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Neuro Exam

3

QuestionAnswer
A. Mental Status (Higher Cortical Function) - 1. Level of Consciousness: Alert, lethargic, stuperous, comatose, semi-coma, deep coma, EO, motor response, responds/localize to pain.
A. Mental Status (Higher Cortical Function) - 2. Appearance, Behavior, Mood: Communication, obeys commands, emotional state.
A. Mental Status (Higher Cortical Function) - 3. Cognitive Function: Orientation, confused, attention (7 digits), cognitive skill level, memory (short and long term), calculations, abstract reasoning, problem solving, judgement.
A. Mental Status (Higher Cortical Function) - 4. Language Function: Verbal, fluency, production of speech (expressive), dysphasia (difficult speech) (nominal = inability to) repetition, naming, comprehension of commands, utters, groans, non-verbal.
A. Mental Status (Higher Cortical Function) - 5. Non-Dominant Hemisphere Function: Constructional dyspraxia (putting cap back on pen, copy drawings), hemi-neglect or inattention, spatial disorientation, R/L disorientation, finger agnosia (absence of finger knowledge).
A. Mental Status (Higher Cortical Function) - Mini Mental Status Exam (MMSE): Used often in older pts with suspected dementia. Well educated people with mild dementia can ace this. A score of less than 20/30 has 87% dementia. Several orientation questions: Full date, location and building, and the pt's name.
B. Cranial Nerves (I - XII)- I - Olfactory: Test with odorants, one nostril at a time. Most physicians don't carry so the screening exam usually omits this cranial nerve. Common causes of cranial nerve I dysfunction include: trauma to the cribriform, frontal lobe mass/stroke, allergy/viral.
B. Cranial Nerves (I - XII)- II - Optic: Visual acuity. Use Funduscopy for: direct look at optic nerve for atrophy, papilledema, retina for evidence of systemic disease (diabetes, hypertension, atherosclerosis, endocarditis). Check visual fields by confrontation. Indicative of mass or stroke.
B. Cranial Nerves (I - XII)- III, IV, VI - Oculomotor, Trochlear, Abducens: Checking Extra-Ocular Movement (EOM), full range of motion, abnormality of movement (nystagmus, breakup), pupil size, symmetry, reaction to light and accommodation. Check Ptosis (drooping of upper eyelid due to paralysis, disease, congenital) for CN III.
B. Cranial Nerves (I - XII)- V - Trigeminal: Test facial & nasal sensation to light touch, and strength of the masseter muscles with a jaw jerk. Corneal Reflex (touching with wet cotton) should produce a bilateral blink response. Common abnormality is stroke in the contralateral sensory cortex.
B. Cranial Nerves (I - XII)- VII - Facial: Test this with facial movts: ask pt to raise eyebrows, show teeth, smile, puff out cheeks, whistle. Injuries often caused by stroke cause weakness of the lower face. Injuries to the facial nerve itself cause weakness of the entire side of face.
B. Cranial Nerves (I - XII)- VIII - Acoustic: Use hearing test by whisper into ear, or use your tuning fork (Weber). We do this as part of the ear examination. In pts with vertigo or dizziness, you may test also with positional maneuvers, trying to reproduce. Use air conduction to test bone (Rinne).
B. Cranial Nerves (I - XII)- IX, X - Glossopharyngeal, Vagus: Check rise of palate and uvula in midline and gag reflex. A common cause of abnormality is a large stroke.
B. Cranial Nerves (I - XII)- XI - Spinal Accessory: Test this nerve by asking patient to shrug shoulders or turn head against resistance. A common cause of abnormality is neck injury.
B. Cranial Nerves (I - XII)- XII - Hypoglossal: Test this nerve by asking patient to protrude tongue and move it from side to side. Function abnormalities are often caused by stroke. The tongue points toward its weak side.
C. Motor System Examination - 1. Muscle Appearance: Observe for bulk, (atrophy, hypertrophy), involuntary movements (fasciculations, myoclonous, sz activity, etc.)
C. Motor System Examination - 2. Muscle Tone: Test resistance to passive movement.
C. Motor System Examination - 3. Muscle Power: Check strength and drift for major muscle groups. Elaborate with further individual muscle testing if indicated.
C. Motor System Examination - 4. Muscle Coordination: Test with finger-to-nose, heel-to-shin, and rapid alternating movements.
D. Sensory Examination - 1. Touch: Both modalities should be tested in major dermatomes, comparing L to R, as well as proximal vs. distal sensation, boundaries of deficits must be delineated (precisely) if found.
D. Sensory Examination - 2. Sharp: Break off the wooden part of a cotton swab to make a sharp object. Ask the patient with eyes closed to distinguish sharp from dull.
D. Sensory Examination - 3. Vibration: Test with low-frequency (128) tuning fork.
D. Sensory Examination - 4. Proprioception (Position): With eyes closed, patient distinguishes whether finger and toe are moved up or down. This tests posterior column function. Compare to proximal sensation if deficits are found.
D. Sensory Examination - 5. Cortical Sensory Function: Stereognosis: Identifies object in hand. Graphesthesia: Identifies 'writing' on palm. Two-point discrimination: pt should be able to distinguish points 2 to 10 mm apart on fingers and hands. Sensory Extinction: Pt is given 2 stimuli and asked to localize.
E. Reflexes - 1. Deep Tendon Reflexes: Biceps, triceps, brachioradialis, patellar, Achilles.
E. Reflexes - 2. Plantar Reflex (Babinski Response): (Usually only in newborns.) Stroke lateral aspect of sole and across ball of foot. Note first movement of big toe. Flexion should occur. Extension due to contraction (Babinski Response). Upward pointing of big toe indicates upper motor neuron lesion.
E. Reflexes - 3. Superficial Reflexes: Any withdrawal reflex elicited by noxious or tactile stimulation of the skin, cornea, or mucous membrane, including the corneal reflex, pharyngeal reflex, cremasteric reflex, etc.
E. Reflexes - 4. Pathological Reflexes: a. Associated with hyperreflexia, finger flexor (Hoffman's), exaggerated jaw jerk. b. Frontal lobe release signs or primitive reflexes, palmomental (Myerson's sign), grasp, suck, root, snout.
F. Gait and Station - 1. Coordination: Nothing abnormal of arm swing, leg movement, or ataxia. Ask pt to repeatedly run the heal from the opposite knee down the shin to the big toe. Look for Ataxia. Ask pt to repeatedly tap foot on floor looking Dysdiadochokinesia (difficult rapid movements).
F. Gait and Station - 2. Tandem Gait: Walking a straight line heel-to-toe.
F. Gait and Station - 3. Walking on Toes: Causes include a congenital short Achilles tendon, muscle spasticity (especially associated with CP) and paralytic muscle disease such as Duchenne muscular dystrophy. May also be a separate condition, foot drop, which is a potential early sign of autism.
F. Gait and Station - 4. Walking on Heals: A good way to test balance as well as strength of the distal lower extremities is to have the patient heel and toe walk. The patient should be able to balance without falling or stepping to the side.
F. Gait and Station - 5. Monopedal Stance: Standing on one leg to test balance.
F. Gait and Station - 6. Romberg's Test: Ask pt to stand with heels together, first with EO then with EC. Note any excessive postural swaying or loss of balance. If present with EO, could mean cerebellar ataxia. If present with EC, could mean sensory ataxia.
F. Gait and Station - Spastic Hemiplegia: Foot is held inverted, leg too straight and swung out, arm flexed and held close to chest - a sign of old stroke or other cortical injury.
F. Gait and Station - Parkinsonian Gait: Shuffling gait, rapid small steps, little arm swing, turning "en bloc".
F. Gait and Station - Antalgic Gait (Pain-Avoiding): Not due to neurologic illness. In this gait, patient spends minimal time on the painful leg or side. You can also test coordination with tandem gait: the patient walks heel to toe (the drunk test). It's abnormal in cerebellar or posterior column disease.
F. Gait and Station - Ataxic Gait: Wide-based, irregular gait, a sign of cerebellar disease.
What is included in the conscious level assessment? EO: Spontaneous to speech, pain, none. Verbal response: Orientated, confused, words, sounds, none. Motor Response: Obeys commands, localize, flexing, extending, no rxn to pain.
Cranial Nerve Exam - Olfactory Nerve (I) Perception and identification of smell.
Cranial Nerve Exam - Optic Nerve (II) Visual acuity to light, mvt, chart. Visual fields, peripheral fields, central fields, optic fundus, pupils.
Cranial Nerve Exam - Oculomotor (III), Trochlear (IV), Abducens (VI) Pupil dilation, Ptosis (droopy eyelid), ocular mvt (looking in different directions), diplopia (double vision), nystagmus.
Cranial Nerve Exam - Trigeminal Nerve (V) Facial response to pain & temperature. Corneal reflex, jaw mvts. Always compare sides.
Cranial Nerve Exam - Facial Nerve (VII) Talking, smiling, eye closure, asymmetry of mouth, nose. Forehead, lips, shows teeth. Taste.
Cranial Nerve Exam - Auditory Nerve (VIII) Cochlear (whispering), use Weber's test (tuning fork on vertex), Rinne's test (vibrating tuning fork on mastoid bone). Check vestibular component if possible.
Cranial Nerve Exam - Glossopharyngeal Nerve (IX), Vagus Nerve (X) Impairment usually effects both. Vocal, nasal, swallowing, ("Say Ahhh") gag reflex, palatal weakness (uvula swings), taste in posterior third of tongue.
Cranial Nerve Exam - Accessory Nerve (XI) Sternomastoid (rotate head against resistance). Right turns left, vise versa. Trapezius: shrug shoulders against resistance (holding).
Cranial Nerve Exam - Hypoglossal Nerve (XII) Tongue (atrophy, wasting, increased folds, fibrillation/small wiggling). Protrude, deviation, side to side.
Brain Death Exam Depressant drugs may contribute to state. Pupil response to light, Corneal Reflex (use cotton), Vestibulo-Occular Reflex (ice water on meatus), Gag Reflex (bronchial stimulation with suction tube to produce cough), Motor Response (painful stimulation).
A. B. C. D. E. F. A. Mental Status B. Cranial Nerves C. Motor Systems D. Senses E. Reflexes F. Gait & Station
A. Mental Status Exam 1. Level of Consciousness 2. Appearance, Behavior, Mood 3. Cognitive Function 4. Language Function 5. Non-Dominant Hemisphere Function
B. Cranial Nerves Exam I - Olfactory: II - Optic: III, IV, VI - Oculomotor, Trochlear, Abducens: V - Trigeminal: VII - Facial: VIII - Acoustic: IX, X - Glossopharyngeal, Vagus: XI - Spinal Accessory: XII - Hypoglossal
C. Motor Systems Exam 1. Muscle Appearance 2. Muscle Tone 3. Muscle Power 4. Muscle Coordination
D. Senses Exam 1. Touch 2. Sharp 3. Vibration 4. Proprioception (Position) 5. Cortical Sensory Function
E. Reflexes Exam 1. Deep Tendon Reflexes 2. Plantar Reflex (Babinski Response) 3. Superficial Reflexes 4. Pathological Reflexes
F. Gait & Station Exam 1. Coordination 2. Tandem Gait 3. Walking on Toes 4. Walking on Heals 5. Monopedal Stance 6. Romberg's Test -Specific Gaits: Spastic Hemiplegia, Parkinsonian Gait, Antalgic Gait (Pain-Avoiding), Ataxic Gait
Created by: kmburg5840