Adult Neuro exam
Terms
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- Delirium:
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An abnormal mental state characterized by disorientation, fear, irritability, a heightened or decreased sense of vigilance, misperception of stimuli, hallucinations. A major feature is alteration in arousal.
Delirious patients often are often loud, talkative, offensive,suspicious and agitated. Or they may have decreased psychomotor activity.
Delirious states tend to begin rapidly and resolve after a few days. - Causes of Delerium
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Delirium is a major feature of toxic-metabolic disorders of the nervous system.
Examples: organophosphate poisoning, accidental plant ingestions (Jimson weed, amanita mushroom poisoning with strong anticholinergic side-effects). ETOH-barbiturate O.D. or withdrawal, renal, hepatic failure, mercury poisoning (“Mad as a Hatterâ€). - Obtundation
- Refers to a mental blunting or torpor. Applies to patients with a mild to moderate reduction in alertness.
- Stupor
- Is a condition of deep sleep or behaviorally similar unresponsiveness; these patients can only be aroused momentarily by vigorous and repeated stimuli.
- Coma
- Characterized by a state of unarousable unresponsiveness in which the patient lies with their eyes closed, failing to demonstrate any understanding to external stimuli or inner need. These patients do not utter any speech, nor do they accurately localize to noxious stimuli.
- Dementia
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Defines an enduring or permanent decline in mental processes secondary to organic processes, not accompanied by a reduction in arousal. Typically applies to diffuse reduction in cognitive function rather than a specific area of cognitive functioning such as language.
A constant feature of dementia is impairment of memory. - Persistent Vegetative State (PVS):
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Proposed by Jennett and Plum (1972) to describe a chronic condition that sometimes manifests after severe brain injury. These patients return to a state of wakefulness without any evidence of cognitive function.
These patients demonstrate sleep-wake cycles, but manifest no localizing motor responses, no language, nor do they obey commands. - Locked-in-Syndrome:
- Typically results from selective brainstem (pontine) lesions typically produced by de-efferentation with paralysis of all four extremities and the lower cranial nerves without disturbances in consciousness. Thus these patients cannot communicate verbally or move their bodies. Usually they are left with only the ability to use vertical eye movements and blinking to communicate in a type of “Morse code†fashion.
- In elderly pt with altered mental status what is the first test you should run.
- UA/UC - test for underlying infection
- Folstein’s Mini-Mental State Exam
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Developed by Folstein and McHugh in 1975.
Consists of an eleven element bedside examination that evaluates the patient in the spheres of orientation, registration, attention & calculation, recall and language.
The individual elements are ranked on a 0-30 scale. Scores at or below 23 have a fairly high correlation with dementia or delirium. -
A 34 year old male presents to the ER with an altered mental status characterized by a mild to moderate blunting of his attention/alertness. The odor of his breath smelled like ETOH.
He was unable to verbalize the date/day.
Nor was he able to g - Obtundation
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Upon physical examination, the patient presented with the following findings:
-A bluish discoloration behind the ear (post auricular)
-“watery†fluid leaking from the external auditory orifice
-The findings on otoscopic examination - Head trauma with basilar skull fracture
- Ice water is placed in ear and patient displays permanant eye deviation towards ice water stimulation. This means?
- Patient is alive but in coma
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COWS
What does it mean? -
cold opposite, warm same
cold water in ears causes eyes to shift away from water, warm causes eyes to look towards.
Means patient is alive and alert. - If a formal Folstein is not performed
- the examiner can assess attention (digit span), orientation (person, place, time, purpose, [“oriented X 4â€]); language (fluency, naming, object recognition, repetition, comprehension and following commands; reading comprehension, writing, finger and color naming.
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Gerstmann’s syndrome
Where is it localizes, what is it -
localizes to left parietal lobe
The inability to distinguish right from left, inability to name fingers (finger agnosia), inability to calculate (acalculia) and inability to write (agraphia) - Other Features of the Mental Status Examination
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Calculation
Right-Left Discrimination
Inability to name fingers (finger agnosia),
Inability to calculate (acalculia) - *****syndrome of the angular gyrus
- The inability to distinguish right from left, inability to name fingers (finger agnosia), inability to calculate (acalculia) and inability to write (agraphia) associated with a homonymous hemianopsia (Loss of vision for one half of the visual field of one or both eyes)or lower quandrantopsia
- Constructional Ability:
- Clock drawing test, flower drawing, or house drawing.
- constructional apraxia
- The impaired ability to put together different parts of a spatial array
- constructional apraxia) is a feature of
- parietal lesions
- Constructional apraxias secondary to right sided lesions
- will result in impaired spatial relationships among parts of the model; they tend to neglect the left half of the model and tend to be oriented diagonally on the paper. These patients may leave out all of the left-sided numbers on the face of a clock (the numbers would be crowded onto the right clock face).
- Praxis:
- “Motor Planningâ€: Ask the patient to demonstrate saluting, blowing out a match, or combing their hair.
- Proverb Interpretation:
- Ask the patient to interpret the meaning of several well known proverbs; be aware of educational or cultural biases.
- Judgement:
- “Lost Letter†scenario, “Burning Building†scenario.
- Memory:
- Immediate recall, Recent recall, and Remote recall.
- Optic
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-Rosenbaum Screener or Snellen Chart
-Confrontation visual fields to evaluate for visual field deficit (“cutâ€)
-color vision - Opthalmoscopy Routine
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Begin with a darkened but not completely dark room.
The examiner should turn the disc to ~plus 15 diopters and view the red reflex; have the patient look in all four quadrants.
Then decrease the plus power until a clear fundus image is viewed and the refractive error neutralized.
Then examine the optic disc, the four quadrants of the retina, and then the macula. - Optic and Oculomotor Nerves
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Test direct and consensual pupillary responses.
Swinging flashlight test for Afferent Pupillary Defect (APD=Marcus-Gunn Pupil). - Oculomotor, Trochlear & Abducens Nerves
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Evaluates eye movments
Opticokinetic Responses
Eyelid position
Doll’s Head Maneuver (Oculocephalic)
Cold Caloric (Oculovestibular) Testing
? Consider Forced ductions if entrapment is suspected (A maneuver in which an opthalmic anesthetic is instilled in the eye, then using an opthalmic forcep the eye is manually moved) - Trigeminal Nerve
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Evaluates facial and oral mucous membrane sensation (pinprick, cold, heat, light touch)
Corneal Blink Response
? Jaw Jerk Reflex (not commonly performed) - Facial Nerve
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Evaluates muscle of facial expression
Taste on anterior 2/3’s of the tongue - Vestibulocochlear Nerve
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Evaluates hearing to whispered voice.
Weber and Rinne tests - Weber Test
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Weber Test: Place the vibrating tuning fork on the vertex of the patient’s head (256 or 512 Hz).
In normal hearing, the sound will be sensed in midline.
In middle ear disease (otosclerosis), the patient will hear the louder vibration on the diseased side (side of hearing impairment).
In nerve deafness (sensori-neural hearing loss), the vibratory sound will be louder in the normal ear. - Rinne Test
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Place a vibrating tuning fork (256 or 512 Hz) on the mastoid process.
When the patient indicates that the sound appears to have ceased, hold the tines near the acoustic meatus.
In the normal ear, or when nerve deafness is not advanced, the waning vibrations will still be audible. In middle ear deafness, the sounds will not be audible. - Glossopharyngeal & Vagus Nerves
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Palatal Elevation with Phonation
Gag Reflex
Taste and superficial sensation on the posterior 1/3 of the tongue (glossopharyngeal) - Spinal Accessory Nerve
- Evaluates strength and bulk of SCM and Trapezius muscles.
- Hypoglossal Nerve
- Evaluates bulk, strength and tongue movements.
- Motor Examination
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Inspection for bulk, fasiculations and involuntary movements.
Test for passive resistance, “cog-wheelingâ€
Evaluate for spasticity.
Grade muscle strength on 0-5 scale. - Coordination
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Fine finger movements
Finger-to-nose test
Heel-to-shin maneuvers
Rapid alternating movements - Reflexes
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Myotatic (Deep Tendon) reflexes
Other: Superficial abdominal=“Beevor’s†sign, glabellar, snout, Chaddock, Oppenheim.
Grade DTR’s on a 0-4 scale. - Sensory Examination
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Primary Modalities: Pinprick, heat, cold,vibratory and position sense
Cortical Modalities: Graphesthesia, stereognosis, two point discrimination, detection of a moving stimulus on the skin. - Romberg Test:
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Not exclusively a test for cerebellar dysfunction.
The patient stands erect, with the feet approximated looking straight ahead.
Vision, even if defective, can substitute in part for defects of peripheral sensation or posterior column disease.
If the patient has peripheral sensory disease (e.g. diabetes), then with the eyes open their balance will be fairly intact; however with the eyes closed and losing the visual sensory input, the patient will begin to sway.
However! With disease states of the cerebellum, the patient will sway ipsilateral to the side of the cerebellar lesion whether the eyes are open or closed. - Gait
- Evaluate casual, heel, toe, and tandem gait.