Ch3. Neurology Approach Flashcards
A) Clinical features of neuromuscular junction disease can be elicited by history?
B) what findings can be expected on physical examination?
A) Fatigability is the hallmark of diseases affecting the neuromuscular junction, such as myasthenia
gravis. Strength improves with rest, fatigability does not usually manifest as a steadily progressive
decline in function.
B) Fatigable proximal symmetric weakness without sensory loss. Repetitive testing weakens the muscles. Muscles are normal in size, without atrophy or fasciculations, with normal tone and reflexes. Weakness is extremely proximal, involving muscles of the face, eyes (ptosis).
Which clinical features of peripheral neuropathies can be elicited by history?
Distal leg weakness: Does the patient trip, drag the feet, or wear out the toes of shoes?
• Distal arm weakness: Does the patient frequently drop things or have trouble with the grip?
• Denervation changes: Is there a wasting or shrinkage of the muscle (atrophy) or quivering and
twitching within the muscle (fasciculations)?
• Sensory changes: Has the patient felt numbness, tingling, or paresthesia?
Which clinical features of muscle disease can be elicited by history?
- Proximal leg weakness: Can the patient get out of a car, off the toilet, or up from a chair without using the hands?
- Proximal arm weakness: Can the patient lift or carry objects, such as grocery bags, garbage bags, young children, school books, or briefcases?
- Normal sensation: Is there numbness or other sensory loss?
After a history of peripheral neuropathy is elicited, what findings can be expected on physical examination?
Power – Tone – Sensation – Inspection/Palpation – DTR • Atrophy • Fasciculations • Sensory loss • Muscle tone decreased. • Reflexes are usually diminished. • Involvement of autonomic fibers
After a history of a radiculopathy is elicited, what findings can be expected on physical examination?
Power – Tone – Sensation – Inspection/Palpation – DTR • Muscle weakness • Atrophy • Fasciculations • Tone decreased • Reflexes diminished or absent. • Myotomal & dermatomal distribution
Which clinical features of spinal cord disease can be elicited by history? TRIAD
- A sensory level is the hallmark of spinal cord disease
- Distal, symmetric, and spastic weakness. (stiffness in the legs)
- Bowel and bladder problems.
Patient presented with spinal cord lesion, why they have spasticity?
Damage to the spinal cord produces upper motor neuron lesions, affecting the pyramidal (or corticospinal) tract and increase in tone.
Which questions should be asked during the history to elicit the symptoms of spinal cord disease? TRIAD
TRIAD of weakness – sensory – sphincter
- Distal leg weakness: Does the patient drag the toes or trip?
- Distal arm weakness: Does the patient drop things or have trouble with the grip?
- Symmetric symptoms: Does the process involve the arms and/or legs approximately equally?
- Sensory level: Is a sensory level present? Patients often describe it as a band, belt, girdle, or tightness around the trunk or abdomen.
- Sphincter dysfunction: Is there retention or incontinence of bowel or bladder?
After a history of spinal cord disease is elicited, what findings can be expected on physical examination?
• spinal disease usually affects the legs more than the arms.
• level of the symptoms detected clinically does not always correspond to the true anatomic site of the damage.
• examination shows evidence of the following upper motor neuron damage (Power – Tone – Sensory – DTR – Babinski)
1. Distal weakness greater than proximal weakness.
2. Greater weakness of the extensors and antigravity muscles than of the flexors.
3. Increased tone (spasticity)
4. Increased reflexes, Clonus
5. positive Babinski sign
6. Absent superficial reflexes
Which clinical features of brain stem disease can be elicited by history?
- Cranial nerve symptoms characterize brain stem disease.
- Lesions in the brain stem do not produce a horizontal motor or sensory level as they do in the spinal cord but rather produce a vertical motor or sensory level—that is, hemiparesis or hemianesthesia affecting one side of the body.
- Diplopia 3rd 4th 6th
- Facial sensation 5th 7th
- Dysarthria and dysphagia 9th 10th 12th
Which questions elicit symptoms of combined cranial nerve and long tract dysfunction?
- Cranial nerve signs: Does the patient have diplopia, dysarthria, dysphagia, dizziness, deafness, or decreased strength or sensation over the face?
- Crossed signs: Because the long tracts cross, but the cranial nerves generally do not, brain stem lesions often produce symptoms on one side of the face and the opposite side of the body.
After a history of brain stem disease is elicited, what findings can be expected on physical examination?
• Ptosis; diplopia; nystagmus
• Decreased corneal and blink reflexes
• Facial weakness or numbness
• Deafness; vertigo
• Dysarthria; dysphagia;
• Weakness or deviation of the palate; decreased gag reflex;
• Weakness of the neck, shoulders, or tongue.
Long tract abnormalities may include hemiparesis, which shows an upper motor neuron pattern of distal extensor weakness with hyperreflexia, spasticity, and a positive Babinski sign.
Which clinical features of cerebellar disease can be elicited by history?
- Clumsiness in the legs: Does the patient have a staggering, drunken walk? (ataxic, wide-based, staggering gait)
- Clumsiness in the arms: Does the patient have difficulty with targeted movements, such as lighting a cigarette or placing a key in a lock?
- Brain stem symptoms: Are brain stem symptoms present? (Because the cerebellar inflow and outflow must pass through the brain stem)
After a history of cerebellar disease is elicited, what findings can be expected on physical examination?
• Cerebellar Signs
How can the history determine whether disease of the brain is subcortical or cortical?
Think about anatomy, regions of brain:
• specific cortical deficits
• motor and sensory deficits
• visual field deficits
