Neurological Screening

1. head trauma

2. stroke

3. diabetes w/ background retinopathy

4. unexplained VF defect

5. recurrent optic neuritis/MS

6. bilateral ptosis

7. Bell’s palsy

8. Adie’s Tonic pupil 

9. hypothyroidism

10. HA of recent origin, severe or increasing in severity which cannot be linked to a physical finding of another system 

what are the indications for neurological screening?

>3

if ___ areas are questionable on an abbreviated neurological screening, conduct a full exam

alert

level of consciousness: eyes open, responds fully

lethargy

level of consciousness: opens eye, responds sleepily

obtundation

level of consciousness: eyes open, fixates, responds slowly, confused

stupor

level of consciousness: arouses only w/ pain, responses slow or absent, lapses back to unresponsiveness

coma

level of consciousness: eyes closed, no response, unarousable 

1. check patency of each nostril

2. test sense of smell

how do you screen CN1?

T

T/F: even if a pt is congested, they still may be able to perceive the smell stimulus presented to evaluate CN1

frontal lobe lesion

what pathology is associated w/ a unilateral loss of smell?

smoking, cocaine use, nasal dz, congenital, head trauma, radiation/chemotherapy, allergies

what pathology is associated w/ a bilateral loss of smell? 

allergies

what is the most common cause of bilateral loss/reduction of smell?

1. VAs

2. confrontations 

3. bilateral extinction VF

4. pupils

5. observe for ptosis

6. EOMs

7. NPC

8. inspect ONH 

what are the screening tests for CN2, 3, 4, & 6? 

binocular VF w/ extinction

pt fixates on you w/ both eyes open & you present 1 or 2 fingers in both of the pt’s opposite VFs

palpate temporal & masseter muscles: have the pt bite down, grit their teeth, & relax  

what is the neuro screening test for CN5? 

CN5 lesion

what pathology is associated w/ absence or weakness unilaterally on contraction when palpating the temporal/masseter muscles while evaluating CN5?

upper or lower motor neuron involvement, muscle dystrophies

what pathology is associated w/ absence or weakness bilaterally on contraction when palpating the temporal/masseter muscles while evaluating CN5?

TMJ

pain w/ tenderness on palpation of the temporal & masseter muscles while assessing CN5 suggests what?

CN5 sensory lesion or CN7 motor lesion 

what does impairment of the corneal touch reflex suggest? 

1. wearing soft contacts

2. CL exhaustion

3. HSV keratitis

4. diabetes

5. Bell’s palsy

what things can cause a decreased/abnormal corneal touch reflex?

1. corneal touch reflex

2. light touch reflex on 6 dermatomes 

3. pain reflex on 6 dermatomes 

how is CN5 sensory evaluated? 

temperature sensation

if light touch or pain is abnormal when evaluating CN5, confirm w/ ___________

CN5 lesion

when conducting light touch or pain reflex screening, unilateral decrease or loss of sensation indicates a _______

upper or lower motor neuron involvement

when conducting light touch or pain reflex screening, bilateral decrease or loss of sensation could indicate ________

1. observe face at rest & during conversation 

2. instruct pt to raise brows, frown, close eyes, smile, show teeth, & puff their cheeks 

how do you evaluate CN7 motor? 

1. unilateral loss of brow wrinkles

2. inability to close both lids

3. flattening of nasolabial fold

4. drooping of lower lid

5. asymmetrical smile

what are the facial signs of Bell’s palsy?

lower

Bell’s palsy is a ______ motor neuron lesion

upper

upper facial symmetry w/ lower facial weakness or asymmetry indicates a __________

stroke or cortical CNS lesion

what is the most likely cause of an upper motor neuron lesion?

1. gross hearing

2. Weber test

3. Rinne test

how is CN8 evaluated?

Weber test

start the tuning fork then set in the middle of the forehead at the hairline & ask if the sound is heard & heard equally in both ears

Rinne test

start the tuning fork then place on mastoid process & ask the pt if they can hear it, and when they can no longer hear it; once not heard, quickly place it next to their ear & ask if they can hear it then 

air conduction > bone conduction

what is the normal expected finding for the Rinne test?

conduction loss from obstruction/FB, perforated ear drum, acute otitis media, or wax

if Weber lateralized to bad ear & Rinne shows BC>AC in that ear w/ AC>BC in the good ear, what is the dx and potential causes?

nerve damage

if Weber lateralized to good ear w/ Rinne showing AC>BC and AC>BC or equal in other ear, what is the dx?

1. assess & ask about voice quality 

2. ask the pt to swallow 

3. ask pt to open wide & say ah 

what are the screening tests for CN9 & 10? 

CN10 lesion

if there is no rise in the palate or the uvula deviates w/ unilateral rise when assessing CN9 & 10, what should you suspect?

normal variation

if the uvula only deviates slightly w/ symmetrical bilateral palate raise when assessing CN9 & 10, what should you expect?

CN9 or 10 lesion

if there is a unilateral loss of the gag reflex when assessing CN9 or 10, what should you expect?

bilateral CN lesion or other neurological disorder

if there is a bilateral loss of gag reflex when assessing CN9 or 10, what should you expect? 

1. test trapezius muscle

2. test sternocleidomastoid muscles

what are the screening tests for assessing CN11?

peripheral nerve disorders, lower motor neuron disease, hypothyroid

what can cause weakness, atrophy, or fasciculations in the trapezius detected on CN11 assessment?

1. listen to articulation of words

2. inspect tongue as it lies in the oral cavity

3. inspect tongue as pt sticks out their tongue

4. ask pt to move tongue side to side

what are the screening tests for CN12?

upper or lower motor neuron disease, cerebellar disease, extrapyramidal tract or muscle disease 

what are the potential causes of poor articulation (dysarthria) when assessing CN12? 

lower motor neuron disease

if there is atrophy/fasciculations of the tongue on CN12 assessment, what does htis suggest?

away

if there is a unilateral cortical lesion, the protruded tongue deviates _____ from the side of the cortical lesion

weak

with CN12 lesions, the tongue deviates to the _____ side

distal to proximal 

when testing light touch on the extremities, what direction do you test in? 

anesthesia 

absence of feeling

hyperesthesia

increased sensitivity

hypoesthesia

decreased sensitivity

polyneuropathy globe & stocking defect

seen in any micro-vascular disease (DM, alcoholism, etc) or hysterics or conversion disorders

sensory cortex or posterior column disease

what diseases can cause loss of discriminative sensations seen when assessing stereognosis? 

astereognosis

inability to recognize objects placed in hand

pt has motor impairments, arthritis, or other conditions that impair manipulations, or the pt has failed stereognosis

when is graphesthesia indicated?

sensory cortex lesion

inability to recognize the number when testing graphesthesia suggests what?

ataxia

lack of coordination w/ feeling of instability 

spastic hemiplegia

stroke pt will drag on one side

spastic diplegia

scissor gait

steppage gait or foot drop

type of ataxia, muscle weakness

cerebellar ataxia 

type of ataxia, wide stance & waddle walk 

sensory ataxia

type of ataxia, loss of sensation, smacks foot down

dystonic

jerky dancing movements which appear nondirectional

Parkinson’s gait

pt will be hunched, have unusual balance & irregular arm swing

quad

the shallow knee bend test assesses strength of what? 

1. weakness of quads

2. proximal weakness

3. weakness in pelvic girdle & legs

if the shallow knee bend test is difficult, what are the potential causes?

weakness, lack of position sense, or cerebellar dysfunction

if the hop in place test is difficult, what might this indicate?

pt has intact motor system, good position sense, & intact cerebellar function

if the pt does good on the hop in place test, what does this tell us?

shallow knee bend, plantar flexion, & dorsiflexion 

what tests are covered by the hop in place test? 

position sense & cerebellar function

what does the Romberg test assess?

open

cerebellar function is the strongest when the eyes are ____ (Romberg test)

closed

position sense is the strongest when the eyes are ____ (Romberg test)

closed

a +Romberg = loss of balance when eyes are ______

cerebellar ataxia

pt has difficulty standing w/ feet together w/ eyes open or closed

closed

the pronator drift test is performed when the eyes are ______ only

contralateral lesion or corticospinal tract

when there is pronation of 1 forearm, what does this mean?

position sense problems

if there is pronation or drift downward w/ flexion of fingers & elbows & the arm drifts up or sideways, what does this indicate?

stroke

if there is pronation or drift downward w/ flexion of fingers & elbows & the arm drifts down, what does this indicate?

cerebellar incoordination

if there is pronation or drift downward w/ flexion of fingers & elbows, & with tap, the arm overshoots & bounces, what does this indicate?

pronation

rotation in of the arm 

ulnar nerve disorder

if there is weak finger abduction, what does this indicate? 

median nerve disorders (carpal tunnel), polyneuropathy, stroke

what can cause weak opposition of the thumb when testing finger adduction/opposition?

peripheral nerve disease, CNS disease producing hemiplegia

what can cause weakness of wrist extension?

Phalen’s test for carpal tunnel

• have pt hold both wrists in acute flexion-90deg

• press the back of both hands together to form a right angle & hold for 60sec

• + if pt gets numbness or tingling over the palm, thumb, middle, & index fingers

Tinel’s 

• tap along median nerve w/ reflex hammer

• + if pt notes any tingling in fingers 

peripheral nerve disease, CNS disease producing hemiplegia (stroke, MS)

what can cause weakness in elbow extension?

cerebellar disease

when testing rapid rhythmic movements in the upper extremity, if 1 movement is not followed quickly by another, what might this indicate?

cerebellar disease

when testing rapid rhythmic movements in the upper extremity, if movements are slow, irregular, or clumsy, what might this indicate?

upper motor neuron weakness & extrapyramidal disease 

when testing rapid rhythmic movements in the upper extremity, if rapid alternating movements are impaired, what might this indicate?

frontal lobe lesion

when testing rapid rhythmic movements in the upper extremity, if the pt cannot switch from patting to over & back w/o stopping, what might this indicate?

cerebellar disease

when performing point to point in the upper extremity, if the movements are clumsy, unsteady, varying in speed/force/direction, what might this indicate?

cerebellar or vestibular disease

when performing point to point in the upper extremity, if the pt is past pointing, what might this indicate?

loss of position sense

when performing point to point in the upper extremity, if the pt shows inaccuracy w/ their eyes closed, what might this indicate?

cerebellar disease

when performing point to point in the lower extremity & the pt’s heel overshoots the knee & oscillates from side to side, what might this indicate? 

loss of position sense

when performing point to point in the lower extremity & the heel is lifted too high & the pt tries to look, what might this indicate? 

pointed end

what end of the reflex hammer is used for the biceps reflex?

flat end

what end of the reflex hammer is used for the patellar reflex?

flat end

what end of the reflex hammer is used for the achilles reflex? 

have pt look away & clench their teeth

how do you reinforce an upper extremity reflex?

have pt look away & clasp their hands together & pull firmly at chest level

how do you reinforce a lower extremity reflex?