Peripheral neurological examination and MMSE

Question 1

Six subsets of neuro exam

Answer 1

Mental Status 
Cranial
Motor
Coordination
Sensory
Gait

Question 2

Mental status

Answer 2

Conscious level is a continuum
Alert and full cognition	--> coma
Level of Alertness
-subjective view of examiner (drowsy, responding to commands etc.)
Degree of Orientation
-to what?
-time, person, place, recent events

Question 3

Glasgow coma scale

Answer 3

Eye(s) opening
Verbal response
Best motor response
-dependent on score best response, comatose pt or totally unresponsive

Question 4

Mini mental state exam

Answer 4

A brief measure of amnestic and cognitive processing functions
Assess short-term changes in mental functioning in hospitals
Assess changes in cognitive functioning in emergencies
Assess progressive changes in cognitive functioning in long term care settings
Obtain a “snapshot” of patient’s functioning in outpatient mental health settings

Question 5

MMSE assesses:

Answer 5

Orientation
Short, recent, remote memory
Sustained concentration
Executive functions
-recognition
-registration
-sequencing and organisation
-comprehension
-perceptual - motor skills
Scores range from 0-30
Scores below 24 indicative of dementia or cognitive deficit

Question 6

Mental status language

Answer 6

Aphasia (speech) vs dysarthria (understanding)
Receptive language - command following
Expressive language - word finding
Repetition
-screens for receptive, expressive and conductive aphasias

Question 7

Areas of brain for language

Answer 7

Central sulcus (fissure of Rolando)
Broca's area
-aphasia
Arcuate fasiculus
-connect Broca's and Wernicke's
Wernicke's area
-dysarthria
Lateral sulcus (fissure of Sylvius)

Question 8

Gerstmann’s syndrome

Answer 8

Dominant parietal lobe
Calculations
R-L confusion
Finger agnosia
Agraphia

Question 9

Non-dominant parietal lobe condition

Answer 9

Hemineglect

Question 10

Importance of delusional thinking, abstract reasoning, mood, judgement, fund of knowledge in mental status exam

Answer 10

Important for psychiatry
Does not localise well to one region of cortex
Neurocognitive testing required to get at more specific deficits

Question 11

Motor examination

Answer 11

Tone
Power
Reflexes
Plantar responses
Involuntary movements

Question 12

Tone

Answer 12

Resistance appreciated when moving a limb passively
'Normal tone'
Hypotonia
-'central hypotonia'
-'peripheral hypotonia'
Increased tone
-spasticity (corticospinal tract)
-rigidity (basal ganglia, Parkinson's disease)
-dystonia (Basal ganglia)

Question 13

Power: Medical Research Council Scale

Answer 13

5/5 = Full Power
4/5 = Weakness with Resistance
3/5 = Can Overcome Gravity Only
2/5 = Can Move Limb without Gravity
1/5 = Can Activate Muscle without moving Limb
0/5 = Cannot Activate Muscle

Question 14

Reflexes scale

Answer 14

0/4 = Absent
1-2/4 = Normal Range
3/4 = Pathologically Brisk
4/4 = Clonus

Question 15

UMN vs LMN problem

Answer 15

Both have low strength
UMN has > tone (spasticity)
LMN has hypotonia
UMN has > reflexes (brisk deep tendon reflexes)
LMN has diminished or absent DTRs
UMN has > lpantar responses (up going toes)
LMN has < plantar responses (down going toes)
UMN has no atrophy/ fasciculations; LMN has atrophy but no fasciculations

Question 16

Involuntary movements

Answer 16

Hyperkinetic

Bradykinetic

Question 17

Hyperkinetic movements

Answer 17

Chorea
Athetosis
Tics
Myoclonus

Question 18

Bradykinetic movement

Answer 18

Parkinsonism (Bradykinesia, Rigidity, Postural Instability, Resting Tremor)
Dystonia

Question 19

Sensory examination: primary sensory modalities

Answer 19

Light Touch (Multiple Pathways)
Pain/Temperature Sensation (Spinothalamic Tract)
Vibration/Position Sensation (Posterior Columns)

Question 20

Sensory examination: cortical sensory modalities

Answer 20

Stereognosis
Graphesthesia
Two-Point Discrimination
Double Simultaneous Extinction

Question 21

primary sensory modalities

Answer 21

Reflect Input from sensory receptors, sensory nerves, spinal cord, brainstem, through to the level of the Thalamus

Question 22

cortical sensory modalities

Answer 22

Reflect Processing by the Somatosensory Cortex (post-central gyrus)

Question 23

Dermatomes

Answer 23

Pain and Temperature
-pinprick
-sensation of Cold
-look for Sensory Nerve or    Dermatomal Distribution
Vibration Sensation
-C-128 Hz Tuning Fork (check great toe)
Joint Position Sensation
-check great toe
-Romberg Sign

Question 24

Higher Cortical Sensory Function

Answer 24

Graphesthesia
Stereognosis
Two-Point Discrimination
Double Simultaneous Extinction
Gerstmann’s Syndrome (acalculia, right-left confusion, finger agnosia, agraphia)
-usually seen in dominant parietal lobe lesions

Question 25

Coordination: hemisphere dysfunction

Answer 25

Dysdiadochokinesis
Ataxic Gait
Nystagmus (Variable Directions)
Impaired Heel-Knee-Shin/ Intention tremor
Slurred Speech (Scanning dysarthria)
Hypotonia

Question 26

Gait

Answer 26

A normal Gait requires multiple levels of the neuroaxis to be intact

• vision
• strength
• balance/ coordination
• joint position

Question 27

Observe Different Aspects of Gait

Answer 27

Arm Swing
Base of Gait
Heel Strike
Time Spent on Each Leg
Posture of Trunk
Toe Walking
Heel Walking
Tandem Walking

Question 28

Classical Patterns of Abnormal Gait

Answer 28

Parkinsonism Gait
Hemiparetic Gait
Spastic Diplegia Gait
Acute Ataxia Gait
Chronic Ataxia Gait
Waddling Gait (Hip Girdle Weakness)
High Stepping Gait