Ch 22 Flashcards
What does this: Motor cortex (voluntary skeletal movement, fine repetitive motor movements), Executive functions (Phineas Gage story)
frontal lobe
What does this:
Processing of sensory data, tactile sensations, visual, gustatory, olfactory, auditory sensations, proprioception
parietal lobe
What does this:
primary vision center, interpretation of visual data
occipital lobe
What does this:
perception and interpretation of sounds, integration of taste, smell and balance
Temporal Lobe
What does this:
Refine motor movements
Basal Ganglia
What are the parts of the cerebrum?
frontal lobe parietal lobe occipital lobe temporal lobe basal ganglia
What does this:
■ Integration of voluntary movement, control of muscle tone, balance, posture and production of steady and precise movements
■ Integrates multiple inputs: Motor Cortex, Vestibular System, Sensory input from eyes, ears, touch, musculoskeletal system
Cerebellum
What does this:
Controls many involuntary functions see Table 22-1. Contains the nuclei of the 12 Cranial nerves.
Brainstem
What is the acronym for the cranial nerves?
ooo to touch and feel ariels glistening violin at home
olfactory, optic, oculomotor, trochlear, trigeminal, abduces, facial, acoustic, glossopharynngeal, vagus, spinal Accessory, hypoglossal
What are the two sensory tracts?
Dorsal posterior columns and spinothalamic tracts
What are the motor tracts?
lateral corticospinal tract, rubrospinal tract, reticulospinal vestribulospinal tracts anterior corticospinal
The spinal cord begins as it exits the (blank) and terminates around (blank)
skull
L1 and L2 vertebral column (important for lumbar punctures, spinal anesthesia).
What does this describe?
Nerve cell bodies, the butterfly-shaped center of the cord, consists of anterior and posterior horns (contain nerve cell bodies of autonomic and sensory neurons).
gray matter
What does this describe?
Nerve Tracts, ascending and descending
o Dorsal Column (ascending tracts called the fasiculus gracilis and fasciulus cuneatus) transmit Touch, vibration, and proprioception (TVP)
o Spinothalamic Tracts (ascending tracts) transmit Pain and Temperature (P&T)
o Corticospinal Tracts (Descending tracts) conduct signals of skilled, delicate, and purposeful movements.
White matter
What are the 1 column and the 2 tract of the white matter?
dorsal column, spinothalamic tracts, corticospinal tracts
What does this:
ascending tracts called the fasiculus gracilis and fasciulus cuneatus) transmit Touch, vibration, and proprioception (TVP)
dorsal column
What does this:
ascending tracts) transmit Pain and Temperature (P&T
spinothalamic tracts (ascending tracts)
What does this
(Descending tracts) conduct signals of skilled, delicate, and purposeful movements.
corticospinal tracts (descending tracts)
What is this important for?
○ Has this ever happened before, acute or insidious onset, what was the patient doing at the time of the event, worsening or improvement of symptoms, time of day, exact time of symptom onset, stresses, anxiety, depression, etc.
HPI (sequence of events leading up to complaint and thereafter
What are these important for:
sequence of events (aura, activities preceding event, loss of consciousness, fall, automatism, muscle tone, postictal behavior), relationship of seizure to day/activity/etc., frequency, medications
seizures
What are these important for:
loss of balance, falling in one direction, leg weakness, associated problems, rheumatoid arthritis, ataxia, stroke, seizure, arrhythmias, sensory changes, medications.
gait problems
What are these important for:
onset, character (generalized or specific area, transient or progressively ascending, proximal/distal extremities, unilateral/bilateral, hypersensitivity), associated symptoms (tingling, numbness, pain, spasms), concurrent chronic illness (HIV, nutritional/ vitamin deficiency), medications.
Weakness or parasthesia
(blank) is a sensation of tingling, tickling, prickling, pricking, or burning of a person’s skin with no apparent long-term physical effect.
paresthesia
What is this important for:
acute/chronic, timing, associated disorders, EtOH, drugs, medications, associated symptoms such as hallucinations or delusions, trauma, fever/infection
Disorientation and confusion
What is this important for:
SIGECAPS to screen for depression, Beck Depression Inventory (BDI), Geriatric Depression Scale, etc, rule out suicidal or homicidal ideation.
Disorientation and Confusion
What is this important for:
Onset of memory loss (recent, chronic), worsening or progressive, types of things forgotten, ability to perform activities of daily living (ADL’s) , level of concern of patient and/or family members, screen for depression.
memory loss
What is this important for:
Onset (sudden or gradual), Character (worse with rest, intentional movement, anxiety), unilateral or bilateral, body location, interference with daily activities, associated problems (hyperthyroidism, familial tremor, alcohol consumption, multiple sclerosis), relieved by rest/activity/alcohol, medications.
Tremor
Who is this important for: prenatal hx (mother’s health, meds, infections, exposures (TORCH), trauma, HTN, alcohol), birth hx (apgar score, fetal distress, birth weight), respiratory status at birth, neonatal health (jaundice, infection, seizures, poor coordination, congenital anomalies.
infants
Who is this important for:
developmental milestones, loss of previously achieved function, performance of self-care activities (dressing, feeding, toileting), health problems (headaches, seizures, clumsiness, progressive muscular weakness, inability to go up and down stairs).
Children
Who is this important for:
weeks of gestation, convulsions/ headache, h/o pregnancy induced hypertension, nutritional status.
pregnant women
Who is this important for:
increased pattern of falls, safety in home, interference of daily activities, hearing/ vision deficits, development of tremor (anxiety, alcohol), fecal/ urinary incontinence, transient neurological deficits (TIA).
Elderly
What is this important for:
• Trauma, meningitis, encephalitis, congenital anomalies, HTN, stroke, aneurysm, neurologic disorder, brain surgery, residual effects.
• Psychiatric disorders: Anxiety, depression, psych medication history
• Surgery/hospitalizations (brain or spinal cord surgery)
• Medications
• Drug Allergies
PMH
What is this important for:
• Environmental/ occupational hazards (lead, arsenic, insecticides, organic solvents, etc.), sleep, eating patterns, alcohol use, tobacco, drugs.
• If Sexually active and STD history (e.g. Neurosyphilis, HIV related dementia)
• Daily living activities and ability to care for self, home support.
Social history
What is a Formal screening tool that assesses several domains such as: Orientation, Registration, Attention and Calculation, Language
Folstein Mini Mental Status Exam MMSE
How many points is the MMSE out of?
30
What does greater than 25 points on the MMSE denote?
normality
What does 21-24 points on the MMSE tell you?
mild cognitive impairment
What does 10-20 on MMSE tell you?
moderate cognitve impairment
What does less than 9 on a MMSE tell you?
severe cognitive impairment
What can be used to screen dementia, and may prompt more formal neuropsychologic evaluation. Note that level of education and language skills may factor into scores.
MMSE
What does this test for?
close eyes, occlude one nare, test 2-3 familiar odors bilaterally, with rest periods in between (essential oils, lip gloss, coffee beans)
cranial nerve I
What does this test for?
(optic): visual acuity testing, pupils reactive to light , confrontation visual fields
Cranial nerve II, some III
What does this test for?
o Movement through 6 cardinal motions
o Pupil size, reactive, shape, accomodations
III (oculomotor) *also tests IV, VI
What is this important for?
SO4 and LR6?
IV trochlear cranial nerve
What does this test for?
o Inspect: observe atrophy, deviation of face, fasciculations
o Palpate: clenched teeth, palpate the muscles over the jaw, should be symmetric with no fasciculations
o Sensation
3 divisions: ophthalmic (V1), maxillary (V2), mandibular(V3)
Evaluate for sharp, dull, and light touch sensation
o patient closes eyes, in an unpredictable manner test each area of the trigeminal distribution alternating a sharp and dull stimuli
o Alternatively: use one stimuli like a finger or tongue depressor
o With impairment you need to test temperature sensation with hot and cold water in some container
o Corneal reflex: patient looks up and away, lightly touch the cornea with a cotton wisp
Should see an equal blink reflex
Absent in contact lens wearers
Cranial nerve 5 (facial sensation)
What does this test for?
first CN to lose function in the presence of increased intracranial pressure! See above for examination
cranial nerve VI (abducens)
What does this test for?
facial movement
o Inspect: eliciting facial expressions (frown, smile), blow cheeks out
o Taste: 4 solutions with applicators, patient with eyes closed samples the taste and ID’s it, applying one taste at a time to the lateral side of the tongue
taste regions: from anterior to posterior – sweet, salty, sour, bitter
facial movement
o Inspect: eliciting facial expressions (frown, smile), blow cheeks out
o Taste: 4 solutions with applicators, patient with eyes closed samples the taste and ID’s it, applying one taste at a time to the lateral side of the tongue
taste regions: from anterior to posterior – sweet, salty, sour, bitter
Cranial nerve VII (facial)
What does this test for?
audiometer and hearing tests
cranial nerve VIII (acoustic)
What does this test for?
(glossopharyngeal): taste over the posterior 1/3 of the tongue
o Gag reflex (tested simultaneously with the vagus)
cranial nerve IX (glossopharyngeal)
What does this test for?
o Nasopharyngeal sensation- gag reflex. Touch the posterior wall of the pharynx with applicator, watch for upward movement of the uvula, should remain midline
o Say “ah” to watch for symmetry of the soft palate
o Water sip and swallow to watch for complete passage of water, no retrograde passage of water through the nose
o Listen to patient speech
Cranial nerve X (vagus)
What does this test for?
o Shoulder shrug (controls the trapezius and sternocleidomastoid muscles)
Cranial nerve XI (spinal accessory)
What does this test for?
o Inspect tongue at rest, tongue as it protrudes from mouth, movement of tongue in and out of mouth, side to side
Cranial nerve XII (hypoglossal)
What is the Rinne and Weber test?
differentiates between conductive and sensorineural hearing loss
when patients have an issue with taste what is the culprit? Which is normal AC or BC being greater?
olfactory senses
AC
When assessing motor function what does 0/5 mean 1 2 3 4 5
0=no movement
1=barest flicker of movement of the muscle, though not enough to move the structure to which its attached
2= voluntary movement which is not sufficient to overcome the force of gravity.
3=voluntary movement capable of overcoming gravity, but not applied resistance.
4= voluntary movement capable of overcoming “some” resistance
5=normal strength
What are the primary sensory functions?
Superficial touch, pain, temperature and deep pressure, vibration
What are the four cortical sensory ways to access function?
stereognosis
two point discrimination
graphesthesia
point location
(blank) is the Ability to identify an object by touch in hand
stereognosis
(blank) may indicate a parietal lobe lesion
tactile agnosia
(blank) is when you touch a person in two separated spots simultaneously with two pins and ask how many stimuli are felt
Two point discrimination
(blank) is when you Draw on a part of the body with cotton applicator stick and ask patient to identify the figure
graphesthesia
(blank) is when you Touch a point on the skin and remove the stimulus, then ask the patient to identify the spot touched
point location
What are the three superficial reflexes?
abdominal reflex, cremasteric reflex, plantar reflex
What reflex is this
stroke each quadrant of abdomen, looking for muscle contraction
abdominal reflex
What reflex is this
stroke inner thigh of male, looking for elevation of scrotum
cremasteric reflex
what reflex is this?
stroke bottom of foot, looking for toe flaring (Babinski sign) or flexing
plantar reflex
Is it normal to see a babinski sign in infants up to 6-24 months?
Yes ( abnormal after 2 years)
What do you test with the deep tendon reflexes (DTR)?
Brachioradialis, biceps, triceps, patellar, achilles
What is the grading scale of reflexes?
0=no evidence of contraction
1+= decreases but still present (hypo-reflexic)
2+=normal
3+=super-normal (hyper reflexic)
4+ clonus-repetitive shortening of the muscle after a single stimulation
What are the 3 main things you are assessing in cerebellar function?
Rapid rhythmic alternation movements
Accuracy of movements
Balance
Whats this for
■ Both hands palm down in lap, turning palms up and down in rapid succession
■ Each hand individually; have the patient touch the thumb to each finger of the same hand in order, gradually increasing speed
rapid rhythmic alternation movement
Whats this for
■ With eyes open, place finger 18 inches from their face and have them touch their finger to their own nose and then to the tip of your finger; do this in rapid succession while examiner moves their finger
■ Heel to shin test - have patient rub heel of one foot up and down the shin of the other leg
Accuracy of movements
Whats this for
Romberg test: feet together, arms at sides, eyes closed
○ be sure to be close enough to catch them
● stand on one foot with eyes open
● hop on one foot
Equilibrium
Whats this for;
● watch for spastic hemiparesis, spastic diplegia, teppage gait, cerebellar ataxia, sensory ataxia
gait
how do you distinguish between upper and lower neuron disease affecting the face?
upper=voluntary movements are paralyzed by emotional movements are spared
lower- all facial movements on the affected side are paralyzed
