Approach to the Neurologic Patient Flashcards
Five Common Mistakes with neuro physical assessment
- Inadequate stimulation of the pt
- With adequate stimulation, you can find out the patient’s best response - Inadequate or inaccurate baseline assessment
- The name of the game in neuro is change. Even subtle change requires action - Not using accurate objective terminology when describing your assessment findings. Don’t say “a tad weak”. Make your finding objective
- Failure to recognize subtle clues
- Failure to persist and pursue
what is the nervous system
Complex network of nerves and cells that carry messages to and from the brain and spinal cord to areas of the body
2 categories of the nervous system
- Central Nervous System (CNS)
- Brain and Spinal Cord - Peripheral Nervous System (PNS)
- Autonomic
— Sympathetic
— Parasympathetic
- Somatic nervous system
what part of the CNS has 2 hemispheres which control activities on the opposite side of body from that hemisphere
cerebrum
4 lobes of the cerebrum
- Frontal - consciousness
- Parietal - movement and stimulation perception
- Occipital - vision
- Temporal - speech recognition
which lobe:
- Personality, behavior, emotions
- Judgment, planning, problem solving
- Speech: speaking and writing (Broca’s area¹)
- Short term memory
- Body movement (motor strip)
- Intelligence, concentration, self awareness
frontal
which lobe:
- Interprets language, words
- Sense of touch, pain, temperature (sensory strip)
- Interprets signals from vision, hearing, motor, sensory and memory
- Spatial and visual perception
parietal
which lobe:
- Understanding language (Wernicke’s area)
- Memory (short and long term)
- Hearing
- Sequencing and organization
- Proccessign affect/emotions
temporal
which lobe Interprets vision (color, light, movement)
occipital
which part of the CNS
- relays motor and sensory signals between the CNS and the PNS
- helps to regulate sleep, alertness and wakefulness
Thalamus
parts of the Diencephalon
thalamus
hypothalamus
which part of the CNS
- Releases hormones associated with the endocrine and sexual system
- Controls hunger, body temperature
hypothalamus
which part of the CNS is responsible for muscle coordination and equilibrium
cerebellum
which part of the CNS is responsible for vision, hearing, motor control, sleep/wake, arousal and temperature regulation
midbrain
which part of the brain transmits signals to and from cerebrum, cerebellum and spinal cord
pon
which part of the CNS is responsible for breathing, heartbeat, and vomiting
medulla oblongata
parts of the brain stem
- midbrain
- pons
- medulla oblongata
Two types of Matter
- White Matter
- Contains nerve fibers (axons) that carry information to and from the Grey Matter - Grey Matter
- Contains the cell bodies of the nerves and works to receive and store impulses
the spinal cord is composed of a series of how many segments which contains a pair of spinal nerves from each segment
31
Each segment has both motor and sensory
the spinal cord ends in a “tale” of nerves known as the ?
cauda equina
what are the 3 layers or membranes that cover the brain and the spinal cord
- Dura Mater - Outermost layer
- Arachnoid - Middle layer
- Pia Mater - Innermost layer
protection to the brain and spinal cord by acting as a barrier
A clear colorless fluid created in the choroid plexus, the inner lining of the ventricles
Cerebral Spinal Fluid (CSF)
- Circulates around the brain and spinal cord
- Protects and nourishes the brain/spinal cord
what are the cavities within the brain that contain CSF called?
name each one
Brain ventricles
- 2 lateral ventricles
- third ventricle
- cerebral aqueduct
- fourth ventricle
The nerves of this system innervate the smooth involuntary muscles of the (internal organs) and glands
Autonomic Nervous system
what involuntary systems is the Autonomic Nervous system responsible for?
- Heart rate, BP, RR, temperature
- Digestion, metabolism, water/electrolyte balance
- Urination, defecation, production of bodily fluids
- Sexual response
what are the two ANS response systems
- Sympathetic - arousing - “fight or flight”
- increase BP, HR, RR and slows digestion/voiding during stressful situations - Parasympathetic system - calming
- decreases (controls) BP, HR, RR and promotes digestion/voiding during ordinary situations
what are teh 2 nerve fibers in the somatic nervous system
- 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 can upper motor neurons originate from?
the motor region of the cerebral cortex
in the brain stem and carry information down to the lower motor neurons
UMN Impulses
- stimulation of LMN - muscle “contraction”
- inhibition of LMN - muscle “relaxation”
a block in the inhibitory motor pathway leading to spasticity
UMN Lesions
where are lower motor neurons located?
- the anterior grey column
- anterior nerve roots
- cranial nerves of the brainstem and sends signals to the skeletal muscle
- Impulses - receives stimulation impulse from UMN, transmitting it to the muscle cell leading to contraction of muscle
weakness/paralysis
decreased/absent muscle tone
decreased/absent reflex strength
rapid muscle wasting
where is this neuron lesion?
lower motor
causes: poliomyelitis, motor neuron disease, spinal cord injury at segmented level, peripheral nerve dysfunction, muscle myotonias, myasthenia gravis, muscular dystrophies
weakness/paralysis
increased muscle tone
increased reflex strength
maintained muscle mass
where is this neuron lesion?
upper motor
causes: stroke, cord section
components of a neuro exam
Mental Status
Cranial Nerves
Motor
Reflexes
Sensory
awake, attentive, and follows commands
eyes open, looks at you and when spoken to in a normal tone of voice and responds fully and appropriately to stimuli.
what LOC?
alert
drowsy, awakens to verbal or light physical stimulation, slowly follows commands;
opens eyes when spoken to in a loud voice and looks at you, response to questions, and then falls asleep.
what LOC?
lethargy
difficult to arouse and needs constant stimulation in order to follow simple commands; opens the eyes when tactile stimulus is applied and looks at you but responds slowly and is somewhat confused
what LOC?
Obtundation
arouses to vigorous and continuous stimulation
a painful stimulus is required.
May moan, but does not follow commands. May withdraw from painful stimuli;
patient arouses only after painful stimuli. Verbal responses are slow or even absent. The patient lapses into an unresponsive state when the stimulus ceases
what LOC?
stupor
No response to continuous or painful stimulation. No movement - except, possible, reflexively. No verbal sounds; unarousable with eyes closed
what LOC?
coma
which exam
Assesses orientation to person, place and time
Attention and concentration
memory, language, Visual spatial perception, praxis, calculations
executive functioning, mood, thought content?
mental status exam
assessing the execution of learned motor movement - in the absence of motor or spatial deficits
mimic using scissors, brushing hair/teeth
which mental status exam is this
praxis
what part of the mental status exam assesses insight and judgement
“What problems do you think you are having?”
“How would you handle a minor household emergency, such as a small plumbing leak?”
executive functioning
name the CN and its functions
I. Olfactory - Smell
II. Optic - Vision- visual acuity and visual fields
III. Oculomotor - Eyelid elevation, pupil reactivity, EOM - up,down, peripheral
IV. Trochlear - EOM - centrally downward movement (toward the nose)
V.Trigeminal - Chewing/biting, facial/mouth sensation, corneal reflex
VI.Abducens - EOM - turns eyes laterally outward
VII. Facial - Facial expression - motor control of the facial muscles
VIII. Acoustic - Hearing; equilibrium
IX. Glossopharyngeal - Swallowing; taste of posterior ⅓ tongue
X. Vagus - Gagging, swallowing, speech phonation
XI. Spinal accessory - Shoulder movement; head rotation
XII. Hypoglossal - Tongue movement; speech(articulation)
how to examine olfactory nerve?
Occlude one nostril and identify a common scent (coffee, mint, cinnamon)
how to examine optic nerve?
Visual fields by confrontation
Visual acuity with Snellen chart
Fundoscopic exam
how to exam oculomotor nerve?
Extraocular movements
Pupillary reaction to light
how to exam trochlear nerve?
Extraocular movements
how to exam the trigeminal nerve?
- Facial sensation
- sharp vs dull along all 3 branches - Muscles of mastication
- palpating temporal and masseter muscles - Corneal reflex - cotton wisp
How to exam abducens nerve
extraocular movements
how to exam facial nerve?
Facial muscle movement
- raise both eyebrows
- frown
- close both eyes tight
- show teeth
- smile
- puff out cheeks
how to exam Vestibulocochlear/auditory
nerve
Assess hearing
Whisper
Weber
Renne
how to exam Glossopharyngeal / Vagus nerve
Palatal movement - say “ahhh”
Gag reflex
Articulation errors in speech
how to exam spinal accessory nerve
Shrug shoulders against resistance
Turn head against resistance
how to exam hypoglossal nerve
Tongue movement - Stick tongue out and move side to side
how to exam Oculomotor nerve
When assessing pupils (eyes) it is important to assess the following:
- Size
- Shape
- Reactivity to light
- Comparison of one pupil to the other
normal size of pupils
2-6 mm
- assessment should occur after pupils have accommodated to room light
- Up to 20% have unequal pupils w/o pathology - “physiologic anisocoria”
Pathology that can affect pupillary size
previous eye injury or eye surgery
this pupil size is seen with opiate OD and pontine hemorrhage.
pinpoint
this pupil size may be seen with Horner’s syndrome, pontine hemorrhage, ophthalmic drops, metabolic coma, etc
small
normal if the person is in a bright room.
this pupil size are if pupils are mid position and nonreactive the cause is midbrain damage.
midposition
seen normally too
this pupil size may be seen with some drugs and some orbital injuries.
large
seen normally when the room is dark.
bilateral, fixed and dilated pupils are seen in the terminal stage of severe anoxia-ischemia or at death.
what type of pupil size
dilated
always an abnormal finding.
what specific drug can dilate pupils?
anticholinergics
usually represents the intermediate phase between normal and fully dilated-fixed pupil
what type of pupil shape
ovoid
Causes of ovoid
acute neurologic injury, complication of cataract surgery
often reacts sluggish to light
Causes - coloboma, iridectomy with cataract surgery
what type of pupil shape?
keyhole
this pupil shape is from traumatic orbital injury
irregular
pt had brisk constriction of the pupil with light exposure followed by dilation with removal of light source
how would their pupil reactivity be categorized as?
normal
sluggish pupil reactivity is from what?
conditions that compress the 3rd cranial nerve
Ex: cerebral edema, impending brain herniation
Nonreactive or Fixed pupil reactivity is from what?
more significant compression of the 3rd cranial nerve
Ex: herniation, severe hypoxia and ischemia
Alternating dilation and contraction of the pupil
Often associated with early signs of brain herniation or seizure activity
what is this pupil reactivity
hippus phenomenon
eyes blink periodically
eyes move smoothly and simultaneously in the orbital sockets
eyeball neither protrudes or is sunken into the eye socket
no ptosis
these EOM findings are considered what?
normal findings
abnormal EOM are considered what?
- weakness in specific line of gaze
- compression or damage to associated nerve/muscle - involuntary movements - nystagmus
When assessing motor function, from a neurological perspective, the assessment should focus on arm and leg movement. You should consider the following:
- Muscle size
- Muscle tone
- Muscle strength
- Involuntary movements
- Posture, Gait
what is the most important consideration when identifying focal findings.
Symmetry - Compare one side of the body to the other when performing your assessment
how to Observe the patient’s casual gait
best if patient is unaware of being observed
Posture, stride, stance, arm swing
Walking on heels and tiptoes
Tandem walking (heel to toe in a straight line)
Looking for asymmetry or unsteadiness of movements
pt had involuntary tendency for steps to accelerate and shorten while you were assessing gait
what type of abnormal gait did they exhibit?
shuffling
what is antalgic?
abnormal gait with limp associated with pain
pt had a unsteady, uncoordinated walk, with a wide base and the feet thrown out
what type of abnormal gait?
staggering aka ataxic
pt was lifting of their leg in an attempt to combat drop foot
what type of abnormal gait is this?
steppage
pt had involuntarily moves with short, accelerating steps, often on tiptoe
what type of abnormal gait?
festinating
pt had spasticity, leading to adduction of hip with knee flexion and plantar flexion
what type of abnormal gait?
scissors gait
pts gait had muscles on one side contracted, preventing the natural knee flexion
what type of abnormal gait?
spastic hemiparesis
the affected leg
pts gait had legs spread in an attempt to maintain balance
what type of abnormal gait?
wide-based
types of cerebellar testing
coordination
- 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
7 types of involuntary movements
- Tremor - unintentional trembling or shaking movement
- Myoclonus - rapid, shock like muscle jerks
- Chorea - rapid, jerky twitches, similar to myoclonus but more random in location
- Athetosis - slow movements of the limbs
- Ballismus - large amplitude flinging of the limbs
- Tics - abrupt, stereotyped, coordinated movements or vocalizations
- Dystonia - maintenance of an abnormal posture or repetitive twisting movements
what is the romberg test
- Assesses position sense
- 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.
during a romberg test the patient sways, but stops when the eyes are opened, what is your interpretation?
sensory ataxia
during a romberg test the pt had swaying which occurred and persisted once eyes are open
what is your interpretation
cerebellum ataxia
In a conscious patient, “drifting” in pronator drigt will occur if ?
one side is weak
Unilateral pronator drift suggests?
UMN lesion affecting the arm
how to document strength
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
types of Abnormal muscle tone
-
Hypertonia - resistance to passive movement - UMN lesion
- Spasticity (45 sec) - the limb moves freely for a short distance then “catches” requiring more force to move
- Rigidity - increased resistance throughout the movement
- Clonus - a rhythmic and involuntary muscle contraction that can be provoked by stretching a group of muscles - Hypotonia - decreased tone - LMN lesions and cerebellar disorders
- Paratonia - increased resistance that becomes less prominent when the patient is distracted - associated with both cognitive impairment and mental disorders
how to assess muscle tone?
- Ask the patient to let their legs ‘go floppy’.
- Internally and externally rotate the ‘floppy’ leg. Assess for any increased or reduced tone.
- 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
a pt had increased muscle tone and clonus, what would be your interpretation?
UMN lesion
a pt had decreased muscle tone, what is your interpretation?
LMN lesion
how to test 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
DTR activates _____ in the muscle triggering a sensory impulse that travels to the spinal cord via a peripheral nerve
This then directly synapses with the ________ innervating that muscle and causing the muscle to contract
sensory fibers
anterior horn
increased and decreasedDTR means what?
increased - UMN lesion - lesion of the brain or spinal cord
decreased - LMN lesion - lesion of the spinal nerve root, spinal nerve, plexus or peripheral nerve
grading/documentation of DTR
4 - very brisk, hyperactive, with clonus
3 - brisker than average; may be normal or associated with disease
2 - normal
1 - somewhat diminished; low normal
0 - no response
what are the DTR areas/nerves?
Biceps Tendon - C5,C6
Brachioradialis Tendon - C6
Triceps Tendon - C7
Patellar Tendon - L2 - L4
Achilles Tendon - S1
positive babinski test means?
central nervous system disorder - upper motor neuron lesion
- ALS, brain tumor, meningitis, MS, spinal cord injury, stroke
- temp in unconscious alcohol/drug intoxication and postictal periods following a seizure
babinski test is controlled by what nerves?
Controlled by L5,S1
Positive reflex is normal in who?
children up to 2 years
T/F: sensory exam can be performed with eyes closed or open
F: closed
Start distal and work peripherally
- unless assessing dermatomes
Compare sides
what assessments are part of the sensory exam
- Light touch
- Pain or temperature
- pain - sharp vs dull
- temperature - tuning fork immersed in cold water and dried - Proprioception (position sense)
- Vibration - using the 128 Hz tuning fork (low pitch)
- Discriminative sensations
- stereognosis, graphesthesia, 2-point discrimination, point localization - Dermatomes
what is the Glasgow Coma Scale
- The GCS is used to determine LOC
- Assesses
- eye opening
- verbal
- motor - Score from 3-15
what is Agnosia
- Inability to interpret sensations and and hence recognize things, despite intact sensations
- Results from damage to the occipital or parietal lobes of the brain
MC types of agnosia
inability to interpret sensations and hence to recognize things, typically as a result of brain damage.
Tactile
visual
auditory
prosopagnosia (unable to recognize faces)
autotopagnosia (unable to recognize own body)
topognosia (unable to localize tactile sensation)
causes of agnosia
inability to interpret sensations and hence to recognize things, typically as a result of brain damage.
stroke
dementia
head injury
brain infection
hereditary/developmental disorders
types of aphasias
- Broca’s/Expressive - speech is labored, effortful and nonfluent - comprehension is intact - lesion in posterior inferior frontal region
- Monophasia - limited to saying one word/phrase
- Wernicke’s - words are fluent, but devoid of meaningful content - lesion in posterior superior temporal region.
- Conduction - Unable to repeat statements which worsens with length of statement - lesion in deep white matter in supramarginal gyrus.
- Global - produce few recognizable words and understand little or no spoken language
A moderate loss of language impairment - comprehension is intact
Dysphasia
occasionally used to describe aphasia
Sometimes used to describe language delays in children
Inability to write not resulting from weakness, incoordination, or other neurologic dysfunction of the arm or hand
Agraphia
milder involvement may be referred to as dysgraphia
3 types of agraphia
- Aphasic - associated w/ aphasia
-
Constructional
- impaired visuospatial ability
- letters and words can be written correctly, but not arranged appropriately on a writing surface - Apraxic - distorted, slow, effortful, incomplete, and/or imprecise letter formation
causes of agraphia
- Central - stroke, brain lesion/tumor, traumatic brain injury, and dementia
- Peripheral - disruption in motor function involved with writing
Defined as the inability to perform learned (familiar) movements on command, in the absence of weakness, sensory loss, or other deficit
Apraxia
MC affected areas in apraxia
eyes, walking and talking
gait apraxia - difficulty initiating walking such as with Parkinson’s disease.
Apraxia of the eyelids - seen with blepharospasms
Defined as a decrease in muscle bulk or volume
If neurologic, usually affecting anterior horn cell, the nerve root, the peripheral nerve, or the muscle
Atrophy
neurologic causes of Atrophy
Carpal tunnel syndrome, nerve root impingement, muscular dystrophy, stroke
non-neuro causes of atrophy
Inactivity, immobilization, tendon tenotomy, muscle ischemia, malnutrition, endocrine disorders, and normal aging
An increase in the bulk, or volume, of muscle tissues.
Result from excessive use of the muscles (physiologic hypertrophy) or occur on a pathologic basis. Often associated with persistent abnormal muscle contraction
Hypertrophy
Myotonia congenita
Torticollis
Dystonias
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
causes: Stroke, mental status changes, Parkinson’s disease, ALS, myasthenia gravis, multiple sclerosis
Defined as difficulty swallowing
Caused by lower brain dysfunction
Usually associated with Multiple Sclerosis, Parkinson’s, or acutely, with stroke
Early assessment required due to high risk of aspiration
Dysphagia
Defined as a change in quality, volume, or pitch of voice
Often seen in Parkinson’s disease as hypophonia (low volume of voice)
Dysphonia
spasms of the vocal cords causing high pitch, strained, or squeaky voice
Spasmodic dysphonia
Impaired balance or coordination
Due to damage to brain, nerves, or muscles
ataxia
2 types of ataxia
- Cerebellar - can involve any of the limbs and/or gait. Can be found by examining coordination and gait
- Sensory - lack of proprioception which can cause gait imbalance or poor coordination that occurs or worsens with eyes closed
a condition of muscular weakness caused by nerve damage or disease
Paresis
types of 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
Loss or impairment of the power of voluntary movement
Usually associated with Parkinson’s Disease and other related movement disorders
akinesia
Defined as slow movement
Classic for Parkinson’s and often seen in patient with extrapyramidal symptoms
Problem arises from the basal ganglia
bradykinesia
Defined as abnormal involuntary movement
similar to being fidgety or restless
Hyperkinesia / Dyskinesia
- Defined as inability to sustain a stable posture
- Usually associated with hepatic encephalopathy, cirrhosis
- May also be associated with drug toxicity - 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
Asterixis
Increased sensitivity to sensory stimulus
hyperesthesia
types of hyperesethesia
- photophobia - sensitivity to bright lights
- phonophobia - sensitivity to loud sounds
-
allodynia - a sensation of pain from a stimulus that doesn’t cause pain
- Ex: light touch elicits painful sensation
Loss of sensation - used interchangeably with numbness
Anesthesia
- Decreased sensation
- Not the same a numbness/anesthesia)
- When examining a patient, you need to discern between numbness and hypoesthesia
Hypoesthesia
- Tingling, burning, and needles sensation in the skin
- Often associated with neuropathies, neuralgias or disorders of the spine
Paresthesia
types of pain
- Analgesia - lack of pain sensation
- Hypalgesia - decrease in pain sensation
- Hyperalgesia - exaggerated response to painful stimulus.
- Synonymous with allodynia
Ability to recognize writing on the skin without seeing it visually
Used to look for disorders associated with the parietal lobe, brainstem, spinal cord, thalamus, and sensory cortex
Graphesthesia
Inability to recognize an object by touch alone
Indicates a problem with the parietal lobe of the brain or dorsal column of the spinal cord
Astereognosis
Difficulty with judging distance, speed and power
Assessed by finger-to-nose
Patient will exhibit hesitation or miss the mark
Dysmetria
Inability to perform repetitive movements or rapid alternating movements
Seen in Parkinsonism or cerebellar disease
Dysdiadochokinesia
- Involuntary resistance to passive movement
- 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
rigidity
over responsive
Can be indicative of myopathic process, hyperthyroidism, serotonin syndrome
Sometimes a normal finding if symmetric
what type of reflex?
hyperreflexia
under responsive or absent
Can be normal
Can be associated with lower motor neuron disorder (i.e. peripheral neuropathy)
Also often associated with hypothyroidism
what type of reflex
hyporeflexia
