M1 H&P: The Neuro Exam

Devin Nickol, M.D.

I. Cranial nerve exam

- Olfactory

- Have the patient close their eyes
- Occlude one naris
- Place an aromatic substance beneath the other naris and have the patient inhale deeply
- Repeat on the other side

- Optic

- Perform visual acuity and visual field testing

- Oculomotor, Trochlear, Abducens

- Test extraocular muscle function and lid opening
- Check pupillary response to ______________ and ___________________________

- Trigeminal

- Motor component: look for facial atrophy, fasiculations or drooping
- Palpate jaw muscles as the patient clenches their teeth
- Sensory component: Evaluate sharp/dull and light touch sensation over the forehead, cheek and chin bilaterally
- Test the corneal reflex with a cotton wisp (avoid lashes and conjunctiva)

- Facial

- Motor component: make faces!
- Sensory component: use vials of flavored solutions and applicators, ask the patient to identify tastes with their eyes closed

- Vestibulocochlear

- Formally tested with audiometry
- Bedside screening for gross hearing deficits with Rinne/Weber tests and soft sounds

- Glossopharyngeal

- Sensory function: taste of posterior 1/3 of tongue. Evaluate during taste testing of _________________ nerve
- Motor function: Oropharyngeal muscles and gag reflex are evaluated in conjunction with testing of the _____________ nerve

- Vagus

- Sensory component: evaluate gag reflex by touching the posterior oropharynx with a swab. The contraction of the pharyngeal muscles should be symmetrical and the uvula should remain in the midline as it elevates
- Motor component: have the patient say "ah" and watch for symmetry of the oropharyngeal muscles and movement of the uvula
- Evaluate swallowing with water
- Listen to speech

- Hypoglossal

- Inspect the tongue inside and outside of the mouth, look for atrophy or fasiculations
- Observe range of motion of the tongue
- Assess strength of tongue by having the patient press it against the cheek
- Listen for difficulty with lingual speech (l, d, t, n)

II. Cerebral function testing

- Three types of memory:

- Immediate recall: ______________________
- Short-term recall: _______________________ to ____________
- Long-term recall: _________________________

- The Montreal Cognitive Assement (MoCA)

- A quick and dirty screening tool to assess for cognitive dysfunction
- Most useful when administered in serial fashion over hours or days
- A score of 25/30 or lower may indicate delerium, dementia or psychiatric disorders

- Language skills

- Verbal expression

- perseveration
- flight of ideas
- gibberish
- neologisms
- echolalia
- aphasia
- dysarthria
- strange sounds

- Written expression: look for omissions/insertions, lack of coordination

- Speech comprehension: response to instruction, interpretation of proverbs

- Written comprehension: ability to follow a complex written command ("Pick up this paper, fold it in half and put it on the floor.")

III. Meningeal signs
- Provide evidence of meningeal irritation from infection, bleeding, etc.
- May be detectable in an unresponsive patient, thereby serving as the first clue towards an underlying CNS process

- Kerning's sign:

- Patient lies flat on their back with one knee drawn up, which the physician then tries to straighten
- If the patient unconciously resists straightening of the leg, the test is positive

- Brudzinski's sign:

- Patient lies flat on back
- If passive flexion of the patient's neck by the physician results in spontaneous flexion of the hips and knees, the test is positive

- Nuchal rigidity:

- Decreased range of motion of the neck or resistance to passive movement of the neck
- May be the only meningeal sign detectable in a comatose patient
IV. Sensory exam
- Light touch
- Superficial pain perception
- Joint position
- Vibratory sense
- Romberg test - have patient stand with feet together, arms at sides and eyes closed. ________________________________________ is a positive test.

V. Motor exam

- Assess muscle strength and score appropriately:

0 : No evidence of contractility
1 : Slight contractility
2 : Full range of motion, gravity eliminated
3 : Full range of motion with gravity
4 : Full range of motion against gravity, some resistance
5 : Full range of motion against gravity, full resistance

- Evaluate for involuntary movements

- tremor
- tics
- fasiculations
- hemiballismus

- Differentiate between upper and lower motor neuron disease:

Upper motor neuron signs:

- Muscle spasticity, possibly contractures
- Little or no muscle atrophy
- Hyperreflexia
- Damage above the level of the brainstem will affect the opposite side of the body

Lower motor neuron signs:

- Muscle flaccidity
- Loss of muscle tone
- Muscle atrophy
- Hyporeflexia or areflexia
- Fasiculations
- Changes in muscles supplied by that nerve, usually a muscle on the same side as the lesion

- Assess gait for shuffling, wide stance, staggering, etc.

VI. Reflexes

- Check deep tendon reflexes (DTRs):

- Triceps
- Biceps
- Brachioradialis
- Patellar
- Achilles

- Scoring:

0+ :
1+ :
2+ :
3+ :
4+ :

 

- Check superficial reflexes:

- Abdominal
- Cremasteric
- Plantar response (aka Babinski's)
VII. Cerebellar testing

- Rapid alternating movements

- Sequential finger touching

- Past pointing

- Finger-to-nose

- Heel-shin test