Exam 3 - Neurovascular Exam Flashcards
1
Q
Neuro ROS
A
Fainting, blackouts, seizures, weakness, paralysis, numbness, tingling, tremors or other involuntary movements, change in attention span.
2
Q
What items will you need to perform a complete neuro physical exam?
A
Reflex hammer Small vials of material readily sensed via olfaction, such as coffee grounds, peppermint, cloves, cinnamon Tuning forks Dermatome map Paper clips Cotton balls Tongue depressor Simple, everyday objects for identification, such as a coin or key
3
Q
Patient observation and examination?
A
Is mental status intact?
Observe appearance, behavior, orientation
Are right and left-sided findings symmetrical?
Test motor and sensory function by examining CNs
Decreased agility, strength
Interference with ADLs?
Increased falls/stumbling
Hearing loss, vision deficit, anosmia (loss of smell)
Development of tremor
4
Q
What are PNS-Sensory Pathways (Ascending)?
What are the 2 tracts listed and what do they do?
A
Ascending tracts send sensory information to the brain
Spinothalamic Tract
Transmits sensations of pain, temperature and crude or light touch.
Posterior Column
Conduct sensations of position, vibration and finely localized touch.
5
Q
What are PNS- Motor Pathways (Descending)?
What are the 3 tracts listed and what do they do?
A
Descending tracts deliver motor information to the periphery
Corticospinal Tract
Voluntary movement that is complicated, delicate and skilled; controls muscle tone.
Basal Ganglia System
Complex system of pathways between the cerebral cortex, basal ganglia, brainstem and spinal cord; helps maintain muscle tone and control body movement.
Cerebellar System
Receives both sensory and motor input and coordinate motor activity, maintains equilibrium and posture.
6
Q
Aphasia (examples)
A
Aphasia: disorder of language
Examples:
Expressive: know what you want to say, but have trouble saying/writing what you mean
Receptive: hear the voice or see the print, but cannot make sense of the words
Anomic: have trouble using the correct word for objects, places or events
Global: cannot speak, understand speech, read or write
7
Q
Expressive
A
Expressive: know what you want to say, but have trouble saying/writing what you mean
8
Q
Receptive
A
Receptive: hear the voice or see the print, but cannot make sense of the words
9
Q
Anomic
A
Anomic: have trouble using the correct word for objects, places or events
10
Q
Global
A
Global: cannot speak, understand speech, read or write
11
Q
Dysarthria
A
Dysarthria: defective articulation
12
Q
Diplopia
A
Diplopia: double vision
13
Q
Ataxia
A
Ataxia: gait lacking coordination; reeling, unstable
14
Q
Agnosia (and types)
A
Agnosia: loss of comprehension of auditory, visual, or other sensations although sensory pathways intact.
Auditory: mental inability to interpret sounds
Optic: mental inability to interpret images
Tactile: mental inability to distinguish objects by touch
Time: unawareness of the sequence or duration of events
15
Q
Atrophy
A
Atrophy: loss in muscle bulk; wasting
16
Q
Fasiculation
A
Fasiculation: involuntary muscle twitching
17
Q
Flaccid
A
Flaccid: lacking muscle tone
18
Q
Paresthesia
A
Paresthesia: sensation of numbness/tingling/prickling
19
Q
Paresis
A
Paresis: partial or incomplete paralysis
20
Q
Paralysis/plegia
A
Paralysis/plegia: temporary suspension or permanent loss of function, especially loss of sensory and voluntary function.
21
Q
Paraplegia
A
Paraplegia: paralysis of the lower portion of the body and both legs
22
Q
Quadriplegia
A
Quadraplegia: paralysis of all 4 limbs and usually the trunk also; spinal cord injury at the cervical level.
23
Q
Hemiplegia
A
Hemiplegia: paralysis of only 1 side of the body
24
Q
Myopathy
A
Myopathy: any disease or condition of striated muscle.
25
Polyneuropathy
Polyneuropathy: disease of the nerves involving more than one nerve.
26
Dysdiadochokinesis
Dysdiadochokinesis: inability to quickly substitute an antagonistic motor impulse to produce antagonistic muscular movements
Inability to tap toes against examiner’s hands, or tap the thumb with tip of index finger
27
Stereognosis
Stereognosis: the ability to recognize the form of a solid object by touch
28
Graphesthesia
Graphesthesia: the ability to recognize outlines, numbers, words or symbols traced or written on the skin
29
How many nerve pairs are there at the spinal cord?
```
Cervical?
Thoracic?
Lumbar?
Sacral?
Coccygeal?
```
31 pairs of nerves that attach to the spinal cord
| 8 cervical, 12 thoracic, 5 lumbar, 5 sacral, 1 coccygeal
30
What does the anterior or ventral root contain? Posterior or dorsal root?
Each nerve has an anterior (ventral) root containing motor fibers and a posterior (dorsal) root containing sensory fibers
31
The anterior and posterior roots merge to form what? Size?
The anterior and posterior roots merge to form a short spinal nerve; less than 5mm
32
What do spinal nerve fibers come together to form?
Spinal nerve fibers come together with similar fibers from other levels to form peripheral nerves
33
What is the peripheral nervous system composed of?
Cranial Nerves
CN I-XII
```
Spinal and peripheral nerves
1. Motor pathways
Corticospinal tract
Basal ganglia system
Cerebellar system
```
2. Sensory pathways
Spinothalamic tract
Posterior column
34
What is CN I?
| How do you test for it?
CN I – Olfactory (sensory)
Odor identification
Have patient occlude one nostril, and with eyes closed, identify a smell such as coffee grounds, mint, cloves
35
What is CN II?
| How do you test for it?
```
CN II – Optic (sensory)
-Visual acuity
>>Snellen Eye Chart
-Visual fields
>>By confrontation
-Fundoscopy
```
36
What are CN III, IV, and VI?
| How do you test for them?
CN III – Oculomotor (motor)
CN IV – Trochlear (motor)
CN VI – Abducens (motor)
```
Observe eyelids for lag
6 cardinal fields of gaze: EOMs LR6(SO4)3
Nystagmus
PERRLA
Convergence
```
37
What is CN V?
| How do you test for it?
CN V – Trigeminal (mixed)
3 divisions: ophthalmic, maxillary, mandibular
Motor: muscles of mastication
>Clench teeth: palpate temporal/masseter muscles
Sensory
Test pain sensation: sharp/dull
>Compare sides: is sensation equal bilaterally?
Light touch sensation: cotton wisp
>Compare sides: is sensation equal bilaterally?
Touch cornea with cotton wisp
38
What is CN VII?
| How do you test for it?
CN VII – Facial (mixed)
Innervates muscles of facial movement and expression
Taste sensation in anterior 2/3 of tongue (sweet/salty)
```
Inspect face at rest and during conversation
Raise eyebrows
Smile
Show teeth
Close eyes tight
Puff out cheeks
```
39
What is CN VIII?
CN VIII – Acoustic (sensory)
Also called Vestibulocochlear
Hearing and balance
Test gross hearing via whisper or rubbing of fingers
Weber test for CHL
Rinne test for SNHL
40
What is CN IX?
| What does it do?
CN IX – Glossopharyngeal (mixed)
| Taste: bitter/sour; posterior 1/3 of tongue
41
What is CNX?
CN X – Vagus (mixed)
Sensory and motor functions of palate, pharynx and larynx
Swallow
Say ahhh
>Voice hoarse?
>Soft palate rises symmetrically, uvula remains midline
Gag reflex bilaterally
>Prompt rise of palate, gagging
42
What is CN XI?
CN XI – spinal accessory (motor)
Innervates SCM and upper trapezius muscles
Test shoulder strength bilaterally - trapezius
Turn head against resistance - sternocleiomastoid
43
What is CN XII?
CN XII – hypoglossal (motor)
Motor function of tongue affecting articulation of words
Inspect tongue for atrophy, fasciculation, symmetry
Stick out tongue: protrudes straight out?
Push tongue against cheek and against resistance
44
Components of the Neurologic Exam
Mental Status Exam (MSE)
>Scored out of a possible 30 points
>See handout
```
Speech and language
Cranial nerve exam
Motor system
Sensory system
Reflexes
```
45
The motor system requires, what?
Requires combined and coordinated interaction between:
1. Cerebellum
2. Upper motor neurons
3. Lower motor neurons
46
What does the motor system exam consist of?
Position, movement, muscle bulk, and tone
Observe body position and involuntary movements
Tremors, tics, fasciculations
Inspect muscle bulk, note atrophy
Assess muscle tone
Flex/extend arm and lower leg for residual tension
Spasticity = increased resistance at extremes of ROM
Rigidity = increased resistance through whole ROM
47
Spasticity
Spasticity = increased resistance at extreme ROM
48
Rigidity
Rigidity = increased resistance through whole ROM
49
Examination of Muscle Strength - Ranks?
0 - No evidence of movement
1 - Traces of movement
2 - Full range of motion, but not against gravity
3 - Full range of motion against gravity, but not against resistance
4 - Full range of motion against gravity with some resistance, but weak
5- Full range of motion against gravity, full resistance; this is normal muscle strength
50
Muscle Strength Exam
All performed against resistance, such as
1. Biceps, triceps, wrist in flexion and extension
2. Handgrip abduction, adduction, thumb opposition
3. Trunk flexion, extension, lateral bending
4. Hip flexion, extension, abduction, adduction
5. Knee ankle flexion, extension
6. Ankle flexion, extension, rotation
See grading rubrics for complete list
51
Coordination Exam
How do you assess gait?
How do you assess rapid alternating movements?
How do you assess point-to-point movements?
```
Gait – assess gait as patient:
Walks across room
Walks heel-to-toe (tandem)
Walks on toes, then on heels
Hops in place
Demonstrates shallow knee bend bilaterally
```
Rapid alternating movements
Patient turns hands rapidly over and back on thighs, taps tip of index finger rapidly on distal thumb, taps ball of foot rapidly on examiner’s hand
Point-to-Point movements
Patient touches nose then examiner’s index finger as examiner moves it to different positions; patient moves heel from opposite knee down shin to great toe
52
Coordination Exam
How do you do Romberg Test? Whats a positive finding?
Stance: Romberg test
Patient stands with feet together, eyes open, then with eyes closed for 30-60 seconds without support
Loss of balance when eyes closed is a positive test
53
Coordination Exam
How do you do pronator drift?
Whats a positive finding?
Pronator drift
Patient stands for 20-30 seconds with both arms extended straight and forward, palms up, eyes closed; examiner taps patient’s arms briskly downward
Pronation and downward drift of arm is a positive test
54
Sensory system exam
General principles
Compare symmetric areas on both sides of body
When testing pain, temperature, and touch, compare distal with proximal areas of the extremities
Map out boundaries of any area of sensory loss or hypersensitivity
Know the dermatome map
55
How do you test pain in sensory exam?
Test pain: use disposable object (broken tongue blade/cotton applicator stick, reflex hammer handle)
Ask if sensation is sharp or dull; ask patient to compare the 2 sensations
56
How do you test light touch? Vibration? Proprioception?
Test light touch using cotton wisp
Test vibration: tap tuning fork on your hand and place it on DIP of patient's finger; ask patient if sensation is felt and if it is felt once you terminate the vibration
Test proprioception: hold patient’s big toe by its sides between your thumb and index finger; pull it away from other toes and move it up, then down.
Ask patient to identify direction of the movement without watching what you are doing
57
Sensory system exam purpose?
Assess discriminative sensation to test ability of the sensory cortex to analyze and interpret sensations
58
How to test graphesthesia?
Graphesthesia (number identification): outline a large number in the patient’s palm and ask the patient to identify the number
59
How to test stereognosis?
Stereognosis: place a key, coin, or other familiar object in patients hand (patient’s eyes closed) and ask patient to identify it
60
How to test two point discrimination?
Two-point discrimination: using 2 ends of an opened paper clip, touch the finger pad in 2 places simultaneously; ask patient to identify 1 touch or 2 without patient seeing what you are doing
61
Deep Tendon Reflexes Exam - General tips?
Encourage patient to relax; position limbs properly and symmetrically
Strike the tendon with a brisk direct movement
Use the minimum force needed to obtain a response
Use reinforcement when needed
Use distraction when necessary
Grade the response
62
How do you grade reflexes?
4+ - very brisk, hyperactive with clonus
3+ Brisker than average, but not necessarily indication of disease
2+ average, normal
1+ somewhat diminished, low normal
0 no response
63
Clonus
Clonus: a hyperactive response required for assigning a reflex grade of 4, usually at the ankle
64
What are DTRs used for?
DTRs with cord levels for responses helps localize any abnormalities
65
Biceps Reflex
Biceps reflex C5-6
66
Triceps Reflex
Triceps reflex C6-7
67
Brachioradialis
Brachioradialis C5-6
68
Knee Reflex
Knee reflex L2-4
69
Ankle Reflex
Ankle reflex S1
70
DTR Examination - What are they?
Where are the three regions and their dermatomes?
Cutaneous stimulation reflexes with cord levels for each response help localize any abnormalities
Abdominal reflexes – upper T8-10; lower T10-12 (umbillicus at T10)
Plantar response – L5-S1
Anal reflex- S2-S4
71
Plantar Response and Babinski Sign
What is a positive finding?
Assess plantar response with a pointed object: stroke lateral side of foot from heel to ball of foot; curve across ball of foot to medial aspect.
Dorsiflexion of great toe with or without fanning of other toes is considered a positive Babinski sign
72
Special Techniques: Asterixis
Asterixis: motor disturbance marked by intermittent lapses of an assumed posture as a result of intermittency of sustained contraction of groups of muscles
73
Special Techniques: Meningeal Signs
Meningeal signs: stiff neck (nuchal rigidity) may be associated with meningitis and intracranial hemorrhage
With patient supine, slip your hand under the head and raise it, flexing the neck. Pain and resistance to neck motion are associated with nuchal rigidity
74
Special Techniques: Brudzinski sign
Brudzinski sign
| Involuntary flexion of hips and knees when flexing the neck is a positive Brudzinski sign
75
Special Techniques: Kernig Sign
Kernig sign
With patient supine, flex the leg at knee and hip then attempt to straighten the leg. Pain in lower back and resistance to straightening the leg at the knee is a positive Kernig sign
Above signs indicate meningeal irritation
76
Biceps flexion
C5, C6
77
Triceps extension
C6, C7, C8
78
Wrist extension
C6, C7, C8
79
Grip strength
C6, C7, C8, T1
80
Finger abduction
C6, C7, C8, T1
81
Thumb opposition
C6, T1
82
Hip Flexion
L2, L3, L4
83
Hip Extension
S1
84
Hip adduction
L2, L3, L4
85
Hip abduction
L4, L5, S1
86
Knee Extension
L2, L3, L4
87
Knee Flexion
L4, L5, S1, S2
88
Ankle dorsiflexion
L4, L5
89
Ankle Plantar Flexion
S1
90
Additional Procedures: Monofilament von Frey hairs
Monofilament (von Frey hairs)
Used to test for sensation on bottom of feet in patient’s with diabetes, peripheral neuropathy
With patient’s eyes closed, touch monofilament, in random pattern to plantar surface of foot. Adequate pressure will bend the monofilament slightly
Patient should feel the sensation at all sites tested
91
Gait abnormalities
Antalgic
Limp is adopted to decrease pain on weight-bearing structure
Ataxic
Unsteady, uncoordinated walk; legs spread apart to widen base for balance
Steppage
Lifts foot high to avoid dragging foot; as foot comes down it “slaps” floor
Spastic hemiparesis
Leg swings outward from hip, may drag on floor; arm flexed at side with minimal swing
Parkinsonian
Posture stooped; flexion of head, arms, hips, knees; steps short and shuffling; arm swing decreased
92
Antalgic
Limp is adopted to decrease pain on weight bearing structure
93
Ataxic
Unsteady, uncoordinated walk; legs spread apart to widen base for balance
94
Steppage
Lifts foot high to avoid dragging foot; as foot comes down it "slaps" floor
95
Spastic hemiparesis
Spastic hemiparesis
| Leg swings outward from hip, may drag on floor; arm flexed at side with minimal swing
96
Parkinsonian
Parkinsonian
| Posture stooped; flexion of head, arms, hips, knees; steps short and shuffling; arm swing decreased
97
Spastic Hemiparesis
One arm held immobile and close to side with elbow, wrist and interphalengeal joints flexed.
Leg extended with plantar flexion of foot.
Upon walking, patient either drags foot, scraping floor with toe or circles it stiffly outward and forward (circumduction)
98
Spastic diplegia (scissors gait)
Gait is stiff.
Each leg advances slowly and thighs tend to cross forward on each other at each step.
Steps are short.
Patient appears to be walking through water.
99
Steppage gait
Patient either drags feet or lifts them high, with knees flexed and brings them down with a slap onto floor.
Appears to be walking up stairs.
Unable to walk on heels.
May involve one or both sides
100
Cerebellar Ataxia
Gait is staggering, unsteady, and wide based with exaggerated difficulty on turns.
Patients cannot stand steadily with feet together, whether eyes are open or closed.
101
Parkinson's Gait
Posture stooped, with head, neck forward and hips, knees slightly flexed.
Arms flexed at elbows and wrists.
Patient slow getting started.
Steps short and shuffling.
Arm swings are decreased.
102
Upper vs. Lower Motor Neuron Lesions
LOOK AT CHART
