Download Neurologic System The nervous system Central and peripheral

Neurologic System
The nervous system
Central and peripheral divisions
Maintains and controls all body functions by its voluntary and autonomic responses
Neurologic System (Cont.)
The physical examination of the nervous system assesses the following elements:
Motor
Sensory
Autonomic
Cognitive
Behavioral
Physical Examination Preview
Neurologic System
Test cranial nerves I through XII
Cerebellar function and proprioception
Evaluate coordination and fine motor skills by the following:
Rapid rhythmic alternating movements
Accuracy of upper and lower extremity movements
Evaluate balance using the Romberg test
Observe the patient’s gait
Posture
Rhythm and sequence of stride and arm movements
Neurologic System (Cont.)
Sensory function
Test primary sensory responses to the following:
Superficial touch
Superficial pain
Test vibratory response to tuning fork over joints or bony prominences on upper and
lower extremities.
Evaluate perception of position sense with movement of the great toes or a finger on
each hand.
Neurologic System (Cont.)
Sensory function
Assess ability to identify a familiar object by touch and manipulation.
Assess two-point discrimination.
Assess ability to identify a letter or number “drawn” on palm of hand.
Assess ability to identify a body area when touched.
Neurologic System (Cont.)
Superficial and deep tendon reflexes
Test abdominal reflexes.
Test the cremasteric reflex in male patients.
Test the plantar reflex.
Test the following deep tendon reflexes: biceps, brachioradialis, triceps, patellar, and
Achilles.
Test for ankle clonus.
Anatomy and Physiology
Central nervous system
Main network of coordination and control for the body
Brain
Spinal cord
Peripheral nervous system
Carries information to and from the central nervous system
Cranial nerves
Spinal nerves
Anatomy and Physiology (Cont.)
Autonomic nervous system
Coordinates and regulates the internal organs of the body
Two divisions that balance the impulses of each other
Sympathetic division: prods body to action during periods of physiologic and
psychologic stress
Parasympathetic division: functions in a complementary and counterbalancing
manner to conserve body resources and day-to-day functions (e.g., digestion
and eliminations)
Anatomy and Physiology (Cont.)
Brain and spinal cord are protected by:
Skull and vertebrae
Meninges
Cerebrospinal fluid (CSF)
Three layers of meninges produce and drain CSF.
CSF circulates between an interconnecting system of ventricles in the brain and around the brain
and spinal cord, serving as a shock absorber.
Anatomy and Physiology (Cont.)
The intricate interrelationship of the nervous system permits the body to perform the following:
Receive sensory stimuli from the environment
Identify and integrate the adaptive processes needed to maintain current body functions
Orchestrate body function changes required for adaptation and survival
Integrate the rapid responsiveness of the central nervous system with the more gradual
responsiveness of the endocrine system
Control cognitive and voluntary behavioral processes
Control subconscious and involuntary body functions
Brain
Blood supply
20% of cardiac output
Arterial
Two internal carotids
Two vertebral
Venous
Venous plexuses and dural sinuses
Two internal jugular veins
Brain (Cont.)
Three major units
Cerebrum
Cerebellum
Brainstem
Cerebrum
Two cerebral hemispheres, each divided into lobes, form the cerebrum.
Gray outer layer (cerebral cortex) houses the higher mental functions and is responsible for:
General movement
Visceral functions
Perception
Behavior
Integration of functions
Cerebrum (Cont.)
Commissural fibers (corpus callosum) interconnect the counterpart areas in each hemisphere,
permitting the coordination of activities between the hemispheres.
Cerebrum (Cont.)
Frontal lobe
Voluntary skeletal movement
Fine repetitive movement
Control of eye movement
Corticospinal tracts extend from the primary motor area into the spinal cord.
Cerebrum (Cont.)
Parietal lobe
Processes sensory data
Interpretation of tactile sensations (i.e., temperature, pressure, pain, size, shape,
texture, and two-point discrimination)
Recognition of body parts and awareness of body position (proprioception)
Cerebrum (Cont.)
Parietal lobe
Assists with:
Visual sensations
Gustatory sensations
Olfactory sensations
Auditory sensations
Association fibers provide communication between the sensory and motor areas of the
brain
Cerebrum (Cont.)
Occipital lobe
Contains the primary vision center and provides interpretation of visual data
Temporal lobe
Perception and interpretation of sounds and determination of their source
Integration of taste, smell, and balance
Reception of speech and interpretation of speech located in Wernicke area
Cerebrum (Cont.)
Basal ganglia system
Extrapyramidal pathway and processing station between the cerebral motor cortex and
the upper brainstem
Refine motor movements through interconnections with:
Thalamus
Motor cortex
Reticular formation
Spinal cord
Cerebrum (Cont.)
Aids in integration of voluntary movement to produce steady and precise movements
Processes sensory information
Eyes, ears, touch receptors, and musculoskeleton
Uses sensory data for reflexive control of:
Muscle tone
Equilibrium
Posture
Brainstem
Pathway between the cerebral cortex and the spinal cord
Controls many involuntary functions
The nuclei of the 12 cranial nerves arise from these structures
Brainstem (Cont.)
Parts
Medulla oblongata
Site where the descending corticospinal tracts decussate (cross to the
contralateral side)
Midbrain
Pons
Transmits information between the brainstem and the cerebellum
Diencephalon
Thalamus: major integrating center for perception of various sensations
Cranial Nerves
Twelve peripheral nerves that originate from brain
Functions
Motor
Sensory
Parasympathetic
Spinal Cord and Spinal Tracts
Spinal cord
Spinal cord begins as a continuation of medulla oblongata.
Fibers grouped into tracts run through spinal cord and carry sensory, motor, and
autonomic impulses between higher centers and the body.
Myelin-coated white matter contains ascending and descending tracts.
Gray matter contains nerve cell bodies.
Spinal Cord and Spinal Tracts (Cont.)
Ascending spinal tracts: spinothalamic, spinocerebellar
Mediate sensations
Facilitate signals for complex discriminations tasks
Transmit precise information on types of stimulus and location
Spinal Cord and Spinal Tracts (Cont.)
Ascending spinal tracts
Posterior (dorsal) column tract: fasciculus gracilis, fasciculus cuneatus
Carries the fibers for the sensations of fine touch, two-point discrimination, and
proprioception
Spinothalamic tracts carry fibers for sensations of light and crude touch, pressure,
temperature, and pain.
Spinal Cord and Spinal Tracts (Cont.)
Descending spinal tracts: corticospinal, reticulospinal, and vestibulospinal
Originate in the brain
Convey inhibitory or facilitatory impulses to various muscle groups
Play a role in the control of:
Muscle tone
Posture
Precise motor movements
Spinal Cord and Spinal Tracts (Cont.)
Descending spinal tracts
Corticospinal tract permits skilled, delicate, and purposeful movements.
Vestibulospinal tract causes extensor muscles to contract suddenly when falling.
Corticobulbar tract innervates the motor functions of the cranial nerves.
Spinal Cord and Spinal Tracts
(Cont.)
Upper motor neurons
Nerve cell bodies for the motor pathways that all originate and terminate within the
central nervous system
Comprise descending pathways from brain to spinal cord
Primary role is influencing, directing, and modifying spinal reflex arcs and circuits
Can affect movement only through the lower motor neurons
Injury results in initial paralysis followed by partial recovery over an extended period
Spinal Cord and Spinal Tracts (Cont.)
Lower motor neurons
Cranial and spinal: originate in the anterior horn of spinal cord and extend into peripheral
nervous system
Transmit neural signals directly to the muscles to permit movement
Injury often results in permanent paralysis
Spinal Nerves
Thirty-one pairs arise from the spinal cord
Exit at each intervertebral foramen
Sensory and motor fibers of each spinal nerve supply receive information in a specific body
distribution called a dermatome
Spinal Nerves (Cont.)
Within the spinal cord, each spinal nerve separates into anterior and posterior roots.
Motor or efferent fibers of the anterior root carry impulses from the spinal cord to the
muscles and glands of the body.
Sensory or afferent fibers of the posterior root carry impulses from sensory receptors of
the body to the spinal cord, and then on to the brain for interpretation by the cerebral
sensory cortex.
Spinal Nerves (Cont.)
Reflex arcs
Spinal afferent (sensory) neuron may initiate a reflex arc response when it receives an
impulse stimulus.
Response is transmitted outward by the efferent (motor) neuron in the anterior horn of the
spinal cord via the spinal nerve and peripheral nerve of the skeletal muscle.
Spinal Nerves (Cont.)
Reflex arcs (Cont.)
Dependent on:
Intact afferent neurons
Functional synapses in the spinal cord
Intact efferent neurons
Functional neuromuscular junctions
Competent muscle fibers
Infants and Children
Major brain growth and myelinization in first year of life
At birth, the neurologic impulses primarily handled by the brainstem and spinal cord
Sucking, rooting, yawn, sneeze, hiccup, blink at bright light, and withdrawal from painful
stimuli
Infants and Children (Cont.)
Primitive reflexes present in newborn
Moro (startle reflex), stepping, palmar and plantar grasp
Motor maturation in cephalocaudal direction
Head and neck
Trunk
Extremities
Brain growth continues until 12 to 15 years of age
Pregnant Women
Hypothalamic-pituitary neurohormonal changes occur with pregnancy
Specific alterations in the neurologic system are not well identified.
Common alterations
Increase nap and sleep time
Do not feel rested after sleep
Leg cramps and restless leg syndrome
Older Adults
The number of cerebral neurons decreases with aging, but this is not necessarily associated with
deteriorating mental function.
Vast number of reserve neurons inhibits the appearance of clinical signs.
Velocity of nerve impulse conduction declines.
Slowed response time
Diminished touch and pain perception
Review of Related History
History of Present Illness
Seizures or convulsions
Sequence of events
Character of symptoms
Aura
Level of consciousness
Automatism: eyelid fluttering, chewing, lip smacking, swallowing
History of Present Illness (Cont.)
Seizures or convulsions (Cont.)
Muscle tone
Postictal phase behavior
Relationship of seizure to other events
Frequency of seizures
Medication: anticonvulsant; initiation of medication that interacts with prescribed
anticonvulsant
History of Present Illness (Cont.)
Pain
Onset: sudden or progressive
Quality
Location
Associated manifestations
Efforts to treat
Medications: opioids and NSAIDs; prescription, nonprescription
History of Present Illness (Cont.)
Gait coordination
Balance
Falling
Associated problems: arthritis, stroke, seizure
Medications: phenytoin, pyrimethamine, etoposide, vinblastine; prescription,
nonprescription
History of Present Illness (Cont.)
Weakness or paresthesia
Onset
Character: generalized or specific body area
Associated symptoms
Concurrent chronic illness: HIV, nutritional or vitamin deficiency
Medications: zidovudine, diaminodiphenylsulfone, dideoxyinosine, amphotericin B
History of Present Illness (Cont.)
Tremor
Onset: sudden or gradual
Character: worse with rest, intentional movement
Associated problems: hyperthyroidism, familial tremor, liver or kidney disorder,
consumption of alcohol, multiple sclerosis
Relieved by: rest, activity, alcohol
Medications: neuroleptics, valproate, phenytoin, albuterol, pseudoephedrine,
antiarrhythmics, corticosteroids, caffeine
Past Medical History
Trauma: brain, spinal cord, or localized injury
Meningitis, encephalitis, lead poisoning, poliomyelitis
Deformities, congenital anomalies, genetic syndromes
Cardiovascular or circulatory problem
Neurologic disorder, brain surgery, and residual effects
Family History
Hereditary disease
Alcoholism
Mental retardation
Epilepsy, seizure disorder, or headaches
Alzheimer disease or other dementia
Learning disorders
Weakness or gait disorders
Medical or metabolic disorder
Personal and Social History
Environmental or occupational hazards
Hand, eye, foot dominance, family patterns of dexterity and dominance
Ability to care for self
Sleeping and eating patterns
Use of alcohol and drugs
Infants
Prenatal history
Birth history
Respiratory status at birth
Neonatal health
Congenital anomalies
Hypotonia or hypertonia in infancy, developmental delay
Children
Developmental milestones
Age attained
Pattern of development
Performance of self-care activities: dressing, toileting, feeding
Hyperactive or impulsive behavior
Health problems
Headaches, seizures, clumsiness or unsteady gait, muscle weakness or falling
Pregnant Women
Weeks of gestation or estimated date of delivery
Seizure activity: past history of seizures or pregnancy-induced hypertension; frequency, duration,
character of movement
Headache
Nutritional status
Older Adults
Pattern of increased stumbling, falls, unsteadiness, or decreased agility
Interference with performance of ADLs, social withdrawal, feelings about symptoms
Hearing loss, vision deficit, or anosmia
Fecal or urinary incontinence
Transient neurologic deficits
May indicate transient ischemic attacks (TIAs)
Examination and Findings
Neurologic Examination
Components
Cranial nerves
Proprioception and cerebellar function
Sensory function
Reflex function
Cranial Nerves
Olfactory (CN I) Sensory and smell
Test for odor identification
Cranial Nerves (Cont.)
Optic (CN II) sensory and visual acuity
Test for visual acuity
Test visual fields
Perform ophthalmologic examination
Cranial Nerves (Cont.)
Oculomotor, trochlear, and abducens
(CN III, IV, and VI): motor and eye movement, pupil size,
eyelid opening
Inspect eyelids for drooping.
Inspect pupils for size and equality.
Test consensual response and accommodation.
Test extraocular eye movements.
Cranial Nerves (Cont.)
Trigeminal (CN V) Mixed: muscle tone and sensation
Inspect face for atrophy or tremors.
Palpate jaw for tone and strength.
Test for pain and sensation.
Test corneal reflex.
Cranial Nerves (Cont.)
Facial (CN VII) Mixed: facial expressions and taste
Inspect facial symmetry.
Test tongue for salt and sweet.
Cranial Nerves (Cont.)
Acoustic (CN VIII): sensory, hearing, and balance
Test hearing.
Compare bone and air conduction.
Test for sound lateralization.
Cranial Nerves (Cont.)
Glossopharyngeal (CN IX); Mixed: taste and swallowing
Test tongue for sour and bitter.
Test gag reflex and swallow.
Cranial Nerves (Cont.)
Vagus (CN X); Mixed: swallowing and speech
Inspect palate and uvula for symmetry.
Inspect for swallow difficulty.
Evaluate guttural speech sounds.
Spinal accessory (CN XI): motor and muscle strength
Test trapezius and sternocleidomastoid muscle strength.
Cranial Nerves (Cont.)
Hypoglossal (CN XII): motor and tongue strength
Inspect tongue for symmetry/tremors/atrophy.
Test tongue movement.
Test tongue strength.
Evaluate lingual speech sounds.
Proprioception and Cerebellar Function
Coordination and fine motor skills
Observe for any involuntary movements, such as tremors (rhythmic oscillatory involuntary
movements), tics, or fasciculations.
Note the parts of the body affected, quality, rate and rhythm.
Proprioception and Cerebellar Function (Cont.)
Coordination and fine motor skills (Cont.)
Test rapid rhythmic alternating movements:
Alternately turning up and down the palms of the hands
Touching thumb-to-fingers
Test accuracy of movements:
Finger-to-finger test
Finger-to-nose
Heel-to-shin
Proprioception and Cerebellar Function (Cont.)
Balance
Equilibrium
Romberg test
Standing on one foot
Gait
Observe the expected gait sequence, noting simultaneous arm movements and
upright posture
Heel-toe walking
Sensory Function
Test with the patient’s eyes closed.
Observe all sensory function tests for:
Side-to-side differences
Interpretation of sensation
Discrimination
Location
If impairments are found, map boundaries by dermatome.
Evaluate both primary and cortical discriminatory sensation.
Sensory Function (Cont.)
Primary sensory functions
Superficial touch
Cotton wisp or fingertip
Superficial pain
Broken tongue blade or the point and hub of a sterile needle
Temperature and deep pressure
Tested only when superficial pain sensation is not intact
Sensory Function (Cont.)
Primary sensory functions (Cont.)
Vibration
Tuning fork (lower Hz)
Position of joints
Raise or lower
Sensory Function (Cont.)
Cortical sensory function
Test cognitive ability to interpret sensations.
Inability to perform these tests should make you suspect a lesion in:
Sensory cortex
Posterior columns of the spinal cord
Sensory Function (Cont.)
Cortical sensory function (Cont.)
Stereognosis
Familiar object (key, coin)
Tactile agnosia, an inability to recognize objects by touch, suggests parietal lobe
lesion
Two-point discrimination
Distance at which the patient can no longer distinguish two points
Varies with body parts
Sensory Function (Cont.)
Cortical sensory function (Cont.)
Extinction phenomenon
Simultaneously touch two areas on each side of the body.
Similar sensations should be felt bilaterally.
Graphesthesia
Draw a letter, number, or shape on the palm of the patient’s hand.
Point location
Touch an area on the patient’s skin and withdraw the stimulus.
Reflexes
Both superficial and deep tendon reflexes are used to evaluate the function of specific spine
segmental levels.
Reflexes (Cont.)
Superficial reflexes
Abdominal reflex
Equal movement of umbilicus
May be absent on the side of a corticospinal tract lesion, but their presence or
absence may have little clinical significance
Reflexes (Cont.)
Superficial reflexes (Cont.)
Cremasteric reflex
Stroke the inner thigh of the male patient.
Testicle and scrotum should rise on the stroked side.
Reflexes (Cont.)
Superficial reflexes (Cont.)
Plantar reflex
Stroke the lateral side of the foot from the heel to the ball and then curve across
the ball of the foot to the medial side.
Patient should have plantarflexion of all toes.
Babinski sign is present when there is dorsiflexion of the great toe.
Indicates pyramidal tract disease
Reflexes (Cont.)
Deep tendon reflexes
Biceps: elbow flexion
Brachioradial: forearm pronation and elbow flexion
Triceps: elbow extension
Patellar: lower leg extension
Achilles: foot flexion
Clonus: rhythmic oscillating movements
Ankle
Associated with upper motor neuron disease
Reflexes (Cont.)
Deep tendon reflexes (Cont.)
Symmetric visible or palpable responses should be noted.
Scoring deep tendon reflexes:
0 No response
1 Sluggish or diminished
2 Active or expected response
3 More brisk than expected, slightly hyperactive
4 Brisk, hyperactive, with intermittent or transient clonus
Deep Tendon Reflexes
Additional Procedures
Protective sensation
Test for protective sensation on several sites of the foot in all patients with diabetes
mellitus and peripheral neuropathy
Use the 5.07 monofilament or Waardenberg wheel
Loss of protective pain sensation that alerts patients to skin breakdown and injury
Additional Procedures (Cont.)
Meningeal signs
Stiff neck or nuchal rigidity is a sign that may be associated with meningitis and
intracranial hemorrhage.
With the patient supine, slip your hand under the head and raise it, flexing the neck.
Pain and a resistance to neck motion are associated with nuchal rigidity.
Additional Procedures (Cont.)
Meningeal signs (Cont.)
Brudzinski
May also be present when neck stiffness is assessed
May indicate meningeal irritation
Involuntary flexion of the hips and knees when flexing the neck is a positive
Brudzinski sign.
Additional Procedures (Cont.)
Meningeal signs (Cont.)
Kernig
May indicate meningeal irritation
Evaluated by flexing the leg at the knee and hip when the patient is supine, then
attempting to straighten the leg
Pain in the lower back and resistance to straightening the leg at the knee
constitute positive Kernig sign
Brudzinski and Kernig Signs
Infants
Cranial nerves indirectly assessed by observing:
CN II, III, IV, and VI
Optical blink reflex
Gaze and tracking
Doll’s eye
CN V
Rooting
Sucking
Infants (Cont.)
Cranial nerves
CN VII
Facial expressions
Forehead wrinkling
Smile
CN VIII
Acoustic blink reflex
Doll’s eye maneuver
Infants (Cont.)
Cranial nerves
CN IX and X
Swallow and gag reflex
CN XII
Sucking and swallowing ability
Tongue position with pinch test
Infants (Cont.)
Observe the infant’s spontaneous activity for symmetry and smoothness of movement.
Coordinated sucking and swallowing is also a function of the cerebellum.
A withdrawal of all limbs from a painful stimulus provides a measure of sensory integrity.
The patellar tendon reflexes are present at birth, and the Achilles and brachioradial tendon
reflexes appear at 6 months of age.
Infants (Cont.)
Posture and movement are routinely evaluated by primitive reflexes:
Palmar grasp (birth)
Plantar grasp (birth)
Moro (birth)
Placing (4 days of age)
Stepping (between birth and 8 weeks)
Asymmetric tonic neck (by 2 to 3 months)
Inspect and palpate muscle for strength and tone.
Children
Observe neuromuscular development progress and skills displayed during physical examination.
Evaluate developmental level.
Modify CN examination according to age.
Observe at play:
Gait and fine motor coordination
Heel-to-toe walking, hopping, jumping
Children (Cont.)
Deep tendon reflexes are not always tested in a child who demonstrates appropriate
development.
Evaluate light touch sensation by asking the child to close his or her eyes and point to where you
touch or tickle.
Use the tuning fork to evaluate vibration sensation.
Superficial pain sensation is not routinely tested in young children.
Pregnant Women
Same as for adult
Deep tendon reflexes on initial examination can serve as baseline
Older Adults
Same as for adult
Medications can impair CNS function:
Slowed reaction time, tremors, and anxiety
Test gait for decreases in speed, balance, and grace
Check tactile and vibratory sense for impairment
Check deep tendon reflexes for diminished response
Abnormalities
Abnormalities
Disorders of the central and peripheral nervous systems often fall into groups.
Static problems develop at any age and do not get better or worse (e.g., nerve deafness
and some trauma).
Degenerative problems occur when function is lost and it progressively worsens.
Some problems are intermittent, whereas others are genetic or related to a metabolic
disorder.
Central Nervous System
Multiple sclerosis
Progressive autoimmune disorder characterized by a combination of inflammation and
degeneration of the myelin of the brain’s white matter leading to decreased brain
mass and obstructed transmission of nerve impulses
Gradual, but unpredictable, progression, with or without remissions
Central Nervous System (Cont.)
Seizure disorder
Episodic abnormal electrical discharges (excessive concurrent firing) of cerebral neurons
may be caused by:
Central nervous system (CNS) disorder
CNS structural defect
Disorder that affects functioning of the CNS
Examples include brain injury, toxins, stroke, brain tumor, or hypoxic syndromes
Central Nervous System (Cont.)
Encephalitis
Acute inflammation of the brain and spinal cord, involving the meninges, often due to a
virus such as herpes simplex virus
Meningitis
Inflammatory process in the meninges, the membrane around the brain and spinal cord
Intracranial tumors
Abnormal growth of neural or nonneural tissue within the cranial cavity that may be a
primary or metastatic cancer
Central Nervous System (Cont.)
Stoke (brain attack or cerebrovascular accident)
Sudden interruption of blood supply to a part of the brain or the rupture of a blood vessel,
spilling blood into spaces around brain cells
Ischemic
Hemorrhagic
Peripheral Nervous System
Myasthenia gravis
Autoimmune disorder of neuromuscular transmission
Guillain-Barré syndrome
Autoimmune-mediated destruction of peripheral nerve myelin sheaths and inflammation
of nerve roots
Occurs following a nonspecific gastrointestinal or upper respiratory infection 1 to 3 weeks
earlier or following an immunization
Peripheral Nervous System (Cont.)
Trigeminal neuralgia (tic douloureux)
Recurrent paroxysmal sharp pain that radiates into one or more branches of the fifth
cranial nerve
Bell palsy
Temporary acute paralysis or weakness of one side of the face
Peripheral Nervous System (Cont.)
Peripheral neuropathy
Disorder of the peripheral nervous system that results in motor and sensory loss in the
distribution of one or more nerves
Diabetes mellitus
B12 or folate deficiency
Lyme disease
HIV infection
Children
Cerebral palsy
Permanent disorder of movement and posture development
Myelomeningocele (spina bifida)
Congenital defect of one or more vertebrae (commonly the lumbar or sacral) that permits
a meningeal sac filled with a portion of the spinal cord to protrude
Children (Cont.)
Shaken baby syndrome
Severe form of child abuse resulting from the violent shaking of infants under 1 year of
age
Stretching and tearing of nerve tissue and blood vessels causes brain damage and a
subdural hematoma
Spinal cord may also be damaged
Pregnant Women
Intrapartum maternal lumbosacral plexopathy
Neuropathy that can occur during late pregnancy and delivery
Lumbosacral trunk, and sometimes the superior gluteal and obturator nerves, is
compressed between the maternal pelvic rim and the fetal head (a conduction nerve
block)
Motor deficits in a lower extremity
Older Adults
Parkinson disease
Slowly progressive, degenerative neurologic disorder
Deficiency of the dopamine neurotransmitter results in poor communication between
parts of the brain that coordinate and control movement and balance
Older Adults (Cont.)
Normal-pressure hydrocephalus
Syndrome simulating degenerative diseases that is caused by noncommunicating
hydrocephalus
Postpolio syndrome
Reappearance of neurologic signs in survivors of the polio epidemics
Question 1
Testing for sharp, dull and light touch on the face at the scalp cheek and chin examines:
A. CN V
B. CN VI
C. CN VII
D. CN VIII
Question 2
Nerves that arise from the brain rather than the spinal cord are called:
A. Cranial
B. Parasympathetic
C. Sympathetic
D. Lower motor neurons
Question 3
Cerebellar ataxia or vestibular dysfunction is tested by:
A. Testing the acoustic nerve
B. Heel toe walking
C. Finger to nose movement
D. Romberg test
Question 4
A neurologic past medical history should include data about:
A. Family patterns of dexterity and dominance
B. Circulatory problems
C. Educational level
D. Immunizations
Question 5
Hyperactive reflexes indicate:
A. Lower motor neuron disorder
B. Upper motor neuron disorder
C. Lower sensory neuron disorder
D. Upper sensory neuron disorder
Case Study
Julie is a 38-year-old patient who presents acutely to your office for a concern regarding facial
drooping. You diagnose her with Bell palsy. Which of the following is the etiology of the disorder?
A. Bilateral inflammation of CN V
B. Acute inflammation of CN V
C. Acute inflammation of CN VII
D. Chronic inflammation of CN VII
Case Study (Cont.)
On examination, which of the following would you expect to find? (Select all that apply).
A. Drooping of the eyelid on the affected side
B. Facial creases and nasolabial fold disappear on the affected side
C. Absent facial sensation
D. Absent cranial nerves III, IV, and VI
Case Study (Cont.)
In Bell palsy, you will expect to find:
A. Lower motor neuron disorder
B. Upper motor neuron disorder
C. Lower sensory neuron disorder
D. Upper sensory neuron disorder