PD - Neuro Exam Flashcards
CN I
Smell cinnamon/vanilla; ask if smell has changed lately.
CN II
Test visual acuity; pupillary light reflex/accommodation (CN II (aff) + CN III(eff) ).
CN III
Open eye and look up; pupillary light reflex (carries parasympathetics).
CN IV
Look inward and downward (superior oblique).
CN V
Motor (chewing; clench teeth), Sensory (test dermatomal distributions of V1-3)
Corneal reflex: CN V (aff) + CN VII (eff)
CN VI
Look laterally (lateral rectus).
CN VII
Motor (Bare teeth, puff cheeks, close eyes tight)
Sensory (Taste anterior ⅔ tongue)
CN VIII
Hearing: auditory and bone and air conduction tests (Weber and Rinne)
Vestibular: test for Romberg’s Sign; (close eyes on one foot).
CN IX
Motor (stylopharyngeus + parotid gland; say “ahh” and watch for symmetric palate elevation)
Sensory (Taste posterior ⅓ of tongue; pharynx sensation tested with gag reflex [CN IX (aff) + CN X (eff)])
CN X
listen to pt speak
have pt swallow
CN XI
elevate shoulders against resistance (SCM + trapezius)
CN XII
Test by sticking tongue out (lesion to CN XII = tongue deviates toward lesioned side).
General order of neuro exam
- mental status examination
- CN examination
- motor function
- sensory function
- reflex testing
- coordination testing
steps to examine motor function during neuro exam
- Inspect for atrophy, fasiculations, clonus, etc.
- Palpate for muscle tone (decreased, normal, elevated).
- Test major muscle groups and grade 0-5.
- Assess gait: Walk normally, on tiptoes/heels and feet aligned (heel-to-toe).
In the neuro exam, when is gait testing usually performed?
last, after coordination testing
In a patient without any signs or symptoms of neurologic disease, you can quickly screen for sensation how?
using the proximal and distal portion of the upper and lower extremities.
normal examination findings using light touch and pain is probably sufficient to document intact sensation.
Light touch
With patient’s eyes closed, touch various dermatomes and ask them to note feeling it.
Pain
Touch with safety pin (sharp/blunt ends) with eyes closed; ask to tell which side is used.
Vibration
Strike tuning fork and place it on any bony prominence and ask when the vibration ceases.
(then immediately put it on your own extremity to verify vibe ceased)
Proprioception
Move distal phalanx up/down, ask close-eyed pt to say if it is “up” or “down”.
Tactile localization
Double-simultaneous touching in two places with eyes closed; pt reports where you touched them.
Point localization
Patient eyes closed; ask patient to identify where they were touched.
Discrimination
Two-point discrimination:
Hold two pins, touching one or two heads and
ask patient to report if they felt one or two heads.
Fingertip 2-5mm; Palm 10-12mm; Back 40-60mm
Stereognosis
Identify an object placed in the hand with eyes closed.
Graphesthesia
Identify a character written on the hand with eyes closed.
steps to examine sensory function during neuro exam
light touch pain vibration proprioception tactile localization discrimination stereognosis graphesthesia point localization
reflexes grading scale
0 - no response 1 - diminished 2 - normal 3 - increased 4 - hyperactive
*should be equal on both sides
Biceps reflex
C5
Brachioradialis reflex
C6
triceps reflex
C7
patellar reflex
L2-L4
achilles
S1-S2
Babinski’s sign
L5-S2
maintaining balance and posture requires
- Positional sense input (examines visual input, vestibular input, proprioception)
- Sensorimotor Integration (examines cerebellar function)
- Motor Output (examines basal ganglia, corticospinal and pyramidal tracts)
Tests for coordination
- Finger-to-Nose
- Heel-to-Knee
- Rapid alternating movement
- Romberg sign
- Pronator drift
Finger-to-Nose
- Cerebellar test (sensorimotor integration)
- Hold finger out, have patient touch own nose then your finger alternately and quickly.
- Look for intention tremor, overshooting.
Heel-to-Knee
- Cerebellar test.
- With patient lying or sitting, ask them to slide one heel to the knee of the other leg then up and down the shin smoothly.
Rapid alternating movement
- Cerebellar test
- Test in both upper/lower extremity (pronation/supination alternation or pinky to thumb as rapidly as possible)
Romberg Sign
- Tests for sensory ataxia (loss of proprioception);
- ask pt to stand upright, eyes open, arms at side. Then closed eyes. Observe 60 seconds.
+ if pt sways/falls after closing eyes
if pt sways/falls w/ eyes open, is this a + Romberg sign?
No.
if sway/fall with eyes open = cerebellar ataxia, NOT a positive Romberg sign.
Appearance of vestibular imbalance on Romberg examination
may sway more than normal, but still will not fall.
Pronator drift
Tests for position sense, contralateral corticospinal lesions.
-With eyes closed, hold arms extended at shoulder and fully supinated for 30 seconds (should remain stable; if one arm drifts downward and/or pronates = present pronator drift).
Pronator drift can assess for subtle motor weakness from UMN lesion (may be undetectable in routine strength testing)
facial paralysis common causes
stroke
peripheral nerve paralysis
gait disorder common causes
Stroke
Foot drop (peripheral nerve dysfunction)
Ataxia
Parkinson’s
Aging (musculoskeletal disease)
resting tremor common causes
Parkinson’s
Intention tremor common causes
cerebellar stroke
multiple sclerosis
postural tremor common causes
hyperthyroidism
asterixis common causes
liver failure
tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings
