Peripheral neurological examination and MMSE Flashcards
Six subsets of neuro exam
Mental Status Cranial Motor Coordination Sensory Gait
Mental status
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
Glasgow coma scale
Eye(s) opening
Verbal response
Best motor response
-dependent on score best response, comatose pt or totally unresponsive
Mini mental state exam
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
MMSE assesses:
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
Mental status language
Aphasia (speech) vs dysarthria (understanding)
Receptive language - command following
Expressive language - word finding
Repetition
-screens for receptive, expressive and conductive aphasias
Areas of brain for language
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)
Gerstmann’s syndrome
Dominant parietal lobe Calculations R-L confusion Finger agnosia Agraphia
Non-dominant parietal lobe condition
Hemineglect
Importance of delusional thinking, abstract reasoning, mood, judgement, fund of knowledge in mental status exam
Important for psychiatry
Does not localise well to one region of cortex
Neurocognitive testing required to get at more specific deficits
Motor examination
Tone Power Reflexes Plantar responses Involuntary movements
Tone
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)
Power: Medical Research Council Scale
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
Reflexes scale
0/4 = Absent 1-2/4 = Normal Range 3/4 = Pathologically Brisk 4/4 = Clonus
UMN vs LMN problem
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
Involuntary movements
Hyperkinetic
Bradykinetic
Hyperkinetic movements
Chorea
Athetosis
Tics
Myoclonus
Bradykinetic movement
Parkinsonism (Bradykinesia, Rigidity, Postural Instability, Resting Tremor)
Dystonia
Sensory examination: primary sensory modalities
Light Touch (Multiple Pathways)
Pain/Temperature Sensation (Spinothalamic Tract)
Vibration/Position Sensation (Posterior Columns)
Sensory examination: cortical sensory modalities
Stereognosis
Graphesthesia
Two-Point Discrimination
Double Simultaneous Extinction
primary sensory modalities
Reflect Input from sensory receptors, sensory nerves, spinal cord, brainstem, through to the level of the Thalamus
cortical sensory modalities
Reflect Processing by the Somatosensory Cortex (post-central gyrus)
Dermatomes
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
Higher Cortical Sensory Function
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
Coordination: hemisphere dysfunction
Dysdiadochokinesis Ataxic Gait Nystagmus (Variable Directions) Impaired Heel-Knee-Shin/ Intention tremor Slurred Speech (Scanning dysarthria) Hypotonia
Gait
A normal Gait requires multiple levels of the neuroaxis to be intact
- vision
- strength
- balance/ coordination
- joint position
Observe Different Aspects of Gait
Arm Swing Base of Gait Heel Strike Time Spent on Each Leg Posture of Trunk Toe Walking Heel Walking Tandem Walking
Classical Patterns of Abnormal Gait
Parkinsonism Gait Hemiparetic Gait Spastic Diplegia Gait Acute Ataxia Gait Chronic Ataxia Gait Waddling Gait (Hip Girdle Weakness) High Stepping Gait
