1
Q
What are the twelve cranial nerves?
A
CN I (olfactory) CN II (optic) CN III (oculomotor) CN IV (trochlear) CN V (trigeminal) CN VI (abducens) CN VII (facial) CN VIII (vestibulococchlear) CN IX (glossopharyngeal) CN X (vagus) CN XI (accessory) CN XII (hypoglossal)
2
Q
What is the function of the Olfactory Nerve (CN I)?
A
sense of smell
3
Q
What is the function of the Optic Nerve (CN II)?
A
vision
4
Q
What is the function of the Oculomotor Nerve (CN III)?
A
- pupillary constriction
- opening the eye
- most EOMs
5
Q
What is the function of the Trochlear Nerve (CN IV)?
A
inferior and medial movements of the eye
6
Q
What is the function of the Trigeminal Nerve (CN V)?
A
- motor: temporal and masseter muscles, lateral pterygoids
- sensory: facial (ophthalmic, maxillary, and mandibular divisions)
7
Q
What is the function of the Abducens Nerve (CN VI)?
A
lateral deviation of the eye
8
Q
What is the function of the Facial Nerve (CN VII)?
A
- motor: facial movements and expressions (closing eye and mouth)
- sensory: taste on the anterior 2/3 of tongue
9
Q
What is the function of the Vestibulocochlear Nerve (CN VIII)?
A
- hearing (cochlear division)
- balance (vestibular division)
10
Q
What is the function of the Glossopharyngeal Nerve (CN IX)?
A
- motor: pharynx
- sensory: posterior portions of TM and ear canal, pharynx, posterior tongue (including taste), uvula
11
Q
What is the function of the Vagus Nerve (CN X)?
A
- motor: palate, pharynx, larynx, uvula
- pharynx and larynx
12
Q
What is the function of the Accessory Nerve (CN XI)?
A
- motor: SCM and upper portion of trapezius
13
Q
What is the function of the Hypoglossal Nerve (CN XII)?
A
- motor: tongue
14
Q
What are the aspects of the Mental Status Examination (MSE)?
A
- appearance and behavior
- speech
- affect
- mental content
- mental function
- judgment
- insight
- suicidal and homicidal risks
15
Q
What are the components of Appearance and Behavior in the MSE?
A
- level of consciousness
- posture and motor behavior
- dress, grooming and personal hygiene
- facial expression
- manner
- relationship to people and things
16
Q
What are the components of Speech in the MSE?
A
- quantity: talkative vs silent
- rate: fast vs slow
- volume: loud vs soft
- articulation of words
- fluency: look for hesitancies, disturbed inflections (monotone), circumlocations (word substitutions)
17
Q
What are the components of Affect in the MSE?
A
- observable, usually episodic, feeling or tone expressed through voice, facial expression, and demeanor
18
Q
What are the components of Mental Content in the MSE?
A
- what pt thinks about
- included level of insight and judgment
19
Q
What are the components of Mental Function in the MSE?
A
assessed by vocab, fund of info, abstract thinking, calculations, construction of objects that have 2 or 3 dimensions
20
Q
What are the components of Judgment in the MSE?
A
- process of comparing and evaluating alternatives when deciding on a course of action
- reflects values that may or may not be based on reality and social conventions or norms
21
Q
What are the components of Insight in the MSE?
A
- awareness that symptoms of disturbed behaviors are normal or abnormal
- ability of pt to understand and acknowledge their illness or situation
22
Q
What are the components of Suicidal/homicidal Risks in the MSE?
A
- ask direct questions
- depression is twice as common in women and is a frequent complaint of chronic medical illness
- screen high-risk patients for early signs of depression that are often missed: low self-esteem, loss of pleasure in daily activities, sleep disorders, difficulty concentrating or making decisions
23
Q
What are the levels of consciousness? (5)
A
- alert: pt able to open eyes, look at you, respond fully and appropriately
- lethargic: drowsy but can open eyes, look at examiner and respond; falls back to sleep easily
- obtunded: opens eyes and looks at you; offers confused responses, has lack of interest in the environment
- stuporous: wakens only with painful stimuli; verbal responses slow or absent; unresponsive unless stimuli is present
- comatose: unarousable to any stimuli; GCS
24
Q
What is decorticate posture?
A
- upper extremities flexed at elbows and held closely to body
- lower extremities internally rotated and extended
- thought to occur when brain stem is not inhibited by motor function of cerebral cortex
25
What is decerebrate posture?
- pts with extensive brain stem damage to pons and lesions that compress lower thalamus and midbrain
- rigid extension
- arms fully extended, forearms pronated, wrists/fingers flexed
- jaw clenched, neck extended, back may be arched
- feet plantar flexed
- may occur spontaneously, intermittently, or in response to stimuli
26
What is aphasia?
- disorder in producing/understanding speech
- causes: lesions in dominant cerebral hemisphere (L)
- Broca's aphasia: (expressive) nonfluent, slow, articulation is impaired but meaningful (with nouns, transitive verbs, important adjs)
- Wernicke's: (receptive) fluent, rapid, articulation good but sentences lack meaning; words malformed/invented
27
What is dysarthria?
- difficulty speaking due to abnormalities of oral and facial muscles that produce speech
- words may be nasal, slurred, or indistinct
- causes: motor lesions of the central or peripheral nervous system, parkinsonism, cerebellar disease
28
What are paraphasias?
words are malformed, wrong, or invented
29
How do you test for aphasia?
- word comprehension: one-staged and two-staged commands
- repetition: repeat phrase of one-syllable words
- naming
- reading comprehension
- writing
30
What is circumstantiality?
- speech characterized by indirection and delay in reaching the point due to unnecessary detail
- components have meaningful connection
- pts with obsessions
31
What is derailment?
- shifting from subject to others that are unrelated/related only obliquely without realizing subjects have no connection
- schizophrenia, manic episodes, psychosis
32
What is a flight of ideas?
- continuous flow of accelerated speech
- changing abruptly from topic to topic
- plays on words, distracting stimuli, no progress to sensible conversation
- manic episodes
33
What are neologisms?
- invented/distorted words or words with new/highly idiosyncratic meanings
- schizophrenia, psychotic disorders, aphasia
34
What is blocking?
- interruption of speech midsentence/before completion of an idea
- losing a thought
- profound in schizophrenia
35
What is confabulation?
- fabrication of facts/events in response to questions in order to fill in gaps in impaired memory
- Korsakoff's syndrome from alcoholism
36
What is perseveration?
- repetition of words/ideas
| - schizophrenia/psychosis or traumatic injuries
37
What is echolalia?
- repeating words/phrases of someone else
| - manic episodes and schizophrenia
38
What is clanging?
- choosing word based on sound rather than meaning
- usually rhyming/punning
- schizophrenia and manic episodes
39
How can you assess Thought Content?
- assess during interview
- follow leads suggested by patient instead of asking stereotyped list of questions
- abnormalities include: compulsions, obsessions, phobias, anxieties, feelings of unreality, feelings of depersonalization, delusion (of persecution, grandeur, jealousy, reference, being controlled, somatic, systematized)
40
How can you assess Mental Function?
- orientation (name, date, place)
- attention
- digit spans (serial 7s or spell world backwards)
- remote memory
- recent memory
- new learning ability (repeat 3 words)
- higher cognitive functions including vocabulary, calculating ability, abstract thinking (proverb), and constructional ability (draw a clock)
41
How can you assess Judgment?
- ability to evaluate situation and form appropriate response
- assess by asking patient to propose solution to a current problem (how will you get to your follow-up appointment) and/or ask to propose solution to a hypothetical problem
42
How do you test the Olfactory Nerve (CN I)?
- test each nostril with a familiar, non-irritating odor
43
How do you test the Optic Nerve (CN II)?
- test visual acuity (confrontation)
44
How do you test the Optic Nerve (CN II) and Oculomotor Nerve (CN III)?
- inspect size and shape of pupils
- test pupillary reactions to light
- check near response
45
How do you test the Oculomotor Nerve (CN III), the Trochlear Nerve (CN IV), and the Abducens Nerve (VI)?
- test EOM in the six cardinal directions of gaze
| - look for nystagmus, diplopia, and ptosis
46
How do you test the Trigeminal Nerve (CN V)?
- motor: palpate temporal and masseter muscles (ask patient to clench their teeth, ask pt to move jaw side to side)
- sensory: test for pain sensation and light touch in each of the 3 areas (ophthalmic, maxillary, and mandibular); corneal reflex
47
How do you test the Facial Nerve (CN VII)?
- motor limb of corneal reflex
| - ask patient to raise both eyebrows,frown, close eyes tightly, smile, show both upper and lower teeth, puff out cheeks
48
How do you assess motor strength of the elbow?
- flexion (C5,6 - biceps)
| - extensions (C6-8 - triceps)
49
How do you assess motor strength of the wrist?
- extension (C6-8, radial nerve)
50
How do you assess motor strength of the hand?
- test grip of hand (C7-8, T1)
51
How do you assess motor strength of the hip?
- adduction (L2-4, iliopsoas)
- abduction (L4-5, S1, gluteus medius and minimus)
- extension (S1 - gluteus maximus)
52
How do you assess motor strength of knees?
- flexion (L4-5, S1-2, hamstrings)
53
How do you assess motor strength of the foots?
- dorsiflexion (L4-5, tibialis anterior)
| - plantar flexion (S1-gastrocnemius, soleus)
54
How do you assess cerebellar function?
- observe patient's performance in rapid alternating movements (finger tapping)
- point-to-point movements (finger to nose test, heel to chin test)
- gait and other related body movements (walk normally, heel to toe, on toes, on heels, hop in place, shallow knee bed, rise from sitting position)
- standing in specified ways (Romberg test, pronator drift)
55
How you assess sensory pathway integrity?
- test pain and temp (spinothalamic tracts), position and vibration (posterior/dorsal column), light touch (both), and discriminative sensations
- compare symmetric areas
- compare distal with proximal areas
- vary place of your testing
- if you detect sensory loss/hypersensitivity, map out its boundaries
56
What are the deep tendon reflexes?
- ankle (S1)
- knee (L2, 3, 4)
- brachioradialis/supinator (C5, 6)
- biceps (C5, 6)
- triceps (C6, 7)
57
What are the cutaneous stimulation reflexes?
- abdominal: upper (T8, 9, 10) and lower (T10, 11, 12)
- plantar responses (L5, S1)
- anal (S2, 3, 4)
58
How do you assess for discriminative sensations?
- stereognosis
- graphesthesia
- two point discrimination
- point localization
- extinction
59
How do you assess for stereognosis?
- place familiar object in the patient's hands while eyes closed
- ask them to identify it
60
How do you assess for graphestheisa?
- use pen to draw a # on patient's palm
- ask them to ID the number
- bilaterally
61
How do you assess for two point discrimination?
- use 2 ends of an open paper clip to finger pads in two places
- then touch 1 place at a time and ask patient if they feel 1 or 2 points each time
62
How do you assess point localization?
- touch point on patient's skin; ask pt to open eyes and point to place touched
63
How do you assess extinction?
- stimulate corresponding areas on both sides of the body simultaneously
- ask where pts feels your touch
64
What are the levels for Grading Muscle Strength (MRC Scale)?
- 0: no muscular contraction detected
- 1: barely detectable flicker or trace of contraction
- 2: active movement of body part with gravity eliminated
- 3: active movement against gravity
- 4: active movement against gravity and some resistance
- 5: active movement against full resistance without evident fatigue; normal muscle strength
65
What dysfunction is seen in Lower Motor Neuron damage?
- IPSILATERAL weakness and paralysis to the limbs
| - muscle tone and reflexes are decreased or absent
66
What dysfunction is seen in Upper Motor Neuron Damage?
- above crossover in medulla, impairment develops on CONTRALATERAL side
- below crossover, impairment is IPSILATERAL side
- affected limb becomes weak or paralyzed, muscle tone is increased and deep tendon reflexes are exaggerated
67
What is the Babinski response?
- when testing plantar response (L5, S1), the big toe dorsiflexes (CNS lesion in corticospinal tract)
68
What is Clonus?
- test when reflexes seem hyperactive
| - dorsiflex ankle and look to see if it maintains this position or if there are rhythmic oscillations (CNS disease)
69
What is Kernig's sign?
- flex pt's leg at both hip and knee and straighten knee
| - positive sign indicated by pain and increased resistance to extending the knee
70
What is the Brudzinski Sign?
- as you flex neck (pt is passive), hips and knees also move (in pain)
71
What is the Doll's Eye Response?
- hold patient's upper eyelids open, turn head quickly
- eyes should turn toward opposite side otherwise the patient does not have an intact brainstem (used to test comatose patients)
72
What is the Romberg Sign?
- pt stands with feet together and closes eyes
| - positive sign: swaying (dorsal column disease, cerebellar ataxia)
73
What is Pronator Drift?
- stand with arms straight forward, palms up, eyes closed
| - look for drifting of either forearm (corticospinal tract lesion)
74
What is the Straight Leg Raise?
- raise pt's relaxed and straightened leg
- if there is a painful radiculopathy associated with muscle weakness and dermatomal sensory loss can indicate sciatic or herniated disc
75
What is aphonia?
- loss of voice that accompanies disease affecting larynx or its nerve supply
- causes: laryngitis, laryngeal tumors, unilateral vocal cord paralysis (CN X)
76
What are the types of seizure disorders (3)?
- partial seizures
- generalized seizures
- pseudoseizures
77
What are the clinical manifestations of Partial Seizures?
- jacksonian or other motor: tonic than clonic movements that may spread
- ANS symptoms (nausea, pallor, flushing, lightheadedness)
- sensory/psychiatric phenomena: numbness, tingling, auditory/olfactory hallucinations, anxiety or fear
78
What is the postictal state of Partial Seizures?
normal consciousness in all
79
What are the clinical manifestations of Generalized Seizures?
- tonic-clonic (grand mal): loses consciousness suddenly, body stiffens, breathing stop, cyanosis, clonic phase follows, breathing resumes with excessive salivation
- absence: sudden brief lapse of consciousness with momentary blinking, staring, movements of lips/hands, no falling
- myoclonic: sudden, brief, rapid jerks of trunk or limbs
- myoclonic atonic: sudden loss of consciousness with falling but no movements, injury may occur
80
What is the postictal state of Generalized Seizures?
- tonic-clonic: confusion, drowsiness, fatigue, headache, muscular aching, sometimes temporary persistance of bilateral neurologic deficits (hyperactive reflexes, Babinski responses, amnesia for seizure)
- absense: no aura recalled
- myoclonic: variable
- myoclonic atonic: prompt return to normal or brief period of confusion
81
What are Pseudoseizures?
- clinical manifestations: movements may have personally symbolic significance, do not follow neuroanatomic pattern, injury uncommon
- postictal state: variable
82
What are the involuntary movements that we need to know? (6)
- tremors
- oral-facial dyskinesias
- tics
- athetosis
- dystonia
- chorea
83
What are the types of tremors? (3)
- resting: slow, fine, pill-rolling (Parkinson's)
- postural: while maintaining a posture (hyperthyroidism, anxiety, fatigue, or can be benign)
- intention: absent at rest, appear with movement (cerebellar disorders, MS)
84
What are oral-facial dyskinesias?
- rhythmic, repetitive, bizarre movements of face, mouth, jaw, and tongue
- grimacing, pursing of lips, protrusion of tongue, opening and closing of mouth, deviation of jaw
- causes: long term psychotropic drugs, standing psychoses, elderly and edentulous persons
85
What are Tics?
- brief, repetitive, stereotyped, coordinated movements at irregular intervals
- causes: Tourette's, drugs (phenothiazines and amphetamines)
86
What is Athetosis?
- slower, more twisting and writhing than choreiform movements with larger amplitude
- usually of face and distal extremities
- causes: cerebral palsy
87
What is Dystonia?
- similar to athetoid movements but often involve larger portions of body (including trunk)
- causes: drugs (phenothiazines), primary torsion dystonia
88
What is Chorea?
- brief, rapid, jerky, irregular, unpredictable movements that occur at rest or interrupt normal coordinated movements
- seldom repeat themselves
- causes: Sydenham's chorea, Huntington's disease
Clinical Assessment
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