Neurobiology

• slurred speech (able to produce speech)
• vs impaired ability to produce or comprehend language

inability to carry out leaned motor tasks

blindness in half of the visual field

cortex (4 lobes) --> internal capsule --> thalamus --> basal ganglia --> brainstem --> PNS

• 1. mental status
• 2. Cranial nerves
• 3. Motor
• 4. Sensory
• 5. Reflexes
• 6. Cordination
• 7. Gait

• -Set tone for the remainder of exam
• -Level of consciousness
• -Orientation
• -Attention and Concentration
• -Memory
• -Naming
• -Language

alert, lethargic, stuporous, comatose

place, person, date and situation

digit spans (7), serial 7's and spell WORLD backward

immediate recall, recent memory, long-term memory and cueing

fluency, repetition, comprehension

• generally dont test
• Dont use noxious odors (interfere w/ SA of CN V)

• Visual Acuity
• Fundoscopic exam
• Visual Fields
• Pupillary rxn to light

• All eye movement - III
• Toward midline - IV
• Away from midline - VI

• Check light touch and pinprick for facial sensation (V1,V2,V3)
• Corneal reflex (w/CN VII - dab cotton swab to the eye)
• Masseter contraction
• Jaw Jerk

• Facial Movement
• Eye Closure
• Taste
• Bell's Palsy vs. Stroke (wrinkling of the
• forehead)

hearing and balance

• Gag reflex
• Palatal elevation (say AH - uvula will deviate away from the affected side)
• Clarity of Speech

• shoulder shrug (trapezius)
• Turn head against resistance (SCM)

• tongue power
• tongue deviation (to the affected side)

Bulk, Tone and Power

• Relatively preserved in central lesion
• Loss more rapidly in Peripheral lesion

• -Rigidity: inc tone throughout range of motion
• -Spasticity: Initial velocity and Force-dependent "catches during passive movement of extremity
• -Cogwheeling: ratchet-like catches throughout range of motion
• Paratonia: resistance to passive movement in all reaction, seems somewhat willful

• Strength/Power
• Pronator drift
• Graded 0-5

5 – movement against full resistance

4 – movement against some resistance

3 – movement against plane of gravity, but no resistance

2 – movement only in plane

1 – only contraction detectable

0 – no movement

Light touch, pinprick, temperature, vibration, proprioception

2 pathways:

• Dorsal Column Medial Lemniscus (DCML):
• transmits light touch, vibration, proprioception. Crosses in brainstem.

• Anterolateral System: transmits pinprick
• and temperature.  Crosses in spinal cord.

Graded 0, 1+, 2+, 3+, 4+ by convention

0: no reflex

1+: requires reinforcement

2+: normal

3+: spread to adjacent muscle groups

4+: clonus

Testing cerebellum

Finger to nose

Rapid alternating movements

Fine finger movements

Heel to shin

Casual

Toe walk, heel walk, tandem

Arm swing, stride length, posture, turning

Romberg :pt stands with feet together eyes closed.  Look for sway. If pt falls sign of DCML dysfunction.

Cortex (the lobes)

Sub-cortex (basal ganglia, internal capsule, thalamus)

Brainstem

Spinal cord

Plexus

Peripheral Nerve

Neuromuscular Junction

Muscle

Aphasia: impaired ability to produce or comprehend language

Apraxia: inability to carry out learned motor tasks

Hemianopia/Visual Field Cut: blindness in half of the visual field

Neglect: inattention to one side of the universe

No cortical signs, the patient looks relatively good.

Pure motor

Pure sensory

Tremor

Cranial nerve deficits

Crossed signs

Sensory level

Bladder and bowel

Brown Sequard Syndrome

Map out dermatomes (one dermatome -->peripheral ; a region with multiple dermatome --> plexus)

Myasthenia gravis: eyelid weakness (ptosis), eye movement weakness, respiratory weakness, swallowing and speaking difficulty, generalized weakness.  Fatiguable.

Tenderness to palpation

Elevated CK on serum testing

Difficulty rising out of chair, brushing hair, going up stairs.

• Meningeal Signs
•     --Kernig’s sign: flex thigh on abdomen with knee in flexed position. Extend knee
• – positive if elicits pain or resistance.
•     --Brudzinski’s Sign: flexion of the neck leads to flexion of the hips and/or knees

Worst headache of pt’s life, particularly if rapid onset (thunderclap headache)

New-onset headache in pt over 50

Headache and seizures

New onset headache in pt with history of cancer or HIV

Headache worse in morning, with exertion, or valsalva.

Position dependent headaches

Any abnormality in neurological exam

Alteration of consciousness

Vertical nystagmus

Cranial Nerve Abnormalities

Pulsatile tinnitus