Approach To A Patient With Neurological Disease Flashcards by Derrick Obeng

What is the control hub for motor, sensory and cognition (higher cortical functions)

The brain

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What is a conduit for bidirectional flow of impulses to and from the brain

Spinal cord

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The central nervous system is made up of

The brain and the spinal cord

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The peripheral nervous system is made up of

Motor nerves
Sensory nerves
Autonomic nerves

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What is the use of motor nerves

They transmit signals to muscles for contraction/relaxation

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What is the use of sensory nerves

They transmit signals from sensory receptors to the CNS

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What is the function of autonomic nerves

Works automatically to control bodily functions such as heart rate, respiratory rate, digestion, urination and sexual arousal

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What are the three main symptoms of nervous system disease

Motor symptoms
Sensory symptoms
Higher cortical function symptoms

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Examples of motor symptoms

Weakness (paralysis)
Movement problems (fast or slow)
Ataxia (incoordination)

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Examples of sensory symptoms

Numbness
Pain syndromes
Tingling
Burning sensations
Special senses

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Examples of higher cortical function symptoms

Dysphasia (loss of speech)
Amnesia (memory loss)
Poor judgement
Apraxia
Agnosia
Personality changes

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What is apraxia

Inability to perform tasks

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What is agnosia

Inability to recognize objects, people, etc

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In a single patient, you can have a combination of symptoms depending on where the lesion (problem) is in the nervous system
True or false

True

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Upper motor neurons transmit impulses from the cortical bodies to which two other parts of the body

The motor nuclei in the brain stem
The anterior horn cells of the spinal cord

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Lower motor neurons transmit impulses from where to where

From the anterior horn cells to the peripheral nerves, terminating in the neuromuscular junction

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What should be considered in the history taking of weaknesses in a neurologic patient

Duration of weakness
Onset of weakness (sudden vs gradual)
Pattern of weakness (monoparesis, hemiparesis, paraparesis, tetraparesis)
Progression of weakness (ascending from the distal toward proximal)
Distribution of weakness (proximal, distal, total)
Any other symptoms (sensory, higher cortical dysfunction)
Risk factors and possible exposures (vascular risk factors, family history)
Effect of weakness on quality of life

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Steps in doing a motor examination to inspect weaknesses in a neurological patient

Inspection
Palpation
Check motor strength (power grade from 0 to 5)
Check muscle compartments against resistance
Check for deep tendon reflexes

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Active movement with gravity eliminated is what MRC grading

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What does grade 0 correspond to in MRC grading

No contraction detected

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What does grade 1 in MRC correspond to

Barely detectable flicker or trace of contraction

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What does grade 3 in the MRC grading mean

Active movement against gravity but cannot sustain

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What does grade 4 in MRC correspond to

Active movement against gravity and some resistance

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What does grade 5 in MRC mean

Active movement against resistance without evident fatigue (normal)

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Upgoing plantar is also known as

Babinsky sign

Which myotome does plantar reflex occur

Rhythmic oscillations as a reflex of the lower limb is also called

Clonus

What is the C5 myotome responsible for

Shoulder abduction by deltoid

What is the C6 myotome responsible for

Elbow flexion by brachioradialis

What is the C7 myotome responsible for

Elbow extension by triceps

What is the T1 myotome responsible for

Thumb opposition

What is the C8 myotome responsible for

Wrist flexion by palmaris longus

What is the L2 myotome responsible for

Hip flexion

What are some reflexes that could be assessed in the upper limb

Biceps reflex at C5,6 Triceps reflex at C7,8 Supinator reflex at C5,6

What are some reflexes that could be assessed in the lower limb

Patella reflex at L3,4 Achilles ankle reflex at L5 Plantar reflex at S1 Babinsky sign Clonus

Weakness is a sign of a UMN lesion

Yes

Wasting is a sign of a UMN lesion

Fasciculation is a sign of a UMN lesion

Is the tone increased in a UMN lesion

Yes

Describe the nature of reflexes in a UMN lesion

Increased (brisk) reflexes

Name locations of UMN lesions

Brain Spinal cord

Provide yes or not answers to whether or not these various signs apply to LMN lesions. For tone and reflexes, indicate whether they are present or absent (weakness, wasting, fasciculation, tone, reflexes)

Weakness: Yes Wasting: Yes Fasciculation: Yes Tone: Reduced Reflexes: Reduced or absent

Where do you locate lesions in the LMN

Anterior horn cells Spinal roots Peripheral nerves

Provide yes or not answers to whether or not these various signs apply to muscle lesions. For tone and reflexes, indicate whether they are present, absent or normal (weakness, wasting, fasciculation, tone, reflexes)

Weakness: Yes Wasting: Yes Fasciculation: No Tone: Normal Reflexes: Normal

Hemiparesis is only caused in UMNs True or false

True

What are some possible locations of a right hemiparesis

Left motor cortex Left internal capsule Left brain stem Left cervical cord

What are some possible causes of a hemiparesis

Stroke Intercranial space occupying lesion (Eg. Brain tumour, abscess, etc)

Paraparesis is seen in both UMNs and LMNs True or False

True

What causes hypokinesis

Closure of the gate of the basal ganglia

Give one example of a hypokinetic disorder

Parkinson’s disease

What are some symptoms of Parkinson’s disease

Reduced movements Rigidity Stooping posture Shuffling gait Resting tremor

Mention some hyperkinetic disorders

Tremors Chorea Athetosis Ballisms Dystonia Tics Myoclonus

What are tremors

Rhythmic oscillations caused by intermittent muscular contractions

What is chorea

It is a dance-like, rapid, jerk movement which often involves the distal muscles

What is athetosis

Writhing movements, often slow, mostly of arms and hands

What are ballisms

Wild, large-amplitude, flinging movements, affects the proximal muscles

What is dystonia

Sustained or repetitive muscular contractions often produces abnormal posture

What are tics

Paroxysmal, stereotyped muscle contraction, may be suppressible

What is myclonus

Shock-like, arrhythmic twitches. Not suppressible

What is the use of the cerebellum

The cerebellum coordinates on-going muscle movements using sensory input, vestibular and motor systems to ensure accurate movements

The right cerebellar controls which side of the body and vice versa

The right side of the body and vice versa

Which part of the cerebellum controls the trunk of the body

The vermis

Mention some cerebellar function tests

Finger to nose test Rapid alternating hand movement (diadochokinesia) Heel to shin test Assess gait Tandem gait Stance and Rhomberg’s sign

Sensory symptoms can be grouped into

Positive and negative symptoms

What are some positive sensory symptoms

Paraesthesia Pain Tingling Shocks Pricks Burning

Give an example of a negative sensory symptom

Numbness

What are some examples of increased perception of sensory stimuli

Hyperesthesia - Extreme sensitivity to touch Hyperalgesia - Extreme sensitivity to pain Hyperpathia - Increased reaction to a stimulus Allodynia - pain due to a stimulus that does not normally provoke pain

List some sensory testing methods for pain

Use a sharp safety pin or other tool Demonstrate sharp and dull Alternate sharp and dull objects with patient’s eye closed and ask whether instrument is sharp or dull

How is light touch sensory testing done

Use a wisp of cotton to touch gently and avoid pressure Ask patient to respond when touch is felt and compare one area with another

All the cranial nerves are part of the peripheral nerves except

Cranial nerve II

Where does the nuclei of CN II originate

In the brain stem

What is the location of the receptors of CN I

Upper third of the nasal septum

How do you test CN I

Test each nostril separately Identify familiar odours Avoid noxious substances

A unilateral lesion in CN I leads to what kind of anosmia

Ipsilateral anosmia

What do you have to test for in CN III

Visual acuity Pupillary size Visual fields Fundoscopic examination

What test is done to check pupillary size

Swinging-flashlight test

What tests are done to check for visual fields

Peripheral vision Test by confrontation

CN III is involved in

Pupillary reflex Opening of the eyelids Most extraocular movements

What is the function of CN IV

It provides downward and inward eye movement

What is the function of CN VI

It provides lateral eye movement

What are the types of pupillary reflex/reaction

Direct and consensual

Give some examples of pupil abnormalities

Adie’s (tonic) pupil Argyll Robertson pupil Marcus-Gunn pupil Bilateral dilation Unilateral constriction Bilateral constriction

Sluggish response of the pupil is characteristic of

Adie’s pupil

Irregular/unequal pupils, weak/absent reaction to light, exaggerated contraction to accommodation is characteristic of which pupil abnormality

Argyll Robertson pupil

What pupil abnormality results from reduced afferent input in the affected eye and pupil tends not to constrict fully

Marcus-Gunn pupil

Asymmetry of pupil size of >1mm suggests CN III compression which is characteristic of what pupil abnormality

Marcus-Gunn pupil

Which pupil abnormality suggests anoxia or drugs

Bilateral dilation

What pupil abnormality is seen with sympathetic dysfunction (Horner’s syndrome) or carotid artery dissection

Unilateral constriction

Bilateral constriction is seen with

Pontine hemorrhage Drugs (opiates, clonidine) Toxins (organophosphates)

Name some tests done for CN V

Test corneal reflex Test sensation Jaw reflex Compare muscle tension bilaterally with teeth clenched

CN V is has both motor and sensory functions. What are some muscles it innervates

Temporalis Masseter Medial and lateral pterygoids

The motor nerves of the facial nerve innervates which muscles

Muscles of the face, scalp and ears

Which parts of the body does the sensory part of the facial nerve innervates

Taste in anterior 2/3 of the tongue Ear canal/ posterioauricular

What types of nerves comprise the facial nerve

Motor Sensory Autonomic

Central lesions to CN VIi cause ……..

Contralateral paralysis to the lower half of the face (below the eyes)

Palsies in CN VII can occur secondary to

Polio Stroke MS Tumour Syphilis Guillain-Bare syndrome Lyme disease

Higher cortical functions include

Language Vision Visuospacial recognition Awareness

What are the three characteristics of higher cortical function

The cerebral cortex must be involved. Complex interactions occur within the cortex and between it and other brain areas Both conscious and unconscious information processing occurs Higher-order functions are adjusted over time. They are inborn (innate), fixed, or reflexive behaviors

What are the two classes of memories

STM LTM

What are the two subtypes of LTM

Secondary and tertiary memories

What are secondary memories

They are memories which fade over time and require great effort to recall

What are tertiary memories

They are memories which remain with us throughout life

What are the three types of amnesia

Anterograde amnesia Retrograde amnesia Transient global amnesia (TBA)

Loss of ability to remember recent information but remembers old info and event What type of amnesia is this

Anterograde amnesia

Loss of the ability to recall episodic memories and past events What type of amnesia is this

Retrograde amnesia

Temporary loss of memory involving inability to recall events that have occurred a few minutes ago What type of amnesia is this

Transient global amnesia

What are some instruments needed for neurological examination

Patellar hammer Tuning fork 128 Hz (for vibration) and 256/512 Hz (for hearing) Pointed or sharp object like a tooth pick Cotton wool Snellen chart (for assessing visual acuity) Ishihara chart (for assessing color) Mildly scented soap (for assessing smell) Sugar, salt (to assess taste)

What is the term given to problems with articulating words not due to language problems

Dysarthria

What term is given to the quality of rhythm and emphasis that adds more meaning to our words. It’s a function of both hemispheres

Prosody

What term is given to changes in the intensity of speech, the timing of speech segments and words spoken, including their rhythm and pitch

Dysprosody

What are some examples of aphasia

Global aphasia Anomic aphasia Wernicke’s aphasia Broca’s aphasia

Broca’s aphasia: Fluent or non-fluent, patient comprehends speech or patient does not comprehend speech

Non-fluent speech Patient comprehends speech

Anomic aphasia: Fluent or non-fluent, patient comprehends speech or patient does not comprehend speech

Fluent Patient comprehends speech

Wernicke’s aphasia: Fluent or non-fluent, patient comprehends speech or patient does not comprehend speech

Fluent Patient does not comprehend speech

Global aphasia: Fluent or non-fluent, patient comprehends speech or patient does not comprehend speech

Non-fluent Patient does not comprehend speech

What are the three tests in the Glasgow coma scale

Eye opening Best verbal response Best motor response

What are the various levels of consciousness

Alert and oriented Disoriented Obtunded Stuporous Comatose

Completely unconscious Cannot be aroused by painful stimuli Absence of voluntary movement +/- reflexes Characteristic of

Comatose

Drowsy/somnolent Clouded consciousness Slow thought, movement, and speech Characteristic of

Obtounded

Marked reduction in mental and physical activity Vigorous stimuli needed to provoke a response Characteristic of

Stuporous

What alters the state of wakefulness

Abnormal or depressed CNS function

What is consciousness

A state of alertness and attentiveness