EXAM Flashcards
Describe an approach to the neurological examination - GENERAL SIGNS
1) Conciousness
2) nuchal rigidity
- patient lying in bed -examine slips a hand under the occiput and gently flexes the neck – resistance from painful spasm is indiciative of menigeal irritation
- Brudzinski is spontaneous flexion of the hip during the flexion of the neck
- Kernigs - flex the hip the attempt to straighten the knee - greatly limited by spasm of the hams strings when there is meningism
3) handedness
4) oreintation
Describe an approach to the cranial nerve examination
1) olfactory - can you smell coffee - test with alcohol swab
Describe approach to second nerve
2) Optic nerve - purely sensory - fibres from the temporal visual fields (the nasal halves or medial aspect of the retina) cross in the chiasm
HISTORY
-Ask about -ve (loss of vision, amaurosis fugax) and +ve such as flashes and hallucinations
- Migrains may be preceded by scintillating scotomas, photophobia or hemianopia
EXAM
1)VA tested with glasses or through pinhole to avoid refraction error - if not able to read letters, movement of fingers and light testing
2)Visual fields including blind spot
a-) central scotomata or loss of central vision (macular) - due to demyelination of the optic nerve (MS), toxic causes such as methanol
b-) Biltemporal hemianopia due to a lesion in the optic chiasm - pituitary tumor
c-) homonymous hemianopia - lesions damages the optic tract or radiation
3) Fundoscopy
Decribe appraoch to 3,4 and 6th nerve exam
3) Occulomotor, trochlear and abducens
-parasympathetic to the eye is from the third nerve - constrictor pupillae
-3rd nerve also innvervates levator palpabrae and all of the EOM accept for SO4, and LR6
EXAM
1) pupil - PEARLA, ptosis, light reflex, RAPD
-accomodation - focus on a finger 30cm from face and then bring closer into nose normal response is constriction of both pupils.
-Absent light reflex with normal accommodation- argyl robertson pupil of suphilis
2) EOM - follow finger in a H pattern and ask about diplopia - if present clarify if side by side (LR or MR only) or above and below (SR,IR, SO, IO) - ask in which direction max seperation occurs
3) Nystagmus
Describe a 3,4,6 nerve palsy
THIRD
Complete ptosis, divergent strabismus (eye down and out) and a dilated pupil which is unreactive to direct light and accomodation.
DDX
- compressive lesions such as an aneurysms, tumour, or orbital lesion
-ischaemia or infarction - arteritis, t2DM and migraine
-demylination - MS
FOURTH
- Weakness in downward and out movement
- torsional diplopia - difficulty going down stairs
- isolated 4th is rare
SIXTH
- Lateral movement diplopia
DDX- trauma or wernickes
Describe approach to exam of the trigeminal nerve
Both sensory and motor - travels through the CP angle and cavernous sinus
Three branches - opthalmic, maxillary and mandibular
EXAM
1) Corneal reflex - lightly touch the cornea (not conjunctiva) with a wisp of cottonwool should illicit reflex blinking in both eyes
2) Facial sensation in the three divisions of the nerve comparing each side with both sharp and cotton wool (light touch)
3) motor division - inspect for wasting of the temporal and masseter muscles- ask patient to clench teeth - can be tested by asking to bite forcefully onto a toungue depresssor
- hold mouth open while examiner tries to force it shut ( pterygoid)
4) jaw jerk or masseter reflex
DDX
- Central (pons, medulla and upper cervical cord) vascular lesions and tumours.
- cavernous singus causes including aneyurysms, tumor thrombosis
Discuss approach to the 7th nerve
EXAM
1) inspection for facial assymetry
2) test muscle power ask the patient to look up and wrinkle the forehead - looking for sparing of the forehead ( upper motor lesion)
3) other signs - taste in the anterior 2/3rds of toungue - and hyperacusis - rare
Discuss approach to the 8th CN
EXAM
1) inspection - hearing aird
2) finger rub or whispering
3) Rinne test - using a 256 hz tuning fork placed on the mastoid process when the sound is no longer heard fork is held in front of the meatus normally the note is now audible as air contaction is better than bone - Rinne -ve is not being able to hear fork when placed in front of canal
4) Webers - 256 hz placed on the centre of the head - nerve deafness causes the sound to be heard more readily in the non effected ear
5) if complaining of vertigo HINTS exam
6) HINTS
- Head impulse - a positive test indicates that there is disruption to the vestibulo-ocular reflex - so -the eyes move with the head and then saccade rapidly back to the point of fixation.
- should only be positive in one direction
- should only be tested if still symptomatic -
- Test of skew - usually assoicated with veritcal diplopia indicates a central cause
Discuss examination of the glossopharyngeal and vagus nerve and hypoglossal
EXAM
1) Inspect palate and any displacement of the uvula - ask patient to say ah the velecula should remain midline as it rises symmetrically. If drawn to one side this indicates a unilateral 10th palsy - uvula will be drawn towards the non effected side
2) test for gag reflex ( 9th) - alternative tought the back of the pharynx
3) speech as hoarseness (recurrent laryngeal nerve lesion)
TWELVE
1)
Discuss examination of the glossopharyngeal and vagus nerve and hypoglossal
EXAM
GLOSSOPHARYGNEAL
2) test for gag reflex ( 9th) - alternative tought the back of the pharynx
VAGUS
1) Inspect palate and any displacement of the uvula - ask patient to say ah the velecula should remain midline as it rises symmetrically. If drawn to one side this indicates a unilateral 10th palsy - uvula will be drawn towards the non effected side
3) speech as hoarseness (recurrent laryngeal nerve lesion)
TWELVE
1)Toungue wasting, fasicuation and deviation
Discuss examination of the accessory nerve
1) Shrug shoulders - feel bulk of the trap
2) turn head against resistance
Discuss Aetiology of grouped CN palsies
1) unilateral 3,4,5,6 - cavernous sinus pathology - aneurysms, bleeds, tumour
2) 5,7 and 8 - CP angle
3) 9, 10, 11 Jugular foramen lesions
4) 10,11,12 bulbar palsies
Discuss a general appraoch to neuro examination
MOTOR
- 1) general appearance
- posture - ie hemiplegia due to a stroke
- muscle bulk - look for obvious wasting or chachexia
- abnormal movement - tremor or chorea
- fasciculation
2) tone
3) power
4) Rfelxes
5) co-ordination
Sensation
1) pain and temp
2) vibration and proprioception
3) light touch
Discuss approach to upper limb neuro examination
GENERAL APPEREANCE
- hold both hands palms upward and eyes closed and look for drifting
- there are three causes of drift
1) Upper moter neurone weakness - the drift here is due to muscle weakness and tends to be downward
2) cerebella disease - the drift here is generally upwards and includes slow pronation
3) loss of proprioception - the drift here is a really a searching movement and usually only effect the fingers - then relax the arms and look for fasciulations
TONE
-Cogwheel of parkinsons and NMS
POWER -Abduction c5-6 Adduction c6-c8 ELbow flexion - c5,c6 extnesion c7-c8 Wrist flexion c6-c7, extension c7-c8 Finger flexion and extension c7-c8, abduction and adduction c8-t1
REFLEXES
- BICEPS - c5,6
TRCIPES c7-c8
Brachioradialsis c5-c6
Co-ordination
- finger nose test - intention tremor or past pointing for cerebella signs
- Disdochokinesiss
- Rebound
SENSATION
1) spinothalamic - pinprick (pain) start in a normal area such as the anterior chest wall - test in each dermatome down the arm - temperature testing not commonly done
2) Posterior column - vibration 128 hz - placed on a distal DIP - if sense abscent go to a joint proximal
- proprioception - DIP up and down - again if abnormal go a joint proximal
- light touch
Discuss testing of the radial nerve
Motor spupply to the triceps and brachioradialis and the extensor muscles of the hand - palsy of this nerve leads to wrist drop
SENSATION - test over the anatomical snuff box
MOTOR - Extension of the wrist and MCP joints – motor bike
