3a. Approach to Neurologic Complaint Flashcards
1
Q
Defective articulation, usually caused by defect in motor control of speech apparatus
A
Dysarthria
2
Q
Disorder in producing or understanding language, usually caused by lesions in the dominant hemisphere (usually left)
A
Aphasia
3
Q
Oriented x 3
A
Oriented to person, place, and time
4
Q
Oriented x 4
A
Oriented to event
5
Q
Questions to ask to examine for depression
A
- Have you been feeling down, depressed, or hopeless?
- Have you felt little interest or pleasure in doing things?
6
Q
How do you screen for delirium?
A
CAM Diagnostic Algorithm
7
Q
Is delirium reversible or irreversible?
A
Reversible
8
Q
Is dementia reversible or irreversible?
A
Irreversible
9
Q
What must you eliminate before diagnosing dementia?
A
Depression and delirium
10
Q
Drooping of eyelid past upper margin of pupil due to levator palpebrae m weakness
A
Ptosis
11
Q
Pupillary dilation or asymmetry is due to ___.
A
disruption of sympathetic fibers
12
Q
How do compressive brainstem lesions (space occupying or expanding masses) affect the brain?
A
May cause brain to herniate through various dural openings in the cranium
Effects:
- Compressing pupiloconstrictor fibers of CN III causing dilation and fixation of the pupil
- On somatic efferent fibers that supply the extraocular muscles which then cause external strabismus
13
Q
Down and out position of the eye
A
external strabismus
14
Q
CN most vulnerable to head trauma
A
CN IV (long course around the brainstem)
15
Q
Lesions of CN IV result in:
A
- Exotropia of the eye
- Weakness of downward gaze
- Vertical diplopia
- Head tilting to opposite side of lesion
16
Q
Eye position drifts laterally
A
Exotropia
17
Q
Weakness of downward gaze is due to weakness of what muscle?
A
Superior oblique muscle
18
Q
Double vision increases when looking down
A
Vertical diplopia
19
Q
What can head tilting to the opposite side of a CN IV lesion be misdiagnosed as?
A
Idiopathic torticollis
20
Q
Most common isolated CN palsy
Often seen in patients with subarachnoid hemorrhage, late syphilis, and trauma
A
CN VI (due to long peripheral course)
21
Q
CN VI lesions can result in:
A
- Convergent strabismus
- Horizontal diplopia
22
Q
Inability to abduct the eye due to lateral rectus muscle weakness
A
Convergent (medial) strabismus (esotropia)
23
Q
Maximal separation of images when looking toward paretic lateral rectus muscle
A
Horizontal diplopia
24
Q
Rhythmic oscillation of the eyes
Laterality based on fast beating component of _
A
Nystagmus
25
3 types of nystagmus
* Horizontal
* Vertical
* Rotatory
26
Potential causes of nystagmus
* Vision impairment at early age
* Disorder of labyrinth or cerebellar systems
* Drug toxicity
27
Decreased sensation of face and mucus membranes
Loss of corneal reflex
Weakness of muscles of mastication
Jaw deviation toward weak side (due to unopposed action of opposite lateral pterygoid muscle)
Lesion of CN V
28
Recurrent brief episodes of unilateral shock-like pains along 1 or more distributions of this nerve
Can be debilitating
Innocuous stimuli
Trigeminal Neuralgia (CN V)
29
Peripheral facial paralysis which can be caused by trauma or infection, but in most causes is idiopathic
Bell's palsy
30
What other disease(s) cause bilateral facial palsies?
Miller-Fisher variant of Guillain-Barre Syndrome
31
Supranuclear facial palsy (or **central** palsy) spares (1) ____ and usually is associated with (2) \_\_\_\_.
1. Upper face
2. Hemiplegia
32
Weakness to one side of the body
Hemiplegia
33
Ways to test CN VIII
* Whisper test
* Finger rub test
* Weber-Rinne testing
34
Vestibular lesions of CN VIII cause:
* Disequilibrium
* Nystagmus
35
Imbalance
Dysequilibrium
36
Rapid involuntary and rhythmic movement (or oscillation) of the eye
Nystagmus
37
Cochlear lesions of CN VIII cause:
* Destructive lesions cause sensorineural hearing loss
* Irritative lesions cause tinnitus
38
Ringing in the ears
Tinnitus
39
How to test for CN IX and X
* Listen to voice for hoarseness and nasal tone
* Check for gag reflex
* Check for difficulty swallowing
* Ask patient to open mouth and say "ah"
* Unilateral loss\*
40
When testing for CN IX and X, unilateral loss indicates \_\_\_.
Ipsilateral CN X lesion
41
When you ask patient to open mouth and say "ah", what are you looking for?
* Elevation of soft palate
* Midline uvula position
* Medial movement of each side of the posterior pharynx
42
Lesion of CN IX causes:
* Loss of gag reflex
* Loss of sensation in pharynx and posterior 1/3 of tongue
* Slight dysphagia
43
Lesion of CN X:
* Dysphonia
* Dysphagia
* Dyspnea
* Loss of gag or cough reflex
44
2 ways to test CN XI
1. SCM: have patient attempt to turn head against mild resistance, i.e., contraction of L SCM when turning head to right.
* Lesion = paralysis results in difficulty turning head to the opposite side
2. Trapezius: have patient shrug shoulders against mild resistance.
* Lesion = weakness results in unilateral shoulder droop
45
How do you test CN XII?
Have patient protrude tongue then have patient push against their cheeks as you apply mild resistance
Lesion = tongue deviated to weak side & inability to push tongue to opposite side
46
How should you document normal cranial nerve testing?
"Cranial nerves II-XII are intact to testing (or confrontation)."
[This indicates physician performed testing of each nerve bilaterally.]
47
What does it mean when one says "Cranial Nerves are grossly intact"?
Physician spent enough time talking to patient that nothing seen which warrants actual cranial nerve testing
No drooling, ptosis, facial droop, difficulty with articulation, etc.
48
Dermatome of the auricle
C2
49
Dermatome of the earlobe and anterior/posterior neck
C3
50
Dermatome of nipple
T4
51
Dermatome of umbilicus
T10
52
How do you test **pain**?
Use broken tongue depressor or wooden stick part of cotton applicator (spinothalamic tract)
53
How do you test **temperature**?
Use test tubes filled with hot and cold water (spinothalamic test)
Often omitted if pain sensation is normal
54
How do you test **vibration**?
Use 128 Hz tuning fork on bony prominence (posterior columns)
55
How do you test **proprioception** (position)?
Grasp patient's big toe or thumb between thumb and index finger and move through an arc
With patient's eyes closed, ask for response of "up" or "down"
56
Ability to identify shapes of objects or recognizing objects placed in the hand
Stereognosis
57
Ability to identify numbers written on the palm
Graphesthesia
58
Ability to distinguish being touched by one or two points
Two-point discrimination
59
Ability to feel 2 locations being touched simultaneously
Double simultaneous stimulation (extinction)
60
Identify type of **sensory loss**: loss limited to distribution of one nerve
Single nerve
61
Identify type of **sensory loss**: loss in different nerve distributions w/ common root
Root
(C5-C7 = common in arms; L4-S1 = common in legs)
62
Identify type of **sensory loss**: complete transverse section, hemisection of the cord, posterior column, anterior spinal syndrome
Spinal cord
63
Identify type of **sensory loss**: crossed findings with ipsilateral loss in the face and contralateral in the body
Brainstem
64
Identify type of **sensory loss**: hemisensory loss of all modalities
Thalamic
65
Identify type of **sensory loss**: intact primary sensations but loss of cortical sensations
Cortical loss
66
Identify type of **sensory loss**: non-anatomical distribution
Functional loss
67
Types of cerebellar/coordination tests
* RAM: rapid alternating movements
* Finger-to-nose
* Heel-to-shin
* Gait
* Regular, heel-toe, toe-heel
* Hopping, shallow knee bend, get up and go
* Stance
* Romberg test
* Pronator drift test
68
Observation of motor systems
* Gait
* body position
* involuntary movements
* muscle bulk: hypertrophy vs. atrophy
* mustle tone
69
"When a normal muscle with intact nerve supply is relaxed voluntarily, it maintains slight residual tension known as \_\_\_\_, which is best assessed by feeling muscle's resistance to passive stretch."
Muscle Tone
70
Identify **gait patterns**: staggering, unsteady, feet wide apart, other signs usually present
Cerebellar ataxia
71
Identify **gait pattern**: unsteady, feet wide apart, feet thrown forward and slapped down first on heels then forefoot, patients watch ground when walking
Sensory ataxia
72
Identify **gait pattern**: stooped forward, short steps commonly called "shuffling gait" with involuntary hesitation called "festination", decreased arm swing
Parkinsonian
73
No muscular contraction noted
0/5
74
Barely detectable flicker or trace of contraction
1/5
75
Active movement of the body part with gravity eliminated
2/5
76
Active movement against gravity
3/5
77
Active movement against gravity and some resistance
4/5
78
Active movement against full resistance without evident fatigue (normal)
5/5
79
Reflex absent
0/4
80
Somewhat diminished, low normal
1/4
81
Average reflex
2/4
82
Brisker reflex than average possible, but not necessarily indicative of disease
3/4
83
Very brisk, hyperactive, with _clonus_ (rhythmic oscillations between flexion and extension)
4/4
84
Abdominal Reflex
Stroke abdomen around umbilicus causes abdominal muscles to contract
85
Plantar response
Stroke the plantar aspect of the foot causing toes to flex (Down)
(+) = Babinski sign = toes fan out
86
Anal [Wink] Reflex
Stroke around the anus and external anal sphincter contracts
87
Neck stiffness with resistance to flexion
approx 84% patients w/ acute bacterial meningitis
21-86% patients with subarachnoid hemorrhage
most reliable meninges present in menigeal irritation but overall dianostic accuracy low
Nuchal rigidity
88
Stetches femoral nerve
Examiner flexes patient's neck
(+) = patient's hips and knees flex in response
Brudzinski sign
89
Stretches sciatic nerve
Examiner flexes patient's hip and knee then slowly extend leg and knee
(+) = pain or increased resistance to knee extension beyond 135 degrees; can also cause passive flexion of the neck
Kernig sign
