild hemiparesis or CVA

Question 16

Finger-to-nose test

Answer 16

1. Hold your finger in one place so that the patient can touch it with one arm and finger outstretched. Ask the patient to raise the arm overhead and lower it again to touch your finger.
2. After several repeats, ask the patient to close both eyes and try several more times.
3. Repeat on the other side.

• Normal: patient is able to perform maneuver with eyes open and closed.
• In cerebellar disease, the movements are clumsy or unsteady and vary in speed.
  
  • test position sense and the function of both the labyrinth of the inner ear and the cerebellum.

Question 17

Heel to shin (knee)

Answer 17

1. Place one heel on the opposite knee, then go up and down the shin of the big toe.
2. Repeat with eyes closed.
3. Observe for smoothness and accuracy.
4. Repeat on the other side.

Tests coordination of multiple systems motor, basal ganglia, cortical association and cerebellar systems.

Question 18

what is dysdiadochokinesis

Answer 18

in cerebellar disease, pt cannot perform rapidly alyernating movments

they are SLOW, IRREGULAR, CLUMSY

Question 19

Romberg Test

Answer 19

In cerebellar disease, the patient has trouble standing with [feet together, arms extended and palms up] whether the eyes are open or closed.

They may also have a wide-based asymmetric gait called cerebellar ataxia.

Question 20

when do you get gait ataxia

Answer 20

1. cerebellar disease
2. loss of position sense
3. intoxication

Question 21

how do you assess gait?

Answer 21

1. walk NL
2. on toes
3. on heels
4. tadem (one foot in front of other, like on balance beam)

Question 22

Negative gait test

Answer 22

pt can maintain posture and balance during all aspects, including turning andchanging direction

Question 23

if pt has suspected mental status changes, what do you do?

Answer 23

1. Establish BL cognitive function and clincal course of changes to determine if acute or chronic
2. If acute => cognitive assessments (inc delirium rating)
   
   1. DDx:
      
      1. Delirium
         
         1. get history +alchol use
         2. VS
         3. PE and neuro exam
         4. Labs
         5. Look for occult infection
         6. Review meds and alter any to manage
      2. Depression, acute psychotic disorder, other

Question 24

Non pharmacologic appreaches to patients with delrium

Answer 24

1. Reorientation patient and activities
   
   1. At night => keep room quiet with low lights and do not intterupt them while sleeping
2. Use sitters or family members
3. Relaxation techniques, music, massage
4. AVOID physical restraints and immobilizing devices
5. Maintain mobility and self-care
6. Use eyeglassess, hearing aids and interpreters