Neurological Exams Flashcards
Neurological Exam
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!
8 reasons for a neurological exam
- 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
Aim of the neurological exam
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
Composition
observation + formal testing
- Can consist of regular questions - how are you, how did you get here today…
Common Components of the Neurological Exam
- Patient history
- Cranial nerves
- Motor system
- Somatosensory
- Coordination
- Mental status
- + Follow-up neuropsychological testing
- Patient history - what should we find out? (5)
- Age, education, handedness
- Past medical history
- Use of medication and/or recreational drugs
- Family medical history
- Disease process
- Patient history - disease process: what do we need to find out?
- Timing: sudden v gradual; acute v chronic
- Change over time: static, improving, worsening
- Triggers or relievers of symptoms
- Severity of symptoms
2.Cranial nerves
- Testing the Cranial Nerves
- 12 nerve pairs
- Afferent, efferent, or both
- Test to localize deficits to particular systems
Which cranial nerves are connected to the midbrain?
3-4
Which cranial nerves are connected to the pons?
5-8
Which cranial nerves are connected to the medulla?
9-12
Cranial Nerve I
Olfactory
Cranial Nerve I - tests:
- Identify familiar smells, one nostril at a time
- Compare strength of smell
Cranial Nerve I - types of problems:
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
Cranial Nerve II
Optic (functioning)
Cranial Nerve II - 3 tests
- 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)
Cranial Nerve II - issues
damage to various levels of the visual system
Cranial Nerve II - Fundoscopy (test); what for?
- …to look for papilledema (optic disk swelling - nervous tissue behind eye is swollen and pushing into the eye)
- Can indicate swelling in the brain
Cranial Nerve II - Possible causes of increased intracranial pressure
- TBI
- Brain tumour
- Encephalitis (inflammation)
- High blood pressure
- Bleeding
Cranial Nerves III, IV, and VI
- Oculomotor, trochler, abducens
- all are optical motor nerves
- Control eye position by via paired muscles that move and hold the eye
Cranial Nerves III, IV, and VI - test
Follow an object/light without moving their head (6 cardinal directions)
Cranial Nerves III, IV, and VI - issues
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
Cranial Nerve V
Trigeminal (3 parts)
- Motor
- Sensory
- Trigeminal neuralgia (symptom)
Cranial Nerve V - Motor tests
- feel activation of muscles when biting down
- holding mouth open
Cranial Nerve V - sensory:
- detection of location
- sharp/dull, hot/cold
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
Cranial Nerve VII
Facial
Cranial Nerve VII - tests
Test for asymmetry and strength:
- Face: drooping, sagging, facial creases
- Raise eyebrows
- Smile
- Puff out cheeks
- Close eyes hard
Cranial Nerve VII - issues
Bell’s Palsy = paralysis of facial nerve causing weakness on one side of face
Cranial Nerve VIII
Vestibulocochlear
Cranial Nerve VIII - tests
- Whisper test
- Test hearing with tuning fork touching + not touching skull bone
Cranial Nerve VIII - issues
- Unilateral hearing loss = peripheral lesion
- Bilateral hearing loss = more central damage
Cranial Nerve IX and X
- IX Glassopharyngeal
- X Vagus
Cranial Nerve IX and X - test
Assess voice, swallowing, gag reflex, cough
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
Cranial Nerve XI
XI Accessory
Cranial Nerve XI - testing
- Shrugging of shoulders
- Head resistance
- Looking for weakness + location
Cranial Nerve XII
XII Hypoglossal
Cranial Nerve XII - testing
- Stick out tongue, lateral movement
- Looking for direction deviation + strength
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
Upper motor neurons originate in _ or _ and use _
motor cortex; brainstem; glutamate
Upper motor neuron lesions can lead to
- Weakness
- Spasticity - Muscle “catches”; ridgity
- Hyperreflexia
- Retained primitive reflexes (e.g., grasp, suck, snout)
Lower motor neurons originate in _ or _ , _ , and use _ (incl. motor cranial nerves)
spinal cord or brainstem, innervate muscles or glands, and use acetylcholine
Lower motor neuron lesions can lead to:
- Weakness
- Hypotonia (low tone)
- Hyporeflexia
- Atrophy
- Fasciculations: fine movements of the muscles under the skin
4.Somatosensory
Somatosensory Function
- Temperature
- Pain
- Vibration
- Proprioception
- Touch
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
5.Coordination - Quick, alternating movements can test…
- Dysdiadochokinesia > MS in adults; cerebellar tumours in kids
- Inability to perform rapid, alternating movement
5.Coordination - Point-to-point movement can test…
- Dysmetria > impairment performing accurate movements
- EX: putting the cap on a pen
5.Coordination - Romberg’s test
- balance with eyes open vs closed
- +ve Romberg points to cerebellar damage
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)
Lower side of mental status exam scale
- Mental status
EXAMPLES:
* MoCA
* MMSE
Time:
* Brief (<10)
Purpose:
* Screening
Higher side of mental status exam scale
Comprehensive neuropsychological battery: higher side of scale
Time
* Lengthy, 4-6 hours
Purpose
* Mean for profiling
MOCA
Montreal cognitive assessment tool
4 general components of the MOCA
- Visuospatial
- Memory
- Language
- Attention/orientation
Visuospatial tests
MoCA
- Line cancellation
- Copy geometric designs: 1 full point, Any criteria for 1 point missed = 0
- Judge line orientations
- Object/face/color
Visuospatial - region involved
Right hemisphere attention network
Executive function - what does it test?
- Cognitive control of behavior
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
Cognitive function - region involved
Prefrontal cortex and/or associated projections
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
Memory - regions involved
- Median temporal structures (e.g., hippocampus)
- Prefrontal cortex
- Left parietal lobe
Language - tests
Tasks like naming body parts and reading, writing, and repeating simple phrases
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)
Regions involved with language
Left hemisphere language network
Attention and orientation: observing what?
Observe a patient’s alertness
Attention and orientation tests:
- Spelling a word backwards
- Counting backwards from 20
- Current whereabouts, time
Attention and orientation - regions involved:
- Lots - cortical or subcortical regions
Scoring
- Out of 30
- Ranges from normal cognitive health, mild cognitive impairment, moderate cognitive impairment, and severe cognitive impairment
Scoring - 26 or higher
normal cognitive health
Scoring - 19-25
mid cognitive impairment
Score - 10-18
Moderate cognitive impariment
Less than 10
severe cognitive impairment
MOCA blind
removed parts of test, out of smaller amount
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
