Correlative Neuro Exam

Question 1

Mental status options

Answer 1

alert, lethargic, stuporous, obtunded, comatose

Question 2

decreased alertness: cause?

Answer 2

dysfunction of b/l cerebral hemispheres or brainstem reticular activating system

Question 3

types of involuntary movements

Answer 3

tremor (resting or essential), myoclonus, chorea, athetosis (slow, writhing mvmt), ballismus, tics, seizures, dystonia (sustained abnormal posture), tardive dyskinesia, akathisia (motor restlessness)

Question 4

asterixis

Answer 4

• have pt stop traffic w/ wrists extended; beats of flexion = asterixis
• possibly caused by metabolic encephalopathy ex: UTI, urosepsis, etc.
• a negative myoclonus; cessation of m. activity

Question 5

possible abnormal speech findings

Answer 5

dysphonia, dysarthria (impaired motor function needed for speech - not a language disorder), fluency, comprehension, repetition, aphasia

Question 6

broca’s aphasia

Answer 6

nonfluent, comprehension spared, impaired repetition

Question 7

Wernicke’s aphasia

Answer 7

fluent, impaired comprehension and repetition

Question 8

global aphasia

Answer 8

deficits in all language functions

Question 9

conductive aphasia

Answer 9

frequent paraphasic errors (usually phonemic), impaired repetition
phonemic error = substituting a similar word for a sound i.e. saying pish instead of fish

Question 10

transcortical motor aphasia

Answer 10

repetition intact, pt can comprehend but is not fluent

Question 11

transcortical sensory aphasia

Answer 11

pt is fluent and can repeat but impaired comprhension

Question 12

transcortical mixed aphasia

Answer 12

pt can only repeat; no fluency or compehension

Question 13

anomic aphasia

Answer 13

memory deficits; pt can’t name the word for a particular item

Question 14

CNI: injury w/ likely cause

Answer 14

injury = anosmia
u/l causes = trauma or tumor
b/l causes = virus, allergy, smoking, trauma
head/face trauma, nose surgery, infections, obstructions, lesions at base of frontal lobe, aging
central anosmia can be caused by alcoholism, Alzheimer’s or parkinson’s

Question 15

Foster Kennedy Syndrome

Answer 15

S&S: anosmia, i/l optic atrophy, c/l papilledema
associated w/ lesions of anterior skull base or frontal lobe
ex: meningioma arising from olfactory groove

Question 16

anisocuria

Answer 16

• unequal pupils
• sympathetic nervous system and CNIII
• hippus = normal brief oscillations of pupil size in response to light
• if pupils more unequal in dark the small one is the problem eye; if there is more unevenness in the light the dilated one is the problem

Question 17

Marcus-Gunn pupil aka APD

Answer 17

afferent pupil defect = APD
can be seen w/ interruption of optic pathway anterior to optic chiasm
dx via the swinging flashlight test
seen w/ optic n. or retinal disease

Question 18

Adie pupil

Answer 18

• can be u/l or b/l dilated pupil
• lesion is in the ciliary ganglion
• parasympathetic denervation: pupils react poorly to light but ok w/ accommodation; pupils redilate slowly
• common manifestation of Holmes Adie Syndrome = benighn often familial disorder affecting young women
• can be associated w/ depressed DTRs, segmental anhidrosis, orthostatic hypotension, cardiovascular autonomic instability

Question 19

Argyll Robertson Pupil

Answer 19

• aka prostitute’s eye = accommodation but no reaction
• small, irregular pupils
• lesion involves descending pupilloconstrictor fibers
• cause = neurosyphilis; could also be from lesions in EWN (ex: MS)

Question 20

CNIII, IV, VI problems

Answer 20

• diplopia
• ptosis = lesion in sympathetics, CNIII, NMJ, or from a m. disorder
• pseudoptosis = redundant skin folds associated w/ aging

Question 21

nystagmus

Answer 21

• involuntary, rapid, rhythmic mvmts of eye = oscillopsia
• named for direction of quick component
• if pathologic causes = meds, peripheral vestibular apparatus, central vestibular pathways, cerebellum
• up to 50% of people have a small degree of nystagmus in extreme gaze

Question 22

Ptosis

Answer 22

• CNIII dysfunction
• eye appears “down and out”
• pupil can be spared or impaired

Question 23

vertical diplopia

Answer 23

• pt may have hypertropia: visual axis of one eye is higher than the other
• head tilt to opposite side improves vision
• could be caused by head trauma; CNIV dysfunction

Question 24

horizontal diplopia

Answer 24

• CNVI dysfunction possibly caused by high ICP
• could have esotropia = eye on one side looks turned in
• head tilt to the same side improves vision

Question 25

face droop

Answer 25

LMN: weakness or paralysis of 1/2 of the face; can be from peripheral n. or brainstem (pons) injury UMN: weakness of lower quarter of face; lesion above the pons; innervation to forehead is b/l so forehead not affected - pts won't be able to close eye tightly so be sure to protect it to prevent foreign bodies/corneal abrasions

Question 26

CNVIII: possible dysfunctions and testing options

Answer 26

- vestibulo-ocular reflex - caloric testing: COWS (nystagmus portion of reaction); inject water into external auditory meatus; cold water = eyes deviate toward injection and nystagmus is opposite; warm water = eyes deviate away from injection and nystagmus is same side

Question 27

CN IX and X

Answer 27

- voice gag reflex tests - 20% of normal people don't have a gag reflex - symptoms = hoarseness, swallowing dysfunction, deviation of uvula - uvula will deviated away from the lesion

Question 28

general definitions: weakness/paresis, paralysis/plegia, hemiparesis, hemiplegia, paraplegia, quadriplegia, incompete quadriplegia

Answer 28

weakness/paresis = diminished strength paralysis, plegia = absence of strength hemiparesis = weakness of one side hemiplegia = paralysis of one side paraplegia = paralysis of legs quadriplegia = paralysis of all extremities incomplete quadriplegia = retention of some upper extremity movement

Question 29

DTRs and levels they test

Answer 29

``` C5/6 = biceps and brachioradialis C7/8 = triceps L3/4 = patellar S1/2 = achilles ```

Question 30

possible changes seen in reflexes

Answer 30

hyporeflexia/areflexia, hyperreflexia symmetric change - could be from polyradiculopahty, peripheral neuropathy, myelopathy asymmetric change - possibly from radiculopathy, central nervous system pathology

Question 31

primitive reflexes

Answer 31

1. frontal release signs 2. grasp, root, snout, suck, palmomental 3. glabellar sign (Myerson sign) - blink = abnormal all these are seen in infants and all (except grasp) can be seen in normal adults

Question 32

cerebellar S&S

Answer 32

1. ataxia - can be caused by cerebellum, peripheral neuropathy, spinal cord, brainstem 2. nystagmus 3. dysdiadochokinesia: decreased rapid alternating movements; can be caused by cerebellum, cerebral, arthritic and extrapyramidal processes; functional

Question 33

sensory dysfunctions

Answer 33

symptoms = paresthesias, dysestesias, numbness, pain, etc. | distinguish using onset, course, location, associated symptoms, hx and meds

Question 34

primary sensory v. cortical/discriminative sensory v. gradient

Answer 34

1. primary sensory = light touch, vibration, proprioception, pain and tempterature 2. cortical/discriminative sensory = graphesthesia, stereognosis, 2 point discrimination, extinction 3. gradient: test distal v. proximal sensation; should have more sensation distally

Question 35

heel walking

Answer 35

- anterior tibialis weakness | - L5 radiculopathy or peripheral neuropathy

Question 36

toe walking

Answer 36

- gastrocnemius or soleus weakness | - S1 radiculopathy or peripheral neuropathy

Question 37

tandem walking

Answer 37

- ataxia | - cerebral, brainstem, cerebellum, spinal cord are all possible sites for lesions causing ataxia

Question 38

Rhomberg test: what systems does it test; implications of positive test

Answer 38

- tests visual, PCML, vestibular systems - at least 2 of the systems have to be working for the test to be negative; so if you do the test w/ eyes open v. shut you can rule in/out a problem w/ the visual system - positive test implicates the cause as either a peripheral neuropathy, spinal cord disease, or a vestibular dysfunction