(Enochs + some) Lecture 1: Approach to the Neurologic Patient Flashcards
What is the most important thing when it comes to neuro assessments?
Change from baseline.
What makes up the CNS?
- Brain
- Spinal Cord
What makes up the PNS?
- Autonomic (Symp and Parasymp)
- Somatic
Where is Broca’s area?
Frontal lobe (dominant side)
Speaking and writing
Describe what each lobe does.
- Frontal: Decision-making/problem solving, speech (speaking/writing), intelligence, personality, short term memory.
- Parietal: Interpretation and processing of information (language, words, pain, temperature, five senses, spatial and visual perception).
- Temporal Lobe: understand language (wernickes), long and short memory, hearing, organization, processing others emotions
- Occipital: Interpreting vision (color, light, movement)
Where is Wernicke’s area?
Temporal lobe
Ability to understand speech
What is the main purpose of the thalamus?
Relaying signals back and forth between CNS and PNS.
also helps regulate sleep, alertness and wakefullness
what is the main purpose of the hypothalamus
releases hormones associated with the endocrine and sexual system.
also controls hunger, body temp.
what is the main purpose of the cerebellum
muscle coordination and equilibrium
what controls sleep/wake arousal as well as vision, hearing, motor control and temp regulations
midbrains
What part of the brain controls breathing?
Medulla oblongata
also controls heartbeat and vomiting
what are the 2 types of matter and what is significant about each of them
- white matter - has axons that take info to/from the grey matter
- grey matter - cell bodies of nerves that receive and store impulses
What are the 3 meninges?
- Dura mater (outermost layer)
- Arachnoid (middle layer)
- Pia mater (innermost layer)
Our blood vessels sit within the subarachnoid space.
these layers act as a barrier to brain and spinal cord against bacteria and other microorganisms
wouldnt hurt to label this a bit
what is CSF
- created in choroid plexus (inner lining of ventricles).
- circulates the brain/spinal cord to protect and nourish it.
what are the brain ventricles
cavities within the brain that contains CSF
* 2 lateral
* third ventricle
* cerebral aqueduct
* fourht ventricle
what is controlled by the autonomic nervous system
it innervates smooth involuntary muscles of internal organs and glands.
HR, BP, RR, temp
digestion, metabolism, water/electrolyte balance
urination, defecation, production of bodily fluids
sexual response
What is controlled by the somatic nervous system
- sensory nerve fibers - info from peripheral to CNS
- Motor nerve fibers - impulses for movement from the brain to skeletal muscles
Where do I find Upper Motor Neurons and what do they do?
- Brain and spinal cord
- Tell the lower motor neurons to relax or contract
What happens with an UMN lesion?
- Antagonist muscle will remain contracted
- Spasticity
what is the job of a lower motor neuron
recieves impulses from UMN and transmits it to the muscle cells leading to muscle contraction
What happens with a LMN lesion?
It will stay relaxed (aka muscle weakness)
Lower lesion lax
Lesion Table for Motor Neurons
What makes up a neuro exam? (5)
- Mental Status
- Cranial Nerves
- Motor
- Reflexes
- Sensory
What are the 5 levels of consciousness?
- Alert
- Lethargy (awakens to verbal or light physical stim)
- Obtundation (constant stimulation to stay awake)
- Stupor (vigorous, painful, constant stimulation, does not follow commands.)
- Coma (no response)
Sleeping is not altered because if you wake them up, they will become al
ALOSC
What is praxis?
Muscle memory (like brushing teeth)
sounds like practiced
What does it mean to write neuro grossly intact?
It is purely off observation.
Must write CN 2-12 are grossly intact
Do not write no focal neuro deficits unless you tested it specifically.
What size are pupils normally?
2-6mm
What do pinpoint pupils suggest?
- Opiate OD
- Pontine hemorrhage
What do dilated pupils suggest?
- Severe anoxia-ischemia
- Anticholinergic drugs
Dilated pupils are ALWAYS abnormal
What do ovoid, keyhole and irregular pupil shapes suggest?
- ovoid - intermediate phase between fixed/dilated pupil (acute neurologic injury or cataract surg comp.)
- keyhole - sluggish to light caused by coloboma, iridectomy w cataract surg.
- irregular - Traumatic orbital injury
What cranial nerve does pupillary reactivity fall under
III - oculomotor
What is the hippus phenomenon?
- Alternating dilation and contraction of pupil
- Associated with early signs of brain herniation or seizure activity
Abnormal gaits
Involuntary movement types
What does the romberg test check for?
- Sensory ataxia (swaying but stops when eyes are open)
- Cerebellar ataxia (swaying that persists even when eyes are open)
what does a positive pronator drift test suggest
unilateral pronator drift suggests UMN lesion affecting the arm
How do you grade ROM?
0-5
5 - active ROM, full strength against resistance
4 - active ROM against gravity and some resistance
3 - active ROM against gravity only
2 - weak contraction insufficient to overcome gravity
1 - minimal movement/muscle contraction
0 - no movement/muscle contraction
Must test resistance and gravity.
What are the 3 kinds of hypertonia?
- Spasticity: moves freely but then the muscle catches and locks.
- Rigidity: resistance throughout
- Clonus: Jerking movement
Suggestive of an UMN lesion.
What is the underlying etiology of hypotonia?
- LMN lesions
- Cerebellar disorders
What is paratonia?
- Increased resistance that becomes LESS prominent when you distract the patient.
- Suggested cognitive impairment and mental disorders.
Where do reflex sensory fibers synapse?
Anterior horn cell
What do increased and decreased DTRs suggest? How are they graded?
- Increased: UMN lesion of brain/spinal cord
- Decreased: LMN lesion of spinal nerve root, spinal nerve, plexus, peripheral nerve
- 0-4 grading, but 2 is normal
Lower is lax
what spinal nerve level does each tendon reflex correlate to?
What does a positive babinski reflex suggest?
- UMN lesion
- CNS disorders
- Alcoholics/postictal periods
Normal in children < 2y
controlled by L5, S1
Define agnosia.
- Inability to interpret sensations or recognize things.
- Damage to occipital or parietal lobes
They can feel the sensation, but they can’t tell what it exactly is.
A patient will need to feel, smell, see, and do everything in order to try and recognize something.
What is aphasia?
Inability to express speech (verbal and written)
What are the two primary types of aphasia?
- Broca’s aphasia (Normal comprehension, broken words, difficult to speak)
- Wernicke’s aphasia (fluent gibberish)
Broca’s/expressive: they understand your question and can answer it, but they can’t form a complete sentence
Wernicke’s: They understand your question, but answer it with a random assortment of words.
What is conduction aphasia?
Cannot repeat statements, which worsens with longer duration.
What is dysphasia?
moderate loss of language impairment, intact comprehension.
What is agraphia?
Inability to write that is not due to weakness, poor coordination, or neurologic dysfunction of the hand.
Aphasic
Constructional (scattered letters and words)
Apraxic (distorted, slow)
What is apraxia?
Inability to perform a learned movement, in the absence of weakness, sensory loss, or other deficit
Gait apraxia: difficulty initiating walking, esp. with parkinsons.
Apraxia of eyelids: blepharospasms when asked to open eye
What is the MC neurologic cause of muscle atrophy?
Carpal tunnel syndrome
What are the 3 common neurologic conditions that can result in hypertrophy?
- Myotonia congenita
- Torticollis
- Dystonias
What is dysarthria?
Difficulty articulating sounds or words.
Motor function of speech
What causes dysphagia neurologically?
Lower brain dysfunction
What is dysphonia?
Changes in quality, volume, or pitch of voice
parkinson’s usually has HYPOphonia
Also has spasmodic dysphonia (high-pitched)
What are the two types of ataxia?
- Cerebellar: limbs and gait
- Sensory: lack/worsening of proprioception when eyes are closed.
Impaired balance/coordination
What
is plegia vs paresis?
- Paresis: weakness due to nerve damage/disease
- Plegia: complete paralysis
What is akinesia?
Inability to control voluntary movement
brady is common in parkinsons and extrapyramidal symptoms. (basal ganglia)
hyperkinesia is seen as tardive dyskinesia (fidgety/restless)
What is asterixis?
Inability to sustain a stable posture
Makes a floppy motion (id watch a vid of it)
Palms forwards and push against them. Patient’s hands should start flopping.
What are the hyperesthesias?
- Photophobia
- Phonophobia
- Allodynia (light touch causing pain)
What is hypoesthesia?
Decreased sensation
NOT NUMBNESS OR ANESTHESIA
What is paresthesia?
Tingling, burning, needles sensation in the skin
what are the terms for increased, decreased and lack of pain sensations
- Analgesia - lack of pain sensation
- Hypalgesia - decrease in pain sensation
- Hyperalgesia - exaggerated response to painful stimulus. (Synonymous with allodynia)
What is graphesthesia?
Ability to recognize writing on the skin without seeing it visually
Drawing on the hand
What is astereognosis?
Inability to recognize an object by touch alone
What is dysmetria?
Difficulty judging distance, speed power
Finger-to-nose test
What is dysdiadochokinesia?
Inability to perform repetitive movements or rapidly alternating movements
The alternating hands on the thighs thing
Often seen in parkinson’s and cerebellar
What is the key difference between rigidity and spasticity?
Rigidity is the same degree of resistance consistently.
Spasticity varies and Stops
When can hyperreflexia be considered normal?
If it is symmetrical, could be normal.
What common chronic condition is hyporeflexia seen in?
Hypothyroidism
