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ECOS > Approach to Neuro Complaint > Flashcards

Approach to Neuro Complaint Flashcards

1
Q

What is the first thing you check within the neuro exam?

A

mental status, speech, and language

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2
Q

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

A

dysarthria

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3
Q

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

A

aphasia

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4
Q

How do you report mental status in soap note and what section does it belong in?

A
  • mental status: patient is alert and oriented x4 (to person, place, time, and event)
  • belongs in objective section
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5
Q

What is the difference between delirium and dementia?

What is the correlation between these two conditions and depression?

A
  • delirium is REVERSIBLE (common in older adults during hospitalization) while dementia is NOT REVERSIBLE (depression/delirium must be treated before dx, meds can slow progression)
  • depression can enchance symptoms of both delirium and dementia
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6
Q

CN I function?

A

olfactory nerve (smell)

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7
Q

CN II function?

A

visual acuity

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8
Q

CN III function?

A

raise eyelids, pupillary constriction, most extraocular movements

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9
Q

CN IV function?

A

downward, internal rotation of the eyes (looking toward nose)

*high yield*

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10
Q

CN V function?

A

sensory dermatomes (V1, V2, V3), motor function of mastication, corneal reflex (sensory)

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11
Q

CN VI function?

A

lateral deviation of the eye

*high yield*

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12
Q

CN VII function?

A

motor: facial movements (expression, closing eyes, mouth); sensory: taste of anterior 2/3 tongue

*high yield*

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13
Q

CN VIII function?

A

hearing (test using soft rub finger test, whisper test, or tuning fork)

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14
Q

CN IX function?

A

motor: phonation; sensory: posterior 1/3 taste, gag reflex arc

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15
Q

CN X function?

A

raise palate, motor function of pharynx

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16
Q

CN XI function?

A

shrug shoulders against resistance (traps), turn head L and R against resistance (SCM)

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17
Q

CN XII function?

A

motor function of tongue

(make sure it’s midline)

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18
Q

What are the cardinal gaze signs and their innervations?

A
  • inferior oblique (up and in), medial rectus (inward), superior rectus (up and out), inferior rectus (down and out): oculomotor N. (CN III)
  • superior oblique (down and in): trochlear N. (CN IV)
  • lateral rectus (outward): abducens N. (CN VI)
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19
Q

What are the associated symptoms and presentation of CN III lesions?

A
  • symptoms: ptosis (drooping of eyelid due to levator palpebrae weakness), pupillary dilation/asymmetry (due to disruption of ciliary plexus within parasympathetic innervation of pupil), ophthalmoplegia (denervation of extraocular muscles causing “down and out”)
  • presentation: sudden, unilat ptosis and ophthalmoplegia (diplopia can be masked by severe ptosis)
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20
Q

What are the symptoms and presentation associated with CN IV lesions?

A
  • symptoms: hypertropia (eye drifts medially), weakness of downward gaze (due to superior oblique, eye drifts upwards), vertical diplopia (dbl vision increases w/ downward gaze), head tilting (to oppo side of lesion)
  • presentation: vertical diplopia, difficulty reading/walking downstairs, torticollis secondary to head tilting
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21
Q

What are the associated symptoms of CN VI lesions?

A

(most common isolated CN palsy, seen often in subarachnoid hemorrhage, syphilis, trauma)

  • symptoms: convergent (medial) strabismus (esotropia) (inability to abduct eye due to lateral rectus weakness) and horizontal diplopia (esp when looking toward affected lateral rectus)
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22
Q

What are the symptoms and presentation a/w CN V lesions?

A
  • symptoms: decreased sensation, loss of corneal reflex, weakness of muscles of mastication, jaw deviation (toward weak side)
  • presentation: recurrent brief episodes of unilat shock-like pain, can be triggered by innocuous stim, can be reprod on exam by stroking dermatome w/ light touch

(90% of cases caused by aberrant vein or artery compression of N.)

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23
Q

What are the symptoms a/w CN VII lesions?

A
  • paralysis of muscles of facial expression of upper/lower facial portions: presents as widened palpebral fissure and increased nasolabial fold (Bell’s palsy)
  • loss of corneal reflex (efferent limb of CN VII)
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24
Q

What is the difference between Bell’s palsy and supranuclear (central) facial palsy?

A
  • Bell’s palsy (peripheral): etiology usually unknown, can be caused by trauma or infection
  • supranuclear facial palsy (central): spares upper face, usually a/w hemiplegia (important for determining if weakness is central or peripheral)
  • DIFFERENCE: Bell’s palsy is a peripheral nerve lesion on the unilat side of facial weakness, the entire affected side of the face shows weakness; supranuclear palsy is a central lesion on the contralat side of weakness, only affects lower muscles of face because unilat nerve fibers make up for lost innervation
25
Q

What are the symptoms a/w CN VIII lesions?

A
  • vestibular division: disequilibrium and nystagmus
  • cochlear division: destructive (sensorineural hearing loss) and irritative (can cause tinnitus)
26
Q

What is nystagmus, what are the 3 types, and what are potential causes?

A
  • nystagmus: rhythmic oscillation of eyes (2 phases, 1 is slow drift away from object, 2 is saccade phase quick rxn back), named for saccade phase
  • types: horizontal, vertical, rotatory
  • causes: vision impairment at early age, labyrinth or cerebellar disorder, drug tox

(1-2 beats of nystagmus is nml physiologically, however sustained beats is abnormal/pathological)

27
Q

What are symptoms a/w CN IX lesion?

A
  • loss of gag reflex
  • loss of sensation in pharynx and posterior 1/3 of tongue
  • mild dysphagia
28
Q

What are symptoms a/w CN X lesions?

A
  • dysphonia (difficulty speaking)
  • dysphagia (difficulty swallowing)
  • dyspnea (difficulty breathing)
  • loss of gag or cough reflex
29
Q

What are symptoms a/w CN XI lesions?

A
  • in SCM: paralysis of muscle, difficulty turning head to opposite side of affected muscle
  • in trap: weakness results in unilat shoulder droop

(testing for these is against mild resistance)

30
Q

What are symptoms a/w CN XII lesions?

A

tongue deviates to weak or affected side and patient is unable to push tongue to opposite side

(testing: patient protrudes tongue while physician applies mild resistance against cheeks)

31
Q

How do you document that you tested cranial nerves?

A
  • never just put “cranial nerves are intact”
  • if you did a partial test: “cranial nerves are grossly intact”
  • if you did a thorough test: “cranial nerves II-XII are intact to testing”

(CN I is usually not tested unless in special circumstances)

32
Q

dermatome of auricle of ear?

A

C2

33
Q

dermatome of earlobe, ant/post neck?

A

C3

34
Q

dermatome of superior shoulder?

A

C4

35
Q

dermatome of radial aspect of forearm?

A

C6

36
Q

dermatome of middle finger?

A

C7

37
Q

dermatome of little finger?

A

C8

38
Q

dermatome of nipple?

A

T4

39
Q

dermatome of umbilicus?

A

T10

40
Q

dermatome of inguinal region?

A

L1

41
Q

dermatome of patella and medial calf?

A

L4

(this is what we test w/ the patellar reflex)

42
Q

dermatome of anterolateral calf and great toe?

A

L5

43
Q

dermatome of posterolateral calf and little toe?

A

S1

(this is what we test w/ Achilles reflex)

44
Q

What are the primary sensations and how do we test them?

A
  • pain: sharp object and gently touch patient (spinothalamic tract)
  • temp: often omitted if pain is nml, use cold metal object or test tubes w/ water (spinothalamic tract)
  • vibration: use tuning fork on bony prominence (posterior column)
  • proprioception: big toe positioning test w/ patient’s eyes closed (posterior column)
45
Q

What are the discriminative (cortical) sensations?

A
  • stereogenesis: ability to identify shapes of objects
  • graphesthesia: ability to identify numbers/letters written on palm
  • two-point discrimination
  • double simultaneous stimulation
46
Q

What are the 7 different patterns of sensory loss?

A
  • single nerve
  • root or roots: loss in nerve distributions w/ single root (ex: C5-7 common in arms, L4, L5, S1 common in legs)
  • spinal cord: complete transection, hemi-section, posterior column, or anterior spinal syndrome
  • brainstem: crossed findings, ipsilat loss in face and contralat loss in body
  • thalamic: hemisensory loss of all modalities
  • cortical: intact primary sensations, loss of cortical sensations (i.e. graphesthesia and stereogenesis)
  • functional: non-anatomical (i.e. psychosomatic)
47
Q

What are the different types of cerebellar/coordination testing?

A
  • rapid alternating movements, finger-to-nose, heel-to-shin
  • gait: regular, heel-toe, toe-heel, hopping, shallow knee bend, get-up-and-go
  • stance: pronator drift test (ability to maintain body position w/ eyes closed)
48
Q
  • test that has patient stand with feet together and eyes closed
  • (+) test: patient is not able to stand upright
  • tests proprioception, vestibular system, and vision (you must have 2/3 of these functioning properly to stand upright, so this tests takes away vision and is focusing on proprioception and vestibular aspects)
  • best for testing proprioception b/c dysfunction w/ vestibular system presents more obviously w/ dizziness and loss of balance
A

Romberg test

(did not include this w/ cerebellar testing b/c Dr. Pence said if you had an issue w/ cerebellar system you would not be able to stand w/ feet together even w/ eyes open)

49
Q

What aspects of the motor system can you observe during a physical exam?

A
  • gait
  • body position
  • involuntary movements
  • muscle bulk: hypertrophy or atrophy
  • muscle tone
50
Q

How do you grade DTR’s?

A
  • 0-4/4
  • 1-3 are not indicative of disease
  • 0/4: reflex absent
  • 4/4: issue w/ UMN
51
Q

How do you grade strength?

A

0-5/5

(see chart for further info)

52
Q

Review of gait cycle:

A
53
Q
  • abnormal gait pattern
  • staggering, unsteady, feet wide apart, other cerebellar signs usually present
  • staggering will be toward side of lesion/damage
A

cerebellar ataxia

54
Q
  • abnormal 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

55
Q
  • abnormal gait pattern
  • stooped forward, short steps commonly called “shuffling gait” w/ festination (involuntary hesitation), decreased arm swinging
A

Parkinsonian gait

56
Q

What are the 3 common cutaneous or superficial reflexes?

A
  • abdominal reflex: stroke skin of abd and look for involuntary reflex of abd muscles
  • plantar response: move from lateral portion of posterior foot and move anteriorly toward toes, intact reflex is toes curling down, non-intact reflex (Babinski sign) toes curl up which is nml in infants
  • anal reflex: stroke edge of anus w/ Q-tip, anus should wink, usually patients w/ non-intact reflex present w/ fecal incontinence
57
Q

What are signs of meningeal infection?

*high yield*

A

nuchal rigidity: neck stiffness w/ resistance to flexion

  • occurs in ~84% of patients w/ acute bacterial meningitis and 21-86% of patients w/ meningeal irritation due to subarachnoid hemorrhage
  • most reliable presentation in meningeal irritation (but diagnostic accuracy is low)
  • must be sure no concern for vertebral fx before testing
  • important to use imaging to r/o presence of trauma
58
Q

What are the 2 physical exam tests for meningeal infection?

A
  • Brudsinski sign: patient is supine while physician slowly flexes patient’s neck; (+) test if patient involuntary flexes their hips and knees in response
  • Kernig sign: physician flexes patient’s hip and knee then slowly extends knee straight keeping hip flexed; (+) test: pain or increased resistance to knee ext, also can cause passive flexion of neck

ECOS (6 decks)

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