How do we test consciousness
is the patient awake and alert?
How do we test attention/concentration?
Ability to FOCUS on, but exclude other stimulation
How do we test insight or judgement?
ften gathered from history, but can be given a proverb or hypothetical situation
How do we test affect?
External behavior - facial expression (Normally, affect and mood support each other, but not in certain psychiatric and neurologic conditions)
How do we test a patients mood?
Internal feeling (Patient's affect may be "flat" but when asked to express their mood, patient's may be happy or content in diseases like Parkinson's) Or affect might be tearful, emotional, but patient states they aren't feeling sad. (Indicates disorder i
What is expressive aphasia?
Broca
Comprehension in intact but difficulty speaking and repeating
What does transcortical expressive phase look like?
comprehension and repetition is intact but not fluent
what does global aphasia look like?
Not comprehending, speaking or repeating
What does Wernicke aphasia look like?
talking but not making sense
What are the 12 cranial nerves?
Olfactory: I
Optic: II
Oculomotor: III
Trochlear: IV
Trigeminal: V (often, branches referred to separately as V1, V2, V3)
Abducens: VI
Facial: VII
Acoustic or Vestibulo-Cochlear: VIII
Glossopharyngeal: IX
Vagus: X
Accessory (spinal accessory) XI
Hypogloss
Loss of CN I
lack of sense of smell
How do we test CN II?
Optic nerve
1. Visual acuity
2. visual fields
3. pupillary light reflex and accommodation
4. visualize fundi
What nerves are involved in the pupillary light reflex?
CN II (afferent) and CN III (efferent)
What is the direct vs. indirect response in the pupillary light reflex?
Direct: ipsilateral pupil constricts
Indirect: contralateral constricts
What does papilledema look like?
optic disc swelling
Adies pupil?
unilateral, tonic pupil- large, reacts sluggishly to light and accommodation
Argyll-Robertson pupils
Small, poorly reactive to light
What does a unilateral significantly dilated pupil suggest?
lesion of CN III, including herniation of the ipsilateral cerebral hemisphere
What does EOMI test?
CN III, IV, VI
What does CN III paresis look like?
Levator palpebrae affected, so there is lid droop
Several muscles are affected, so inhibited movements in multiple directions, with sparing of the lateral/horizontal gaze.
At rest/primary gaze, pupil may be slightly laterally deviated due to unopposed act
What does an injured CN IV look like?
Patient's see double, most obviously when looking down while in adduction
The affected eye may slightly elevate due to unopposed action of its antagonist muscle, the inferior oblique.
Head tilt OPPOSITE the lesion improves double vision.
What does an injured CN VI look like?
Pts see double only when looking laterally to the side of the lesion
can't abduct
When ptosis is not due to CN III lesion, what does it look like?
Partial and mild
What is horners?
ptosis, miosis, and anhidrosis (lack of sympathetic)
How do you test CN V
sensation from face/head, muscles of mastication
What CN are involved in the blink reflex?
CN V sensation
CN VII blinking
How do you test CN VII?
Tested by closing the eyes, raising the eyebrows, for the UPPER FACE
Tested by smiling, puffing cheeks, pursing lips or whistling for the LOWER FACE
Taste is usually not tested, but derived from history
What does a peripheral CN VII lesion look like?
BOTH the upper and the lower facial muscles on that side are impaired
Idiopathic paralysis is called Bell's Palsy (most often related to viral/post-viral)
Usually an isolated cranial nerve finding, remaining exam is normal
What does a central CN VII lesion look like?
Contralateral
ONLY the lower facial muscles are impaired
a. Unclear why this occurs, perhaps because the lower facial muscles receive innervation from BOTH SIDES of the motor strip in the frontal lobes
Often associated with other CN or extremity symptoms/
How do you treat bells palsy?
Initiate steroids immediately
saline eye drops
How do you test CN VIII?
Hearing (finger rub)
How do you test CN IX?
Tested by asking patient to say "ahhh".
Palate will fail to elevate to affected side.
Dysfunction can also be perceived by having patient say repetitive "k"
Gag reflex: touch simulation to back of tongue or pharyngeal walls elicits gag, or contraction of
How does glossopharyngeal neuralgia present?
sharp, lancinating pain in region of tonsil, radiating to ear
triggered with yawning
How do you test CN X?
tested as part of the gag
How do you test CN XI?
The RIGHT SCM and LEFT trapezius are controlled by the same side of the cortex, so that when the LEFT upper limb/shoulder is in use (trapezius activated to elevate shoulder) the RIGHT SCM is activated, causing head to rotate left and chin slightly elevate
CN XII testing?
Ask patient to "stick-out" tongue
I usually have patient wiggle tongue from side to side
Can also have patient repeat "la"
If concerned, have patient drop jaw open and observe tongue at rest
What is "give-way" weakness?
patient suddenly release tension/effort. Can often be noted by keeping hand on contralateral extremity while testing
What is tone?
Tone is the resistance in the muscle to passive stretch.
what DTR ratings are pathologic?
0 and 4
What does a decreased DTR represent?
Diabetes
hypothyroid
vit b12 deficiency
chemotherapy
What does an increased DTR represent?
central nervous sytem
normal pregnancy
What is the normal babinski reflex?
flexion of the toes downward
What is an abnormal babinski?
extension and separation of toes
Cerebellar disease in one lobe produces abnormalities...
on the SAME side of the body
What does the Romberg test test?
posterior columns