PDS Week 6 - Neurologic Flashcards
How do you test CN I (olfactory) function?
Have patient close their eyes and occlude one nostril at a time, hold an item (coffee beans, eucalyptus oil, etc.) 10 cm away from their nose, and have them smell.
What is anosmia?
Loss of smell due to CN I dysfunction
How to test CN II (optic) function?
Visual acuity test (snellen chart) visual field testing, and pupillary light reflex testing
How to test CN III (oculomotor)
Pupillary light reflex test - should see both direct and consensual constriction of pupils if CN III is intact
Pupillary light reflex test tests which cranial nerves?
CN II (sensory) - light gets in through the optic nerve CN III (motor) - constriction of pupils
What muscles does CN III (oculomotor) control?
Superior rectus, medial rectus, inferior rectus, and inferior oblique (extraocular eye muscles)
What muscle does CN IV (trochlear) control?
Superior oblique (extraocular eye muscle)
What muscle does CN VI (abducens) control?
Lateral rectus (extraocular eye muscle)
How to test CN V (trigeminal)
Sensory:
1. Corneal cotton swab test
2. Cotton swab test
- R/L of forehead for ophthalmic division
- R/L of cheeks for maxillary division
- R/L of jaw for mandibular division
Motor:
- patient will clench teeth as you palpate masseter muscle
- if jaw deviates to one side, CN V is affected
-pt does not feel any pain
How to test CN VII (facial)
Motor:
- have pt make facial expressions (smile, frown, puff cheeks)
- have patient close eyes, and see if you can force them open (orbicularis oculi muscle closes eyelid)
Sensory:
-sends taste to anterior 2/3 of the tongue
How to test CN VIII (vestibulocochlear)
whisper technique, finger rubbing technique, Weber test, and Rinne test
Which two CN are responsible for keeping the uvula elevated and in midline?
CN IX (glossopharyngeal) and CN X (vagus)
What are the functions of CN IX (glossopharyngeal)
Sensory: taste to posterior 1/3 of tongue
Motor: keeping uvula elevated and in midline
What are the functions of CN X (vagus)
Gag reflex and keeping the uvula elevated and in midline
How to test CN XI (spinal accessory) function
Have patient laterally rotate head against resistance and shrug shoulders against resistance
What muscles does CN XI (spinal accessory) innervate?
SCM and trapezius muscles
How to test XII (hypoglossal)
Have patient stick out tongue; it should be midline with no contractures, fasciculations, or scalloping
Where do upper motor neurons start?
The cerebrum
Where do the upper motor neurons provide function?
CNS
Where do lower motor neurons provide function to?
PNS
Where do upper motor neurons go?
Cerebrum > brain stem > spinal cord
Why do upper motor neurons affect the opposite side of the body?
They cross over (decussate) in medulla, causing their function to be on the opposite side of the body
Spinal nerves are all -
- Sensory,
- Motor, or
- Mixed neurons?
mixed neurons
Peripheral nerves are made up of…
Multiple nerve roots
Motor nerves exit through the
Ventral root
Sensory nerves enter through
The dorsal root ganglion
What are the tests for basic sensory testing?
- Sharp/dull for pain
- Proprioception test
- Vibratory test
- Two-point discrimination test
- Stereognosis test
- Point localization test
- Graphesthesia test
Basic motor testing
- Finger abduction
- Finger adduction
- Wrist extension
- Wrist flexion
- Forearm (elbow) flexion
- Forearm (elbow) extension
- Hip abduction
- Hip adduction
- Knee flexion
- Knee extension
- Ankle dorsiflexion
- Ankle plantarflexion
All motor testing should be against…
Resistance
Explain the muscle strength scale
0 = no movement/strength 1 = trace - slight movement/contraction 2 = weak - can move, but not against gravity 3 = fair - can move against gravity but not resistance 4 = good - can move against some resistance 5 = normal
For all motor and sensory testing, you should
- Test bilaterally (right and left) and both upper and lower extremities (both hands and feet)
- check for muscle atrophy
- check for tremors
- check for muscle strength (0-5)
How to test finger abduction strength
Have patient stretch fingers out wide, push in on the pinky and pointer finger
How to test finger adduction
Have patient squeeze your first two fingers as hard as they can (R and L simultaneously to see if there is a difference in strength)
What is drop foot?
If someone is unable to dorsiflex (foot is always plantarflexed), so when they walk, they need to pick up their entire leg and slam their foot down
How do reflexes work?
Hit tendon (which crosses a joint) > muscle stretches > sensory information sent to spinal cord > spinal cord will send back impulses through motor nerve > muscle contracts to avoid over stretching > leg extends
Reflex test is checking if…
Motor and sensory nerves are working together
Grading scale for reflexes
0 = no contracture at all 1 = diminished (hyporeflexia - lower motor neuron) 2 = normal 3 = excess/exaggerated/increased 4 = hyperreflexia (upper motor neuron)
How to test for sharp/dull sensory
Find something sharp (pin, tongue compressor broken, etc). And lightly prick the skin. Do on both hands and both feet
How to test for proprioception
- testing to tell if someone can tell where their body parts are in space
- hold lateral aspect of digit
- with patients eyes open, show them what up is and what down is
- then have them close their eyes and see if they can tell if their digit is up and down
- do on fingers and toes and both right and left
What is vibratory sensory testing
Strike a 1/28 Hz tuning fork, hold on big toe, have them tell you when they can no longer feel the vibration. You will know if it is still vibrating from holding it
- very important for diabetics
- do this on both feet and hands
What is two-point discrimination testing?
- used to test for neuropathy (as neuropathy worsens, so does this touch sense)
- set tool to 3mm, hold on skin, have them say if they can differentiate the two points
- 5mm is baseline - keep going up if they cannot differentiate
Describe stereognosis sensory testing
- place common item in patients hand
- have them identify item
- testing parietal or occipital lobe for Stereognosis
Describe point localization testing
- with patients eyes closed, touch an area on their body
- have them identify the body part that was touched
Describe graphesthesia test
- with patients eyes closed
- draw a number 0-9 in the patients hand (drawn towards patient)
- have them identify number
- if they cannot, may indicate graphesthesia parietal dz
Wrist extension and flexion motor test
- Have patient make fist
- have them flex and extend wrist against your hand
Forearm (elbow) flexion and extension testing
- have patient curl arm (like flexing their bicep)
- have them push to test extension and pull towards them for flexion - against your grip
Hip abduction and adduction motor testing
- patient lays supine
- have patient push knees in against your hands for abduction
- have patient push knees out against your hands for adduction
Knee flexion and extension motor testing
- have patient bend knee on bed while laying supine
- try to pull their leg out to test knee flexion
- try to push their leg in to test for knee extension
Ankle dorsiflexion and plantarflexion motor testing
- Have patient push ankle up against your hand for dorsiflexion
- have patient push down on your hand for plantarflexion
What reflex’s should you test?
- Achilles’ tendon
- Patellar tendon
- Babinski
What are the deep tendon reflex’s?
Achilles and patellar
How are reflexes graded?
0 = no contracture at all 1 = diminished (hyporeflexia - lower motor neuron dz) 2 = normal 3 = excess/exaggerated/increased 4 = hyperreflexia (upper motor neuron dz)
What should you see when striking the Achilles’ tendon?
- calf contraction
- Achilles’ tendon contraction
- small plantarflexion
What should you see when you strike the patellar tendon?
- Slight extension of knee
- feel contraction on thigh
How can you distract a patient while completing a reflex test?
Have patient lock both hands together and pull apart
What is a + babinski test?
Dorsiflexion of hallux and 4 other digits fan out
indicative of lower motor neuron disease
What is a - babinksi sign?
Small plantar flexion or nothing
How to complete the babinksi reflex test
- Use handle of hammer
- begin at the heal > up the lateral aspect of the foot > to hallox
Who is it normal to see a + babinski sign in?
Children under 6months old may react in the same way as a + babinski. this is not because they have babinski, only because their neurons are not fully formed
What tests should you carry out for cerebellum function testing?
- Finger to nose test
- The 3 rapid alternating movement tests
- touch each finger to thumb rapidly
- supinate and pronate palm on thigh rapidly
- heel against shin from foot to knee rapidly
- Romberg test
- Tandem gait
What is finger to nose testing?
- With eyes open, have patient touch their finger to their nose
- With eyes closed, repeat
- With eyes open, have patient touch their finger from their nose to your finger (if they cannot touch your finger, it is called past pointing)
What is it called when a patient cannot complete the rapid alternating movement testing?
Adiadochokinesia - inability to perform rapid alternating movement of muscle
When should you complete the Romberg test?
When watching your patient walk, ask them to stop suddenly. If they do not sway when they stop, complete Romberg test
What is the Romberg test?
Have patient stand with their eyes close, arms out, and palms supinated. If patient is able to stay still, this is a (-) Romberg test.
If patient sways, has an arm that drifts, or fingers flex, this is a (+) Romberg test. (Pronation drift or fingers flexing may be due to hemiparesis - from a stoke)
Always stand behind or next to patient to ensure they do not fall.
How to asses tandem gait
Have patient walk heel to toe in a straight line. Also check for imbalance and muscle atrophy.
Why is it important to give all diabetics a full neurological exam?
They are at risk for neuropathy
How big is CN V (trigeminal)? What does it span?
huge nerve that spans the entire face and head
What are the 3 divisions of the CN V (trigeminal)?
ophthalmic, maxillary, and mandibular division
If you have shooting or stabbing pain around, in, or both of maxillary and mandibular division, this indicates….
trigeminal neuralgia
also called tic douloureux
The motor branch of CN V (trigeminal) innervates what?
the muscles of mastication (temporalis and masseter muscle)
The radial nerve is made up of which 3 cervical nerve roots?
6, 7, and 8
Which 2 tests are extremely important to do in diabetic patients?
viboratory and 2-point discrimination tests
What is hyporeflexia indicative of?
lower motor neuron disease
What is hyperreflexia indicative of?
upper motor neuron disease
What two nerves innervate taste?
Facial: anterior 2/3
Glossopharyngeal: posterior 1/3
What two nerves innervate the uvula?
Glossopharyngeal and vagus
If a patient has a foot drop, what nerve is damaged?
Peroneal
