Neuro Diagnosis Basic Tests.txt

Ask the patient's Name, location, and date

1.) Ask the patient to spell "WORLD" frward then backward.

2) Ask the patient to repeat a string of numbers frward then backward.

3.) Ask the patient to name the months forward then backward.

• Recent:
• Recall 3 items after 5 minutes (House, Pencil, Lizard.

• Remote:
• Recall Historical facts from patient's life.
• (What twn did you grow up in?, What High School did you attend?)

• 1. Object Naming
• 2. Repetition of single words and sentences.
• 3. Reading a sentence. ("A stitch in time...")

• Simple addition and subtractions.
• Should be two or more steps.

• Follow a complex mtr command like:
• "Pretend to comb your hair"
• "Pretend t brush your teeth"

Ask the patient to tap the table with:

• Fist ---> Open Palm ---> Side of open hand
• (Rock, Paper, Scissors)

As fast as he/she can

Have patient interpret a proverb or colloquialism

"Can you tell me what "A stitch in time saves nine" means?"

1. Check hands, shoulders, thighs for fasciculations.

2. Look for atrophy / hypertrophy

3. Observe posture and gait

1. Passively move patient's limbs through range of motion. Note any resistance or rigidity.

2. Ask patient to hold arms straight out front, palms up for 20-30 seconds with eyes closed. Look for lateral / medial / pronator drift.

3. Test muscle strength at multiple pints and record.

Rapid, rythmic alternating movements.

Have patient drum leg with each hand as fast as possible.

Have patient pronate and supinate palms as fast as possible.

Have patient touch your (doctor's) index finger (while dr moves finger) and then his/her nose alternately, several times.

Note any tremors or lack of coordination.

Perform bilaterally

Have patient run their heel from their knee to their foot.

Perform bilaterally

1.) Observe patient walking away from then towards you.

2.) Tandem Gait - Ask patient to walk heel-to-toe (DUI Test)

3.) Forced Gait: Ask patient to walk on heels then toes.

Note posture, stability, foot elevation, trajectory of leg swing, balance, and arm motions.

Topognosis = Point Localization

The ability to recognize points being touched on the body.

• * Use DULL end of neuro tip
• * EYES CLOSED
• * Perform BILATERALLY

Pain = Pin Prick

• * Use SHARP end of neuro tip
• * EYES CLOSED
• * Perform BILATERALLY

Pallesthesia = Vibration

Place the handle of a vibrating 128 Hz tuning fork on the bony prominences of the upper and lower extremities.

Ask "Can you feel vibration?" and "When does it stop?" (Dr. stops it)

• * Start distally, progress proximally
• * EYES CLOSED
• * Perform BILATERALLY

Gently stroke skin with a wisp of cotton or a camel hair brush.

• * Start distally, progress proximally
• * EYES CLOSED
• * Perform BILATERALLY

Doctor stabilizes lateral surface of fingers or toes and asks patient to identify if finger or toe is up or down.

• * Start with DIP, then PIP, then MCP.
• * EYES CLOSED
• * Perform BILATERALLY

Alternate sharp and dull (use neuro tip) stimuli on the hands and feet. (spinothalamic)

• * Start distally, progress proximally
• * EYES CLOSED
• * Perform BILATERALLY

Stereognosis:

The ability to recognize familiar objects by the sense of touch

(Keys, a pen, etc.)

• * EYES CLOSED
• * Perform BILATERALLY

• Graphesthesia:
• The ability to recognize numbers traced lightly on the skin.

• * EYES CLOSED
• * Perform BILATERALLY

Determining the smallest area within which two separate points can be perceived.

• * Use opened paper clip.
• * Start distally, progress proximally
• * EYES CLOSED
• * Perform BILATERALLY

Touch patient on the same point bilaterally.

• Possible Findings:
• - Extinction (Only one side is felt)
• - Displacement (One side is felt normally, other side displaced)
• - Synesthesia (One side is felt normally, the other is a vague burning)

* EYES CLOSED

- Ipsilateral pupillary constriction when light shined in the eye.

- Afferent Nerve: Optic Nerve CNII

- Integrating Center: Midbrain

- Efferent Nerve: Oculomotor Nerve CNIII

Contralateral pupillary constriction when light is shined in the eye.

• - Afferent Nerve: Optic Nerve CNII
• - Integrating Center: Midbrain
• - Efferent Nerve: Oculomotor Nerve CNIII

Convergence of the eyes, pupillary constriction, lens convexity when object is brought into near vision.

• - Afferent Nerve: Optic Nerve CNII
• - Integrating Center: Occipital Cortex
• - Efferent Nerve: Occulomotor Nereve CNIII

Reduction in heart rate when examiner presses the carotid sinus.

• - Afferent Nerve: Glossopharingeal Nerve CN IX
• - Integrating Center: Medulla
• - Efferent Nerve: Vagus Nerve CNX

Reduction in heart rate when examiner presses the eye.

• - Afferent Nerve: Trigeminal Nerve CNV
• - Integrating Center: Medulla
• - Efferent Nerve: Vagus Nerve CNX

Pupillary DILATION when examiner pinches the base of the neck at the anterior cervical sympathetic chain.

• - Afferent Nerve: Cervical Sympathetic Chain
• - Integrating Center: T1-T2 spinal cord
• - Efferent Nerve: Cervical Sympathetic Chain

Blinking & tearing of the eye upon touching the cornea with a cotton wisp.

• - Afferent Nerve: Trigeminal Nerve CNV
• - Integrating Center: Pons
• - Efferent Nerve: Facial Nerve CNVII

Gagging upon touching the back of the throat with a tongue depressor.

• - Afferent Nerve: Glossopharyngeal Nerve CNIX
• - Integrating Center: Medulla
• - Efferent Nerve: Vagus Nerve CNX

Raising of the uvula upon phonation, or touching with a tongue depressor.

• - Afferent Nerve: Glossopharyngeal Nerve CNIX
• - Integrating Center: Medulla
• - Efferent Nerve: Vagus Nerve CNX

Drawing in of scapula when skin of interscapular space is irritated.

• - Afferent Nerve: T2-T7 Spinal Nerves
• - Integrating Center: T2-T7 Spinal Cord
• - Efferent Nerve: Dorsal Scapular Nerve (Rhomboids)

* Not everyone has this reflex

• Stroke away from umbilicus towards the 4 corners of the belly.
• Umbilicus deviation to the stroked side.

Absence is normal only if bilateral. (See Beevor Sign)

• - Afferent Nerve: Upper = T7&-T10, Lower = T11-T12
• - Integrating Center: Spinal Cord T7-T12
• - Efferent Nerve: T7&-T10, Lower = T11-T12

Plantar flexion (curling) of toes upon stroking sole of foot.

• - Afferent Nerve: Tibial Nerve
• - Integrating Center: Spinal Cord S1-S2
• - Efferent Nerve: Tibial Nerve

1. Ask patient about any disorders of taste or smell.

2. Use a penlight, make sure nostrils are not blocked.

3. Occlude 1 nostril at a time (Eyes should be CLOSED)

4. Have patient sniff two different familiar and non-irritating odors. (Use milder scent first)

5. Ask Patient: "Can you smell anything?", then "What do you smell?"

• a) Inspect external structures of eye.
• b) Inspect optic fundi with opthalmoscope.
• c) Test Visual Acuity (Read print AND Shapes / Colors)
• d) Confrontation Test (directly in front of patient, one eye covered, bring object into view from 8 directions)
• e) Direct Light Reflex
• f) Indirect Light Reflex
• f) Accommodation Reflex (Instruct patient to follow object inward. Observe pupil constriction)

• CNIII:
• a) Direct Light Reflex
• b) Indirect Light Treflex
• c) Accommodation Reflex
• d) Check for Ptosis

• CNIII, IV, and VI
• Extraocular Movements: Trace out 6 cardinal field of gaze with an H pattern.
• Trochlear = Down & In
• Abducens = Lateral
• Occulomotor = All other fields

• a) Have patient clench teeth. Palpate Masseter and Temporalis Muscles.
• b) Test sharp/dull pain discrimination (all 3 divs)
• c) Test light touch sensitivity (all 3 divs)
• d) Test Corneal reflex with wisp of cotton
• e) Light touch on anterior 2/3 of tongue, inside cheeks, and hard palate.
• f) Oculocardiac Reflex. Take pulse, apply pressure over patient's closed eye. Pulse rate should decrease 2-3 beats per 15 sec.

A. Inspect face for symmetry (at rest and during motion)

• B. Ask patient to:
• 1 - Raise eyebrows
• 2 - Close eyes tightly
• 3 - Show teeth
• 4 - Puff out cheeks
• 5 - Smile
• 6 - Frown

C. Ask "Do you have any changes in taste sensations for sweet, salty, or sour on the anterior 2/3 of tongue?"

• 1. Finger Rub Test
• 2. Whisper Test
• 3. Weber's Test
• 4. Rinne's Test
• 5. Labrynthine Test for Positional Nystagmus
• 6. Barany's Whirling Chair Test
• 7. Mittlemeyer's Test aka Fukuda Step Test
• 8. Vestibulo-ocular Reflex

Place the handle of a vibrating 512 Hz tuning fork n the midline of the skull and ask the patient to compare the intensity of the sound in the two ears.

• (-) Normal: Sound is equal in both ears.
• (+) Conductive Deafness: Sound lateralizes to the BAD ear.
• (+) Sensorineural Deafness: Sound lateralizes to the GOOD ear.

Place the handle of the vibrating 512 Hz tuning fork against the mastid process. Have the patient signal when the sound ceases (20-30 sec). Then hold the tuning fork near the external ear without touching the patient and have the patient signal when the sound ceases.

Normal: Air conduction persists twice as long as bone conduction.

Abnormal: Conduction Deafness: Air conductin is less than or equal to bone conduction.

Abnormal: Sensorineural Deafness: Air conduction and bone conduction are both radically decreased or absent.

A) Patient seated, examiner inspects patient's eyes for spontaneous nystagmus.

• B) Then inspect for nystagmus for 30 sec in each of the following positions:
• - Patient Supine.
• - Turn head to one side.
• - Turn head to other side.
• - Patient's head hanging off the table.
• - Patient returns to seated position

• Indicates
• Peripheral Lesion: The patient will exhibit nystagmus within 2-5 sec and it disappears within 30 sec.

Medullary Lesion: Nystagmus begins immediately upon movement and may change direction while the patient is stationary (Also, patient does not have vertigo)

Seated patient is spun in one direction.

Normal = Fast component of nystagmus will be in the direction of the spin.

Patient marches in place, eyes open then closed.

Positive Sign: A turning toward one side.

Indicates: Side of vestibular lesion

Dr. holds patient's head and instructs patient to fix vision on the doctors's face. Doctor then turns into rotation, lateral flexion, and flexion and extension.

Normal patient should maintain eye contact, eyes moving at the same speed in the direction opposite of head movement.

Positive / Abnormal:

Peripheral Lesion: The patient will exhibit nystagmus within 2-5 sec and it disappears within 30 sec.

• Medullary Lesion:
• Nystagmus begins immediately upon movement and may change direction
• while the patient is stationary (Also, patient does not have vertigo)

• 1. Note any hoarseness in voice.
• 2. Uvula Reflex: Patient syas "Ah" while doctor shines light in mouth and depresses tongue as necessary.

• Watch for symmetrical rising of the palate.
• - Bilateral Lesion of Vagus: Palate does not rise.

- Unilateral Paralysis: One side of palate does not rise and Uvula will deviate to the NORMAL side

• 3. Gag Reflex
• 4. Have patient swallow while Dr. palpates thyroid cartilage. Feel for smooth voluntary movement.
• 5. Carotid Sinus Reflex / Monitor Pulse
• 6. Ask patient, "Do you have any change in bitter taste sensation on the psterior 1/3 of your tongue?"

• A) Trapezius Muscle
• 1. Inspect contour & shape
• 2. Palpate
• 3. Muscle Test (Shrug shoulders)

• B) Sternocleidomastoid Muscle
• 1. Inspect contour & shape
• 2. Palpate
• 3. Muscle Test: Ask patient to rotate head to one side and slightly flex. Dr. instructs patient to hold while Dr. attempts to return head to neutral.

• A) Inspect tongue for:
• - Atrophy
• - Fasciculations
• - Deviation

B) Have patient stick out tongue and check with tongue depressor, or use the tongue-in-cheek method.

Unilateral Paralysis: Protruded tongue deviates to INVOLVED side.

• a) Disc Level: C4
• b) Muscle Test(s):
• - Shoulder Abduction; Deltoid, Axillary Nerve
• - Forearm Flexion; Biceps, Musculocutaneous Nerve
• c) Reflex: Biceps
• d) Sensation: Lateral arm & shoulder

• a) Disc Level: C5
• b) Muscle Test(s)
• - Wrist Extension; extensor carpi radialis longus & brevis, extensor carpi ulnaris, Radial Nerve
• c) Reflex: Brachioradialis
• d) Sensation: Anterior lateral forearm, palm, thumb and index finger.

• a) Disc Level: C6
• b) Muscle Test(s)
• - Elbow Extension; Triceps, Radial Nerve
• - Wrist Flexion; flexor carpi radialis, Median Nerve, and flexor carpi ulnaris, Ulnar Nerve.
• - Finger Extension; extensor digitoum communis, extensor indices profundus, extensor digiti minimi, Radial Nerve
• c) Reflex: Triceps
• d) Sensation: Middle finger & middle palm

• a) Disc Level: C7
• b) Muscle Test(s)
• - Finger Flexion; flexor digitorum superficialis, flexor digitorum profundus, lumbricals, Median & Ulnar Nerves
• c) Reflex: None
• d) Sensation: 4th & 5th phalanges, anteromedial hand & forearm.

• a) Disc Level: T1
• b) Muscle Test(s)
• - Finger Abduction; Dorsal interossei, Ulnar Nerve
• - Finger Adduction; Palmar interossei, Ulnar Nerve
• c) Reflex: None
• d) Sensation: Medial Arm (distal aspect of arm to proximal forearm)

• - Disc Level: L3
• - Muscle Test(s):
• Foot Inversion with slight dorsiflexion; tibialis anterior, Deep Peroneal/Fibular Nerve.
• - Reflex: Patellar Tendon
• - Sensation: Medial aspect of Leg, medial foot, medial aspect of big toe.

• - Disc Level: L4
• - Muscle Test(s):
• - Foot Dorsiflexion and Big Toe Dorsiflexion; extensor hallicus longus, Deep Peroneal/Fibular Nerve
• - Toes 2, 3, and 4 Dorsiflexion; extensor digitorum longus & brevis, Deep Peroneal/Fibular Nerve.
• - Hip/Thigh Abduction; gluteus medius & minimus, Superior Gluteal Nerve
• - Reflex: None
• - Sensation: Lateral leg, Dorsum of foot, Middle 3 toes.

• - Disc Level: L5
• - Muscle Test(s):
• - Foot Plantar Flexion; gastrocnemius & soleus, Tibial Nerve
• - Foot Plantar Flexion & Eversion; Peroneus Longus & Brevis, Superficial Peroneal/Fibular Nerve
• - Hip Extension; gluteus maximus, Inferior Gluteal Nerve
• - Reflex: Achilles tendon
• - Sensation: Posterior aspect of the leg, Lateral aspect of the foot, Lateral aspect of little toe.