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PCM 2 Final Exam > CNS exam > Flashcards

CNS exam Flashcards

1
Q

Scope of the system

A

Narrow the picture as much as possible using a good history. Look to answer these questions:
Local or diffuse?
How has it developed over time?
Restricted to nervous system or include other systems?
CNS, PNS or Both?

Goal: Integrate History and PE
Get to WHERE the lesion is
Then you can develop a meaningful “WHAT the lesion is” differential. Don’t jump too fast

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2
Q

CNS scope

A 
Cortex
Basal Ganglion
Brain Stem
Cerebellum
Spinal Cord
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3
Q

PNS scope

A 
Cranial Nerves
Sensory Afferents
Motor Efferents
Neuromuscular Junction
Muscle itself
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4
Q

Anxiety and depression

A

estimated to be 30% of primary care visits.

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5
Q

Unexplained persistent symptoms frequent:

A

Headache, GI issues, insomnia, fatigue, chronic pain

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6
Q

Mental Status Exam

A 
1. Appearance and Behavior
		level of consciousness
		posture, motor behavior, hygiene
2. Mood/Affect   
3. Speech/Language
		articulation, relevance, word finding,
		rate, fluency
4. Thoughts/Perceptions
		logic, coherence, content,  insight, 	judgment
5. Cognitive/Executive Function
		orientation, memory, abstract thinking, 	performance
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7
Q
  1. Appearance and Behavior
A

Level of Consciousness: 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 the 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
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8
Q

Posture and Motor Activity:

A

Calm? Constant motion?
Depression with anxiety?
Side effect to neuroleptic medication?
thyroid medication?

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9
Q

Hygiene

A

You think it is fine, They think they smell.

Delusion?

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10
Q

. Affect/Mood

A

Observe expressions and affect

Appropriate for situation?
	Engaged?
	Angry?  Anxious?  	Indifferent?
	Detached?
Depression            Drugs 
Fatigue		       ETOH
Insomnia		       Meds
Concentration	Steroids
			       Endocrine
Anxiety:
   Palpitations      Breathless
   Tremors             Numbness
   Dry mouth  
   ETOH withdrawl?
   Hyperthyroid?

Fear
Paranoia?
Complex Partial Seizure?
Completely appropriate?

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11
Q

Language

A 
The clinical exam of language should include assessment of:
		Spontaneous Speech
		Naming
		Comprehension
		Repetition
		Reading
		Writing

You are evaluating for Aphasia: Disorder in producing or understanding language.

Spontaneous Speech: Look for

Articulation

Appropriate word finding.   Assess for  Paraphasia = Substituting similar sounding syllables or words; Paraphasic errors.  
		“pen”  for   “pencil”	
		 “plentil”  for  “pencil”

 Is there normal prosody: the melody or 	variable tone of speech?

Spontaneous Speech:

Verbal Fluency:  do they maintain appropriate rate, flow, volume, content, meaning and melody (prosody)?

If your patient lacks meaning or fluency, evaluate for Aphasia: Disorder in understanding or producing language: spoken or written

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12
Q

Testing for Aphasia:

A

Naming: test the ability to name objects
ANOMIA: loss of the ability to name common objects; the most common deficit in true aphasia

Comprehension: follow commands.
“Point to nose” Point to nose then knee”

Repetition: have the patient repeat some simple words or a phrase
“No if’s, and’s or but’s”

Reading and Writing: short exercises

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13
Q

Aphasia

A

Disorder in understanding or producing language: spoken or written
Injury, Disease, Psychogenic

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14
Q

Dysphasia

A

Impairment in use of speech that is clear “Dys-phasia”

Failure to arrange properly in sentence

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15
Q

Dysarthria

A

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

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16
Q

More stuff on aphasia

A

Aphasia is due to a localized lesion of the dominant hemisphere of the brain:
The left cerebral hemisphere in 99% of all right-handed patients and probably 70% of left-handed patients

Most ambidextrous patients are also left hemisphere dominant

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

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17
Q

Wernicke’s area

A

transforms sensory input into neural word representations to give a word meaning.

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18
Q

Broca’s area

A

transforms these neural word representations into actual articulations that can be spoken.

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19
Q

Aphasia

A

Loss of power of expression or the comprehension of spoken or written language

Damage to Broca’s or Wernicke’s or their interconnection causes aphasia

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20
Q

the language of broca’s vs wernicke’s aphasia

A

Brocas Aphasia click to see video
“Expressive” Aphasia
understanding of spoken language mostly preserved

Wernicke’s Aphasia click to see video
“Receptive” Aphasia
fluent speech that makes no sense

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21
Q

Thoughts and Perception

A

Brocas Aphasia click to see video
“Expressive” Aphasia
understanding of spoken language mostly preserved

Wernicke’s Aphasia click to see video
“Receptive” Aphasia
fluent speech that makes no sense

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22
Q

Cognitive Function

A

Orientation: Person, Place, Time
Attention: Ability to concentrate
Memory: Recent and Remote

Executive Function
Abstract Thinking/Insight
Calculation
Constructional Ability

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23
Q

Orientation

A

PERSON (name): seldom lost unless the patient has aphasia or schizophrenia

  1. PLACE (location): often lost in some hospitalized patients, or delirious/extremely demented outpatients
  2. TIME: most commonly lost of these three; include time of day, day of week, month, year if possible

Typically, physicians write “A&O x 3”

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24
Q

Memory

A

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.)

Can be the only sign or symptom of a brain disease

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

25
Q

Recent Memory

A

Testing recent memory: “Please listen to these 3 words, and then repeat them. I will ask you to remember them soon.” Ask them in approximately 3-5 minutes.

Occasionally a normal patient will recall only 2/3, but recalling 0, or 1 words on two attempts is pathologic

Also tested by:

	1. “How long have you been in the hospital?”
	2. Giving a patient a brief story to remember, 	     	perhaps three or four sentences long
	3. “What did you have for breakfast (or lunch, 		dinner)?”
26
Q

Remote Memory

A

Less often tested, mostly for confirming a diagnosis of dementia

Examples:

1. When did you graduate from high school?
2. When did you get married?
3. How many children do you have?
4. When did you retire?
5. When did the Vietnam War (or World War  	II) occur?
6. Can you name some recent presidents?
27
Q

Executive Function: Insight

A

Insight/Judgment, Reasoning Ability, Abstract thinking

It tests the “higher abilities” that patients should possess, or had before they became ill

Tests mostly for dementia, or any disease of the FRONTAL lobes and their connections

Crucial in diagnosing Alzheimer’s Disease and the other common causes of dementia.

Proverbs

1. “Look before you leap”
2. “People in glass houses shouldn’t throw stones”
3. “Still waters run deep”

Situational questions for choice “What would you DO if you:

1. Found a closed envelope fully-addressed and stamped ?
2. Found a wallet on the street?

Similarities can be tested; How are the following alike (or different)?

1. Apples and oranges
2. Tables and chairs
3. Californians and Texans
4. Shirts and dresses
28
Q

Delirium

A

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

29
Q

Dementia:

A

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.

30
Q

What’s the best way to distinguish agitated dementia from delirium?

A

Attention testing typically the best exam to distinguish agitated dementia from delirium . Poor attention think delirium

31
Q

____ is often disturbed, but ___ is seldom disturbed

A

Language is often disturbed, but speech is seldom disturbed

32
Q

Executive Function: Calculation

A

Number span: normal patients should be able to repeat 5 or 6 numbers in correct order, or do 4 numbers in reverse order

  1. Spelling a common word, backwards and forwards, ‘WORLD’
  2. Do the months of the year or the days of the week, forwards and backwards
  3. Doubling a number; 9X9=81, 162, 324
33
Q

Executive Function: Constructional Ability

A

Constructional Ability: copy a figure or ask them to draw something simple

Integration of Motor Activity: ask to perform a task, see if they can. Apraxia is the inability to perform the command. Can also be tested here.

34
Q

Mini Mental Status Exam:

A

Screening tool for mental status

23-30= normal
19-23= borderline
35
Q

Mental Status Screening

A

Recent study found elderly well still able to visit their doctor alone for a routine PE rated their cognition equally good as those with known dementia. Yikes.

Use cognitive screening tests like MMSE or Folstein

Refer to Neurophychologist for full evaluation, diagnosis and treatment options
depression, dementia, concussion/TBI 	
detect malingering
determine competence
cognitive rehabilitation (TBI)	
behavioral therapy (chronic pain
36
Q

cerebellum

A

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

37
Q

cerebellar testing

A 
Gait
		Regular walk
		Tandem: one foot in front of the other
		Heel/toe: away on heels, back on toes
Heel to Knee and slide down shin (heel to shin)
		Bilateral smoothness, accuracy
		Repeat eyes closed for higher sensitivity
Romberg/Pronator Drift:  tested together
38
Q

tracts and the cerebellar testing

A

Posterior column = motor efferents
Contralateral lesion in corticospinal tract because it decussates as it leaves the medulla; this tract is most responsible for motor signals to the hands, particularly fine movement. So drift in the right arm is a bad signal originating in the left corticospinal tract before it decussates.
Tandem is one foot directly in front of the other, can go forward then backwards. Be there to catch them if needed
Heel/Toe is walking forward on heels, then turning around and walking forward on toes. The order is not important

39
Q

Romberg

A

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.

40
Q

Pronator drift:

A

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

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

41
Q

Fingers to nose cerebellar testing

A

Finger-to-Nose Eyes Open (“your nose, my finger”)
Make sure the patient extends his arm “completely” to reach your own index finger, this enhances any
abnormality if present.
Move finger up, down and
cross midline
Clumsy, vary in speed/force, past point
= Dysmetria
Finger to Nose Eyes Closed (drunk test)
Standing, eyes closed, arms stretched
out to side, bring each in to nose.
Poor coordination worsens with eyes
closed.

42
Q

voice dysmetria

A

Voice Dysmetria:
Count to 10 as quickly as possible.
Motor coordination

43
Q

dysdiadochokinesis and cerebellar testing

A

Rapid Alternating Movements
Flip hand over in other palm
rapid; must lift hand off palm
Can also use the thigh

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

44
Q

what does the cranial nerve exam do?

A

Localizes pathologic processes specific to individual cranial nerves and can indicate where pathology is involved. This assists in diagnostic accuracy of neurologic disorders.

45
Q

Olfactory nerve

A

Olfactory is seldom tested, unless the patient complains of a loss of smell, or there is a frontal injury or possible frontal lobe tumor

Usually tested only for presence/absence, with some coffee beans, or cinnamon

Abnormalities seen with concussion(mild traumatic brain injury or TBI)

Typically, physicians will write, “Cranial nerves 2 through 12 intact.” CN 2-12 intact
But be sure to DO IT if you document this

46
Q

Optic nerve

A

Acuity

	Pupillary Reflex:  
		Afferent is CN II, it senses the light. 		           Efferent: CN III  (Oculomotor) 	

	Visual field exam

Ophthalmoscopic examination is direct
visualization of retina including optic disc and vessels. Optic nerve exam is primarily functional

47
Q

CN III, IV, VI

A

Look at eyes in the primary position:
esotropia (medial deviation)
exotropia (lateral deviation)

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

48
Q

CN VI palsy

A

Mild or total loss of lateral rectus function = horizontal diplopia

Often without a localizing sign; INCREASED INTRACRANIAL PRESSURE ANYWHERE may cause a unilateral or bilateral CN VI palsy

49
Q

CN V: The Trigeminal Nerve

A

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

There is sensory innervation from the cervical root in these same distributions.

To localize Trigeminal distribution test across midline in these areas ONLY.

50
Q

CN VII: The Facial Nerve

A

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)

CN VII can be affected either centrally or peripherally.

Central:
 ­   Cortex or brainstem 
    Muscles of lower face only

Peripheral: muscles of unilateral, 	     	    same side upper and lower face
51
Q

Facial nerve central lesions

A
  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.
52
Q

facial nerve peripheral lesions

A

Peripheral Lesion: After leaving the brainstem

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

53
Q

Facial nerve lesions: peripheral vs central recap

A

In peripheral VII nerve interruption you will see full, unilateral facial weakness or paralysis on the same side as the nerve problem. Bell’s Palsy is a common example

In central (brainstem or cortex) interruption, only the lower face will be affected. The actual lesion will be on the opposite side if it originates in the cortex ( = cerebral hemisphere), and will be on the same side as the weakness if from the brain stem. Peripheral crossover innervation of upper motor facial nerves is intact.

54
Q

CN VIII: Vestibulocochlear

A

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

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

55
Q

CN IX, X: Glossopharyngeal and Vagus nerves

A

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

56
Q

CN XI: Spinal Accessory Nerve

A

Innervation of the sternocleidomastoid and trapezius muscles

Resist the patient shrug both shoulders simultaneously

Resist a head tilting to each side

57
Q

CN XII: Hypoglossal

A

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

58
Q

summary of screening neuro exam

A

The exam should contain assessment of:
Mental Status: alertness, appropriate responses, orientation to date and place
Cranial Nerves: acuity, pupillary light reflex, eye motion, hearing, facial strength
Motor: major muscle group strength upper and lower extremity, gait, coordination (finger to nose)
Sensory: test toes/feet – one modality of light touch, pain, temp or proprioception
Reflexes: DTR upper/lower, Babinski

PCM 2 Final Exam (8 decks)

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