Neuro exam & mental status

combined set

segments of the spinal cord

segments of the spinal cord

7 cervical vertebra, 12 thoracic, 5 lumbar, sacral fused bones

difference between efferent and afferent

• afferent: sensory info (dorsal root)

• efferent: motor info (ventral root)

what are the parts and functions of both the central nervous system and peripheral nervous system?

• CNS: spine, brain, brainstem

  • synthesizes information and produces output

• PNS: autonomic (sympathetic + parasympathetic) involuntary, somatic voluntary

  • intakes and reacts to information

CN 1

olfactory, scent - close one nare at a time, patient identifies smell

CN 2

optic, visual acuity + visual fields - fundoscopy exam, swinging flashlight test

CN 3

Oculomotor, eye movement - H-test extraoccular movements, pupil constriction with bright light, convergence, alternate gaze between nose and finger

CN 4

trochlear, eye movement down and laterally (similar to CN3)

CN 5

trigeminal, mastication + facial sensation - clench teeth, palpate masseter and temporalis muscle, use sensory testing soft sharp dull for V1 (opthalmic above eyebrow), V2 (maxillary cheek), V3 (mandibular) aspects of face

CN 6

Abducens, lateral eye movement (similar to CN 3)

CN 7

facial expressions - smile with teeth + puff cheeks + close eyes tightly

CN 8

vestibulocochlear, hearing + balance - gross hearing test finger rub, Weber and Rinne tests if indicated

CN 9

glossopharyngeal, speech + swallowing + gag reflex - wide mouth say “ahh” and watch for uvula deviation and/or soft palate raise

CN 10

vagus nerve, parasympathetic innervation (similar to CN 9) - check uvula deviation

CN 11

spinal accessory nerve - sternocleidomastoid muscle strength turn head with resistance, shrug shoulders against resistance

CN 12

hypoglossal, tongue muscles - extend tongue, test lateral tongue strength resist against tongue in cheek, listen for speech difficulty

what is an upper motor neuron? how does it appear in physical examination?

-Cell bodies of upper motor neurons lie in the motor strip of the cerebral cortex

Exam- Characteristic upper motor neuron signs: increased muscle tone, hyperreflexia

what is an upper motor neuron? how does it appear in physical examination?

-Cell bodies of lower motor neurons reside in the anterior horns of the spinal cord, so they are also called anterior horn cells

Exam- Characteristic lower motor neuron signs: decreased muscle tone, hyporeflexia, fasciculations and atrophy

components of a mental status exam

A&Ox4, graphesthesia, and stereognosis

components of cognitive evaluation

orientation (A&Ox4), attention/focus, memory (short/long term), calculation, abstract thinking, constructional ability (drawing)

difference between roots and ramus

• roots (either motor OR sensory) combine to the spinal nerve ramus (both sensory + motor)

cerebrum

• largest part of the brain

• surface of brain, consists of frontal lobe (executive function/thinking), motor cortex, sensory cortex, parietal lobe (perception), occipital lobe (vision), temporal lobe (memory)

cerebellum

•  balance, coordination, muscle tone

• walking/standing

brainstem

• consists of midbrain, pons, and medulla - responsible for automatic life functions (breathing, sleep, regulation, etc.)

basal ganglia

motor movements, connects motor cortex to upper brainstem - important in movement disorders!

limbic system

• long term memory, olfaction, motivation, emotion, behavior

What are the locations their associated dermatomes for testing light/pain sensation in the UE/LE?

• UE:

  • dorsal web space of thumb and index finger (C6)

  • pad of long finger (C7)

  • pad of little finger (C8)

• LE:

  • medial aspect of foot (L4)

  • great toe web space (L5)

  • lateral aspect of foot (S1)

Steps for testing proprioception?

• Grasping digit from their lateral sides: IP joint of great toe & MCP joint of long finger

• Have patient close their eyes

• Have patient identify direction in which you are moving digit (up or down)

• Test bilaterally

  *be sure to stabilize wrist for hand

Steps for testing vibration?

• Using 128 hz tuning fork

• Set on bony prominence: DIP of long finger & IP joint of big toe

• Have patient close their eyes

• Ask if buzzing/not buzzing, ask when buzzing stops

• Test bilaterally

Stereognosis

ability to identify an object by feeling - with patient’s eye closed, place familiar object in their palm and ask them to identify, repeat bilaterally

Graphethesia

number identification - with patient’s eye closed, with blunt end of pen/reflex hammer, draw large number in the patient’s palm and ask them to identify, repeat bilaterally

Rapid-alternating movements - What are the steps/purpose?

• Testing coordination, rhythm/speed

  *you can show patient how to perform, but then stop and watch patient

• UE: have patient flip their hands over and back as fast as they can and stop. Do left, then right, then both at the same time

• LE: toe taps for as fast as possible, can brace patient’s ankle. One side at a time

  *their is typically less coordination in the feet vs. hand

Finger-to-nose test - What are the steps/purpose?

*be far enough to where patient must fully extend their arm

• with eyes open, have patient alternative touching your index finger and their nose

• move your finger continuously and have patient continue alternating touching your index finger and their nose

• with your finger unmoving directly in front of patient, have them touch your finger then have them close their eyes and repeat

watching for: end point tremor, dysmetria: problems with coordination/point passing

Heel-to-shin test steps?

• seated: have patient place their heel on their knee and move down shin to foot & back up

  • repeat with eyes closed

• test can also be performed with patient supine

Gait testing includes?

• casual walk: observe posture, stance, balance, swinging of the arms, movement of legs

• heel walking/toe walking: watch for sinking in each step, testing strength

• heel-to-toe in straight line (tandem walking): may reveal ataxia, which is cerebellar dysfunction, loss of muscle control

Romberg test - what are the steps?

• position sense test

• with patient standing and feet together, arms to their side

• then have patient close their eyes and watch for excessive postural sway or loss of balance *be sure to spot patient

• if positive: could indicate proprioceptive deficit (sensory ataxia)

Pronator drift - steps?

• motor function test

• patient can be seated or standing

• have patient hold both arms forward, parallel to ground, palms up

• have patient close their eyes and watch to see if arms drift

• have patient keep their eyes closed while you tap the arms briskly downwards

Grading scale for deep tendon reflexes

• 0: no response

• 1+ sluggish or diminished

• 2+ active or expected responses

• 3+ brisk or more than expected

• 4+ hyperactive, may elicit clonus

• ‘normal’ can vary from person to person, can be between 1+-3+, always compare side to side

Spinal nerve innervation associated with each reflex location

• bicep - musculocutaneous nerve (C5)

• brachioradialis - radial nerve (C6)

• triceps - radial nerve (C7)

• patellar - femoral nerve (L4)

• achilles - tibial nerve (S1)

Babinski (Plantar response) reflex assessment/significance

• a type of superficial reflex: motor response when skin is stroked

• use blunt edge of reflex hammer or pen to trace path from heel curved out to big toe

• extended great toe when there is pressure applied to the lateral/distal plantar surface of the foot

• plantar flexion of big toe is normal

• document: plantar response is extensor/flexor, upgoing/downgoing toes

• NOT Babinski positive

• dorsiflexion of the big toe indicates positive CNS lesion affecting the corticospinal tract

What are the tests for meningeal inflammation? What are the steps?

• Kernig

  • patient supine

  • flex one of the patient’s legs at the hip and knee

  • straighten the knee

  • check for pain or resistance to knee extension

• Brudzinski

  • patient supine

  • place your hands behind the patient’s head and passively flex their neck forward until the chin touches the chest

  • check if knees and hips flex in response to the head movements/if patient is in pain

Clonus definition & purpose?

Greek for violent, confused motion. A repetitive contraction of a muscle when attempting to hold a stretched state

Purpose: indicates possible damage in CNS that could be temporary, an acute change or chronic

Method for eliciting clonus

1. Patient in relaxed supine position

2. Support the patient's lower leg. 

3. Slightly flex the patient's leg at the knee. 

4. Gently move the ankle in dorsiflexion and plantarflexion a few times. 

5. Quickly dorsiflex the ankle upwards. 

6. Hold the ankle in dorsiflexion. 

7. Look for oscillations against the pressure. If you feel and see oscillations, you've recorded a positive clonus sign.

Decorticate

abnormal extensor response; jaws are clenched, and the neck is extended

Decerebrate posturing

abnormal flexor response; upper arms are flexed tight to the sides with elbows, wrists, and fingers flexed

Flaccidity

no response on one side suggests a corticospinal tract lesion

Spasticity

increased tone that is velocity-dependent and worsens at the extremes of range of motion. Resistance increases with more rapid movement

Hemiplegia

paralysis of one side of the body

Paraplegia

paralysis of the legs

Delirium

multifactorial syndrome; an acute confusional state marked by sudden onset; fluctuating course, inattention, and changing levels of consciousness (at times)

Dementia

major cognitive disorder causing decline in at least two cognitive domains (loss of memory, attention, language, executive function) that is severe enough to impact social/occupational functioning

Depression

characterized by at least 2 weeks of depressed/irritable mood causing insomnia or hypersomnia, decreased self esteem, low energy, poor concentration, changes in appetite, feeling slowed or restless

Stupor

state of near-unconsciousness

The stuporous patient arouses only after painful stimuli. Verbal responses are slow or even absent. The patient lapses into an unresponsive state when the stimulus ceases

Lethargy

appearance of drowsiness. state of sluggishness, tiredness, or lack of energy, often accompanied by a decreased interest in activities

Coma

deep state of prolonged unconsciousness, unresponsive to external stimuli, no evidence of inner need

Areflexia

muscles do not respond to stimuli

Hyperreflexia

increased muscle tone

Hyporeflexia

decreased muscle tone

paresthesia

irritative phenomena '“pins and needles” sensation

receptive

Wernicke aphasia; with impaired comprehension with fluent speech

Expressive aphasia

Broca aphasia; nonfluent speech slow and broken, with few words and laborious effort

Vertigo

a spinning sensation within the patient or of the surroundings