Neurologic Examination Flashcards
Use: Measuring occipitofrontal and body circumferences, size of skin lesions, length of extremities, etc.
What instrument?
Flexible steel measuring tape scored in metric units
Used for auscultation over the neck vessels, eyes, and cranium for bruits:
Stethoscope
Why do you use 3 tongue blades per px?
- Depressing tongue
- Elicit gag reflex
- Broken longitudinally for eliciting abdominal and plantar reflexes
What is the recommended Hz for tuning fork?
256 cps
Other use for tuning for other than vibratory sensation and hearing:
Temperature discrimination
Used for caloric irrigation of the ear
10 cc syringe
Used for eliciting muscle stretch reflex and muscle percussion for myotonia
Reflex hammer
Testing for astereognosis, instruments used:
Penny, nickel, dime, key, paper clip, and safety pin
PARTS OF A COMPLETE NEUROLOGIC EXAM
I. Mental Status Exam
II. Higher Cortical Function
III. Cranial Nerve
IV. Motor Examination
V. Muscle Stretch Reflexes – pathological reflexes VI. Cerebellar Function
VII. Gait
VIII. Sensory Exam
IX. Meningeal Exam
A structured assessment of a patient’s behavioral and cognitive functioning.
MENTAL STATUS EXAMINATION
MENTAL STATUS EXAMINATION
○ Level of consciousness (name, age, place of living)
○ Observe for appearance, behavior
○ Stream of talk/language
○ Mood, affect, emotional status
○ Illusions/hallucinations
○ Orientation (Time, Place, Date)
○ Test for attention
○ Recent and remote memory
○ Insight, judgment, abstract thinking
■ Insight: ask why patient sought consult with you
■ Judgment: ask a situational scenario
■ Abstract thinking: ask to interpret a proverb
○ Calculation
■ Serial 7’s
Levels of consiousness
Awake
Drowsy
Lethargic
Obtunded
Stupor
Comatose
● Very common
● Easy to identify
● Appearance of wakefulness
● Aware of the self and the surroundings
● Test if the patient is fully awake:
○ Ask name, age, place of living and if the patient answers the questions correctly
Awake
● Arousable to mild stimuli, such as tapping or name calling
● Falls back to sleep with no stimulus
● Test:
○ pat/tap
○ Ask name, age, place
○ Usually px responds appropriately but falls back
to sleep again
Drowsy
● Used interchangeable with obtunded, since patients are both arousable to moderate to vigorous stimuli
● Falls back to sleep with no stimulus
● Test:
○ Pat/tap
○ Do pain stimulation
○ Ask name, age, place
Lethargic
Also Obtunded
Difference are the effects, Obtunded can’t be fully aroused and more depressed lvl of consciousness
● Arousable to continuous stimuli
● Falls back to sleep immediately if the stimulus is
absent already
● Test:
○ Apply painful stimulus continuously
Stupor
● Unarousable to any type of stimuli
● Test:
○ Apply painful stimuli continuously – you would not elicit any change in sensoria
Comatose
Quick Mental Status Examination (MSE)
● Consciousness
● Regard?
○ Respond to stimulation
● Able to follow commands?
● Oriented?
○ Time
○ Place ○ Person
Example of reporting
Awake, with regard, able to follow commands, oriented to 3 spheres (place, person, time)
○ Motor initiation
○ Goal-directed behavior
○ Motivation
○ If damaged, it will lead to apathy, indifference, and loss of initiative
Ventromedial prefrontal cortex
○ Judgment
○ Inhibition of socially inappropriate words
○ If this part is damaged, it will lead to social
disinhibition; or hypersexual
Orbitofrontal prefrontal cortex
○ Planning of motor activity
○ Behavior
○ Executive functioning
○ Judgment
○ Problem solving
○ If damaged, it will result to impaired judgment with impaired planning and problem solving ability, also anhedonia, which is the lack of will to do activities
Dorsolateral prefrontal cortex
Sample Case:
● 64 year old patient
● Recurrent headaches
● Higher cortical problems
○ Always forgetful
○ Acts like a child, always cries and shouts at daughter when not given what she wants
○ Cannot make her own decisions
What specific areas of the brain could have the problem?
Answer: FRONTAL LOBE
■ Control over emotions located on this lobe
○ Modulation of body arousal
○ Memory, spatial
○ Memory, Retrieval long term
○ Movement, self initiated
○ Mediated emotional response to pain
○ Making Decisions
Ventromedial Prefrontal Cortex (6 M’s)
○ sOcial behavior
○ Reward Expectations
○ Response inhibition
○ Behavioral self-regulation
○ Impulse control
○ Taste, aversive/pleasurable
Orbitofrontal Prefrontal Cortex (ORRBIT)
○ Demands attention
○ Orientation
○ Response Conflict
○ Spatial and conceptual reasoning
○ Organization
○ Language, learning and memory
○ Attention
○ Temporal ordering of events
Dorsolateral prefrontal Cortex (DORSOLAT)
4 basic parts of testing higher cortical functions:
1. Test for Aphasia
a. Receptive (Wernicke)
b. Expressive (Broca)
2. Gerstmann Syndrome
a. Finger agnosia
b. R-L Confusion
c. Dysgraphia
d. Dyscalculia
3. Apraxia
4. Higher Sensory
a. Astereognosia, Agraphestesia, Sensory inattention
● How to test
○ Name objects
○ Repeat whatever you say
○ Comprehend
○ Fluent
● Two general types:
○ Broca’s Aphasia
○ Werncke’s Aphasia
Aphasia
■ Semantic paraphasia
■ Cannot repeat
■ Fluent – can speak but with disorganized words
and sentences
■ Cannot comprehend
Werncke’s Aphasia
■ Unable to name
■ Cannot repeat
■ Non-fluent – Speech problem
■ Can comprehend
Broca’s Aphasia
Difficulty in producing voice sounds (phonating)
Dysphonia
■ Difficulty in articulating the individual sounds or the units (phonemes) of speech
■ f’s r’s g’s
■ Vowels, consonants, labials (CrN VII), gutturals
(CrN X) and linguals (CrN XII)
Dysarthria
Difficulty with the melody and rhythm of speech, the accent of syllables, the infections, intonations, and pitch of the voice
Dysprosody
Difficulty in expressing or understanding words as the symbols of communication
Dysphasia
Types of aphasia:
Fluent?
NO: global, mixed, broca, transcortical motor (GMBT)
YES: wernicke, transcortical sensory, conduction, anomic (WACT)
Comprehends?
NO: global, wernicke
YES: transcortical motor, anomic
Repeats?
NO: g, b, w, c
YES: the rest
VA, VF, fundoscopy
CN 3
Pupillary, direct/consensual
2 & 3
EOMS, convergence
3, 4, 6
Taste posterior 1/3 of tongue, afferent of gag, swallowing
9
sensory receptors are located
in the ____________, which is located in the upper art/roof of the nasal septum
olfactory epithelium
Avoid irritating substances because it stimulates:
trigeminal nerve (CN V); not olfactory nerve (CN I)
There are 3 layers that encloses the eye:
○ Outermost: sclera
■ Consists of tough white fibrous tissue
■ Anterior: cornea
○ Middle: choroid
■ Very vascular
○ Innermost: retina
■ Optic nerve exits at the retina
■ The pale circular region called the optic disc forms the optic nerve head
What is the primary
visual cortex?
Cortical area 17 or brodmann area 17
● Papilledema is graded accordingly to know the severity of
the patient’s condition
● Stage 5
○ The optic disc is very edematous
○ No detectable disc obscuration of the disc
○ No blood supply and blood flow is restricted because of edema and compression
C-shaped ring that is subtle and grayish with a temporal gap; obscures underlying retinal details;
Temporal disc margin normal; Nasal disc margin obscured
Grade 1: Minimal
Circumferential ring
Elevation; nasal border
Temporal disc margin obscured in addition to nasal
Grade 2: Low grade
Obscuration in 1 or more segments of major BV
Elevation, all boarders
Ring, irregular outer fringe with finger-like extensions
Grade 3: Moderate
Total obscuration of a segment of a major artery or vein at its central origin
Ring, complete
Grade 4: Marked
Obscuration of all vessels both on the disc and leaving the disc
Grade 5: Severe
Sample Case
● 45 y.o. Male
● Uncontrolled hypertension
● Sudden onset right sided hemiplegia
● Slurred speech
● Preferential gaze to the left
● Right homonymous hemianopsia
● 100% sensory loss on the right side of the body
● Question: Where in the visual pathway is the lesion?
In a patient with a right hemianopsia, gaze palsy and sensory deficit, the most probable area will be the optic tract extended to the LGBT
Unequal pupils
Anisocoria
Tonic pupil
Adie’s pupil
Small, irregular pupils that accomodate but don’t react to light:
Also seen in CNS syphilis
Argyll Robertson pupils
the complete cranial 3 paralysis where you cant elicit any movement of the pupil
Oculomotor nerve paralysis
the other eyes is miosis and the
other eye is mydiatric and there is ptosis
Horner’s Syndrome
Sample Case:
● 30 y.o. Male
● No comorbidities
● 2 hours PTC, had MVA
● Fractured right clavicle
● Went to ER fully awake
● 1 hour after admission:
Right pupillary dilation; left constrict (picture)
● What do you think is the result of your pupillary exam?
● Cranial nerve responsible for pupillary movement:
● What do you think is the result of your pupillary exam?
○ Pupillary movement palsy
● Cranial nerve responsible for pupillary movement:
○ Oculomotor nerve
● If there is a palsy in the movement, even though the other eye has been shown. There is still no movement. There is no consensual movement that means there is a complete cranial nerve palsy.
What serves as a valuable signpost for the localization of lesions of the
cerebral hemisphere?
Abnormalities with oculomotor motility (CN III)
Results from lack of visual fusion of the perceived object and is projected to the non corresponding points of the retina and therefore is viewed as two objects.
Diplopia
Even if you close one eye, there’s still double vision
Monocular Diplopia
Laws of Diplopia
● The aberrant or “false” image is always hazier than the “true” image.
● The false image appears peripheral to the true image.
● The false image projects in the opposite direction as the direction of the eye deviation.
● The false image projects from the normal direction of pull of the paretic muscle.
Sample Case:
● 35 y.o. Male
● Had recurrent headaches for the past 6 months
● Decided to seek consult on you for evaluation
● On neuro exam, you did visual confrontation testing, to
which the patient showed this result:
Picture is: L & R nasal can see
● Question: Where do you think the lesion is?
● Question: What is this eye problem
● Question: Where do you think the lesion is?
○ Answer: Optic chiasm
● Question: What is this eye problem?
○ Answer: Bitemporal Hemianopsia – one side same eye
● Problem is in the temporal side
● Problem is in the optic chiasm – consistent with optic chiasm problem
Bitemporal Hemianopsia
What compresses the optic chiasm resulting in Bitemporal hemianopsia?
Pituitary Macroadenoma
MRI shows a mass in the pituitary gland, resting below the optic chiasm
What do you call the transient MONOCULAR Blindness from occlusion of the retinal artery?
Amaurosis fugax is a transient occlusion of a retinal artery.
What is a mixed nerve that provides sensory innervation to the face, mucus membranes of the oral and nasal cavities, and motor innervation to the muscles of
mastication?
V
4 Nucleus
● Main Sensory
● Motor
● Mesencephalic
● Spinal
elicit response to the face and compare it to the contralateral face. Elicit the right side then left side
Corneal Reflex
palpate the muscles in the temporalis area if it is atrophic. Let the patient move side to side the jaw. If there is weak movement then there is a problem in the cranial nerve.
Test for the temporalis and masseter tone
Sample Case:
● 40 y.o. Female
● Sudden severe jaw pain 10/10 pain score, stabbing character at the left after biting an ice – the pain is in the distribution of V2
○ V stands for Cranial Nerve V
○ CN V affects three regions – V1, V2, V3
○ The cranial nerve affected is CN V, the sensory part, affecting 2nd and 3rd regions
● Diagnosis?
Trigeminal Neuralgia
● Chronic pain condition that affects the trigeminal nerve
● Sudden burning or shock like facial pain that last anywhere from a few seconds to as long as hours.
4 segments
Mastoid, Horizontal, Labyrinthine, and
Meatal
Facial nerve problem wherein stapedius is impaired wherein the patient has an abnormally loud sound sensation to a normal sound.
● It’s actually caused by the damage of the facial nerve to
the stapedius causing abnormally loud sound sensation of the patient. It’s called:
Hyperacusis
whisper or use fingers to elicit minimal sounds, and let the
patient hear it
Schwabach Test
Differentiate conductive vs sensorineural hearing loss
○ According to the severity of the hearing loss, we
have:
■ Mild (20-29 decibels)
■ Moderate (40-69 dB)
■ Severe (>70 dB)
Weber Test
○ If there is a decreased tone or vibratory sensation at the and it’s lateralized at one side, you may suspect that the patient has conductive hearing loss.
○ If it is lateralized to the normal ear, the patient has sensorineural hearing loss.
○ If the tone is better or normal on both ears, most probably the patient is normal.
● Tests what type of abnormality the Weber’s test has. In the Weber’s test there is lateral sensation in the bad ear, the type of hearing is not known still
● Done through striking the tuning fork making a sound and placing it in the mastoid process. Ask the patient to indicate when they stop feeling the vibratory sensation
● Vibratory sensation usually stops before the sound.
● When the vibratory sensation can’t be felt in the mastoid
process let the patient hear the tuning fork by placing it beside the ear
● If the patient can hear the vibratory sounds then that
indicates normal hearing
● If the patient cannot appreciate the vibratory sensation and cannot hear the tuning fork when it is placed beside the ear then that indicates an air conductive problems (air conduction is longer than bone conduction)
● Air conduction is twice as long as bone conduction
○ Conductive hearing loss - bone conduction is longer or equal to air conduction
○ Sensorineural hearing loss - air conduction is abnormally prolonged compared to bone conduction
Rinne’s Test
CN IX Tests
● For motor assessment: you test for the stylopharyngeal function
● Test for glossopharyngeal nerve lesions; if there is dysphagia then that may be a sign of glossopharyngeal lesion.
● Gag reflex (very common and easy test) - you stimulate
the posterior laryngeal wall or the tonsillar area or the base of the tongue (these are the areas of the innervation of the glossopharyngeal nerve);
○ The response is tongue retraction with elevation and constriction of the laryngeal musculature.
CN X: VAGUS NERVE
● Vagus or “pneumogastric nerve”
● It has motor, sensory, and parasympathetic fibers
● It has 6-8 rootlets of the vagus nerve which emerge at the posterior sulcus of the medulla oblongata.
● Leaves the skull through the Jugular Foramen. Testing for vagus function
● When you test for the glossopharyngeal nerve you are
also testing for the vagus nerve.
● The vagus nerve innervates the soft palate, pharynx, and larynx.
● Examine soft palate and uvula at rest.
● Pharyngeal function elicited during phonation and swallowing.
● Usually, with unilateral vagal lesions there is ipsilateral flattening of the pharyngeal arch.
● Also patients may have phonation problems and the
ipsilateral palate fails to elevate and the uvula is retracted.
● Dysphagia and articulation disturbances may occur
CN XI: SPINAL ACCESSORY
● The spinal accessory nerve is a purely motor nerve that originates partly in the medulla.
● It has two roots, cranial and spinal root, that is why it is called the spinal accessory nerve.
● The cranial root arises from the cells in the caudal part of the nucleus ambiguous of the medulla;
○ Its fibers emerge at the lateral medulla below the roots of the vagus.
○ The spinal root arises from a column of cells that extends from the first to the sixth cervical cord segments
● The spinal root arises from a column of cells from C1-C6 Cord segments.
● A column of cells on the lower motor neurons of the spinal accessory nerve are somatotopically arranged therefore:
○ Cord levels 1 and 2 innervate predominantly the ipsilateral sternocleidomastoid.
○ Cord levels 3 and 4 innervate primarily the ipsilateral trapezius.
Testing for Cranial Nerve XI Function
● We have to test two muscles: the sternocleidomastoid and trapezius muscles ( these are the muscles that are innervated by the CN XI).
● Sternocleidomastoid muscle flexes the head and turns it to the side, when one muscle contracts the head is drawn towards the ipsilateral shoulder and rotated so that the occiput is pulled toward the side of the contracting
muscle.
● When you test for sternocleidomastoid you ask the patient to move the head side to side; if he can move then probably no lesion but you have to test for the strength.
● Let the patient move next time in the opposite direction and apply opposite pressure to test for the resistance if it is really strong.
● And you may apply both resistance in the shoulders to
test for sternocleidomastoid.
CN XII: HYPOGLOSSAL NERVE
● Pure motor nerve of the tongue.
● Fibers arise from the hypoglossal nucleus
● Fibers emerge from the medulla between the inferior olives and pyramid
● 10-12 rootlets
● Leaves the skull through the hypoglossal foramen
● Passess between the mylohyoid and hypoglossus
CN and brainstem
● Cranial Nerves II, III, IV- arises from the midbrain
● Cranial Nerves V, VI, VII, VIII-arises from pons
● Cranial Nerves IX, X, XI,XII- arises from medulla
● Clinical evaluation of the hypoglossal nerve consist of observation of the tongue at rest, protrusion, strength and its movements
● Visually unilateral lesion of the hypoglossal nerve results in paresis.
● First Picture (Left), evidence of atrophy, furrowing, fibrillations and fasciculations of half of the tongue.
● Second picture (Middle), deviated tongue, atrophy, furrowing
Testing for CN XIII function
Which is the ONLY cranial nerve that does not
pass through the thalamus?
CN I
When the examiner does a finger to nose test and the patient shows tremors or when the patient holds a cup of coffee then sips it and there is presence of tremors this is
called:
Intention tremors, there is intentional activity of the hand.
● But when the patient maintains a single position, this is Postural tremors.
marker of atrophy
prominence of shin
bone
ideally it should not be seen because of the
bulk of the gastrocnemius muscle.
○ But if the gastrocnemius is very atrophic already, the shin bone appears.
The degeneration of muscle nerve fibers and can be due to a nerve damage or atrophy
MUSCLE ATROPHY
Standard grading for manual motor examination also known as MME:
5 - normal strength
4 - against resistance greater than gravity
3 - against gravity but not against resistance
2 - eliminated gravity
1 - only a flicker of contraction
0 - complete paralysis
● Clasp-knife phenomenon in hemiplegic. Quadriplegic, monoplegic, or paraplegic distribution.
● Clonus and hyperactive MSRs
● Extensor toe sign
● Tends to predominate in one set of muscles, such as the flexor of the upper extremity, the extensors of the knee, and plantar flexors of the ankle.
● EMG inactive with muscle at complete rest.
Spasticity
What is seen in basal ganglia or cerebellar lesions?
Rigidity
● Lead-pipe phenomenon, often with cogwheeling and tremor at rest; usually in all four extremities but may have a “hemi” distribution.
● The examiner elicits the lead-pipe phenomenon of rigidity by making a relatively slow movement of the patient’s resting extremity.
● No clonus; MSRs not necessarily altered.
● Normal plantar reflexes
DTR Grading
0 = no reflex, hyporeflexia, abn condition
1+ = slight resp, present but diminished
2+ = normal and active
3+ = increased response, may or may not be normal
4+ = hyperreflexia, very hyperactive response
What is a sign of an upper motor neuron lesion?
○ The brain regulates all movements, specifically the cerebrum or the cerebellum.
○ It enables fine motor movements. No overshooting, no atresia.
Hyperreflexia
Type of dizziness:
○ caused by lesion in the inner ear (cochlea/inner ear structures) not extending to the brain
○ onset of peripheral lesion has a greater intensity which can cause severe vomiting and dizziness
○ duration of peripheral type of dizziness is usually seconds and the direction of nystagmus is usually horizontal
○ Head position: exacerbated
○ Neurologic findings: weakness, sensory deficit like numbness
Peripheral
Type of dizziness:
○ Outside parenchyma (brain)
○ effects on central lesion such as stroke, brain tumor has mild symptoms of dizziness
○ Head position: unchanged
Central type
Test for Overshooting
● Arm overshooting
○ Examiner tries to place resistance to the patient’s
hand then let go suddenly
○ The goal is to see if the patient will be able to prevent
his hand from hitting him
○ Examiner protects the patient by placing their hand
across patient’s chest
● Pendular reflexes
○ Like a pendulum
○ Ideally, when testing for reflexes, a little flicker will do
■ Already +2
Different types of gait
○ Spastic gait - usually seen in stroke patients; there is hypertonus at the area of the hand and feet of the side affected
○ Scoliotic gait those with scoliosis
○ Propulsive gait also called Parkinsonian gait; has tremors during involuntary movement, there is flex position and rises and walks slowly with short steps
○ Steppage gait - those with foot drop; there is prominent lifting of the foot every time px steps
during walking
○ Waddling gait - for patients with muscular dystrophy or muscular diseases due to the weakness of the muscles needed for ambulation
○ Tandem Gait doing this will allow for the assessment of balance or motor weakness as well as coordination
Sensory exam tests for:
● Pain/Temperature
● Light touch
● Vibration
● Position sense
What is the inability to flex the Pt’s head because of reflex spasm of the nuchal (extensor) muscles of the neck?
Nuchal rigidity
Cause: irritation of the subarachnoid space
When testing for nuchal rigidity, watch out for abduction and flexion of the legs as you attempt to flex the head.
Brudzinski sign
There is stiffness in the movement of the head and neck.
Paratonia
