Exam 1 Flashcards
What are the various forms of augmentation for enhancing DTR responses?
“counter-pressure” and Jendrassik maneuver (clasped hands pulling apart)
What kind of motor neuron lesions can be found by testing sensory, DTR and motor changes?
LMNLs
What kind of motor neuron lesions can be found by testing DTR and motor changes?
UMNLs
Five things to keep in mind when performing a neuro exam?
- “overlap” in distribution 2. pt’s history and natural hx of dz 3. overlap of sensory fibers of adjacent peripheral nn. 4. dermatomes aren’t clear-cut 5. “pure patches”
What is the dermatome map called?
Hoppenfeld-dominant dermatomes
What can cause “foot drop”?
nerve root lesions (L5) OR common peroneal nerve lesions
What are the findings for foot drop d/t L5 NR lesion?
dermatomal sensory changes and possible back pain/signs of disc herniation
What are the findings for foot drop d/t common peroneal nerve lesion?
non-dermatomal sensory changes, poss. Injury around head of fibula, Hx of degenerative knee changes
What NR controls triceps DTR and wrist flexion?
C7
What NR controls finger flexion?
C8
What NR controls interossei mm?
T1
What NR controls biceps DTR and lateral deltoid shoulder abduction?
C5
What NR controls brachioradialis DTR and wrist extension?
C6
What peripheral nerve controls sensation over deltoid tubercle and shoulder abduction?
Axillary n
What peripheral nerve controls sensation to lateral tip of index finger and flexion of thumb and first finger?
Median n.
What peripheral nerve controls opposition of thumb and little finger?
Median n.
What peripheral nerve controls sensation of dorsal thumb web and finger extension (and wrist extension)?
Radial n.
What peripheral nerve controls sensation of medial tip of little finger and interossei mm?
Ulnar n.
Are complaints of numbness and/or paresthesia objective or subjective?
Subjective
What tract is pain sensation associated with?
Lateral spinothalamic tract (LST)
What does the sharp-dull test assess?
pain perception (LST)
What is -algesa?
pain perception
What is -esthesia?
touch perception
What is dysesthesia?
distortion of any sense, especially touch. Unpleasant abnormal sensation produced by normal stimuli
What part of SC is vibration/pallesthesia classically associated with?
dorsal columns
What tuning fork is used to test vibration?
128 cps
When should you test vibration?
suspected peripheral neuropathy (diabetes, alcoholism) OR suspected cord compression (esp. cervical cord)
What is L’Hermitte’s sign associated with?
cervical flexion
What is the “barber chair” sign associated with?
cervical extension
How do L’Hermitte’s sign and “barber chair” sign present?
electrical shock sensation down the arms OR down the arms and legs (“tingling”)
What is palsy?
“an enfeebled condition”
What is paresis?
weakness of voluntary movement (partial paralysis)
What is paralysis?
loss of muscle function (total)
What are fasciculations?
“muscle twitches” arising from skeletal muscle fibers in a single motor unit
T/F: fasciculations in an otherwise strong muscle are usually benign.
TRUE
What do fasciculations in weak muscles indicate?
LMNLs of slow onset or dz of anterior horn cells (ALS)
When should you consider repetitive or sustained muscle testing?
if there is weakness or fatigue, abnormalities on sensory exam, or abnormalities of DTRs
What are the findings for classic myopathy?
Proximal bilateral weakness WITHOUT sensory loss. Weakness does NOT get better with rest
In classic myopathy, do you see atrophy or fasciculations?
No
What results in waddling/dystrophic gate?
late-stage myopathy pt
What is the first symptom of Duchenne’s muscular dystrophy?
Waddling gait (lumbar lordosis and protruding abdomen are common)
What leads to msl weakness that increases after periods of activity and improves after periods of rest?
myasthenia gravis
What is the first stage of myasthenia gravis?
ocular MG with fluctuating double vision and ptosis (dz remains solely ocular in only 16% of pts)
What is the most commonly affected msl of ocular MG?
superior rectus
What is the second stage of MG?
MG involving facial and bulbar msls
What is the older imprecise term that refers to medulla oblongata?
bulbar (the way Jim Carollo learned it)
What is the third stage of MG?
“generalized” MG involving muscle girdles. Might exhibit waddling gait
When grading DTRs, what is normal?
2+
When grading DTRs, what is clonus?
4+
What is the only reflex that is always abnormal?
clonus
What is clonus?
hit once => more than one response
What peripheral nerve is assoc. with C5?
musculocutaneous n
What peripheral nerve is assoc with C6?
radial n.
What peripheral nerve is assoc with C7?
radial n.
What peripheral nerve is assoc with L4?
femoral n.
What peripheral nerve is assoc with L5?
sciatic n.
What peripheral nerve is assoc with S1?
tibial n.
What NR is assoc with patellar tendon DTR?
L4
What NR is assoc with medial hamstring DTR?
L5-S1
What NR is assoc with achilles tendon DTR?
S1
What does a pure LMNL present with?
motor deficits only
What is presentation for LMNL with peripheral n lesion (or NR lesion)?
combined motor and sensory deficits
What are the 5 classic signs of LMNLs?
- hyporeflexia 2. flaccid paralysis 3. marked atrophy 4. fasciculations 5. possible nerve irritability
What does SLR test for?
nerve irritability
What is a common cause of hyporeflexia?
technique errors
Classic signs of UMNLs?
- hyperactive DTRs 2. clonus 3. spastic paresis/paralysis (clasp knife phenomenon) 4. presence of pathologic reflexes (Babinski, etc)
T/F: All abnormal reflexes are “pathologic”.
TRUE
How many types of peripheral neuropathies have been ID’ed?
More than 100
What are the 2 common sub-sets of peripheral neuropathy?
- symmetric/bilateral 2. asymmetric/unilateral
What are symmetric polyneuropathies most often due to?
diabetes and/or alcoholism
What are asymmetric polyneuropathies due to?
peripheral nerve entrapment/impingement/injury
Which type of polyneuropathy will we see more often in practice?
Asymmetric
T/F: Almost all peripheral neuropathies begin proximally.
False - begin distally
What is the first sign of peripheral neuropathy?
Paresethesia or pain
What is the second sign of peripheral neuropathy?
sensory deficits
What is the third sign of peripheral neuropathy?
possible focal ANS dysfunction
With a peripheral neuropathy, will you see sensory or motor changes first?
sensory
What is the most common cause of peripheral neuropathy in the US?
diabetes and alcoholism
What is the most common presentation of peripheral neuropathy?
distal symmetric/bilateral sensori-motor dysfunction
What is the distribution pattern of metabolic neuropathy?
symmetric “stocking and glove”
Two common asymmetric mononeuropathies?
- common peroneal nerve palsy 2. carpal tunnel syndrome
What is “steppage gait” (foot drop) CLASSICALY assoc with?
L4-L5 NR LMNLs
What is “steppage gait” (foot drop) COMMONLY assoc with?
compression of common peroneal n. at fibular head
What is radiculopathy?
peripheral neuropathy d/t nerve root dz
What are the 3 “classic” symptoms of radiculopathy?
- asymmetric pain 2. flaccid weakness 3. sensory deficits
Do all radiculopathies manifest in pain?
No
What is the quality of pain in a radiculopathy?
“sharp”, “stabbing”, “hot”, or “shooting”
What denervation changes occur in the area served by the NR in a radiculopathy?
atrophy and fasciculations
Which type of atrophy occurs quicker - denervation or disuse?
Denervation
What happens to DTRs with a radiculopathy?
diminished or absent
Do sensory abnormalities accompany radiculopathies?
Yes
Do sensory or motor changes occur first in radiculopathies?
Sensory
Which sensory modalities are affected in radiculopathy?
All 4
Are most radiculopathies symmetric?
No - usually asymmetric
What is the Heel Walk?
Pt walks 10 steps on heels
What does the heel walk screen for?
L4-L5 NRs, peroneal fibers of sciatic n, and common & deep peroneal nn
Two abnormal findings of the heel walk?
foot drop or steppage gait
What is the Toe Walk?
Pt walks 10 steps on toes
What does the toe walk screen?
L5-S2 NRs
Abnormal finding of the toe walk?
heel drop
What is a common cause of cervical NR impingement?
cervical spondylosis
What findings would compression of the WHITE matter in the SC cause?
UMNL findings
What findings would compression of the gray matter in the SC cause?
LMNL findings
How do “incomplete” cord lesions present?
“mixed” LMNL/UMNL presentation
How does “central cord syndrome” present?
LMNL findings in upper extremity and UMNL findings in lower extremity
What is central cord syndrome usually assoc with?
combination of trauma/whiplash and cervical spondylosis
What does SLOW onset of mixed upper and lower motor neuron lesions classicaly signify?
ALS (Lou Gehrig’s)
What are slurring of words and/or choking during a meal the first clinical indications of?
UMNL of slow onset
What are a common symptom of corticospinal tract lesions?
muscle cramps
What are wide-spread fasciculations an early sign of?
LMNLs of slow onset
What causes wide-spread fasciculations in LMNLs?
irregular firing at anterior horn cells
What are the three categories of CN lesions?
- supranuclear 2. nuclear 3. infranuclear
What are supranuclear lesions?
“central lesions” - involve CORTEX
What are nuclear lesions?
“peripheral lesions” - involve CN nucleus
What are infranuclear lesions?
“peripheral lesions” - involve nerve fibers
What causes a large portion of olfactory defects?
obstruction of nasopharynx (polyps, mucus accumulation, etc)
Why should you not use noxious substances when testing sense of smell?
Could stimulate CN V instead of CN I
What do most olfactory problems originate from?
disorders of nasopharynx and/or paranasal sinuses
What can swelling of the mucosa and submucosa lead to that can last for months or years?
olfactory deficits
What is seen in 33% of rhinitis cases?
Hyposmia/anosmia
What is -osmia?
olfaction
What is dysosmia/parosmia?
can notice presence of odor but have trouble identifying it (distorted/altered)
What is phantosmia?
reporting an odor when no odor is present
What causes dysosmia?
damage to receptors and neuroepithelium (infranuclear)
What causes phantosmia?
supranuclear lesion - damage to olfactory cortex
T/F: CN V sensory innervation includes the angle of the jaw.
False
What are the afferent and efferent nerves for the corneal reflex?
Afferent = CN V Efferent = CN VII
What is the normal result of the corneal reflex?
both eyes blink
What are the results of a neuro exam for pts with idiopathic trigeminal neuralgia?
Neuro exam is NORMAL
What is the typical age of onset for idiopathic TN?
60-70 yrs (assoc w/ shingles in younger)
How does TN present?
severe stabbing, paroxysmal, and unilateral facial pain that is triggered by chewing or similar activities or by touching the affected facial areas
When assessing mm of facial expression (CN VII LMNL), which msl should you pay special attention to?
Frontalis m
What could result from ipsilateral orbicularis oris dysfunction?
Possible dysarthria with lip sounds “B” “P” and “M”
How does a LMNL of CN VII present?
Ipsilateral flaccid paresis/paralysis
How does a UMNL of CN VII present?
Contralateral spastic paresis/paralysis
During what action is an UMNL of CN VII most obvious?
lip retraction
What does the term “Bell’s palsy” refer to?
idiopathic facial paralysis
What does assessment of CN VIII consist of?
hearing exam (vestibular function not tested in routine exam)
How do you separate the testable functions of CN IX and X?
You can’t - Usually tested together
What is the best screening exam for CN IX, X, and XII?
listen to the pt’s speech. If they speak clearly, everything else will be redundant
Signs of abnormal oropharynx?
Decreased or absent pharyngeal sensation, decreased gag reflex, decreased upward movement of post. Aspect of soft palate when “aaahhhh”
What does a “peripheral” nuclear/infranuclear lesion of CN IX/X imply?
ipsilateral lesion involving medulla or CNs
What does a “central” supranuclear lesion of CN IX/X imply?
bilateral lesion involving cerebral hemispheres
What conditions can LMNL of CN XI lead to?
“shoulder droop”, “winged scapula” (unilateral weakness and atrophy)
What sounds are difficult with CN XII lesions?
“L”, “D”, “T”, and “N”
What msls are used to pull the tongue toward your chin (stick out your tongue)?
Inferior fibers of genioglossus m
What do LMNLs of CN XII affect?
ipsilateral tongue
In a pt with a left CN XII LMNL, the tongue deviates toward which side?
To the left
What is Romberg’s test?
Pt stands erect with feet together and arms at their sides. 20-30 sec with eyes open and 20-30 sec with eyes closed
What are the signs of an abnormal (positive) Romberg’s test?
Takes a step, pt falls, or truncal ataxia, takes a step, and body wobbles
What is ataxia?
“a lack of order”
What are the findings for bilateral peripheral neuropathy with the Romberg’s test?
50% take a step or fall within 10 seconds after closing their eyes
What are the findings for cerebellar dz with romberg’s test?
50% take a step or fall within 60 seconds
What are the findings for vestibular dz with Romberg’s test?
Not as clear-cut, pts sway more after closing their eyes
How does the sensory exam and speech present with cerebellar ataxia?
sensory = normal speech = slurred
What does the finger-to-target/finger-to-nose test for?
upper extremity cerebellar limb ataxia
What does heel-to-shin test for?
lower extremity cerebellar limb ataxia
What are 4 other forms of neurologic gait abnormalities?
- cerebral palsy 2. spastic hemiplegia/”circumduction” gait 3. “scissors gait”/spastic diplegia 4. parkinsonism
What presents with a resting tremor in ONE upper extremity that is usually maintained, but can progress?
Parkinsonism
What type of stimulus should you use to test a superficial reflex?
Noxious stimulus
What does “pathologic reflex” indicate?
abnormal response to superficial reflex, indicative of UMNL
What is an abnormal Babinski response?
extensor response/big toe up
What is the finger flexor reflex classically assoc with?
hyperreflexia (UMNL)
Why do signs of brainstem stroke sometimes overlap?
shared blood supply
What is Wallenberg syndrome aka and how does it present?
aka lateral medullary artery infarct/PICA. Gait ataxia/staggering in 88% of pts
Does PICA present contralaterally or ipsilaterally?
Contralateral body (loss of pain/temp) and ipsilateral face (numbness/paresthesias)
What is the diameter of the fovea centralis and what does it contain?
1.5 mm cones only
What happens with progressive decrease in acuity outside the fovea?
peripheral vision is not as sharp as central vision
What are the three requirements for development of binocular vision?
- conjugate eye movements 2. yoked vergence movements 3. lens accommodation for near vision
What is hyperopia?
far-sighted
What do the ciliary msls do to accommodate for far vision?
ciliary msls relax
What do the ciliary msls do to accommodate for near vision?
ciliary msls contract
What is the concurrent requirement for the development of binocular vision?
cortical mapping (“wire together fire together”)
Where do the optic n fibers terminate?
lateral geniculate nuclei (processing center for visual info)
how is the balancing of ocular dominance columns accomplished?
learned, activity-driven sorting process
Where should the corneal light reflections land?
same clock position in each eye
What is the accommodative “triad”?
- convergence 2. pupillary constriction 3. lens accommodation for near vision
What happens in a “convergence break”?
One eye deviates back to original starting position as pencil approaches nose
What is an abnormal result for the convergence insufficiency self-test?
double image of the line is seen as the paper nears the eye (implies ciliary msl fatigue)
What is strabismus?
an eye is obviously deviated when both eyes are open (“a squint”) (old term)
What is tropia?
an eye is obviously deviated when both eyes are open (“a turning”)
What is phoria?
an eye that deviates only when it is covered and its visual stimulus is taken away (“a bearing”)
What test do you use for evidence of a phoria?
cover-uncover test
What do the cardinal fields of gaze evaluate?
fixation and pursuit movements
What does an “undershoot” or “overshoot” during cardinal fields of gaze indicate?
possible cerebellar dz or acute alcohol intoxication
What do “jittery eye movements” during a cardinal field of gaze indicate?
early indication of MS
What can an eyestrain headache be due to?
convergence insufficiency
What is the most common cause of eye strain headache?
extended use of a computer or digital electronic device
What are the complaints of eye strain?
blurred vision, double vision, difficulty focusing, and moving print
What are the serious/long-term consequences of eye strain?
There are none
What is amblyopia?
lazy eye
Is amblyopia usually unilateral or bilateral?
unilateral
What is the leading cause of monocular vision loss in those age 20-70?
amblyopia
What is anisometropia?
unequal refractive power, one eye is more far-sighted or near-sighted than the other
What are constant tropias aka?
concomitant strabismus
