NEUROLOGIC EXAMINATION p1

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When checking mental status for cerebral examination, what are the global brain functions?

• Level of alertness

• Attention

• Cooperation

Checking the following are necessary for cerebral examinations except:

• General behaviour and appearance 

• Orientation 

• Motor Coordination

• Calculation

Except Motor Coordination

Which hemisphere is responsible for language

Left hemisphere

Which lobe is responsible for neglect and constructions

Parietal

In the MMSE-P, when you ask the patient to repeat 3 words, what does this test?

Registration (only involves attention, no retention)

When you ask the patient to repeat the 3 words after a few minutes what does this test?

Recent/Short term memory

Cut off score for the MMSE-P

27/30

The Mini-Mental Status Examination - Philippines is usually used in what condition?

Dementia

What does MOCA-P stand for?

Montreal Cognitive Assessment - Philippines

True or False:

When calculating the total score for the MOCA-P sum up all subscores on right hand side then add one point for those with 15yrs or fewer of formal education, for a max score of 30

False:

+1 for 12yrs or fewer not 15yrs

• Normal MOCA-P cut off score:

• DSP MOCA-P cut off score:

• 26/30

• 21/30

When testing for level of Alertness, Attention and Cooperation, what is the normal digit span a person can repeat forwards and backwards?

• 6 or more forward

• 4 or more backward

When naming months forward and backward how long does it take to recite the months backwards compared to reciting it forwards?

Twice as long

Structure in the brain responsible for consciousness

A small lesion here can impair consciousness

Reticular formation

found in the tegmentum in all levels of the brainstem

Consciousness can be severely impaired when the lesion in the cerebral hemispheres or thalami is _______

Mildly impaired if the lesion is _______

• Bilateral

• Unilateral

 dysfunction of cerebral functions

Encephalopathies

• Hypoxic (no oxygen)

• Hepatic ()

causes behaviour and mood disorders

You ask the patient to recall 3 items after a delay of 3-5 mins what does this test?

Recent memory

Another way to test this is to give the patient several words to remember and test for recall 4-5 min later

During the delay, distractions are provided to prevent what?

rehearsing

Memory for historical or verifiable personal information

Remote Memory

If the patient has no attention this signifies?

Impaired Registration or Immediate Recall

What structures are affected when the patient has an Impaired Delayed Recall

Medial temporal lobes and medial diencephalon

inappropriate substitutions of words or syllables

Paraphrasic errors

Creation of non-existent words

Neologisms

Fluency, abundance, content, tonal modulation (cerebellum), grammar are all elements of?

Spontaneous Speech

Thinking for language is important for?

Form and content 

Grammar and structure

Understanding simple questions and commands requires?

Comprehension

Agnosia and apraxia implicate a lesion at the ____________ or its connections

Association Cortices

Cannot follow instructions but is able to do it alone/spontaneously

Apraxia

Inability to formulate the correct movement sequence or Inability to carry out an action in response to verbal command, in the absence of any comprehension deficit, motor weakness or incoordination.

Ideomotor Apraxia

Ideomotor Apraxia arises from a lesion in what area

dominant temporoparietooccipital area 

Inability to recognize letters or numbers traced on the palm

Agraphesthesia/Agraphognosia

Inability to understand meaning, import, or symbolic significance of ordinary sensory stimuli even through the sensory pathways and sensorium are relatively intact

Agnosia

Inability to recognize faces but recognize the voice and can describe the parts

Prosopagnosia

Lack of awareness of body defect

Anosognosia

abnormality in attention to one side that is not due to a primary or secondary sensory or motor disturbance

Hemineglect

lesions on the right parietal lobe causes?

Left hemineglect

Tests for neglect

• Neglect drawing tests 

• Visual extinction 

• Copy drawing 

• Tactile extinction

Manual alternating sequence test, written alternating sequence test, auditory go-no-go are examples of?

Sequencing Tasks

difficulty in changing from one action to the next when asked to perform repeated sequence of action

Perseveration

What task asks the patient to tap table with fist, open palm, side of open hand then repeat

Luria Manual Sequencing Tasks

Frontal release signs are also known as?

Primitive reflexes

Proverbs and similarities are used to test what frontal lobe function?

Abstract Reasoning

Judgement and Logic are also tested

These impairments are categorized as diffuse brain dysfunctions or psychiatric disorders

Delusions and Hallucinations

When examining mood for mental status watch out for the following:

• Signs of depression, anxiety, mania 

• Congruence between external appearance and feelings 

• Psychiatric in origin 

• Biochemical neurotransmitter imbalances 

• Somatization and conversion disorders

Nasal obstruction, damage to olfactory nerves in the mucosa as they cross the cribriform plate, or intracranial lesions affecting the olfactory pathway can lead to what?

Anosmia

Parkinson’s disease can also cause anosmia

Tested using coffee grounds or beans

Cranial nerve 1 (olfactory)

Noxious odors may stimulate pain fibers of which CN

Trigeminal

Visualization of the retina, retinal vessels, optic nerve atrophic changes, papilledema

Ophthalmoscopy

swelling of optic disc; sign of increased intracranial pressure 

Papilledema

a measure of the ability of the eye to distinguish shapes and the details of objects at a given distance, tested using a Snellen Chart

Visual acuity

What test is used to test for color vision

Ishihara test 

The patient is instructed to fixate on examiner’s nose and report when a finger can be seen moving in each quadrant or how many fingers are held up, what is being tested?

Visual fields

double simultaneous stimulation is used to test for?

Visual extinction or hemineglect

Visual hemineglect is caused by a contralateral parietal lesion, more robust on which side?

Right

What are the afferent and efferent fibers of the direct and consensual pupillary light reflex?

Afferent: CNII

Efferent: CNIII

Characterized by convergence of the medial recti, pupillary constriction, and lens thickening

Accommodation (Near Response)

• Observe for dysconjugate gaze, spontaneous nystagmus 

• Look in all directions without moving head 

• Ask for double vision (diplopia) → check if eye movement is not focused together 

  • Can indicate problem in extraocular muscle

The following test which cranial nerves?

Cranial Nerves 3, 4, 6

patient can track full range of vertical and horizontal eye movement, this eye movement is known as?

Smooth pursuit

patient cannot track full range of vertical and horizontal eye movement and there is rapid fixation, this eye movement is known as?

Saccades

General Sensation of the face can be impaired in lesions of what structures?

• CN V

• trigeminal nuclear complex in brainstem

• thalamus

• somatosensory cortex

Tactile Extinction is caused by?

right parietal lesions

Corneal reflex afferent and efferent fibers:

Afferent: CNV

Efferent: CNVII

Impaired in UMN lesions that synapses with trigeminal motor nucleus to peripheral nerve, NMJ, and muscle

Masseter and Temporalis

Sign of hyperreflexia associated with UMN lesion to trigeminal motor nucleus

Jaw Jerk Reflex

Afferent and efferent → CN V

• Observation 

  • Asymmetry, depth of nasolabial fold (NLF), spontaneous facial expression, blinking 

  • Compare with old photos 

• Smile, puff cheek, close eyes tightly, wrinkle eyebrows 

• Taste in anterior ⅔ of tongue

All of the above tests what nerve?

Cranial Nerve VII

Caused by lesions in the ear, cochlea, and CN VIII

Unilateral hearing loss

Screening for CN VIII tests

• Finger rubbing

• Whispered words 

• Ticking of watch

Weber’s Test

• Location of tuning fork

• Normal:

• Conductive hearing loss:

• Sensorineural hearing loss:

Weber’s Test:

• Vertex of skull

• Normal: pitch heard equally on both ears

• Conductive hearing loss: louder on affected side

• Sensorineural hearing loss: softer on affected side

Rinne’s Test

• Location of tuning fork

• Normal:

• Conductive hearing loss:

• Sensorineural hearing loss:

Rinne’s Test

• EAM

• Normal: AC > BC

• Conductive hearing loss: BC>AC

• Sensorineural hearing loss: AC>BC but decreased in affected ear 

  
  

Exercise for CN VIII (???)

Cover one EAM and hum

Cranial nerves responsible for Palatal Elevation and Gag Reflex

CN IX, X

Gag reflex makes you gag when the _______ pharynx is brushed

Posterior pharynx

When is gag reflex tested?

• suspected brainstem pathology,

• impaired consciousness

• impaired swallowing

Cranial nerves responsible for the muscles of articulation:

CN V, VII, IX, X, XII

Lesions in these structures can cause impaired modulation of tone and sound, coordination

motor cortex, cerebellum, basal ganglia

abnormal pronunciation of speech (slurred speech)

Dysarthria

abnormality in language comprehension or production (cerebrum)

Aphasia

CN for traps and SCM

CN XI

What do we observe for when testing CN XII (tongue muscles)

muscle bulk, presence of fasciculations (spontaneous, quivering) 

Fasciculations and atrophy are signs of _____ lesion

LMN lesion

Unilateral Tongue Weakness deviates towards the ____ side

weak side

LMN = ipsilateral to the lesion

UMN = contralateral to the lesion

Components of an UMN

Supraspinal neurons and their tracts

Components of a LMN

• Anterior horn cell

• Peripheral nerve 

• Neuromuscular junction 

• Muscle

Identify if UMN or LMN:

• Weakness below the lesion

• (+) Fasciculations

• (-) Babinski reflex

• Hyperreflexia

• Areflexia

• Hyporeflexia

• Spastic muscle

• Flaccid or hypotonic muscle

Identify if UMN or LMN:

• UMN

• LMN

• LMN

• UMN

• LMN

• LMN

• UMN

• LMN

Identify if UMN or LMN:

• hemiplegic, quadriplegic, or paraplegic distribution

• individual or sets of muscles in root or peripheral nerve distribution 

• severe atrophy

• mild atrophy

Identify if UMN or LMN:

• UMN

• LMN

• LMN

• UMN

abnormal muscle twitching due to spontaneous activity in groups of muscle cells

Fasciculations

During inspection and palpation, there is need for special attention to intrinsic hand muscles, shoulder girdle, and thigh in patients with _____ disorders

LMN disorders

Amount of tension (or resistance to movement) in muscles or the partial state of contraction at rest

Muscle tone

Abnormalities in functional testing:

• Pronator drift

• Abnormalities in fine movements 

  • Finger tapping, rapid foot tapping 

MMT (Alam nyo na to)

Spinal level of Ankle/Achilles reflex:

S1

Spinal level of the Brachioradialis reflex

C5-6

Spinal level of the Knee Reflex

L2-4 (predominantly 4)

Spinal level of the triceps reflex

C7-8 (predominantly 7)

Spinal level of the Jaw jerk / Masseter reflex

CN V3

Spinal level of the biceps reflex

C5-6

Grading for reflexes

Name the reinforcement procedure

Pull method (of Jendrassik)

Name the reinforcement procedure

Counterpressure