Neurological Exam Flashcards
What are the seven parts of the neurological exam?
- mental status
- CN function
- Motor function
- Sensory function
- Reflexes
- Coordination Exam
- Station and Gait
When doing the mental status exam, what is the first thing to assess?
Sensorium- what is the persons level of arousal and do they know who they are and where they are
What are the different levels of arousal
- Awake- eyes open, responsive to stimuli
- Lethargic- reduced consciousness but can be brought to awake with surprising, loud stimuli or touch
- Stuporous- low level of consciuosness that can be stimulated with noxious stimulus but not brought to a full level of awake
- Coma- unable to arouse even with noxious stimuli
During the mental status exam, what is a way to test global cortical function?
Memory- test encoding and recall by having them repeat three words to you.
Ask them again in a minute and then ask them again after you test CN
What is the major way to asses left hemisphere function?
- test language by asking them to repeat a sentence. Comprehension and fluency are judged.
- test calculation, spelling, praxis, multimotor tasks
What is the major way to assess right hemisphere function
Attention (count back from 100) and focus (neglect) as well as spatial orientation (draw a polygon)
What is the major way to test frontal lobe function?
executive functioning (planning and initiation of events, cause and effect)
What does a person have to be considered non-comatose?
A working ARAS and atleast one of the cerebral hemispheres
What is orientation?
a part of the patients sensorium where they are able to recognize who they are, where they are and what they are doing there
If a patient has delerium, what is intact and what is not right?
Intact- higher cortical function like math and problem solving
Not there- sensorium. they wax and wane
What are the three Rs for testing memory?
register, recall, remote
When checking CNI, what can an anosmia clue you in to?
frontal lobe or limbic injury
Why shouldnt you use ammonia to test CN1?
Because it will stimulate the pain fibers in CN5 instead of CN1. Use peppermint or coffee
What four things must you test when checking CN2?
Visual field cuts to localize lesions
Acuity - each eye separate (read)
Pupillary light reflexes
Check fundus for papilledema
In addition to shining a light in the patients eye to test pupillary reflex, why must you turn the lights down low?
To see if the eye dilates. This is testing the sympathetic chain and superior cervical ganglion to ensure that the patient does not have Horner syndrome
How do you check CN3,4,6?
the movement of EOM in all six directions, plus check gaze and convergence at near targets
What would you see if there was a CN3 palsy?
eyes would be down an out, the pupil would be blown, there would be ptosis
Patients with a trochlear nerve palsy would be doing what when they come in?
The affected eye would be extorted and up because the SO is not operating (usually keeps the eye intorted and down) so the patient will have their head turned toward the “good eye” and chin tucked
Someone with a CN6 palsy will be doing what with their head?
The affected eye will be stuck in an inward position because the lateral rectus is weak. If they need to look to the side, they will have to turn their whole head toward the affected eye
How do you test CN5?
- jaw strength
- symmetry of opening jaw
- fine touch and pin on the opthalmic, maxillary and mandibular regions
How do you test CN7?
Look for symmetry in facial movements of upper and lower face. Bells palsy will affect the whole face on one side but a contralateral UMN deficit will affect the bottom half of the face only
Why is the top half of the face spared in an UMN injury to CN7?
the corticobulbar tract is bilateral
To test for CN8, you assess what two things?
- Hearing (weber and rinne)
2. Vestibular function- nystagmus, vertigo etc
To test CN9 and 10, what do you do??
Have the patient say “ah” and assess the palate and uvula. 9 is sensory and 10 is motor so also do the gag reflex
To test CN 11 what do you do?
Push on the patients sholders and ask them to shrug (SCM)
To test CN12, what do you do?
have the patient stick out their tongue. LMN is will go toward the lesion. UMN it will go away from the lesion
Assessing speech will test which cranial nerves?
7 and 12 with la la la and papapa (tongue)
9 and 10 with cacaca and gagaga (palate)
What tests would assess the integrity of the midbrain?
pupillary light reflex (2 and 3)
What is the corneal reflex? What two CN does it test? What brainstem level does this test the integrity of?
touch a wisp to the persons cornea
afferent is CN5, efferent is CN7.
This reflex is used to test the pons
What is used to assess the integrity of the medulla?
the gag reflex which tests CN 9 and 10
How can you test the integration between the pons and the midbrain?
by checking the connections between the vestibular nuclei, MLF and lateral gaze centers of CN3 and 6
What is the oculocephalic reflex?
have the patient stare straight ahead and then turn their head side to side. The eyes should travel opposite to the head
If you do a cold water test for vestibular function, what direction do the eyes drift?
the ipsilateral eye will drift toward the cold water (6) and the contralateral eye should adduct also toward the water (cn3)
If the CN tests are not normal, what is the likely cause of your patients coma?
a disruption of the ARAS
When testing motor function, what three things do you look for?
- inspection
- tone
- movement
If your patient has decerebrate posture, where is the lesion of the brainstem?
below the red nucleus and their elbows will be flexed and arms turned in
If the patient has decorticate posture, where is the lesion in the brainstem?
Above the red nucleus. The elbows will be extended and the arms pronated
When assessing muscle strength on the MRC scale, what is a 1, 3, and 5?
1- muscle contracts without moving the joint (fasciculation)
3- the person can move the muscle against gravity but not against resistance
5- the person has normal strength
Mild weakness is more easily seen in upper extremity _________ and lower extremity _________.
extensors; flexors
What is pronator drift? What is the likely cuase?
have the person close their eyes and extend their hand.
The arm will turn in and drop a little if there is an UMN deficit
Resting tremors point to what?
Intention tremors are a sign of what?
Resting tremors are a problem with the basal ganglia and intention tremors usually are an issue with the cerebellum
What is a rubral tremor and what is the typical cause?
both rest and intention tremor and the cause is a midbrain insult
Where do you test deep tendon reflexes?
biceps triceps, patella and achilles as well as the jaw
What is hyporeflexia usually a sign of?
What is hyperreflexia a sign of?
Hypo- peripheral neuropathy or LMN
Hyper- UMN
What is clonus?
involuntary rhythmic movements you would see if the patient had an UMN lesion and you did wrist or ankle dorsiflexion
What is spreading?
multiple muscle groups in the same body region respond to the reflex test instead of just the one associated with the muscle group you are testing
What happens to the toes in a positive Babinksi test?
Toes will extend if there is an UMN lesion
To test the cerebellum, what coordination tests should you use?
look for action tremors, motor speed, abnormal magnitude of motion, alternating movements using:
finger-nose-finger
heel-knee-shin
heel-toe-heel-toe
What non-motor functions can be assessed when checking basal ganglia and cerebellum?
scanning speech and nystagmus
