Neurological Exams Flashcards
1
Q
Neurological Exam
A
A series of tests conducted by a neurologist to evaluate the integrity of the nervous system
- Can be narrowed down if a person is showing signs in a particlar area!
2
Q
8 reasons for a neurological exam
A
- Differential diagnosis - does an individual have this or that? (identifying between 2 potential diagnosis)
- Monitor disease progression - e.g., MCI > dementia; impact of meds
- Clarify impact of injury/disease - e.g., following toxin exposure
- Determine rehabilitation needs - e.g., cognitive rehab vs modify environment
- Capacity for ADLs, work, study - e.g., ready to return to work?
- Surgical candidacy - e.g., deep brain stimulation
- Triaging - for the healthcare systen to weigh patient severity - can they wait for treatment or is this an emergency? e.g., thunderclap headache vs, migraine
- Legal - e.g., NFL concussion lawsuits, sentencing
3
Q
Aim of the neurological exam
A
Lesion localization (identify where the dysfunction is coming from) – level and lateralization
- 5 divisions of brain
- Internal capsule
- Spinal cord
- Cranial nerves
- Neuromuscular junction
- Muscle
4
Q
Composition
A
observation + formal testing
- Can consist of regular questions - how are you, how did you get here today…
5
Q
Common Components of the Neurological Exam
A
- Patient history
- Cranial nerves
- Motor system
- Somatosensory
- Coordination
- Mental status
- + Follow-up neuropsychological testing
6
Q
- Patient history - what should we find out? (5)
A
- Age, education, handedness
- Past medical history
- Use of medication and/or recreational drugs
- Family medical history
- Disease process
7
Q
- Patient history - disease process: what do we need to find out?
A
- Timing: sudden v gradual; acute v chronic
- Change over time: static, improving, worsening
- Triggers or relievers of symptoms
- Severity of symptoms
8
Q
2.Cranial nerves
A
- Testing the Cranial Nerves
- 12 nerve pairs
- Afferent, efferent, or both
- Test to localize deficits to particular systems
9
Q
Which cranial nerves are connected to the midbrain?
A
3-4
10
Q
Which cranial nerves are connected to the pons?
A
5-8
11
Q
Which cranial nerves are connected to the medulla?
A
9-12
12
Q
Cranial Nerve I
A
Olfactory
13
Q
Cranial Nerve I - tests:
A
- Identify familiar smells, one nostril at a time
- Compare strength of smell
14
Q
Cranial Nerve I - types of problems:
A
Unilaterally abnormal (only on one side/nostril)
* Possible structural brain lesion to olfactory bulb or tracts
Bilaterally abnormal
* Anosmia = loss of smell (due to affected/broken bones in the face)
* Possible damage to ethmoid ridge via trauma/TBI > CSF leakage
15
Q
Cranial Nerve II
A
Optic (functioning)
16
Q
Cranial Nerve II - 3 tests
A
- Standard visual acuity tests for each eye separately (Snellen chart or “near card”)
- Visual field confrontation (can you see my finger now? Now?)
- Pupillary light reflexes – cranial nerves II & III (speed and duration)
17
Q
Cranial Nerve II - issues
A
damage to various levels of the visual system
18
Q
Cranial Nerve II - Fundoscopy (test); what for?
A
- …to look for papilledema (optic disk swelling - nervous tissue behind eye is swollen and pushing into the eye)
- Can indicate swelling in the brain
19
Q
Cranial Nerve II - Possible causes of increased intracranial pressure
A
- TBI
- Brain tumour
- Encephalitis (inflammation)
- High blood pressure
- Bleeding
20
Q
Cranial Nerves III, IV, and VI
A
- Oculomotor, trochler, abducens
- all are optical motor nerves
- Control eye position by via paired muscles that move and hold the eye
21
Q
Cranial Nerves III, IV, and VI - test
A
Follow an object/light without moving their head (6 cardinal directions)
22
Q
Cranial Nerves III, IV, and VI - issues
A
Gaze palsy = weakness or loss of certain eye movements
- Character of the palsy (voluntary/reflexive/both, one/both eyes) points to location; e.g., nystagmus
- Inner ear Cerebellum brainstem
e.g., pontine stroke
23
Q
Cranial Nerve V
A
Trigeminal (3 parts)
- Motor
- Sensory
- Trigeminal neuralgia (symptom)
24
Q
Cranial Nerve V - Motor tests
A
- feel activation of muscles when biting down
- holding mouth open
24
Cranial Nerve V - sensory:
* detection of location
* sharp/dull, hot/cold
25
Cranial Nerve V - trigeminal neuralgia (symptom)
* **A severe chronic pain condition**
* Feeling of electric shock to one side of the face, triggered by light touch or sometimes spontaneously
* **Causes**: pressure on trigeminal nerve by a blood vessel; MS; tumor; stroke
* **Treatment**: anticonvulsant drugs, surgery to move blood vessels
26
Cranial Nerve VII
Facial
27
Cranial Nerve VII - tests
Test for asymmetry and strength:
* Face: drooping, sagging, facial creases
* Raise eyebrows
* Smile
* Puff out cheeks
* Close eyes hard
28
Cranial Nerve VII - issues
Bell’s Palsy = paralysis of facial nerve causing weakness on one side of face
29
Cranial Nerve VIII
Vestibulocochlear
30
Cranial Nerve VIII - tests
* Whisper test
* Test hearing with tuning fork touching + not touching skull bone
31
Cranial Nerve VIII - issues
* **Unilateral** hearing loss = peripheral lesion
* **Bilateral** hearing loss = more central damage
32
Cranial Nerve IX and X
* IX Glassopharyngeal
* X Vagus
33
Cranial Nerve IX and X - test
Assess voice, swallowing, gag reflex, cough
34
Cranial Nerve IX and X - issues
**Pseudobulbar palsy = bilateral central lesions (pseudobulbar/corticobulbar tracts = cortex + medulla)**
* Strained, strangled voice
* Emotional lability
* Gag normal or increased
**Bulbar palsy = bilateral peripheral lesions (bulbar = medulla)**
* Nasal speech
* No emotional lability
* Gag absent
35
Cranial Nerve XI
XI Accessory
36
Cranial Nerve XI - testing
* Shrugging of shoulders
* Head resistance
* Looking for weakness + location
37
Cranial Nerve XII
XII Hypoglossal
38
Cranial Nerve XII - testing
* Stick out tongue, lateral movement
* Looking for direction deviation + strength
39
3.Motor Function - Key features to examine:
* Gross appearance of muscle
* Muscle **tone**, **strength**
- Strength: how much force can a muscle exert, when you're trying to exert force
- Muscle tone: how active is a muscle at rest
40
Upper motor neurons originate in _ or _ and use _
motor cortex; brainstem; glutamate
41
Upper motor neuron lesions can lead to
* Weakness
* Spasticity - Muscle "catches"; ridgity
* Hyperreflexia
* Retained primitive reflexes (e.g., grasp, suck, snout)
42
Lower motor neurons originate in _ or _ , _ , and use _ (incl. motor cranial nerves)
spinal cord or brainstem, innervate muscles or glands, and use acetylcholine
43
Lower motor neuron lesions can lead to:
* Weakness
* Hypotonia (low tone)
* Hyporeflexia
* Atrophy
* Fasciculations: fine movements of the muscles under the skin
44
4.Somatosensory
Somatosensory Function
* Temperature
* Pain
* Vibration
* Proprioception
* Touch
45
Somatosensory - issues with touch
* **Astereognosis** = inability to recognize objects by touch
* (Subtype) **Agraphesthesia** = inability to recognize letters/numbers by touch
* > both point to sensory cortex of parietal lobe
46
5.Coordination - Quick, alternating movements can test...
* Dysdiadochokinesia > MS in adults; cerebellar tumours in kids
* **Inability to perform rapid, alternating movement**
47
5.Coordination - Point-to-point movement can test...
* Dysmetria > impairment performing accurate movements
* EX: putting the cap on a pen
48
5.Coordination - Romberg’s test
* balance with eyes open vs closed
* +ve Romberg points to cerebellar damage
49
5.Coordination - Pronator drift
Pronator drift = rotation and vertical motion of arm
* EX: in the neurological exam video - when eyes are closed, hands held out either rotate (pronates) or one raised above the other
* Points to damage to the pyramidal tract (efferent fibres from cortex to brainstem or spinal cord)
50
Lower side of mental status exam scale
## Footnote
6. Mental status
EXAMPLES:
* MoCA
* MMSE
Time:
* Brief (<10)
Purpose:
* Screening
51
Higher side of mental status exam scale
Comprehensive neuropsychological battery: higher side of scale
Time
* Lengthy, 4-6 hours
Purpose
* Mean for profiling
52
MOCA
Montreal cognitive assessment tool
53
4 general components of the MOCA
1. Visuospatial
2. Memory
3. Language
4. Attention/orientation
54
Visuospatial tests
| MoCA
* Line cancellation
* Copy geometric designs: 1 full point, Any criteria for 1 point missed = 0
* Judge line orientations
* Object/face/color
55
Visuospatial - region involved
Right hemisphere attention network
56
Executive function - what does it test?
* Cognitive control of behavior
57
Cognitive function - tests:
* Verbal fluency
* Abstraction - EX: similarity between an orange and banana = fruit (looking for categorical relationship - not both have "peels")
* Trail-making or drawing patterns: Like connect the dots, but with alternating numbers/letters in ascending order (EX: 1 -> A -> 2 -> B…)
* Clock drawing tests - "wrong": too many numbers, spacing
58
Cognitive function - region involved
Prefrontal cortex and/or associated projections
59
Memory - tests
* Digit span or N-back
* Short-term memory: "remember these 3 words…" for 2-5 minutes, to be recalled a few minutes after during the test
* Long-term memory
60
Memory - regions involved
* Median temporal structures (e.g., hippocampus)
* Prefrontal cortex
* Left parietal lobe
61
Language - tests
Tasks like naming body parts and reading, writing, and repeating simple phrases
62
Language - observes features such as...
* Fluency: maximum amount of words recalled in a certain time frame (like one minute)
* Comprehension
* Prosody (analyzing the use of intonation, stress, and rhythm)
63
Regions involved with language
Left hemisphere language network
64
Attention and orientation: observing what?
Observe a patient's alertness
65
Attention and orientation tests:
* Spelling a word backwards
* Counting backwards from 20
* Current whereabouts, time
66
Attention and orientation - regions involved:
- Lots - cortical or subcortical regions
67
Scoring
* Out of 30
* Ranges from normal cognitive health, mild cognitive impairment, moderate cognitive impairment, and severe cognitive impairment
68
Scoring - 26 or higher
normal cognitive health
69
Scoring - 19-25
mid cognitive impairment
70
Score - 10-18
Moderate cognitive impariment
71
Less than 10
severe cognitive impairment
72
MOCA blind
removed parts of test, out of smaller amount
73
MOCA blind scoring
* 19 or higher: normal cognitive health
* 14-18: mild cognitive impairment
* 7-13: moderate cognitive impairment
* Less than 7: severe cognitive impairment
