Approach to the Neuro Pt - Exam 3 Flashcards
The name of the game in neuro is _____. Even subtle _____ requires action
change
change
What are the 2 categories of the nervous system?
Central Nervous System (CNS): brain and spinal cord
Peripheral Nervous System (PNS): autonomic and somatic nervous system
______ comprises the majority of the brain. What are the 4 lobes of the brain?
cerebrum
frontal
parietal
occipital
temporal
_____ hemispheres which control activities on the _____ side of body from that hemisphere
Two
opposite
What are each of the lobes of the brain responsible for?
Frontal - consciousness
Parietal - movement and stimulation perception
Occipital - vision
Temporal - speech recognition
Personality, behavior, emotions
Judgment, planning, problem solving
Speech: speaking and writing (Broca’s area)
frontal lobe
Where is Broca’s area located?
frontal lobe
Short term memory
Body movement (motor strip)
Intelligence, concentration, self awareness
frontal lobe
Interprets language, words
Sense of touch, pain, temperature (sensory strip)
parietal lobe
Interprets signals from vision, hearing, motor, sensory and memory
Spatial and visual perception
parietal lobe
interprets other sensations like what we are seeing and hearing
walking down stairs
the part of the brain that is responsible for why kids lack depth perception
parietal lobe
Understanding language (Wernicke’s area) aka make words make sense
Memory (short and long term)
Hearing aka ability to hear sound
temporal lobe
Sequencing and organization aka ordering of events
Processing affect/emotions
temporal lobe
Interprets vision (color, light, movement)
occipital lobe
What two parts make up the diencephalon?
thalamus and hypothalamus
what part of the diencephalon relays motor and sensory signals between the CNS and the PNS?
thalamus
what part of the diencephalon helps to regulate sleep, alertness and wakefulness?
thalamus
what part of the diencephalon releases hormones associated with the endocrine and sexual system?
hypothalamus
what part of the diencephalon controls hunger and body temperature?
hypothalamus
What part of the brain is responsible for muscle coordination and equilibrium?
cerebellum
What part of the brain stem is responsible for vision, hearing, motor control, sleep/wake, arousal and temperature regulation?
midbrain
What part of the brainstem transmits signals to and from cerebrum, cerebellum and spinal cord?
Pons
What part of the brainstem is responsible for breathing, heartbeat and vomiting?
Medulla Oblongata
What are 3 parts to the brainstem?
midbrain, pons, medulla oblongata
What are the 2 types of matter? What is the difference between the 2?
white matter and grey matter
White: has myelin sheath protection cover so appear white due to fat
What is the role of the white matter?
Contains nerve fibers (axons) that carry information to and from the Grey Matter
What is the role of grey matter?
Contains the cell bodies of the nerves and works to receive and store impulses
How many segments does the spinal cord have? each segment has _____ and _____ nerves. What is the end of the spinal cord called?
31 segments
Each segment has both motor and sensory nerves
cauda equina: “tale” of nerves
What are the 3 layers of membranes that cover the brain and spinal cord? Where are blood vessels found?
Dura Mater - Outermost layer
Arachnoid - Middle layer
Pia Mater - Innermost layer
blood vessels are found in the pia mater
(said between arachnoid and pia mater during lecture)
Where is CSF made? What is the function?
choroid plexus, the inner lining of the ventricles
Protects and nourishes the brain/spinal cord
How many ventricles does the brain have? What two ventricles does the cerebral aqueduct connect?
4 ventricles: 2 lateral, 3rd and 4th
cerebral aqueduct connects the 3rd and 4th ventricle
What are the 2 components of the peripheral nervous system?
autonomic and somatic
the autonomic nerve system is responsible for innervating the ?????
the smooth involuntary muscles of the (internal organs) and glands
think: HR, BP, RR, temp, digestion, metabolism etc etc
aka things we do not control
What are the 2 components of the autonomic nervous system?
sympathetic or parasympathetic
What are the 2 different types of somatic nerve fibers? what are the responsibilities of each?
sensory and motor
Sensory nerve fibers that transmit sensory information from the peripheral or distant structures to the central nervous system
Motor nerve fibers transmit impulses for movement from the brain to the skeletal muscles
Where do UPPER motor neurons originate? What do they do?
motor region of the cerebral cortex or in the brain stem
carry information down to the lower motor neurons
What does a UPPER motor neuron impulse stimulate?
stimulation of LMN - muscle “contraction”
inhibition of LMN - muscle “relaxation”
results in both an excitatory and inhibitory response
**What will an UPPER motor neuron lesions present like?
a block in the inhibitory motor pathway leading to SPASTICITY
contraction will always dominate so spasticity will occur
Where does the LOWER motor neurons orginiate? Where does their signals go?
anterior grey column, anterior nerve roots or cranial nerves of the brainstem
signals go to the skeletal muscles
UMN sends signal to ______, which receive the stimulation and transmit it to the ______ leading to ________
LOWER motor neurons
muscle cells
contraction of muscle
watch the khan academy video about motor neurons. link is in the answer
https://www.youtube.com/watch?v=LwA00uqniiU
How will an upper motor neuron lesions present? What are 2 causes?
weakness paralysis with increased muscle tone, increased reflex strength and + babinski sign. Muscle mass will be maintained
stroke or cord section
How will a lower motor neuron lesion present?
as weakness paralysis with decreased/absent muscle tone, decrease/absent reflex strength with rapid muscle wasting
What is important to remember about the neuro assessement? What are the 5 different aspects of the neurological exam?
exam needs to be symmetric!! done in a distal to proximal fashion
change is important!
mental status
cranial nerves
motor
reflexes
sensory
What is the first thing you should assess about the pt? What are the 5 categories?
their level of consciousness
alert
lethargy
obtundation
stupor
coma
LOC: _______ awakens to verbal or light physical stimulation, slowly follows commands.
lethargy
LOC: _______ difficult to arouse and needs constant stimulation in order to follow simple commands
obtundation
LOC: ______ arouses to vigorous and continuous stimulation, typically, a painful stimulus is required. May moan, but does not follow commands. May withdraw from painful stimuli
stupor
LOC: ______ No response to continuous or painful stimulation. No movement - except, possible, reflexively. No verbal sound
coma
_____ is assessing the execution of learned motor movement - in the absence of motor or spatial deficits
praxis
mimic using scissors, brushing hair/teeth
How would you assess executive functioning as part of the mental status exam?
ask the pt what they would do if their oven catches on fire
assessing insight and judgement
**What are all the cranial nerves 1-12 names and functions?
CN: shoulder movement, head rotation
XI: Spinal accessory
CN: tongue movement, speech
XII: Hypoglossal
CN: smell
I: Olfactory
CN: Gaggings, swallowing, speech phonation
X: Vagus
CN: Swallowing, taste of posterior 1/3 of tongue
IX: Glossopharyngeal
CN: visual acuity and visual fields
II: Optic
CN: Hearing, equilibrium
VIII: Acoustic
CN: eyelid elevation, pupil reactivity, EOM: up, down, peripheral
III: Oculomotor
CN: facial expression- motor control of the facial muscles
VII: Facial
CN: EOM- Turns eyes laterally outward
VI: Abducens
CN: Chewing/biting, facial/mouth sensation, corneal reflex
V: Trigeminal
CN: EOM: centrally downward movement-> towards the nose
IV: Trochlear
How do you evaluate CN II?
optic: Visual fields by confrontation
Visual acuity with Snellen chart
Fundoscopic exam
How do you evaluate CN III?
Oculomotor:
Extraocular movements
Pupillary reaction to light
How do you evaluate CN IV and VI?
Trochlear- IV and Abducens - VI
Extraocular movements
How do you evaluate CN V?
trigeminal:
sharp vs dull along all 3 branches
muscles of mastication
corneal reflex with a cotton wisp
How do you evaluate CN VII?
facial
facial muscle movements
raise both eyebrows
frown
close both eyes tight- against resistance
show teeth
smile
puff out cheeks- against resistance
How do you assess CN VIII?
Vestibulocochlear/auditory
assess hearing:
Whisper
Webber
Renne
How do you assess CN IX and X?
Glossopharyngeal / Vagus
palatal movement: say “ahhh”
gag reflex
articulation errors in speech
How do you asses CN XI?
Spinal Accessory
Shrug shoulders against resistance
Turn head against resistance
How do you assess CN XII?
hypoglossal
tongue movement: stick out tongue and move side to side
When assessing pupils what 4 things do you need to note?
size
shape
reactivity to light
comparison of one pupil to the other
What is the normal pupil size? What is the name for unequal pupils without pathology?
pupils should be the same size between 2-6mm
physiologic anisocoria: up to 20% of people have normal unequal pupils
When are pinpoint pupils commonly seen?
seen with opiate overdose and pontine hemorrhage
When is mid position and nonreactive pupil commonly seen?
cause is midbrain damage
What type of pupils are always abnormal? When are they seen?
dilated
bilateral, fixed and dilated pupils are seen in the terminal stage of severe anoxia-ischemia or at death or anticholingergic drugs can dilate pupils
What type of pupil is this? What does it represent? What are the causes?
ovoid pupil
usually represents the intermediate phase between normal and fully dilated-fixed pupil
acute neurologic injury, complication of cataract surgery
Name? What does it represent? What are the causes?
keyhole
reacts sluggish to light
coloboma, iridectomy with cataract surgery
What is an coloboma?
a genetic defect resulting in missing part of the eye
Name? What causes it?
irregular
traumatic orbital injury
What does a sluggish or nonreactive or fixed pupil make you think?
some sort of condition or compression of the 3rd cranial nerve
What is hippus phenomenon? What condition?
Alternating dilation and contraction of the pupil
Often associated with early signs of brain herniation or seizure activity
What does it make you think if there is weakness in specific line of gaze?
compression or damage with the associated nerve or muscle
When assesses motor skills, what 6 things do you need to note? Which one is most important?
muscle size, tone, strength, presence of voluntary movements, posture/gait, symmetry!
symmetry!!
gait: _______ involuntary tendency for steps to accelerate and shorten
shuffling
gait: ______ limp associated with pain
antalgic
gait: ______ unsteady, uncoordinated walk, with a wide base and the feet thrown out
staggering (aka ataxic)
gait: ______ lifting of the leg in an attempt to combat drop foot
steppage
gait: ______ involuntarily moves with short, accelerating steps, often on tiptoe
festinating
gait: ______ spasticity leads to adduction of hip with knee flexion and plantar flexion.
scissor gait
gait: _______ muscles on one side are contracted preventing the natural knee flexion - the affected leg
spastic hemiparesis
gait: _______ legs are spread in an attempt to maintain balance
wide base
go back to the lecture and watch videos associated with each gait pattern
do it!!
coordination is also referred to as _______. What tests do you do to check? What does abnormal findings indicate?
cerebellar testing
Rapid alternating movements (RAM’s)
Finger to Nose testing (F→N)
Heel To Shin testing (H→S)
Abnormal findings indicate damage to the cerebellum but may also be seen in motor weakness affecting extremity
involuntary movements: _________ unintentional trembling or shaking movement
Tremor
involuntary movements: _________ rapid, shock like muscle jerks
myoclonus
involuntary movements: _________ rapid, jerky twitches, similar to myoclonus but more random in location
chorea
involuntary movements: _________ slow movements of the limbs
athetosis
involuntary movements: _________ large amplitude flinging of the limbs
ballismus
involuntary movements: _________ abrupt, stereotyped, coordinated movements or vocalizations
tics
involuntary movements: _________ maintenance of an abnormal posture or repetitive twisting movements
dystonia
Describe the Romberg test. What does it assess? What is a negative test result?
Stand with feet together and arms at their sides. Close his/her eyes and maintain this position for 10 seconds. If the patient begins to sway, have them open their eyes.
position sense
negative: no loss of balance with eyes closed
during the romberg test, if the patient sways, but stops when the eyes are opened. What is the problem?
sensory ataxia
during the romberg test, if the swaying continues occurs and persists once eyes are open. What is the problem?
cerebellum ataxia
Describe the pronator drift test. If the pt is conscious, what will the weak side do?
Have patient stretch out the arms so they are level and fully extended with the palms facing straight up, and then close the eyes. Watch 5-10 seconds to see if either arm tends to pronate and a slight drift DOWNWARD
“drifting” downward will occur in the one side that is weak
What does a drifting downward during pronator drift suggest?
Unilateral pronator drift suggest UMN lesion affecting the arm
weakness of the extensor muscles more than the flexor muscles
What is the motor skills strength scale? What is normal? give numbers with explanations
5 - active ROM, full strength against resistance
4 - active ROM against gravity and some resistance
3 - active ROM against gravity only
2 - weak contraction insufficient to overcome gravity
1 - minimal movement/muscle contraction
0 - no movement/muscle contraction
______ is a slight residual tension present in voluntarily relaxed muscle
tone
_____ is resistance to pass movement- found in ____ lesion
hypertonia
UMN
____ is decreased tone that is found in ____ lesions
hypotonia
LMN lesions
but normal in newborns
types of hypertonia: ______ the limb moves freely for a short distance then “catches” requiring more force to move.
spasticity
types of hypertonia: _____ increased resistance throughout the movement
rigidity
types of hypertonia: ______ a rhythmic and involuntary muscle contraction that can be provoked by stretching a group of muscles
clonus
______ increased resistance that becomes less prominent when the patient is distracted - associated with both cognitive impairment and mental disorders
paratonia
What is another test that need to be done when assessing muscle tone?
assessing tone will asking the pt to let their leg ‘go floppy’
Then lift the knee off the bed with one of your hands. If the ankle raises off the bed as well, this is indicative of increased tone
How do you test for ankle clonus?
Flex the patient’s knee, resting the ankle on the bed.
Dorsiflex the foot quickly and keep the pressure applied.
You will be able to see the foot moving up and down if clonus is present
What is happening during a DTR?
This activates SENSORY FIBERS in the muscle triggering a sensory impulse that travels to the spinal cord via a peripheral nerve
This sensory fiber then directly synapses with the ANTERIOR HORN INNERVATING THAT MUSCLE and causing the muscle to contract
What is the scale of rating DTR? What is normal?
increased DTR think UMN lesions
decreased DTR think LMN lesion
What are the coresponding nerve roots for each of the following DTR locations:
Biceps
Brachioradialis
Triceps
Patellar
Achilles
Biceps Tendon - C5,C6
Brachioradialis Tendon - C6
Triceps Tendon - C7
Patellar Tendon - L2 - L4
Achilles Tendon - S1
What is the Babinski test? What is a positive test and negative test? What does a positive test indicate? What nerve roots?
positive test: indicates a central nervous system disorder - upper motor neuron lesion
L5-S1
When can a positive Babinski test be seen briefly? What age range is a positive test normal?
Can be seen temporarily in unconscious alcohol/drug intoxication and postictal periods following a seizure
Positive reflex is normal in children up to 2 years of age and disappears as the child gets older
How is the sensory exam performed?
eye CLOSED
start distal and work peripherally
need to compare sides
What are the components of the sensory exam?
light touch
pain/temp
Proprioception (position sense)
Vibration
discriminative sensation: stereognosis, graphesthesia, 2-point discrimination, point localization
dermatomes
Write the dermatome chart from lecture
Describe the Glasgow Coma Scale
______ inability to interpret sensations and and hence recognize things, despite intact sensations
Agnosia
aka you feel something but cannot tell what it feels like
**agnosia results from damage to the _______ or _____ lobes of the brain
occipital or parietal
______ is inability to recognize faces.
prosopagnosia
______ is inability to recognize own body
autotopagnosia
______ is inability to localize tactile sensation
topognosia
_____ is inability to express speech both verbally and written
aphasia
Types of aphasia: _________ speech is labored, effortful and nonfluent - comprehension is intact - due to lesion in ______ region
Broca’s/Expressive
posterior inferior frontal
aka can think of what words they want to say, but words do not come easily
Types of aphasia: _________ similar to Broca’s except patient is limited to being able to say one word or phrase
monophasia
Types of aphasia: _________ words are fluent, but devoid of meaningful content - due to a lesion in the _______ region.
Wernicke’s
posterior superior temporal
aka string of words make no sense but can speak easily
Types of aphasia: _________ Unable to repeat statements which worsens with length of statement. due to lesion in ______ in the region of the ______
conduction
deep white matter
supramarginal gyrus
Types of aphasia: _________ patients who can produce few recognizable words and understand little or no spoken language
global
______ is MODERATE loss of language impairment - comprehension is intact. When is it commonly used to describe?
dysphasia
Sometimes used to describe language delays in children
aka not as significant as aphasia
_______ Inability to write not resulting from weakness, incoordination, or other neurologic dysfunction of the arm or hand. What is the milder form called?
Agraphia
dysgraphia
type of agraphia: ______ due to impaired visuospatial ability.
letters and words can be written correctly, but not arranged appropriately on a writing surface
constructional
type of agraphia: ______ distorted, slow, effortful, incomplete, and/or imprecise letter formation
apraxic
______ is defined as the inability to perform learned (familiar) movements on COMMAND, in the absence of weakness, sensory loss, or other deficit. What are the 3 MC affected areas?
Apraxia
eyes, walking and talking
aka were once able to perform the activity but stops suddenly, pauses then starts again
What is hypertrophy a result of?
Result from excessive use of the muscles (physiologic hypertrophy) or occur on a pathologic basis. Often associated with persistent abnormal muscle contraction
______ is defined as having difficulty articulating sounds or words. Associated with the motor function of speech as opposed with language as you see with aphasia
dysarthria
_____ is defined as difficulty swallowing. What is it usually caused by?
dysphagia
lower brain dysfunction
_____ is defined as a change in quality, volume, or pitch of voice
dysphonia
______ spasms of the vocal cords causing high pitch, strained, or squeaky voice
Spasmodic dysphonia
What type of dysphonia is commonly see in Parkinson’s disease?
hypophonia: low volume of voice
_____ is impaired balance or coordination. What are the 2 different types?
ataxia
cerebellar and sensory
Type of ataxia: ______ can involve any of the limbs and/or gait. Can be found by examining coordination and gait
cerebellar
think tremor
Type of ataxia: ______ lack of proprioception which can cause gait imbalance or poor coordination that occurs or worsens with eyes closed
sensory
think worse when eyes are closed
______ a condition of muscular weakness caused by nerve damage or disease. What are the 4 types? Give brief description of each
paresis
Hemiparesis - weakness on one side
Hemiplegia - paralysis of one side
Paraplegia - paralysis of both legs from usually damage to the spinal cord or degenerative muscle disease
Quadriplegia - paralysis of all four limbs due to spinal cord damage
______ is the loss or impairment of the power of voluntary movement
Akinesia
____ is defined as slow movement. What type of pt? Where is the problem coming from?
bradykinesia
parkinson’s pt and pts with extrapyramidal symptoms
problem arises from the basal ganglia
______ is the abnormal involuntary movement that is similar to being figety or restless
Hyperkinesia / Dyskinesia
_____ is defined as inability to sustain a stable posture. How do you test it? What 2 conditions is it associated with?
asterixis
Can be detected when patient’s arms are outstretched with wrists extended. The hands will flop down and then quickly recover making an odd “flapping” motion
Usually associated with hepatic encephalopathy, cirrhosis
aka flapping clonus when you try and hold body part in the same position
_____ is increased sensitivity to sensory stimulus
hyperesthesia
________ a sensation of pain from a stimulus that doesn’t cause pain. What conditions are good examples of this? What is a synonym?
allodynia -> light touch elicits painful sensation
think shingles or gout
hyperalgesia
_____ is loss of sensation, used interchangeably with ______.
_____ is decreased sensation
_____ is tingling, burning, and needles sensation in the skin
anesthesia
numbness
hypoesthesia
paresthesia
_____ - lack of pain sensation
______ - decrease in pain sensation
_______- exaggerated response to painful stimulus
Analgesia
Hypalgesia
hyperalgesia
______ ability to recognize writing on the skin without seeing it visually. Used to look for disorders associated with what 5 areas?
Graphesthesia
parietal lobe, brainstem, spinal cord, thalamus, and sensory cortex
______ is the inability to recognize an object by touch alone. What 2 places is usually the source of the problem?
Astereognosis
parietal lobe of the brain
or
dorsal column of the spinal cord
_______ is difficulty with judging distance, speed and power. How is it assessed?
dysmetria
assessed by finger-to-nose
________ inability to perform repetitive movements or rapid alternating movements
Dysdiadochokinesia
aka not fluid or consistent when doing rapid alternating movements
______ is involuntary resistance to passive movement. What is the key different between spasticity?
rigidity
aka same regardless of the speed
Key difference from spasticity is the that the degree of resistance remains the same regardless the speed of movement.
Spasticity is more noticeable with fast and slow passive movement
What can hyperreflexia indicate? Is it always abnormal?
Can be indicative of myopathic process, hyperthyroidism, serotonin syndrome
NO! can be normal if the finding is symmetric
What can hyporeflexia indicate?
Can be associated with lower motor neuron disorder (i.e. peripheral neuropathy) or hypothyroidism
but also can be normal
