Block 5 - Neurology Flashcards
What 4 questions should you ask yourself with any neurological complaint?
1) Where is the anatomical location of the lesion?
2) What is the underlying pathophysiology?
3) What are my differential diagnoses?
4) Which tests will be most appropriate to reach a definitive diagnosis?
Neurological History Protocol? (6)
Neurological History
1. Introduction
2. Presenting Symptoms
3. Past Medical History
4. Treatment/Medications
5. Allergies
6. Social History
4. Family History
5. Review of Systems
6. Collateral History
11 Neurological Complaints?
Neurological History - Presenting Complaints
1. Weakness
2. Gait disturbance
2. Altered sensation
3. Alterned balance
3. Headache
4. Symptoms of raised intracranial pressure
5. Scalp sensitivity + associated visual problems
6. Seizure
7. Sphincter disturbance – constipation, obstipation, faecal incontinence, urine retention or incontinence.
8. Vision, swallow or speech problems?
9. Other - WEIGHT LOSS? INFECTIVE SYMPTOMS? FEVER?
7 Risk factors for cerebrovascular disease?
**Risk factors for cerebrovascular disease
**1. Hypertension
2. Smoking
3. Diabetes mellitus
4. Hyperlipidaemia
5. Atrial fibrillation, bacterial endocarditis, myocardial infarction (emboli)
6. Haematological disease
7. Family history of stroke
What questions about a patient’s past medical history should you ask about in a Neurological History? (13)
Neurological History - Past Medical History
Chronic diseases commonly have neurological complications. For example peripheral neuropathy may be caused by:
1. Diabetes Mellitus
2. HIV
3. SLE
4. Alcohol excess to name but a few.
5. General – medical - active/inactive
6. General surgical
7. Hypertension
8. Smoking
9. Atrial fibrillation
10. Haematological disease
11. Fits/faints/funny turns?
12. Visual problems?
13. Sexually transmitted infections? (neurosyphilis)
What questions about a patient’s family history should you ask about in a Neurological History? (5)
Neurological History - Family History
1. Chronic neurological diseases
2. Unexplained deaths/symptoms?
3. Vascular risk factors – CVA
4. Hypertension
5. DM etc.
5. Malignancies?
What questions about a patient’s medications should you ask about in a Neurological History? (5)
Neurological History - Medications
1. Prescribed
2. Over the counter
3. Alternative
4. Allied health- e.g. physiotherapy.
5. ANTICOAGULANTS??
What questions about a patient’s Social History should you ask about in a Neurological History? (7)
Neurological History - Social History
1. Occupation
2. Home life – lives with?
3. Independence for ADL’s, OT/physio input previously?
4. Stresses at home/work
5. Smoking – pack years
6. DRUGS OR ALCOHOL?
7. Country of origin
If a patient presents with weakness/gait disturbance, which 7 specific things should you ask about in the history?
- 13 questions to ask the patient with muscle weakness?
**Neurological History - Weakness/Gait disturbance
**
1. Define site
2. Symmetry
3. Severity
4. Constancy
5. Temporal course
6. Onset speed
7. Previous episodes.
If a patient presents with weakness/gait disturbance, which 8 specific things should you ask about in the history?
Neurological History - Altered sensation/balance
1. Site
2. Symmetry
3. Tingling or numbness
4. Progression
5. Precipitants/relieving factors.
6. Temporal course
7. Speed of onset
8. Previous episodes?
If a patient presents with headaches, which 6 specific things should you ask about in the history?
Neurological History - Headache - SOCRATES - PLUS:
1. Light, and noise sensitivity?
2. Neck stiffness/pain?
3. Vomiting?
4. FEVER?
5. Symptoms of raised intracranial pressure – Effect of cough/sneeze/lying down, worse in morning, relieved by upright positioning.
6. Scalp sensitivity, associated visual problems (temporal arteritis)
What questions should you ask a patient who presents with seizure(s)?
Neurological History - Seizure
1. Details of what pt remembers
2. Pre-ictal – warning
3. Nausea
4. Noises/lghts
5. What was pt doing?
6. Post ictal (confused, lethargic, where did they wake up?) WITNESS HISTORY.
7. Head trauma?
11 QUESTIONS TO ASK THE (NON- APHASIC) PATIENT WITH A POSSIBLE STROKE OR TRANSIENT ISCHAEMIC ATTACK?
15 QUESTIONS TO ASK THE PATIENT WITH A POSSIBLE NEUROLOGICAL PROBLEM?
12 QUESTIONS TO ASK THE PATIENT
WITH HEADACHE?
What are 6 abnormal movement types which are suggestive of a seizure?
11 QUESTIONS TO ASK THE PATIENT WITH DEFINITE OR SUSPECTED EPILEPSY?
4 Differentials for vertigo?
Headache History Protocol? (6)
Headache History Protocol
1. Introduction
2. Presenting Symptom
3. Past Medical History
4. Treatment/Medications
5. Allergies
6. Social History
Which associated symptoms should you enquire about with a patient presenting with headache?
Headache - Associated symptoms:
1. Nausea and Vomiting
2. Altered conscious state
3. Fits, faints, Funny turns
4. Paraesthesia
5. Motor disturbance
6. Altered vision
7. Altered smell
8. Altered hearing
9. Fever
10. Light sensitivity
11. Noise sensitivity
12. Neck Stiffness
13. Rash
14. Weight loss
15. Loss of appetite
Which 4 medications should you enquire about in patient presenting with headache?
Medications:
1. OCP
2. Anticoagulants
3. Antihypertensives (CCBs)
4. Steroids
5 Things to ask about in the social history of headache history taking?
Headache History Protocol
Differentials for headache?
3 primary?
14 secondary?
Primary Headaches
1. Tension
2. Migraine
3. Cluster
Secondary Headaches
1. Meningitis
2. Intracerebral haemorrhage
3. Subarachnoid haemorrhage
4. Subdural haematoma
5. Epidural haematoma
6. Cerebral venous sinus thrombosis
7. Giant cell arteritis
8. Hypertensive crisis
9. Ischemic stroke
10. Intracranial space occupying lesion - eg. tumour
11. Concussion
12. Acute angle-closure glaucoma
13. Trigeminal neuralgia
14. Medication overuse
Cranial Nerve Exam Protocol? (12)
Cranial Nerve Exam Protocol
1. Introduction
2. Exposure and Positioning
3. Inspection
4. I Olfactory
5. II Optic = Visual acuity, Visual fields, fundi
6. III, IV VI Oculomotor, Trochlear, Abducens = Pupils, Accommodation, Eye movements.
7. V Trigeminal = Facial sensation, Masseter and temporal muscles, corneal reflex
9. VII Facial = droop? power?
10. VIII Acoustic = Whisper, Rinnes, Webers, (Hallpikes)
11. IX, X, Glossopharyngeal, Vagus = Uvula, Gag, Voice, Cough, Sip Water
12. XI Accessory = Trapezius, Sternocleidomastoid
13. XII Hypoglossal = Stick out tongue
14. Other = KERNIGS & BRUDZINSKI for neck stiffnes & Rash?
Cranial Nerve Exam - Introduction, Exposure and Positioning?
**Cranial Nerve Exam - Introduction **
1. Introduces self
2. Washes hands
3. Explains examination & gains verbal consent
4. Confirms Name & Age
5. Shakes hand, assessing handedness
Exposure and Positioning
Sitting upright if well, with legs over side of bed if possible
“Hi, my name is Kitty, I’m a second year medical student from the University of Notre Dame. I’ve been asked to come and examine your cranial nerves. These are the nerves in your head and neck that control our senses like seeing, hearing, taste and swallowing. Is that ok with you? The exam shouldn’t take to long and if at any point you feel uncomfortable we can stop. Before we get started please can I confirm your Name & Age? Is there anything I can get you before we start to make you more comfortable?
Perfect, please can you hop up onto the bed, facing me with your legs hanging over the edge. Thank you. As we go along I will just relay my findings to the doctor but if you need to please feel free to interrupt.”
Cranial Nerve Exam - General Inspection? (6)
Cranial Nerve Exam - General Inspection
1. General Condition – well/unwell?
2. Septic/rash?
3. Conscious level (GCS score if pt obtunded)?
4. Facial asymmetry?
5. Facial/neck masses?
6. Face/neck surgical scars?
Cranial Nerve Exam - How do you test CNI?
Cranial Nerve Exam - CNI: Olfactory
“We will start with the first cranial nerve, the olfactory nerve. Have you noticed any changes in your sense of smell recently?”
If yes - coffee/orange test
Cranial Nerve Exam - How do you test CNII?
Cranial Nerve Exam - CNII: Optic
1. **Visual acuity **– Snellen chart stand: 6ms away and read lines one eye at time with glasses
2. Visual fields – direct confrontation, testing each quadrant and central vision in each eye. - Cover same side eye to the patient and 4 times bring your finger out and into the visual field. “I’m going to cover the same eye as you and I want you to tell me when you can see my red pin.”
3. Fundi (ophthalmoscopy) -right eye examiner into right eye patient and left into left - raised ICP? Hypertensive retinopathy?
Cranial Nerve Exam - How do you test CNs III, IV & VI?
- 4 things to assess?
Cranial Nerve Exam = III - Oculomotor, IV - Trochlear, VI - Abducens
1. Pupils – size and symmetry, direct and consensual light reflex.
2. Accommodation – move finger from a distance towards patient. Pupils constrict and converge.
3. Eye movements – full range, conjugate. Move hat pin/pen in H shape ask patient to report diplopia. Image separation is maximal where affected muscles action is purest.
4. Ptosis.
How do you assess CNV? (4)
**Cranial Nerve Exam - V: Trigeminal **
1. Facial sensation – ophthalmic, maxillary, mandibular divisions
2. Masseter and temporal muscles – Clench teeth, palpate masseters.
3. Masseter reflex (Jaw jerk).
4. Corneal reflex (only test on real patients with a genuine possibility of abnormality)
How do you assess CNVII? (2)
Cranial Nerve Exam - CNVII: Facial
1. Facial droop
2. Test muscle power – show teeth/smile, close eyes tight, raise eyebrows to ceiling. (UMN lesion - forehead is spared)
How do you assess CNVIII? (5)
Cranial Nerve Exam - CNVIII: Acoustic
1. Whisper in each ear = ‘I’m going to whisper a number in your ear and I want you to tell me what it is. 99 and 33”
2. **Rub fingers moving away from ear until pt cannot hear it **= “Let me know when you can no longer hear me rubbing my fingers.”
3. Rinnes Test = Tuning fork (512Hz) on mastoid bone until they can no longer hear then infront of ear until it stops
4. Webers tests = Place tuning fork (512Hz) on centre of forehead. If it’s heard louder on one side - that is the side with conductive hearing loss.
5. If complains of vertigo – Hallpikes manoeuvre
How do you assess CNIX & X? (5)
Cranial Nerve Exam - IX = Glossopharyngeal & X = Vagus
1. Open mouth inspect uvula, ask patient to say ‘Ah’ - uvula deviates towards side of lesion
2. Gag reflex/touch sides of pharynx, ask if sensation present
3. Quality of voice
4. Ask patient to cough.
5. Swallow sip of water
Which 5 other things should you consider examining in a cranial nerve exam?
Cranial Nerve Exam - Other
1. Perform Peripheral nervous system examination.
2. Movement, Higher functioning
3. Mental state examination
4. Test for neck stiffness - Kernigs and Brudzinski if present.
5. Examine for rash.
KERNIGS – with patient lying flat perform passive hip flexion with knee flexed. Then extend the knee. This will elicit pain in meningeal irritation
BRUDZINSKI – patient lying flat, place one hand behind head and other on chest to restrain patients thorax. Lift patient’s head off bed. Positive when patient’s legs flex
Name the 12 Cranial Nerves.
Which cranial nerves have motor, sensory or both functions?
Cerebellar Exam Protocol? (10) = IEIESATLGO
Cerebellar Exam Protocol
1. Introduction
2. Exposure and Positioning
3. Inspection
4. Eyes
5. Speech
6. Arms
7. Trunk
8. Legs
9. Gait
10. Other
Cerebellar Exam Protocol - Introduction & Exposure and Positioning?
Cerebellar Exam Protocol - Introduction & Exposure and Positioning
“Hi, my name is Kitty and i’m a second year medical student from the university of Notre dame. I’ve been asked to come and examine you for any cerebellar problems. The cerebellum is the area of the brain that controls things like coordination, how our eyes move and how we speak. So i’ll be testing to make sure they are all normal. It shouldn’t take long and if you’re uncomfortable at any point we can stop. Does that all sound ok?
Before we get started please can I confirm your name and age? Great thank you for that. I’ll just get you to sit up on the bed facing me with your legs hanging over the edge if thats ok?”
Cerebellar Exam Protocol - General Inspection? (5)
Cerebellar Exam Protocol - General Inspection
1. General Condition: well/unwell
2. Walking aids
3. Obvious limb weakness
4. Tremor
5. Facial asymmetry
Cerebellar Exam Protocol - Eyes? (1)
Cerebellar Exam Protocol - Eyes
1. Nystagmus – ‘follow my finger with your eyes’ move finger in horizontal and vertical planes. (Nystagmus will be elicited in everyone at extremes of lateral gaze). Direction of fast movement is side of lesion
Cerebellar Exam Protocol - Speech? (1)
Cerebellar Exam Protocol - Speech
1. Dysarthric speech – ‘West register street’, ‘baby hippopotamus’ usually said to have abnormal scanning speech not slurred
Cerebellar Exam Protocol - Arms? (4)
- Where is the lesion if the pathology is unilateral?
Cerebellar Exam Protocol - Arms
1. Drift – Raise arms out in front with palms facing up and eyes closed, look for arm drift due to hypotonia which only occurs in very acute cerebellar lesions. Examine for tone in the usual way when appropriate
2. Intention tremor and past pointing – ‘Move index finger of right hand from your nose to my finger as quickly and as accurately as you can’ check both sides
3. Dysdiadochokinesis – Ask patient to turn hand over on palm of opposite hand as fast as possible. Check both sides
4. Rebound - Raise arms rapidly from sides then stop – inability to stop
(Drift and rebound will also occur in proprioceptive lesions)
(Ipsilateral cerebellar lesion, unless bilateral disease)
Cerebellar Exam Protocol - Trunk? (2)
Cerebellar Exam Protocol - Trunk
1. Ask to sit unsupported on side of bed (if previously lying down) note imbalance
2. Check knee reflexes whilst sat up (pendular)
Cerebellar Exam Protocol - Legs? (3)
- Where is the lesion if the pathology is unilateral?
Cerebellar Exam Protocol - Legs
1. Check tone
2. ‘Run heel of left foot down right shin’ check both sides
3. Toe to finger tapping
Cerebellar Exam Protocol - Other? (4)
Cerebellar Exam Protocol - Other
1. Cranial and Peripheral nerve examination
2. Vascular exam if suspect CVA
3. Peripheral signs of malignancy
4. At completion of respiratory exam
7 Causes of Anosmia?
Peripheral Nervous System Examination Protocol - Upper limbs? (11)
Peripheral Nervous System Examination Protocol - Upper limb
1. Introduction
2. Exposure & Positioning
3. General Inspection
4. Pronator drift + rebound
5. Tone - wrist, hand, elbow
6. Power - shoulder, elbow, wrist, fingers
7. Reflexes - biceps, triceps, supinator, finger jerk
8. Coordination - finger nose & dysdiadochokinesis
9. Sensation - temperature, light touch, vibration, proprioception
10. Functional - button up shirt, write with a pen
11. Additional
Peripheral Nervous System Examination Protocol - Introduction & Exposure and Positioning?
Peripheral Nervous System Examination Protocol - Introduction & Exposure and Positioning
1. Introduces self
2. Washes hands
3. Explains examination and gains consent
4. Confirms name & age
5. Shakes hand - myoclonus/weakness
“Hi, my name is Kitty, I’m a second year medical student. I’ve been asked to come and examine your upper limbs for any problems. This will involve me having a look at how they move and checking your reflexes and sensation. Does this all sound ok to you? Before we get started please can I confirm your name and age?
Are you in any pain at all? Please can you sit on the bed with your legs hanging over the end? I will need to see your arms if thats ok to remove your shirt?”
Peripheral Nervous System Examination Protocol - Inspection? (9)
Peripheral Nervous System Examination Protocol - Inspection
1. General Condition: well/unwell
2. Conscious level
3. Rash
4. Cachectic
5. Walking aid
6. Muscle wasting
7. Fasciculation
8. Tremor
9. Scars
Peripheral Nervous System Examination Protocol - Upper Limb?
- How do you assess pronator drift?
- 3 Causes of arm drift?
Peripheral Nervous System Examination Protocol - Upper Limb?
- How do you assess tone in the upper limbs? (3)
Peripheral Nervous System Examination Protocol - Upper Limb
Tone
1. flexion/extension at wrist
2. supinate/pronate hand
3. flexion/extension at elbow
Peripheral Nervous System Examination Protocol - Upper Limb?
- How do you assess power in the upper limbs? (4)
Peripheral Nervous System Examination Protocol - Upper Limb
Power:
1. Shoulder abduction & adduction
2. Elbow flexion, extension
3. Wrist flexion, extension
4. Fingers – flexion, extension, abduction, thumb abduction
Peripheral Nervous System Examination Protocol - Upper Limb?
- Which reflexes should you check in the upper limbs? (4)
- Which nerve roots are they testing?
Peripheral Nervous System Examination Protocol - Upper Limb - Reflexes
1. Biceps (C5,C6) - one finger on antecubital fossa
2. Triceps (C6,C7) - arm across patient
3. Supinator (C5,C6) - 2 fingers over distal radius
4. Finger jerk (C8) - loosely grip the patients fingers in yours and tap your own fingers
Peripheral Nervous System Examination Protocol - Upper Limb?
- How do you assess coordination? (2)
- How do you assess sensation? (4)
- Dermatomes?
Upper Limb Neuro Exam
Co-ordination
1. Finger nose - remember pt must reach
2. Dysdiadochokinesis - hand pronate/supinate with speed
Sensation
1. Spinothalamic tracts – pain, temperature, light touch with cotton wool
2. Posterior columns – vibration (128 Hz on distal finger joint, eyes closed until it stops) and proprioception (eyes open, show pt fingers up and down then eyes closed and ask if the finger is up or down)
Get patient to close eyes when testing light touch - place on chest first then on the upper arm (C5), outside forearm (C6), index finger (C7), inside forearm (C8), inside upper arm (T1).
Grading for power in neuro exam?
Classification of muscle stretch reflexes?
Peripheral Nervous System Examination Protocol - Lower Limb? (9)
Peripheral Nervous System Examination Protocol - Lower Limb
1. Inspections
2. Tone - log roll & leg drop & ankle clonus
3. Power - Hip (4), Knee (2), ankle (2), tarsal joint (2)
4. Reflexes - knee, ankle, plantar (babinski)
5. Coordination - heel/shin & foot tapping
6. Sensation - pain, temp, light touch, vibration & proprioception
7. Saddle sensation/anal tone as needed
8. Gait - walk, turn around quickly, heel-toe, tippy-toes, heel walk, squat
9. Romberg’s
Dermatomes for lower limbs?
Locomotion (Parkinsonism) Examination Protocol? (10)
Locomotion (Parkinsonism) Examination Protocol
1. Introduction = 5
2. Exposure and positioning
3. General inspection = 4
4. Gait = 7
5. Face = 3
6. Upper Limbs = 5
7. Speech = 3
8. Handwriting = 1
9. Parkinson’s Plus = 1
10. Other = 3
Locomotion (Parkinsonism) Examination - Introduction, Exposure and positioning?
Locomotion (Parkinsonism) Examination - Introduction, Exposure and positioning
1. Introduces self
2. Washes hands
3. Explains exam & gains consent
4. Shakes patient’s hand
5. Confirms name and age
“Hi, my name is Kitty I’m one of the medical students. I’ve been asked to come and examine you for any problems you might have with locomotion or Parkinsons. This will involve me having a look at how you walk and move around, your eye movements, your speech and your hand movements. Does this all sounds ok to you?”
“Great, before we get started please can I confirm your name and age? And are you in any pain at all? Is there anything I can get to make you more comfortable? Are you able to walk safely without an aid? Do you feel well enough to sit up?
Locomotion (Parkinsonism) Examination - General Inspection? (4)
Locomotion (Parkinsonism) Examination - General Inspection
1. General Condition: well/unwell.
2. Limb weakness/paralysis.
3. Tremor or other extra movements.
4. Walking aids
Locomotion (Parkinsonism) Examination - Gait? (4)
- What are you looking for when they walk?
Locomotion (Parkinsonism) Examination - Gait
1) Ask to walk in straight line, turn quickly and walk back again and stop - looking for:
1. Shuffling
2. Festination
3. Increased number of steps on turning
4. Imbalance
5. Drift
2) Walk heel to toe if possible
3) Explain that you would perform Retropulsion – pull pt backwards by shoulders whilst standing behind to catch them if they fall. Generally would describe to examiner rather than do
4) In a clinical setting “timed get up and go”
Locomotion (Parkinsonism) Examination - Face? (3)
Locomotion (Parkinsonism) Examination - Face
1. Lack of facial expression
2. Head titubation
3. Glabellar tap (tap on forehead with finger out of vision of patient. Positive when ongoing blink response to tapping)
Locomotion (Parkinsonism) Examination - Upper Limbs?
Locomotion (Parkinsonism) Examination - Upper Limbs
1. Observe hands in lap
2. Tremor – ‘pill rolling’? Resting?
3. Tremor - Increases with distraction? (Ask pt to do serial 7’s) postural?
4. Tremor - On intention? (Nose to finger testing)
5. Fine motor/bradykinesia – finger tapping on desk ‘as though playing the piano’
6. Assess tone at wrist and elbow (cog-wheeling, lead pipe rigidity) assess symmetry - passive movements
Locomotion (Parkinsonism) Examination - Speech? (3)
Locomotion (Parkinsonism) Examination - Speech
Ask the patient a question about their life in general as you are assessing upper limb tone - eg. Ask the patient how their day has been so far? How they got into hospital? What they would normally be doing on a ‘Tuesday’? History of their symptoms?
Check speech:
1. Monotonous
2. Quiet
3. Palilalia (repeating end of word)
Locomotion (Parkinsonism) Examination - Handwriting? (1)
Locomotion (Parkinsonism) Examination - Handwriting
Ask the patient to write “The dog went to the park.” followed by their name and address.
- Look for micrographia
Locomotion (Parkinsonism) Examination - Parkinson’s Plus? (3)
Locomotion (Parkinsonism) Examination - Parkinson’s Plus
1. Eye movements - H pattern = loss of vertical (Idiopathic parkinsons) & loss of vertical and horizontal (progressive suprnuclear palsy)
2. Autonomic dysfunction - BP on lying and standing & feel brow for sweatiness
3. MMSE for dementia
Speech & Higher Centres Examination Protocol?
**Speech & Higher Centres Examination Protocol **
1. Introduction
2. Exposure and Positioning
3. General Inspection
4. Language
5. Mouth
6. Parietal Lobe
7. Temporal Lobe
8. Frontal Lobe
9. Cranial Nerves and PNS
10. Other
