Neurological Examination Flashcards
what is a neurological exam?
series of test conducted by a neurologist to evaluate integrity of nervous system
what are the 8 reasons for a neurological exam?
- differential diagnosis
- monitor disease progression
- clarify impact of injury/disease
- determine rehabilitation needs
- capacity for daily living, work, study
- surgical candidacy
- triaging (limited resource, who gets?)
- legal
what is the aim of the neurological exam?
lesion localization (level & lateralization)
- 5 divisions of brain
- internal capsule
- spinal cord
- cranial nerves
- neuromuscular junction
- muscle
composition of neurological exam =
observation + formal testing
what are the 6 common components of neurological exam?
- patient history
- cranial nerves
- motor system
- somatosensory
- coordination
- mental status
what are the 6 things you look at when determining patient history?
- age
- education
- handedness (which side brain dysfunction)
- past medical history
- use of meds/drugs
- family medical history (genetics)
what are the 4 things to look at in patient history when determining disease process?
- timing - sudden vs gradual, acute vs chronic
- change over time - static, improving, worsening
- triggers/relievers of symptoms
- severity of symptoms
what are the cranial nerves?
12 nerve pairs at neck & head, afferent, efferent, both
- test to localize deficits to particular systems
what is cranial nerve I ?
olfactory (smell)
how do you test for cranial nerve I ?
identify familiar smells 1 nostril at a time, compare strength of smell
what does it mean when cranial nerve I is “unilaterally abnormal” and what area is damaged?
smell is bad on 1 side, olfactory bulb or tracts
what does it mean when cranial nerve I is “bilaterally abnormal” and what area is damaged?
smell is bad on both sides, ethmoid ridge via impact -> CSF leakage
what is cranial nerve II ?
optic (vision)
what tests can test for cranial nerve II?
- snellen chart/near card (read letters)
- visual field confrontation (can u see my finger)
- pupillary light reflexes, shine light & see speed & duration pupil change
what are possible causes of increased intercranial pressure (cranial nerve ii)?
- Traumatic brain injury (TBI)
- brain tumour
- encephalitis (inflammation)
- high blood pressure
- bleeding
what do cranial nerves III, IV, VI do?
control eye position via paired muscles that move & hold eye
how do you test for cranial nerves III, IV, VI?
follow object/light without moving their head
what is a result of damage to cranial nerves III, IV, VI?
gaze palsy, weakness/loss of certain eye movements
- character of palsy (voluntary, reflexive, both & 1/both eyes) points to location
what is cranial nerve V?
motor (activation of muscles) & sensory (detection of location)
how do you test for motor function of cranial nerve V?
biting down & holding mouth open, feeling activation of muscles
how do you test for cranial nerve V?
detection of location of object, sharp vs dull, hot vs cold
what is trigeminal neuralgia (cranial nerve V) & what are the causes & treatments?
severe chronic pain condition, feeling electric shock to 1 side of face (triggered by light touch/spontaneously)
- cause: pressure on trigeminal nerve by blood vessel; MS; tumour; stroke
- treatment: anticonvulsant drugs, surgery to remove blood vessels
what is cranial nerve VII?
facial (expressions)
how/what do you test for cranial nerve VII?
test for asymmetry & strength
- face: drooping, sagging, facial creases
- raise eyebrows
- smile
- puff out cheeks
- close eyes hard
what is bell’s palsy (cranial nerve VII)?
paralysis of facial nerve causing weakness on 1 side of face
what is cranial nerve VIII?
vestibulocochlear (hearing)
how to test for cranial nerve VIII?
whisper test, hearing w/ tuning fork touching & not touching skull bone
what is damaged if there is unilateral hearing loss?
peripheral lesion
what is damaged if there is bilateral hearing loss?
more central damage
what is cranial nerves IX and X?
glassopharyngeal & vagus (voice, swallowing, gag reflex, cough)
what is pseudobulbar palsy?
bilateral central lesions (cortex + medulla)
- strained, strangled voice
- emotional lability
- gag normal/increased
what is bulbar palsy?
bilateral peripheral lesions (medulla)
- nasal speech
- no emotional lability
- gag absent
what is cranial nerve XI?
accessory
- shrugging of shoulders
- head resistance
- looking for weakness + location
what is cranial nerve XII?
hypoglossal
- stick out tongue, lateral movement
- looking for direction deviation & strength
what are the key features to examine motor function?
gross appearance of muscle, muscle tone/strength
whats the difference between muscle tone & strength?
muscle tone: how activated muscles are at rest
muscle strength: how much force muscle can exert at max
where do upper motor neurons originate from & what used?
motor cortex / brain stem, use glutamate
where do lower motor neurons originate from & what used?
spinal cord/brain stem, innervate muscles/glands, use acetylcholine
what does upper motor neuron damage lead to?
weakness, spasticity (abnormal muscle tightness), hyperreflexia, retained primitive reflexes
what does lower motor neuron damage lead to?
weakness, hypotonia (low tone), hyporeflexia, atrophy (physically small muscle), fasciculations (twitching)
what is somatosensory function?
ability to touch (temperature, pain, vibration, proprioception-where body in space)
what are the 2 types of touch (somatosensory) disabilities?
astereognosis, agraphesthesia (both point to sensory cortex of parietal lobe)
what is astereognosis?
inability to recognize objects by touch
what is agraphesthesia?
inability to recognize letters/numbers by touch
what is dysdiadochookinesia (coordination)?
inability to perform rapid muscle movements
what is dysmetria?
impairment performing accurate movements (cerebellar damage)
- asymmetries (poor timing, width of steps -esp turning & stopping)
- abnormalities point to = ethanol inebriation, cerebellum
what is Romberg’s test?
balance with eyes open vs closed, positive romberg = cerebellar damage
what is pronator drift?
rotation & vertical motion of arm = damage too pyramidal tract (efferent fibres from cortex to brainstem/spinal cord)
what are the 6 general components of a mental status exam?
- level of consciousness
- attention & orientation
- language
- memory
- visuospatial function
- executive function
what does “attention & orientation” entail?
what are the regions involved?
what do problems include?
observing patient’s alertness (spelling word/counting backwards, current whereabouts, time)
regions
- lots (cortical/subcortical regions), may spread
problems
- contralateral neglect
- anosognosia
what does “language” entail?
what are the regions involved?
what do problems include?
naming body parts, reading/writing/repeating phrases (check for fluency, comprehension, prosody, praxis)
regions
- focal/diffuse damage to left hemisphere (if right handed)
problems
- aphasia: difficulty producing languge/comprehension
- alexia: difficulty reading
- agraphia: problems writing
what does “memory” entail?
what are the regions involved?
what do problems include?
digit span/pointing span, short-term memory (remembering 3 wrds for 2-5min), long-term memory (past public/personal events)
regions
- medial temporal structures
- prefrontal cortex
- left parietal lobe
problems
- dementia
- amnesia
what does “visuospatial function” entail?
what are the regions involved?
what do problems include?
line cancellation, copy geometric design, judge line orientations, object/face/colour recognition
regions
- right hemisphere attention network
problems
- agnosias (recognition difficulties)
- apraxias (motor performance difficulties)
what does “executive function” entail?
what are the regions involved?
what do problems include?
cognitive control of behaviour (judgement test, verbal fluency, luria’s 3 step hand movement test, trail-making/drawing patters, clock drawing “10 past 11”
regions
- prefrontal cortex and/or associated projections
problems
- dementia
- mood disorderr
- stroke
what is the ImPACT test?
test for concussion
what is the RBANS test?
test to distinguish types of dementia
