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NEUROLOGICAL EXAM
We skip CN-I Certain nerves are bundled (e.g. eye movements and speech production). Reflexes allow us to evaluate brain stem function, even in comatose patients.
Cranial Nerve II
Cranial Nerve II
Diplopia worsens in gaze direction of the action of the paretic muscle. The outer image is always the pathological image.
Oculocephalic Reflex
Check V with light touch and by palpating the masseter. Check VII by testing frontalis, oculi and oris muscles. Corneal reflex is tested in comatose patient.
Eyes must be closed. Rubbing fingers creates mid to high frequencies. Be random in delivering the stimuli.
Phonation Pa, Ta and Ka Spastic dysarthria (strangled phonation and slowed rates) Flaccid dysarthria (breathy phonation and fairly normal rates)
Use mechanical advantage. Use your own weight. Watch out for muscle substitutions (what muscle(s) is this examiner testing?). Well cover specifics in the small groups.
Patient must be relaxed and well positioned. You must know roots and nerves for reflexes (and muscles).
Upper motor neuron pathology slows rapid alternating movement (RAM) rates. Watch the great toe carefully (Babinski and triple-flexion.
I like finger-nose-finger and toe-finger testing. Heel-shin maneuver. Limb dysmetria is seen with IPSILATERAL cerebellar hemishere disease.
Sensory Examination
Pin and vibratory sense are nice tools for evaluating the nerves, cord and brainstem. Know your cortical sensations (e.g. stereognosis and graphesthesia)
Rhomberg test Regular walking (a fine way to test for early parkinsonism). Tandem walking (rigorous testing for ataxia).
5.
Right frontal lobe Right pons Left frontal lobe Left pons None of the above are correct.
0%
1
0%
2
0%
3
0%
4 5
2. 3. 4. 5.
Bilateral parasagital cortex Thoracic cord Peripheral nerves Medial pons Non-neurological
81%
4%
1 2
8%
3
8% 0%
4 5
2.
3. 4. 5.
Bilateral parasagital cortex C5 cord level T5 cord level T10 cord level Non-neurological
0%
1
0%
2
2%
3 4
0%
5
5.
30%
15% 4%
1 2 3 4
6%
5.
MRI scan of the spine. EEG (Electroencephalogram) Nerve conduction studies. Cerebral angiogram. None of the above.
77%
21% 0%
1 2 3
0%
4
2%
5
2.
3. 4. 5.
Bilateral parasagital cortex Thoracic cord Peripheral nerves Medial pons Non-neurological
68%
18% 11% 2%
1 2 3 4
0%
5
3.
4. 5.
88%
13% 0%
2
0%
3 4 5
MRI scan of the spine. EEG (Electroencephalogram) Nerve conduction studies. Cerebral angiogram. None of the above.
91%
5%
1
0%
2 3
0%
4
4%
5
A Woman in Pain
A 41 year-old woman had the fairly sudden onset of moderate neck pain about two weeks ago. Yesterday, she sneezed several times and afterward noted: 1) the pain has worsened and radiated to her left shoulder, 2) she has left hand numbness, and 3) left arm weakness. She has no significant medical problems and takes no medications. She works as a waitress.
5.
Left median nerve. Right frontal lobe Left C5 root Left C7 root None of the above.
83%
13% 4%
1
0%
2 3 4
0%
5
5.
14% 9% 9%
11%
MRI scan of the cervical spine. EEG (Electroencephalogram) Nerve conduction studies. Cerebral angiogram. None of the above.
82%
14% 0%
1 2 3
0%
4
5%
5
Questions