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101 Cards in this Set

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list 10 parts of the screening neuro exam

1. Well vs. Unwell


2. Vitals


3. GA


4. Mental status


5. Handedness


6. Cranial nerves


7. Motor


8. Sensory


9. Coordination/cerebellar


10. Gait

frontal release signs? (included under mental status)

Glabellar tap..

4 parts of motor exam

1. tone (screen UMN with pronator drift)


2. bulk


3. strength


4. reflexes

4 parts of sensory exam

1. light touch


2. pain/temp


3. proprioception (very SMALL movements)


4. vibration

parts of coordination/cerebellar exam 6

1. bradykinesia


2. coordination


3. tremor


4. nystagmus


5. hypotonia, pendular reflexes)


6. dysarthria

parts of Gait exam 8

1. rhomberg here as they are standing


2. rising from a chair


3. posture


4. arm swing


5. "base" of the gait (wide or narrow)


6. stride length/height


7. turning


8. add'l maneuvers as required

examining for diplopia

d

General inspection of eyes

trauma, inflammation, erythema, discharge

Exam of CN II




6 big points to hit

1. visual acuity with snellen chart


2. colour perception


3. visual fields


4. examine pupils via light reflex


5. check for accommodation


6. fundoscopic exam

note on VA : test one eye at a time!

k

color perception:

test red perception on snellen chart

2 rules for examining visual fields

1. only test one eye at a time


2. compare to your field of vision. if testing left eye, close your right eye and only do things you can see

visual fields: 2 methods

1. static technique 
2. kinetic technique

1. static technique


2. kinetic technique

how to examine light reflex

1. ensure room is dim


2. shine light between eyes, check that both peoples constrict


3. If anisocoria present, move to CN III exam


4. if anisocoria absent, proceed to swinging flashlight test


5. if pupils do not react, check for argyle robertson pupil

HOW to check for argyle robertson pupil

= bilateral small pupils that reduce in size when the patient focuses on a near object (they accommodate) but do not constrict when exposed to bright light

how to check for accommodation

have patient fix on a point far away and then suddenly look at at an object eg finger that moves close to their face.

Next: exam of III, IV, and VI




first glance: how do palsies of each of these present?

III: down and lateral


IV: eye up and medial


VI: eye directed medially

lids; significance of ptosis

suggests CN III palsy or myasthenia gravis

Thyroid opthalmopathy) 4

proptosis, lid edema, lid lag, lid retraction?

examining for diplopia: explain the cover/uncover test

1. monocular if diplopia extinguishes with one eye covered but not with the other eye covered




2. binocular if diplopia vanishes with either eye covered




3. monocular: suggests optho etiology, binocular suggests neuro/muscular cause

if binocular diplopia detected, determine :




which mm is weak




and which eye is the problem?

which mm is weak: which direction makes the diplopia worse narrows it down to two possible extraocular mm.




which eye is the problem: use red glass. the most peripheral image belongs to the affected eye




or ask patient to close one eye: if the more peripheral image is extinguished, that is the affected eye.

CN VI palsy: what is one thing that can exacerbate diplopia

distance vision will cause diplopia

how to test for CN IV palsy

ask pt to tilt head towards affected side. CN IV palsy shows hypertropia

stroke vs bells palsy (essentially UMN vs. LMN cranial nerve findings)

d

CN II: how would stroke affect visual field

depends on site of lesion.. homonymous hemianopia or quadrantanopia

how would stroke affect visual acuity?

should be normal..

stroke: what would findings in pupillary response to light and accommodation?

normal exam in stroke (unless brainstem? or horners)

swinging flashlight test in stroke

should be normal. both pupils should constrict strongly




RAPD is an issue with CN II ..

review: triad of horner's syndrome

ipsilateral miosis, ptosis, and anhidrosis

stroke: III, IV, and VI

binocular diplopia possible.




also note gaze preference towards side of lesion

checking V: sensation:

both sides, 3 divisions


1. light touch: test with cotton/kleenex


2. pain sensation




stroke: sensation may be diminished in hemi distribution

Motor exam of V

1. mm wasting


2. clench teeth, feel masseters


3. test pterygoids: ask patient to open their mouth against your hand



V: jaw jerk reflex

jaw jerk reflex.




mouth hanngs loosely open. use finger as a brace, hit with hammer, and look for reflex closing of jaw.




unilateral stroke: jaw jerk testing usually normal

V: corneal reflex

touch cornea, look for direct and consensual blink




may be absent in brainstem stroke

afferent and efferent component of corneal reflex

afferent: CN V




efferent: CN VII

VII: facial nerve


Inspection

facial symmetry and presence of passive motor signs




possible changes to tearing? and may report changes to hearing (hyperacusis via stapedius involvement)

signs of VII involvement (stroke or bell's palsy)

nasolabial fold flattening, mouth droop, retracted eyelids, other asymmetry

VII: motor exam




4

1. forehead wrinkling (absent = LMN. able to wrinkle = UMN) NB


2. close eyes tightly, resist you trying to open them


3. puff out cheeks


4. show teeth

quick screen for VIII

hearing acuity: rub fingers toogether at side of patients head: move inward till patient hears noise.




compare with other side

IX and X: sensory

gag reflex (plus taste to posterior 1/3 of tongue, which we don't test here)

IX and X: motor 3

say "AH" to check palatal elevation




have patient drink water and assess swallowing




comment on gag reflex, but don't check...

findings if there's a lesion to IX, X?

in brainstem stroke, asymmetric absence of gag reflex and / or dysphagia may occur..




diminished palate elevation may occur ipsilateral

testing XI

cortical stroke: patient may have weakness in ipsilateral SCM and contralateral trapezius...?

testing XII

ask patient to stick out tongue




branstem stroke: deviates to side of lesion


cortical stroke: away from side of lesion

Motor exam:




inspection

bulk, atrophy, fasciculations (no suspected abnormality in acute stroke)

Motor exam: tone

1. flaccid (LMN)


2. velocity dependent = spastic (stroke)


3. rigid = velocity independent (Parkinson's?)

scale for testing muscle strength



note: how does UMN lesion affect upper and lower limb strength?

Flexion predominates in upper limb, extension predominates in lower limb

testing mm strength: list that goes through the exam



Motor exam: 4 tests to do after strength

+ reflexes!! 

+ reflexes!!

when to perform coordination and gait?



exam of arm weakness (UMN vs LMN)



d

arm weakness: Inspection 3

1. Bulk (mainatined in UMN, down in LMN)


2. fasciculation (LMN)


3. position of arm (decerebrate posture = UMN)

arm weakness: Motor exam


0. pronator drift


1. check tone


2. list the myotomes you would check



arm weakness: motor exam


1. check arm reflex


2. special test...



arm weakness: sensory exam:


1. which dermotomes to check?


2. findings if anterolateral pathway disrupted?


3. findings if DCML disrupted

anterolateral: pain, temp, light touch


DCML: proprioception, vibration, light touch

notes:


1. demonstrate on one side, and state that you would compare with the other side of the body


2. offer to demonstrate techniques

k

If UMN signs found when examining arm, what else might be present given left arm weakness is due to a right cortical lesion? 4

1. left lower face droop with forehead sparing


2. cortical sensation loss: 2 point discrim, stereognosis, graphesthesia, localization of tactile stimulus, extinction


3. extension of leg (spastic paralysis)


4. left visual field neglect

patterns of weakness that would be characteristic of


1. Radial neuropathy


2. C6 radiculopathy


3. C7 radiculopathy

j

j

Patterns of sensory loss AND DTRs in


1. radial neuropathy


2. C6 radiculopathy


3. C7 radiculopathy





k

onto exam of Foot drop.




ddx of foot drop? 3

1. sciatic nerve


2. peroneal nerve


3. L5 radiculopathy

foot drop-motor exam. strength testing if peroneal nerve injury? 3

weak ankle dorsiflexsion (tib ant.), eversion (peroneus), and toe extension (ext dig.)

foot drop-motor exam. strength testing if L5 radiculopathy 6

1. weak ankle dorsiflexion


2. weak plantarflexion (gastroc)


3. hip extension (glut max)


4. hip abduction (glut med)


5. knee flexion (hamstrings)


6. toe extension (ext dig

foot drop-motor exam. strength testing findings of sciatic nerve injury

1. ankle dorsiflexion (tib ant)


2. eversion


3. knee flexion


4. ankle plantarflexion


5. ankle inversion


6. toe exetnsion

suggested approach to foot drop




wrt order of testing weakness. NB

1. test sciatic: IF a) plantarflexion and b) toe flexion are intact, tibial nerve and therefore sciatic is intact.




2. THEN distinguish L5 from peroneal by testing


a) knee flexion


b) hip extension


c) hip abduction




all of these are innervated by L5, but are above peroneal nerve.

foot drop-motor exam. reflexes




explain significance of achilles reflex finding

peroneal nerve does NOT contribute to achilles reflex.




therefore, if diminished or absent, suggests sciatic neuropathy or L5 radiculopathy

sensory testing in foot drop. summary given here, refer to tables for details ..



note: sensory distributions for L5, sciatic, and peroneal n.



special tests for sciatic neuropathy/L5 radiculopathy



gait in peroneal vs. sciatic vs. L5

Examination of cerebellar ataxia




prompt: seeing a patien twith pernicious anemia and who is also a heavy alcoholic.. differentiate sensory ataxia from a dorsal column issue or cerebellar ataxia

d

general appearance: 1 relevant finding related to speech, in addition to well/unwell, etc.

cerebellar ataxia: patient may have dysarthria.




slurred, slow, and irregular in rhythm and volume

Cranial nerves, motor, and reflexes.. not expected to complete in this particular prompt

d

Sensory exam in ataxia :




relevant findings with light touch, temp and pain?

may see dimiished light touch if DCML sensory ataxia 

may see dimiished light touch if DCML sensory ataxia

sensory exam in ataxia: how to assess vibration?

check against bony prominennces. begin with sternum. test the distal interphalangeal joints first.




if the patient can feel those, there is no need to test proximally

vibration: findings in ataxia?

cerebellar: no findings




DCML sensory ataxia: diminished vibration sense

ataxia: how to test proprioception

grasp patients toe or finger lightly at the sides and bend it up and down.




with patient watching, demonstrate UP and DOWN.




Have patient close their eyes, and ask if they detect motion, and which direction it is.

proprioception: findings in ataxia 3

normal: this may be incorrect 10% of time




cerebellar ataxia: no expected finding




DCML ataxia: poor detection

onto special tests..




list the special tests to do in cerebellar ataxia 6

1. finger-nose test

2. heel-knee-shin


3. dysdiadochokinesia


4. hypotonia


5. nystagmus


6. rhomberg


and don't forget Gait!




findings in cerebellar vs. sensory ataxia

cerebellar: wide based gait, staggering or swaying possible




DCML sensory ataxia: patient looks down, walks as if throwing feet, feet slap ground. "high-steppage gait"

how to perform finger nose testing?




relevant findings?



heel knee shin testing..


how to perform


relevant findings

1. ask P to move heel of one leg down the shin of opposite leg. repeat on other side




2. cerebellar ataxia: may notice decompensation of movement. ie. patient moving heel abnormally high before starting the maneuver.

4 tests for dysdiadochokinesia + relevant findings

1. forearm pronation an supination


2. hand clapping


3. finger tapping?


4. foot stamping




in cerebellar ataxia, may notice slower speed and irregular rhythm, range, and accuracy.




dysdiadochokinesia = inability to perform rapid movements

how to assess for hypotonia

stabilize joint from above and passively flex and extend limb in slow, repetitive fashion. compare with other side.




tone may be reduced

wtf?



what type of nystagmus consistent with cerebellar lesion?

conjugate horizontal jerk nystagmus (both eyes moving together, with an abnormal slow drifting in one direction, than fast jerk in other direction.




NOT expected in DCML sensory ataxia...

romberg test:

ask patient to stand with feet together and closed eyes for 60 sec. look for swaying.




only positive in sensory ataxia

fundamental signs of cerebellar ataxia? 4

1. cerebellar gait


2. nystagmus


3. hypotonia


4. dysarthria



fundamental signs of DCML sensory ataxia

1. high-steppage gait


2. positive rhomberg


3. impaired proprioception


4. impaired vibration in affected limbs

Parkinson's checklist

d

PD: GA and vitals

comment and offer to assess..

PD: inspection. 6 points

1. resting tremor


2. dry skin (xeroderma)


3. decreased blinking


4. hypersalivation


5. lack of facial expression w/ conversation


6. softened, breathy voice

features of resting tremor 5

1. slow frequency tremor upon resting limb


2. asymmetrical


3. classic pill-rolling tremor


4. aggravated by stress


5. inhibited by movement

PD: 4 special tests to hit

1. bradykinesia


2. glabellar tap


3. test rigidity


4. parkinsonian gait

how to test bradykinesia (4)

1. tap fingers, beginning with index finger and moving laterally


2. inching and circling: patient rapidly pinches together index finger and thumb of one hand while simultaneously performing a circling movement with the index finger of their opposite hand. instruct p. to direct gaze towards the circling finger to distract.




3. twiddling: patient rapidly circumducts their hands over each other. inspect for asymmetry of movement




4. tapping of heels, one foot at a time

glabella tap reflex

percuss patients forehead with index finger. both eyes should reflexly blink




blinking should extinguish after 5-10 cycles.




persistent blinking is positive sign (Myerson sign)

how to test rigidity

1. pick a joint: elbow, wrist, ankle




2. pick a side: the side with the most prominent tremor




3. passively range the joint




4. feel for "lead pipe rigidity" or cogwheeling (alternating periods of resistance and relaxation)

note: why to test rigidity slowly

make sure the increased tone is not velocity dependent

features of parkinsonian gait

1. flexed posture of neck, trunk, hips, arms


2. difficulty initiating gait, freezing, en block turning


3. small, flat footed shuffling steps with narrow base


4. diminished arm swing


5. festination (involuntary speeding up)


6. retropulsion: poor postural control. stand in front of wall with patient in front of you, while giving them a pull from behind

what are 5 features that suggest a parkinson plus syndrome

1. marked autonomic dysfunction (postural hypotension, neurogenic bladder or bowel


2. early severe dementia


3. pyramidal findings (any UMN. hyperreflexia, spasticity, babinski)


4. cerebellar findings (limb ataxia, gait ataxia, nystagmus)


5. supranuclear gaze palsy (difficulty looking down)