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PCM EX 2 > 3a. Approach to Neurologic Complaint > Flashcards

3a. Approach to Neurologic Complaint Flashcards

1
Q

Defective articulation, usually caused by defect in motor control of speech apparatus

A

Dysarthria

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2
Q

Disorder in producing or understanding language, usually caused by lesions in the dominant hemisphere (usually left)

A

Aphasia

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3
Q

Oriented x 3

A

Oriented to person, place, and time

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4
Q

Oriented x 4

A

Oriented to event

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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?
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6
Q

How do you screen for delirium?

A

CAM Diagnostic Algorithm

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7
Q

Is delirium reversible or irreversible?

A

Reversible

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8
Q

Is dementia reversible or irreversible?

A

Irreversible

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9
Q

What must you eliminate before diagnosing dementia?

A

Depression and delirium

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10
Q

Drooping of eyelid past upper margin of pupil due to levator palpebrae m weakness

A

Ptosis

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11
Q

Pupillary dilation or asymmetry is due to ___.

A

disruption of sympathetic fibers

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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:

  1. Compressing pupiloconstrictor fibers of CN III causing dilation and fixation of the pupil
  2. On somatic efferent fibers that supply the extraocular muscles which then cause external strabismus
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13
Q

Down and out position of the eye

A

external strabismus

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14
Q

CN most vulnerable to head trauma

A

CN IV (long course around the brainstem)

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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
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16
Q

Eye position drifts laterally

A

Exotropia

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17
Q

Weakness of downward gaze is due to weakness of what muscle?

A

Superior oblique muscle

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18
Q

Double vision increases when looking down

A

Vertical diplopia

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19
Q

What can head tilting to the opposite side of a CN IV lesion be misdiagnosed as?

A

Idiopathic torticollis

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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)

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21
Q

CN VI lesions can result in:

A
  • Convergent strabismus
  • Horizontal diplopia
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22
Q

Inability to abduct the eye due to lateral rectus muscle weakness

A

Convergent (medial) strabismus (esotropia)

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23
Q

Maximal separation of images when looking toward paretic lateral rectus muscle

A

Horizontal diplopia

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24
Q

Rhythmic oscillation of the eyes

Laterality based on fast beating component of _

A

Nystagmus

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25
Q

3 types of nystagmus

A
  • Horizontal
  • Vertical
  • Rotatory
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26
Q

Potential causes of nystagmus

A
  • Vision impairment at early age
  • Disorder of labyrinth or cerebellar systems
  • Drug toxicity
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27
Q

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)

A

Lesion of CN V

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28
Q

Recurrent brief episodes of unilateral shock-like pains along 1 or more distributions of this nerve

Can be debilitating

Innocuous stimuli

A

Trigeminal Neuralgia (CN V)

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29
Q

Peripheral facial paralysis which can be caused by trauma or infection, but in most causes is idiopathic

A

Bell’s palsy

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30
Q

What other disease(s) cause bilateral facial palsies?

A

Miller-Fisher variant of Guillain-Barre Syndrome

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31
Q

Supranuclear facial palsy (or central palsy) spares (1) ____ and usually is associated with (2) ____.

A
  1. Upper face
  2. Hemiplegia
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32
Q

Weakness to one side of the body

A

Hemiplegia

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33
Q

Ways to test CN VIII

A
  • Whisper test
  • Finger rub test
  • Weber-Rinne testing
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34
Q

Vestibular lesions of CN VIII cause:

A
  • Disequilibrium
  • Nystagmus
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35
Q

Imbalance

A

Dysequilibrium

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36
Q

Rapid involuntary and rhythmic movement (or oscillation) of the eye

A

Nystagmus

37
Q

Cochlear lesions of CN VIII cause:

A
  • Destructive lesions cause sensorineural hearing loss
  • Irritative lesions cause tinnitus
38
Q

Ringing in the ears

A

Tinnitus

39
Q

How to test for CN IX and X

A
  • 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
Q

When testing for CN IX and X, unilateral loss indicates ___.

A

Ipsilateral CN X lesion

41
Q

When you ask patient to open mouth and say “ah”, what are you looking for?

A
  • Elevation of soft palate
  • Midline uvula position
  • Medial movement of each side of the posterior pharynx
42
Q

Lesion of CN IX causes:

A
  • Loss of gag reflex
  • Loss of sensation in pharynx and posterior 1/3 of tongue
  • Slight dysphagia
43
Q

Lesion of CN X:

A
  • Dysphonia
  • Dysphagia
  • Dyspnea
  • Loss of gag or cough reflex
44
Q

2 ways to test CN XI

A
  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
Q

How do you test CN XII?

A

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
Q

How should you document normal cranial nerve testing?

A

“Cranial nerves II-XII are intact to testing (or confrontation).”

[This indicates physician performed testing of each nerve bilaterally.]

47
Q

What does it mean when one says “Cranial Nerves are grossly intact”?

A

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
Q

Dermatome of the auricle

A

C2

49
Q

Dermatome of the earlobe and anterior/posterior neck

A

C3

50
Q

Dermatome of nipple

A

T4

51
Q

Dermatome of umbilicus

A

T10

52
Q

How do you test pain?

A

Use broken tongue depressor or wooden stick part of cotton applicator (spinothalamic tract)

53
Q

How do you test temperature?

A

Use test tubes filled with hot and cold water (spinothalamic test)

Often omitted if pain sensation is normal

54
Q

How do you test vibration?

A

Use 128 Hz tuning fork on bony prominence (posterior columns)

55
Q

How do you test proprioception (position)?

A

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
Q

Ability to identify shapes of objects or recognizing objects placed in the hand

A

Stereognosis

57
Q

Ability to identify numbers written on the palm

A

Graphesthesia

58
Q

Ability to distinguish being touched by one or two points

A

Two-point discrimination

59
Q

Ability to feel 2 locations being touched simultaneously

A

Double simultaneous stimulation (extinction)

60
Q

Identify type of sensory loss: loss limited to distribution of one nerve

A

Single nerve

61
Q

Identify type of sensory loss: loss in different nerve distributions w/ common root

A

Root

(C5-C7 = common in arms; L4-S1 = common in legs)

62
Q

Identify type of sensory loss: complete transverse section, hemisection of the cord, posterior column, anterior spinal syndrome

A

Spinal cord

63
Q

Identify type of sensory loss: crossed findings with ipsilateral loss in the face and contralateral in the body

A

Brainstem

64
Q

Identify type of sensory loss: hemisensory loss of all modalities

A

Thalamic

65
Q

Identify type of sensory loss: intact primary sensations but loss of cortical sensations

A

Cortical loss

66
Q

Identify type of sensory loss: non-anatomical distribution

A

Functional loss

67
Q

Types of cerebellar/coordination tests

A
  • 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
Q

Observation of motor systems

A
  • Gait
  • body position
  • involuntary movements
  • muscle bulk: hypertrophy vs. atrophy
  • mustle tone
69
Q

“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.”

A

Muscle Tone

70
Q

Identify gait patterns: staggering, unsteady, feet wide apart, other signs usually present

A

Cerebellar ataxia

71
Q

Identify gait pattern: unsteady, feet wide apart, feet thrown forward and slapped down first on heels then forefoot, patients watch ground when walking

A

Sensory ataxia

72
Q

Identify gait pattern: stooped forward, short steps commonly called “shuffling gait” with involuntary hesitation called “festination”, decreased arm swing

A

Parkinsonian

73
Q

No muscular contraction noted

A

0/5

74
Q

Barely detectable flicker or trace of contraction

A

1/5

75
Q

Active movement of the body part with gravity eliminated

A

2/5

76
Q

Active movement against gravity

A

3/5

77
Q

Active movement against gravity and some resistance

A

4/5

78
Q

Active movement against full resistance without evident fatigue (normal)

A

5/5

79
Q

Reflex absent

A

0/4

80
Q

Somewhat diminished, low normal

A

1/4

81
Q

Average reflex

A

2/4

82
Q

Brisker reflex than average possible, but not necessarily indicative of disease

A

3/4

83
Q

Very brisk, hyperactive, with clonus (rhythmic oscillations between flexion and extension)

A

4/4

84
Q

Abdominal Reflex

A

Stroke abdomen around umbilicus causes abdominal muscles to contract

85
Q

Plantar response

A

Stroke the plantar aspect of the foot causing toes to flex (Down)

(+) = Babinski sign = toes fan out

86
Q

Anal [Wink] Reflex

A

Stroke around the anus and external anal sphincter contracts

87
Q

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

A

Nuchal rigidity

88
Q

Stetches femoral nerve

Examiner flexes patient’s neck

(+) = patient’s hips and knees flex in response

A

Brudzinski sign

89
Q

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

A

Kernig sign

PCM EX 2 (11 decks)

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