Neurological Exam Flashcards
What structures are required for consciousness?
One cerebral hemisphere and reticular activating system
Level of alertness
Best verbal or motor response that can be elicited from a pt in response to a specific stimulus
Aphasia
Acquired disorder in production or understanding of language due to a lesion involving the dominant cerebral hemisphere.
Expressive aphasia
I.e Broca’s aphasia - significant difficulty producing language but preserved understanding; pts usually have a right hemiparesis due to involvement of adjacent motor cortex
Receptive aphasia
I.e Wernicke’s aphasia - fluent, nonsensical speech with numerous paraphrasic errors and markedly impaired understanding
What do patients with Wernicke’s aphasia frequently also have?
Contralateral homonymous hemianopsia due to involvement of adjacent optic radiation s
Lesion location of conduction aphasia
Arcuate fasciculus
Anomic aphasia
Lesion in post. Inferior temporal lobe with specific deficit in naming things
What are the 6 ways you can assess aphasia?
Fluency Naming Comprehension Repetition Reading Writing
Agnosia
Defect in recognizing a complex stimulus; due to defects involving association cortex ESP in parietal and temporal lobes
Anosognosia
Denial of illness
Asomatognosia
Denial of half of one’s body
Prosopagnosia
Inability to recognize faces
Ideomotor apraxia
Inability to perform motor tasks in command
Ideational apraxia
Inability to plan a series of complex tasks (how would you set the table for dinner)
Constructional apraxia
Inability to copy complex figures
5 ways you can test cognition
Orientation Memory Intellect Abstraction Judgment
How do u assess pts memory
Ask them to immediately recall three objects and after 5 minutes ask them again
At which locations should you auscultate the skull? What do bruits signify?
Over the orbits, mastoid processes and temporal bones
Bruits over these areas can indicate AVM
What should you assess on the spine in physical exam
- check for scoliosis
- palpation to detect tenderness
- ROM in 6 cardinal directions (cervical and lumbar)
Positive straight leg test implies…
Compression or irritation of nerve roots L4-S2
- pain may be increased with dorsiflexion of the foot
Menigismus
Severe neck pain that is made profoundly worse with neck flexion
Brudzinski sign
Spontaneous flexion of the legs at the hips and knees following neck flexion
Kernig sign
Resistance to knee extension when the hips are flexed
When is it especially important to evaluate the olfactory nerve ie sense of smell
After head trauma bc cribiform plate may be sheared off
What type of tumors cause neurologic loss if smell by invading cribiform plate
Basal meningiomas
What does visual acuity evaluate
Only macular vision, which is the central 5 degree of the visual field
How do you evaluate visual neglect
Pt keeps both eyes open and looks are examiners nose, examiner presents bilateral simultaneous stimuli and pt is asked to localize the stimuli
Marcus gunn pupil
Deafferented pupil that constricts to consensual but not direct light; due to lesion in CN 2
Hutchinson pupil
Dilated pupil that does not respond to direct or consensual light; due to lesion in CN 3
Adies tonic pupil
Dilated pupil with impaired light response and slow constriction to near vision; lesion to the parasympathetics
Argyle Robertson pupil
Small, irregular pupil that constricts to near vision by not to light; lesion in pretectum
Vestibulocular reflex (oculocephalic) ie dolls eyes
Reflex fixates image on the retina with respect to head and neck motion; vestibular nuclei project to CN 3,4 and 6 via MLF to maintain stable visual field despite head motion
Visual pursuit
Reflex that fixates the image on retina with respect to image motion; image motion is sensed by occipital cortex that then relays the information in a crossed manner to lateral gaze center in pons and then via MLF to CN 3,4,6
Nystagmus
Rhythmic, oscillatory involuntary eye movement of one or both eyes that may occur spontaneously or be evoked by a specific direction of gaze
Main causes of ptosis
Lesions to CN 3 which innervates the levator palpebrae OR the superior tarsal muscle which is innervated by the sympathetic nervous system
How can u distinguish a sympathetic lesion causing ptosis from a CN 3 lesion causing ptosis
Sympathetic lesion will have accompanying small pupil (Horner’s) while CN 3 lesion will have large pupil
Corneal reflex
Afferent - ophthalmic division of trigeminal
Efferent - facial nerve
Muscles of mastication
Temporalis, masseter, lateral and medial pterygoid mm
- innervated by mandibular division of trigeminal nerve
What do you see in Bell’s palsy?
Lower motor neuron lesion - ipsilateral weakness of entire half of face
Facial weakness due to UMN lesion (corticobulbar tract)
Contralateral weakness of lower half of face
Pattern of sound localization with the Weber test
Normally sound should be heard in both ears
- sound localizes to bad ear in conductive hearing loss and to good ear in sensorineural hearing loss
Latency period before onset of nystagmus in peripheral vs central vertigo
Peripheral is 2-20 sec, whereas central has no lag period
Duration of nystagmus in peripheral vs central vertigo
Peripheral is less than 1 min
Central is greater than 1 min
Which is more severe vertigo.. Peripheral or central?
Peripheral - it also demonstrates fatigability
What do you see with a lesion of the hypoglossal nerve
Atrophy of ipsilateral half of tongue
Tongue will deviate towards the side of lesioned nerve when protruding
Denervation atrophy
Profound form of muscle atrophy seen with LMN lesions
Disuse atrophy
Milder form of muscle atrophy that can be seen with a variety of clinical settings
What is a fasciculation and what could it mean?
Worm like contractions of muscle due to random discharge of an entire motor unit - may be seen with anterior motor horn disorders I.e ALS
Myoclonus
Sudden contractions of a muscle or group of muscles that move an entire limb across a joint; commonly seen with metabolic or hereditary neuro disorders
Muscle tone
Resistance of muscle to passive stretch - can be assessed by moving a relaxed limb passively through an entire ROM
What is spasticity and what does it imply?
Increased muscle tone that has a catch which varies with position and is velocity dependent
- implies UMN lesion
Rigidity
Steady resistance to movement at all speeds and positions; superimposed tremor can lead to cogwheeling
Lead pipe rigidity implies a lesion in…
Basal ganglia - substantia nigra or striatum
Paratonia - gegenhalten and mitgehen
Inability to relax the muscle
- gegenhalten: opposes the examiner
- mitgehen: assists the examiner
Paratonia implies a lesion in…
Bihemispheric lesion
What is ‘functional testing’ of UE and LE
UE: ask pt to raise arms over their head, ability to touch chin to chest
LE: ability to raise from a chair w/o using hands, ability to walk on toes/heels
Pronator drift
Strongly indicates UMN lesion
How do you assess protopathic sensation
Pain (pinprick) and temperature (cold tuning fork)
- carried by small, Unmyelinated fibres, travel contralaterally in lateral spinothalamic tract to brain stem reticular formation and thalamus
How do you test epicritic sensation
Ex, fine touch, vibration, proprioception
Stereognosis
Ability to identify objects by touch alone ex. Place a coin in pts hand and ask them to close their eyes and identify it
Graphesthesia
Ability to recognize numbers drawn on palm of hand
Two point discrimination
Test with paper clip, normal subjects have detection threshold of 2 mm at tip of index finger
Double simultaneous stimulation
Right and left sides of the body are touched at the same time and the patient is asked to localize both stimuli with eyes closed
Romberg test
Functional sensory testing - ask pt to stand with feet together and eyes closed, if they sway/fall to one side then Romberg is positive
- dysfunction implies lesion to either vestibular apparatus or proprioception
Pt cannot stand well with feet together and eyes open - what does this imply
Lesion of cerebellum is expected
How do you assess truncal stability in a pt
Observe pts balance while they are sitting or standing with feet together and eyes open; truncal ataxia suggests cerebellar vermis lesion
How do you assess limb coordination?
Finger to nose and heel to shin tests
Inability to ‘check’ movements indicates lesions of…
Ipsilateral cerebellar hemisphere
Severe sensory disturbances causing altered proprioception
How can you evaluate vestibular coordination
Compass turning - ask pt to march in place with eyes closed, rotation of body in one direction is suggestive of ipsilateral vestibular pathology
Clonus
Rhythmic series of involuntary mm contractions induced by a sudden passive stretch to a muscle; indicative of hyperreflexia
Abdominal reflexes
Stroke skin lightly in all 4 quadrants, look for deviation of umbilicus toward the quadrant that is stroked
- upper quads are t6-t9
- lower quads are t10-12
What nerve roots are needed for anal wink reflex
s3-5
The cremasteric reflex is mediated by what nerve roots
L1-2
Bulbocavernous reflex
Squeezing glans penis and observing for contraction of external anal sphincter; requires nerve roots s3-4
When do frontal release signs occur
Normally present in infancy, reappear with advanced age or diffuse cortical or bihemispheric damage
What are the 4 frontal release signs
Snout reflex
Palmomental reflex
Grasp reflex
Glabellar sign
Inability to perform tandem gait indicates..
Altered proprioception or midline cerebellar lesions
An asymmetric, hemiplegic gait
Upper motor neuron disorder
Asymmetric, steppage (foot drop) gait
Peroneal nerve palsy
Asymmetric, antalgic gait
Foot or leg lakn
Wide based, sensory ataxic gait (foot slap)
Lesion in posterior columns
Wide based, gait apractic gait (gait ignition failure)
Bihemispheric lesions usually frontal lobe dysfunction
Narrow based, spastic scissor gait
Bilateral UMN lesions
Narrow based festinating gait
Basal ganglia ( substantia nigra)
