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PD LAB EXAM 2 – COMPLETE EXAM REVIEW – Sue Bignami & Kristins Lab Groups

PART I – Mini Mental Exam
Materials
-wristwatch
-pencil
-blank paper
-card that reads “close your eyes”
-pen and blank paper
-picture with intersecting pentagons

Orientation (10 pts)
What is today‟s date? (1 pt.)
What is today‟s year? (1 pt.)
What is the month? (1 pt.)
What day of the week is it? (1 pt.)
Can you tell me what season it is? (1 pt.)
Can you also tell me the name of the hospital/clinic? (1 pt.)
What floor are we on? (1 pt.)
What town are we in? (1 pt.)
What country are we in? (1 pt.)
What state are we in? (1 pt.)

Immeadiate Recall (3pts)
Test the patient‟s memory by saying the words “ball”, “flag” and “tree” clearly
and slowly. Ask the patient to repeat the words back to you. The patient is
awarded 1 point for each correct response for a maximum of 3 points.

Attention and Calculation (5 pts)
Spelling Backwards - Have the patient spell the word “world” backwards. 1 point
is awarded for each letter for a maximum of 5 points. OR you can have them count
back from 100 by 7‟s

Recall (3 pts)
Have the patient recall the same three objects from the immediate recall. 1
point is awarded for each object for a maximum of 3 points.

Language (9 pts)
Naming - Show the patient a wristwatch and ask him what it is. Do the same with
a pencil. (1 pt each)
Repetition - Ask the subject to repeat the phrase “No ifs, ands, or buts.” (1
pt.)
Three Stage Command - Put a piece of paper in front the patient. Tell the
patient to take the paper in their right hand, fold it in half and place it on
the floor. (1 pt for each command)
Reading - Hold up a sign that says “Close your eyes.” Tell the patient to read
it and do what is says. (1 pt.)
Writing - Give the patient a pencil and paper and tell them to write a sentence.
The sentence needs to have a subject, verb, and be sensible, but it does not have
to have correct punctuation or grammar. (1 pt.)
Copying - Show the patient the picture of the two overlapping pentagons and ask
him to draw it. If ten angles are present and two intersect, the patient gets 1
point.
Total Number of Points Possible 30
Score is expressed as a fraction such as 20/30 or 25/30.
1
PART II – Cranial Nerves – Head to Toe Version
Action of C.N. Tools Test Notes
VII: Testing the Tuning  Assess hearing by Abnormalities in
Vestibulocochlear Vestibulo- fork occluding one ear Rinne and Weber
cochlear/Acoustic and whispering in indicate
nerve, will test the alternate ear conductive or
hearing, balance,  To further assess sensorineural
and awareness of lateralization, hearing loss.
position you would perform Note any
the Weber test deafness,
 To further assess tinnitus,
Air Conduction vertigo, or
versus Bone nystagmus.
Conduction,
perform the Rinne
Test

II: Optic Vision Snellen  Visual acuity Amaurosis is a
Chart using Snellen lesion affecting
 Visual field by the optic nerve.
confrontation
 Fundoscopic exam
III: Occulomotor The occulomotor Pen Light  Direct and Note which
IV: Trochlear nerve supplies the consensual nerves
VI: Abducens medial, superior, papillary response correspond to
and inferior rectus  Convergence which eye
muscles as well as  Cardinal Gaze muscles and
the inferior (LR6SO4ROM3) which direction
oblique muscles.  Nystagmus they turn the
Trochlear controls  Ptosis eye. Note any
Superior Oblique. diplopia,
Abducens supplies ptosis,
lateral rectus. mydriasis or
loss of
accommodation.
I: Olfactory Sense of smell Scent bag Ask your patient to Hyposmia:
close their eyes and impairment of
occlude on nostril. smell
Examiner should have
a non irritating Anosmia:
substance (coffee Inability to
beans) and bring it smell
close to the patients
other nostril. Ask
patient to identify
the substance. Test
each nostril
separately.

2
Action of C.N. Tools Test Notes
V: Trigeminal V: Motor to Cotton  Check for facial Lesions
VII: Facial temporal and swab with symmetry; look for affecting the
masseter muscles tip forehead wrinkling trigeminal will
(jaw clenching) and pulled to and naso-labial cause “numbness”
lateral movement of a wisp folds or weakness of
jaw  Have pt „smile‟, the jaw muscles.
VII: Motor to „show upper
muscles of facial teeth‟, „puff With a lesion of
expression, cheeks‟ the facial
obicularis oris and  Inspect face- nerve, patients
obicularis occuli. check eyebrows, may complain of:
have pt raise loss of taste
eyebrows against (on ant 2/3),
pressure; test dry mouth, loss
temporal and of lacrimation,
masseter muscles or paralysis of
 Have patient facial muscles.
clench jaw and
move jaw laterally
 Corneal reflex-
sensory in by V
and motor out by
VII

VII: Facial VII: Sensory Lifesaver  Taste: Anterior If nerve
IX: division: taste to 2/3 (VII) and function is
Glossopharyngeal anterior 2/3 of Tongue Posterior 1/3 (IX) disrupted, the
X: Vagus tongue Depressor  Check for uvula will
IX: hoarseness (X) deviate away
Glossopharyngeal  Have pt open and from the
Nerve supplies the say “Ah” look for affected side.
posterior 2/3 of midline uvula and Symmetrical
the tongue and the symmetric soft elevation of the
TM as well as palate rise (IX soft palate
secretory fibers of and X) demonstrates
the parotid gland.  Gag reflex normal function
X: Output to the (sensory in by IX of IX and
various organs in and motor out by actually X.**
the body, conveys X)
sensory information Ageusia: Loss of
about the state of taste
the body's organs
to the CNS.
XII: Hypoglossal Somatomotor that  Ask pt to stick
innervates all out tongue to look
intrinsic and all for midline,
but one of the atrophy, or
extrinsic muscles fasiculations
of the tongue  Have pt put their
tongue in cheek
against pressure
bilaterally

3
Action of C.N. Tools Test Notes
V: Trigeminal Responsible for Paper  Check sharp vs.
providing sensation Clip dull sensation on
to the face via each of the
three divisions- Gauze divisions. (Pts
Opthalmic, eyes closed)
Maxillary, and Hot/Cold  If abnormal, check
Mandibular. Item hot and cold in
same manner
XI: Accessory Provides motor  Note the symmetry Lesions
innervations to SCM of trapezii affecting the
and Trapezius  Have pt shrug accessory nerve
their shoulders can cause
against resistance hoarseness,
 Have pt turn their weakness of the
head into your head, neck and
hand (hand should muscles.
providing
resistance to
contralateral SCM)

PART III – The Motor System
Observe muscle for bulk, tone, and strength. Always compare bilaterally. Look for
any atrophy. Test Pt strength against your active resistance. Also look for any
involuntary movements – tics, tremors. Note where, how long, how intense etc.
Upper Extremity
-Arm ABduction
- Forearm Flexion and Extension
- Wrist Flexion and Extension
- Finger adduction – have Pt grasp your fingers
- Finger ABduction – keep fingers spread against resistance
- Thumb adduction – keep thumb at base of 5th digit against resistance
Lower Extremity
-Hip adduction – Pt supine, spreads legs and attempts to close against active
resistance against medial aspect of knee.
-Hip ABduction – Pt supine, attempts to open legs against active resistance
against the lateral aspect of knee
-Hip/Thigh flexion – Pt supine, attempts to flex hip against active resistance.
- Knee Flexion- Pt supine, places sole of foot on bed. Pt attempts to hold down
foot while you try to extend the leg
- Knee extension – Pt supine, places sole of foot on bed. Pt attempts to extend
knee while you apply downward resistance on shin.
- Ankle dorsiflexion- place hand on dorsum of foot. Pt attempts to dorsiflex
against your resistance
- Ankle plantarflexion – place hand on sole of foot. Pt attempts to plantar flex
against your resistance.
-Great toe dorsiflexion – place hand on dorsum of big toe. Pt attempts to
dorsiflex against your resistance
-Great toe plantar flexion – place hand on sole of big toe. Pt attempts to flex
against your resistance.

Test for ankle clonus – passively dorsiflex and plantar flex the foot several
times ending in dorsiflexion.
(+) clonus – rhythmic involuntary dorsi and plantar flexion result

4
PART IV – Sensory Testing
Materials:
 Gauze
 Q-tip
 Tuning Fork
 Tweezers
 Quarter
 Key

1. Light Touch – Gauze. Pt closes eyes, start distally, tell pt to say when
felt. Sensory level – spinal cord level below where below there is marked
decreased sensation.
2. Pain Sensation – Q-Tip. Sharp and dullloses eyes. Start at fingers/toes.
Ask “is this sharp/dull?” Check UE & LE.
3. Vibration – Tuning Fork. Place tuning fork on distal bony prominence. Ask
Pt to say when it is no longer felt. If there is absence move proximal to
next bony prominence. Do UE & LE
4. Proprioception – Grap Lateral aspect of distal phalynx, move up & down,
telling the PT “this is up, this is down”. Have pt close their eyes, move
digit up & down & stop. Ask Pt if the digit is up or down. Repeat on great
toe.
5. Tactile Localization – double stimultaneous. Pt w/ eyes closed. Touch in
two places. Ask, “Where did I touch you?”
6. Two Point Discrimination – Tweezers. Using tweezers, touch Pt fingerpad.
Slowly bring them closer together. At 2mms apart, the sensation will be
felt as one point. Performed Bilaterally.
7. Stereognosis – Key/ Quarter. Place object in pts hand with their eyes
closed. Ask them to identify it. Do bilaterally, do not use the same
object in both hands.
8. Graphesthesia – Write a number in the palm of the patients hand. Do
bilaterally. Inability to identify # may be parietal lobe dx.
9. Point Localization – Pt closes their eyes. Touch them. Ask them to point
where you have touched them.

PART V – Cerebellar function

Finger to nose Heel-to-knee test Rapid alternating movements
Romberg test Gait assessment Asreixis
1. Finger to nose test: have pt. touch his or her nose and the examiners
finger alternately as quickly, smoothly and accurately as possible.
2. Heel to knee test: Pt should lie on his or her back and slide the heel of
one foot down the shin of the other lower extremity. A smooth movement should
be seen with the heel staying on the shin.
3. Rapid alternating movements: “diadochokinesia”, can be tested on both upper
and lower extremities. The pt should be asked to pronate and supinate one hand
and then the other.
4. Rhomberg Test: have the pt stand in front of the examiner with their feet
together so that the heels are touching. Pt should extend both arms with their
palms facing upward. If the patient can maintain this position without moving
the test is negative. The test is positive if the pt begins to sway and has to
move the feet for balance. Another common finding is for 1 of the arms to drift
downward with flexion of the fingers. This is called pronator drift.
5. Gait assessments: This is the foremost in the assessment of cerebellar
function. The pt is asked to walk straight ahead, returning on their tip toes,
5
walk away again on their heels, and then finally to walk back in a tandem gait
with the heel of 1 foot touching the toes of the other on each step. Look for
posture balance and smooth swing of the extremities.
6. Astreixis: Astreixis is seen in pts with hepatic encephalopathy. Have the
pt hold both arms forward with hands cocked up and fingers spread. Watch for
sudden, brief, nonrhythmic flexion of the hands and fingers (abnormal).
Normally, there is no movement of the hands or fingers.

PART VI – Reflexes
Deep Tendon Reflexes
1. Biceps-
Pronate forearm partially flexed.
Examiner should place thumb on biceps tendon.
Strike examiner‟s thumb.
Observe biceps and elbow flexion (C5-C6).
2. Brachioradialis-
The arm is rested on the patient‟s knee and held in semi-flexion and
pronation.
Strike styloid process of the radius, 1-2 inches above wrist.
Observe for flexion at the elbow and supination of the forearm (C5-
C6).
3. Triceps
Flex the patient‟s elbow and pull forearm toward chest.
The arm should be midway between flexion and extension.
Strike tendon 1-2 inches above Olecranon process.
Observe for contraction of triceps and extension of elbow (C6-C8).
4. Patellar Tendon
Patient should sit with legs dangling off the table.
Place your hands on quadriceps muscle.
Strike patellar tendon.
Feel for contraction of the quads and knee extension (L2-L4).
5. Achilles Tendon (Ankle Reflex)
Patient should sit with feet dangling off bed.
The examiner should dorsiflex the patient‟s foot.
Strike the Achilles tendon just above its insertion on the posterior
aspect of calcaneous.
Observe ankle plantar flexion.
Superficial Reflexes
1. Abdominal
Patient should lie in supine position.
With tongue blade, quickly stroke horizontally laterally to medially
toward umbilicus.
Observe for contraction of abdominal muscles with umbilicus deviating
toward the stimulus.
2. Cremasteric (Men Only)
Lightly stroke inner aspect of thigh with applicator stick.
Observe for elevation of the testicle on same side.
Babinski‟s sign
Use a key to Stroke lateral aspect of the sole from the heel to the
ball of the foot and curved medially across the heads of the
metatarsals.
Observe for plantar flexion of the big toe. –Normal
Observe for dorsiflexion of the big toe, with fanning of the other
toes -*Pathological*

6
Meningeal Tests – not on test, but know them
Brudzinski‟s Sign
Examiner places his/her hands behind pt‟s head and flexes the neck
forward until chin reaches chest.
Observe for resistance or pain. A positive Brudzinski’s sign is when
the patient’s hips and knees flex with this maneuver.
Kernig‟s Sign
Flex patient‟s leg and hips at knee and then straighten knee
Observe for resistance, which is a positive test