CNS

Question 1

what will we be able to evaluate mental status through in the exam?

Answer 1

Cortex
Basal ganglion
Brain stem
Cerebellum
Cranial nerves

Question 2

what are the 5 major categories in mental health exam?

Answer 2

Appearance
Affect
Language
Thought Process/perception 
Cognitive function/Executive fx

Question 3

what can change awareness? what are different descriptions of awareness?

Answer 3

• State of awareness of self and environment. Impaired by disease of the brainstem reticular activating system, or damage in parts of both hemispheres

Alert→ awake, not sleepy or tired, responding appropriately to environment
Lethargic→ (sleepy): awake, but tending to fall asleep if not gently stimulated
Stuporous → falling asleep unless vigorously stimulated
Comatose→ a sleep-like state from which the patient cannot be awakened

Question 4

what should clinical exam of language include?

Answer 4

Spontaneous speech
Naming
Comprehension 
Repetition 
Reading 
Writing

Question 5

aphasia

Answer 5

Disorder in producing or understanding language

aphasia may be the only sign of a new neurological disease, such as stroke, tumor or head trauma, or recent seizure

Question 6

paraphasia

Answer 6

substituting similar sounding syllables or words

- “paraphasis errors”: pen for pencil or plentil for pencil

Question 7

prosody

Answer 7

the melody or variable tone of speech

Question 8

aphasia

Answer 8

disorder in understanding or producing language: spoken or written

• testing for aphasia: naming, comprehension, repetition and reading/writing
• due to localized lesion of dominant hemisphere (70% are left hemisphere dominant)
• can be caused by damage to either Broca’s or Wernicke’s area

Question 9

dysphasia

Answer 9

impairment in USE of speech that is clear

i.e. failure to arrange properly in sentence

Question 10

dysarthria

Answer 10

imperfect articulation due to lack of motor coordination; damaging event CNS or PNS, language comprehension and use may be fine.

Question 11

Wernicke’s area

Answer 11

transforms sensory input –> neural word : giving words meaning

Question 12

Broca’s area:

Answer 12

transforms neural word representations to spoken word

Question 13

Broca’s aphasia

Answer 13

“expressive aphasia” - have understanding of spoken language, but can’t articulate

Question 14

Wernicke’s aphasia:

Answer 14

have ability to produce “fluent speech” but it makes no sense

Question 15

apraxia

Answer 15

inability to turn verbal request into motor performance
(often seen with aphasic patients)

patients have difficulty with complex yet familiar activities, such as dressing or taking a shower, writing with a pen or pencil, using a comb or toothbrush, mimicking an examiner

Question 16

Orientation testing?

Answer 16

1. PERSON (name): seldom lost unless the patient has aphasia or schizophrenia
2. PLACE (location): often lost in some hospitalized patients, or delirious/extremely demented outpatients
3. TIME: most commonly lost of these three; include time of day, day of week, month, year if possible

Question 17

recent vs. remote memory

Answer 17

RECENT Memory: the ability to store new information, up to a few days

REMOTE Memory: more distant memories. Includes autobiographical (dates of graduation, marriage, etc.) or historical (date of wars, elections, sports, etc.)

Alzheimer’s dementia almost always begins as a progressive loss of memory; first recent, and then distant memory

Question 18

how can insight be evaluated?

Answer 18

• explain a proverb
• explain a situational choice
• compare similarities/difference betwen objects

Question 19

delerium

Answer 19

acute confusion episode, may be due to infection, uremia, alcohol withdrawal. Disoriented, poor judgment, delusions common, attention poor, mood fluctuates
“Everything’s an Emergency!”

• if they have poor attention, think delerium

Question 20

Dementia

Answer 20

: insidious, slowly progressive, affect often flat, maintains orientation and attention until late in process. Altzheimer’s, B12 deficiency, hypothyroid, head trauma. Can have acute angry, delusional episodes later in the course of disease.

Question 21

constructional ability

Answer 21

tests executive function

- ability to copy a figure or draw something simple

Question 22

apraxia

Answer 22

inability to perform the command

Question 23

what does cerebellum do?

Answer 23

receives sensory and motor input to coordinate motor activity, maintain equilibrium and control posture

Question 24

rhomberg tests?

Answer 24

tests ataxia specific to posterior column function. While positioned and eyes open, balance is maintained. Closing eyes removes visual input and ataxia (falling over) occurs. Direction of the fall may indicate where the lesion is.

Cerebellar ataxia is present with eyes open or closed, ie, not a function of proprioceptive input.

Question 25

Pronator drift

Answer 25

in same stance as for Romberg, if the arm pronates and drifts downward (and occasionally lateral) when eyes are closed it is specific for a contralateral corticospinal tract lesion/disease

Question 26

dysmetria

Answer 26

movment that is clumsy, varied in speed/force, past the destination point - can be tested with finger-to-nose eyes opened or with eyes closed

Question 27

dysdiadochokinesis

Answer 27

one movement cannot be abruptly stopped and followed by the opposite movement: slow, irregular and clumsy

Question 28

why is cranial nerve important?

Answer 28

Localizes pathologic processes specific to individual cranial nerves and can indicate where pathology is involved. This assists in diagnostic accuracy of neurologic disorders. ``` Headache: new onset or change in character Dysarthria Asymmetric facial features Dysphagia Hearing complaints Visual disturbance Ataxia/Asymmetric motor use ```

Question 29

CN I

Answer 29

Olfactory is seldom tested, unless the patient complains of a loss of smell, or there is a frontal injury or possible frontal lobe tumor Abnormalities seen with concussion(mild traumatic brain injury or TBI)

Question 30

CN II/III testing

Answer 30

Acuity Pupillary Reflex:Afferent is CN II, it senses the light. Efferent: CN III (Oculomotor) Visual field exam Ophthalmoscopic (fundoscopic) examination is direct visualization of retina including optic disc and vessels. Optic nerve exam is primarily functional

Question 31

CN III, IV, VI

Answer 31

Look at eyes in the primary position: esotropia (medial deviation) exotropia (lateral deviation) Occulomotor: Efferent pupillary response to light (III Oculomotor: levator palpebrae, sup/inf rectus, inf oblique, medial rectus) Extraocular movements: Six cardinal directions Trochlear (IV Superior Oblique): moves the eye downward and out. Abducens (VI Lateral Rectus) move laterally Remember the cover/uncover test to check bilateral central focus; looking for strabismus

Question 32

Right fourth nerve palsy

Answer 32

Globe in right eye goes up and in, when it cannot go down and out (superior oblique)

Question 33

Right Sixth nerve palsy

Answer 33

- cannot pull eye lateraly without lateral rectus innervation, results in on eye going in

Question 34

horizontal diplopia

Answer 34

- Mild or total loss of lateral rectus function - due to loss of CN VI - often due to increased intracranial pressure b/c of its location in main sinus

Question 35

how do you test the trigeminal nerve? corneal reflex?

Answer 35

Sensory: for the face, 3 divisions Test sensation to each bilaterally: soft or temperature, and/or pinpick Motor: masseter and pterygoid: clench teeth, move jaw side to side Corneal Reflex: Gently touch lateral cornea w/ cotton or gauze Afferent: CN V senses the stimulus Efferent: CN VII motor to blink Both eyes should blink together

Question 36

central vs. peripheral effect of CN VII

Answer 36

central: cortex or brainstem: muscles of lower face only affected on one side (lesion on opposite side) peripheral: distal to brainstem, muscles of unilateral same side upper and lower face are affected. (lesion on same side)

Question 37

Facial nerve?

Answer 37

Other things facial nerve does: - Muscles of facial expression - Upper face: closing the eyes, raising the eyebrows - Lower face: smiling - Taste of anterior 2/3 tongue - Lacrimation - Salivation - Stapedius muscle of middle ear (dampens sound)

Question 38

2 types of central lesions?

Answer 38

1. Cerebral hemisphere lesion: signal must cross before it is manifested - Lower facial weakness of the opposite side. - Extremities on opposite side 2. Brainstem lesion: - Lower facial weakness of the same side.

Question 39

causes of peripheral lesion of CN VII?

Answer 39

Commonly compressed as it goes through the internal or external auditory canal by unknown, likely auto-immune processes (Bell’s palsy) or tumors, lacerations, infections (Lyme, etc.) In a PERIPHERAL CN VII lesion, the entire seventh nerve is likely damaged, so there is weakness of the upper AND lower facial muscles on that same side

Question 40

CN VIII

Answer 40

Vestibulocochlear Hearing and Balance: The auditory portion of CN VIII is tested by the physician directly; most disorders of the vestibular portion are assumed from a history of positional vertigo Hearing can be determined subjectively by how well the patient seems to understand the physician’s words, or by the examiner rubbing her index and thumb together one inch lateral to each ear of the patient, or the patient’s hair can be rubbed about one inch lateral to each ear

Question 41

which nn. most commonly seen in TBI?

Answer 41

Injured in concussion (TBI): CN I, VII, VIII can be seen

Question 42

CN IX and X testing?

Answer 42

gag reflex tests them both CN IX is sensory to the soft palate, and CN X helps to raise the palate, so the Gag Reflex tests them both: GAG REFLEX:  Afferent: CN IX Efferent: CN X Glossopharyngeal (IX) provides taste on the posterior 1/3 of tongue

Question 43

CN XI testing?

Answer 43

Innervation of the sternocleidomastoid and trapezius muscles Resist the patient shrug both shoulders simultaneously Resist a head tilting to each side

Question 44

CN XII testing?

Answer 44

Purely motor to only the tongue Ask patient to stick out tongue (note if midline) and move side to side Look also for atrophy or fasiculations of the tongue In case of a CN XII peripheral lesion, the tongue deviates to the SAME SIDE

Question 45

how can insight be evaluated?

Answer 45

- explain a proverb - explain a situational choice - compare similarities/difference betwen objects

Question 46

delerium

Answer 46

acute confusion episode, may be due to infection, uremia, alcohol withdrawal. Disoriented, poor judgment, delusions common, attention poor, mood fluctuates “Everything’s an Emergency!” - if they have poor attention, think delerium

Question 47

Dementia

Answer 47

: insidious, slowly progressive, affect often flat, maintains orientation and attention until late in process. Altzheimer’s, B12 deficiency, hypothyroid, head trauma. Can have acute angry, delusional episodes later in the course of disease.

Question 48

constructional ability

Answer 48

tests executive function | - ability to copy a figure or draw something simple

Question 49

apraxia

Answer 49

inability to perform the command