Exam 4 - Nervous system Flashcards
What are the five categories of the neurological exam?
- Mental status, speech, language
- Cranial nerves
- Motor system
- Sensory system
- Reflexes
What are some common or concerning symptoms that the FNP should assess for as part of the neurological history?
- Headache
- Dizziness or vertigo
- Weakness (generalized, proximal, distal)
- Numbness, abnormal or absent sensation
- Fainting and blacking out (near syncope and syncope)
- Seizures
- Tremors or involuntary movements
What information do you know about morbidity and mortality in relation to strokes?
- Leading cause of death in the U.S. and leading cause of long-term disability
- Accounts for 1 in every 20 deaths
- Prevalence and mortality are higher in African Americans
- Cerebrovascular ischemia (87%)
- Hemorrhage (13%)
- Intracerebral (10%)
- Subarachnoid (3%)
What history and exam findings are consistent with TIAs/strokes?
F - face drooping
A - arm weakness
S - speech difficulty
T - time to call 911
What are the vascular territories for strokes and the corresponding clinical findings?
Middle cerebral artery
- Visual field cuts
- Contralateral hemiparesis
- Sensory deficits
Left middle cerebral artery
- Aphasia
Right middle cerebral artery
- Neglect or inattention to the opposite side of the body
What are different types of tremors and how do they present - resting (static) tremor?
Most prominent at rest and may decrease/disappear w/ voluntary movement
Example: slow, fine, pill-rolling tremor of parkinsonism
What are different types of tremors and how do they present - postural tremor?
Appear when the affected part is actively maintaining a posture
Examples:
- Fine rapid tremor of hyperthyroidism
- Tremors of anxiety and fatigue
- Benign essential (often familial) tremor
What are different types of tremors and how do they present - intention tremor?
Absent at rest; appears w/ movement and gets worse as target gets closer
Causes: cerebellar disorders (e.g. MS)
What are dizziness and vertigo?
Dizziness is a nonspecific term used by patients that encompasses several disorders
Vertigo: spinning sensation accompanied by nystagmus and ataxia
- Usually from peripheral vestibular dysfunction or central brainstem lesion
What is presyncope and syncope?
Presyncope: a near faint from “feeling faint or lightheaded”, weak in the legs
- Causes: orthostatic hypotension from medications, arrhythmias, vasovagal attacks
Syncope: sudden but temporary LOC and postural tone
What is weakness? What patterns should you identify about weakness?
Clarify whether patient means fatigue, apathy, drowsiness, or loss of strength
Identify the pattern of weakness - proximal/distal, symmetric/asymmetric
What are some etiologies of weakness - abrupt onset of motor and sensory deficits?
TIA or stroke
What are some etiologies of weakness - progressive subacute onset of lower extremity weakness?
Guillain-Barre syndrome
What are some etiologies of weakness - chronic, more gradual, onset of lower extremity weakness?
Primary and metastatic spinal cord tumors
What are some etiologies of weakness - focal or asymmetric weakness?
Central causes - ischemic, thrombotic, mass lesions
Peripheral causes - nerve injury to neuromuscular junction disorders (e.g. myopathies)
How do you test for discriminative sensations?
- Stereognosis
Ability to identify an object by feeling it - place a familiar object (coin, paper clip, key, pencil, etc.) in patient’s hand and ask patient to tell you what it is
Abnormal: astereognosis - inability to recognize objects placed in the hand
What could abnormal findings with discriminative sensation indicate?
If touch and position sense are normal, decreased or absent discrimination sensation indicates a lesion in the sensory cortex
Stereognosis, number identification, and two-point discrimination are also impaired in posterior column disease
How do you test for discriminative sensations?
- Number identification (graphesthesia)
If arthritis or other conditions prevent the patient from identifying the object w/ stereognosis, test ability to identify numbers
With blunt end of pen, draw a large number in the patient’s palm
Abnormal: inability to recognize numbers indicates lesion in sensory cortex
How do you test for discriminative sensations?
- Two-point discrimination
Using the two ends of an opened paper clip, touch a finger pad in two places simultaneously; alternate the double stimulus irregularly with a one-point touch
Find the minimal distance at which the patient can discriminate one from two points (normally <5mm)
Abnormal: increased distance between two recognizable points indicate lesion of sensory cortex
How do you test for discriminative sensations?
- Point localization
Briefly touch a point on the patient’s skin, then ask patient to open both eyes and point to the place touched
Abnormal: inability to localize points accurately indicates lesion of sensory cortex
How do you test for discriminative sensations?
- Extinction
Stimulate one side or simultaneously stimulate corresponding areas on both sides of the body; ask where the patient feels your touch
Abnormal: only one stimulus may be recognized, indicates lesion of sensory cortex
What tests can be used to assess gait? What are some specific abnormalities of gait and posture?
- Walk across the room, turn, and come back
- Walk heel-to-toe in a straight line (tandem walking)
Abnormal: uncoordinated movement w/ reeling and instability
- Indicates ataxia
What are tests of coordination? What do abnormal findings indicate?
- Arms/legs: rapid alternating movements
Rapid alternating movements
- Arms - rapid alternating arm movements, rapid finger tapping
-
Abnormal: slow, irregular, clumsy hand movements (dysdiadochokinesis)
- Cause: cerebellar disease, upper motor neuron weakness, basal ganglia disease
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Abnormal: slow, irregular, clumsy hand movements (dysdiadochokinesis)
What are tests of coordination? What do abnormal findings indicate?
- Heel-to-shin test
In cerebellar disease, heel may overshoot the knee then oscillate from side to side down the shin
If position sense is absent, heel lifts too high and patient tries to look
Performance is poor w/ eyes closed
What are tests of coordination? What do abnormal findings indicate?
- Finger-to-nose test
Abnormalities seen w/ cerebellar disease
Dysmetria - patients finger overshoots the mark, but then reaches it fairly well
Intention tremor - appears toward end of movement
Past pointing - consistent deviation to one side which worsens w/ eyes closed
What tests can be used to assess gait? What are some specific abnormalities of gait and posture?
- Walk on the toes, then on the heels
Abnormal: inability to heel-walk
- Sensitive test for corticospinal tract damage
- Reveals distal leg weakness
What tests can be used to assess gait? What are some specific abnormalities of gait and posture?
- Hop in place on each leg in turn
Difficulty hopping points to weakness, lack of position sense, or cerebellar dysfunction
What tests can be used to assess gait? What are some specific abnormalities of gait and posture?
- Do a shallow knee bend
Difficulty suggests proximal weakness (extensor of hip), weakness of quadriceps (extensor of knee), or both
What tests can be used to assess gait? What are some specific abnormalities of gait and posture?
- Rise from sitting position w/o arm support OR step up on a sturdy stool
Difficulty indicates proximal muscle weakness in pelvic girdle and legs
What reflexes should the FNP assess?
- Biceps (C5, C6)
- Triceps (C6, C7)
- Brachioradialis (C5, C6)
- Quadriceps/patellar (L2, L3, L4)
- Achilles (S1)
If reflexes seem hyperactive, test for ankle clonus
How does the FNP assess for clonus? What does clonus indicate?
- With one hand support the knee in a partially flexed position
- With the other dorsiflex and plantar flex the foot a few times
- Sharply dorsiflex the foot and maintain it in dorsiflexion
- Look and feel for rhythmic oscillations between dorsiflexion and plantar flexion
Sustained clonus points to CNS disease
How would the FNP assess for diabetic neuropathy?
- Pin-prick sensation
- Ankle reflexes
- Vibration perception (w/ tuning fork)
- Plantar light touch sensation (w/ Semmes-Weinstein monofilament)
- Positive test if patient can’t feel the filament
What is the Romberg test? What does an abnormal finding indicate?
Test of position sense - patient should first stand w/ feet together and eyes open and then close both eyes for 30-60 seconds w/o support
- Note patients ability to maintain upright posture
-
Positive Romberg sign: patient stands well w/ eyes open, but loses balance when they’re closed
- In ataxia from dorsal column disease and loss of position sense, vision compensates for sensory loss
- Cerebellar ataxia: patient has difficulty standing w/ feet together whether eyes are open/closed
What is reinforcement and how can it be used to assess reflexes?
If patients reflexes are symmetrically diminished or absent, use reinforcement
- Technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity
Example: if leg reflexes are diminished/absent, ask patient to lock fingers and pull one hand against the other, tell patient to pull just before you strike the patellar tendon
For each cranial nerve, what is the name, number, how is it performed, and what is a normal finding?
- Cranial nerve I - olfactory
- Ask patient to close both eyes
- Occlude one nostril and test smell in the other with substances like cloves, coffee, soap
- Ask patient to identify each odor
Loss of smell occurs in sinus conditions, head trauma, smoking, aging, use of cocaine, Parkinsons
For each cranial nerve, what is the name, number, how is it performed, and what is a normal finding?
- Cranial nerve II - optic
- Test for visual acuity w/ Snellen chart
- Inspect optic fundi w/ ophthalmoscope
- Inspect optic disc for bulging and blurred margins (papilledema), pallor (optic atrophy), and cup enlargement (glaucoma)
- Test the visual fields by confrontation
For each cranial nerve, what is the name, number, how is it performed, and what is a normal finding?
- Cranial nerves II and III - optic and oculomotor
- Test for pupillary response to light
- Check near response
- Tests pupillary constriction, convergence, and accomodation
For each cranial nerve, what is the name, number, how is it performed, and what is a normal finding?
- Cranial nerves III, IV, VI - oculomotor, trochlear, abducens
- Extraocular movements in six cardinal directions of gaze
- Identify any nystagmus and note the direction of gaze in which it appears (horizontal, vertical, rotary, or mixed)
- Check convergence of eyes
- Look to ptosis (drooping of upper eyelids)
For each cranial nerve, what is the name, number, how is it performed, and what is a normal finding?
- Cranial nerve V - trigeminal
Motor - ask patient to clench theeth while palpating temporal and masseter muscles; move jaw from side to side
Sensory - test forehead, cheeks, and chin on each side for pain sensation (sharp vs dull)
Corneal reflex - ask patient to look up and away from you, approach from the opposite side and lightly touch cornea with fine wisp of cotton
For each cranial nerve, what is the name, number, how is it performed, and what is a normal finding?
- Cranial nerve VII - facial
Ask patient to:
- Raise both eyebrows
- Frown
- Close both eyes tightly so that you cannot open them
- Show both upper and lower teeth
- Smile
- Puff out both cheeks
For each cranial nerve, what is the name, number, how is it performed, and what is a normal finding?
- Cranial nerve VIII - acoustic and vestibular
Whispered voice test
If hearing loss is present with whispered voice test, test for:
- Conductive vs sensorineural hearing loss (lateralization) w/ Weber test
- Air vs bone conduction w/ Rinne test
For each cranial nerve, what is the name, number, how is it performed, and what is a normal finding?
- Cranial nerves IX and X - glossopharyngeal and vagus
- Listen to patients voice
- Ask patient to say “ah” and watch for upward movement of soft palate and pharynx
- Gag reflex
For each cranial nerve, what is the name, number, how is it performed, and what is a normal finding?
- Cranial nerve XI - spinal accessory
- Standing behind patient, look for atrophy or fasiculations (fine flickering irregular movements in small groups of muscle fibers)
- Ask patient to shrug both shoulders upward against resistance
- Ask patient to turn head to each side against resistance
- Note contraction of opposite sternocleidomastoid muscle
For each cranial nerve, what is the name, number, how is it performed, and what is a normal finding?
- Cranial nerve XII - hypoglossal
Ask patient to stick out tongue - look for symmetry, atropy, midline
Ask patient to move tongue from side to side
How is muscle strength graded?
What are meningeal signs? What do positive results indicate?
- Neck mobility/nuchal rigidity
First, make sure there is no injury or fracture to the cervical vertebrae or cervical cord
- With patient supine, place hands behind the patient’s head and flex the neck forward (if possible, until the chin touches the chest)
Neck stiffness indicates acute bacterial meningitis or subarachnoid hemorrhage
What are meningeal signs? What do positive results indicate?
- Brudzinski sign
As the neck is flexed, watch the hips and knees in reaction to your maneuver
Positive - flexion of both hips and knees
What are meningeal signs? What do positive results indicate?
- Kernig sign
Flex patient’s leg at both the hip and knee, then slowly extend the leg and straighten the knee
- Discomfort behind the knee during full extension is normal but should not produce pain
Positive - pain and increased resistance to knee extension
What are the causes of neurologic headaches and how would they present?
Subarachnoid hemorrhage
- “Worse headache of my life” with instantaneous onset
Meningitis
- Severe headache and stiff neck
Brain tumors or abscess
- Dull headache increased by coughing and sneezing, especially when recurring in the same location
What findings are consistent with Parkinson’s disease?
- Low-frequency unilateral resting (static) tremor
- Muscle rigidity
- Stooped posture, short and shuffling gait
- Bradykinesia
- Loss of smell
How would the FNP assess cranial nerves in the infant? What would be a normal response?
- Cranial nerve I - olfactory
- Cranial nerve II - visual acuity
I - very difficult to test
II - have infant regard your face and look for facial response and tracking
How would the FNP assess cranial nerves in the infant? What would be a normal response?
- Cranial nerves II and III - response to light
- Darken room, raise infant to sitting position to open eyes
- Use light and test for optic blink reflex (blink in response to light)
- Use the otoscope’s light (w/o speculum) to assess pupillary responses
How would the FNP assess cranial nerves in the infant? What would be a normal response?
- Cranial nerves III, IV, VI - extraocular movements
Observe how well the infant tracks your smiling face (or a bright light) and whether the eyes move together
How would the FNP assess cranial nerves in the infant? What would be a normal response?
- Cranial nerve V - motor
- Test rooting reflex
- Test sucking reflex (watch infant suck breast, bottle, or pacifier) and strength of suck
How would the FNP assess cranial nerves in the infant? What would be a normal response?
- Cranial nerve VII - facial
Observe infant crying and smiling - note symmetry of face
How would the FNP assess cranial nerves in the infant? What would be a normal response?
- Cranial nerve VIII - acoustic
- Test acoustic blink reflex (blinking of both eyes in response to a loud noise)
- Observe tracking in reponse to sound
How would the FNP assess cranial nerves in the infant? What would be a normal response?
- Cranial nerves IX, X - swallow and gag reflex
- Observe coordination during swallowing
- Test for gag reflex
How would the FNP assess cranial nerves in the infant? What would be a normal response?
- Cranial nerve XI - spinal accessory
Observe symmetry of shoulders
How would the FNP assess cranial nerves in the infant? What would be a normal response?
- Cranial nerve XII - hypoglossal
- Observe coordination of sucking, swallowing, and tongue thrusting
- Pinch nostrils; observe reflex opening of mouth with tip of tongue to midline
How would the FNP assess sensory function in the infant? What would abnormal findings indicate?
Test for pain sensation by flicking the infant’s palm or sole with your finger - observe for withdrawal, arousal, and change in facial expression
- DO NOT use a pin to test for pain
Abnormal finding: if changes in facial expressions or cry follow a painful stimulus but no withdrawal occurs, consider weakness or paralysis
How would the FNP assess primitive reflexes in the newborn? What would abnormal findings indicate?
- Palmar grasp reflex
Maneuver: place your fingers into the infant’s hands and press against the palmar surfaces - infant will flex all fingers to grasp your fingers
Ages: birth to 3-4 months
Abnormal findings:
- Persistence of palmar grasp reflex beyond 4 months = pyramidal tract dysfunction
- Persistence of clenched hand beyond 2 months = CNS damage (esp if fingers overlap thumbs)
How would the FNP assess primitive reflexes in the newborn? What would abnormal findings indicate?
- Plantar grasp reflex
Maneuver: touch the sole at the base of the toes - toes will curl
Ages: birth to 6-8 months
Abnormal finding: persistence of plantar grasp reflex beyond 8 months = pyramidal tract dysfunction
How would the FNP assess primitive reflexes in the newborn? What would abnormal findings indicate?
- Rooting reflex
Maneuver: stroke the perioral skin at the corners of the mouth - the mouth will open and the infant will turn the head toward the stimulated side and suck
Ages: birth to 3-4 months
Abnormal finding: absence of rooting indicates severe generalized or CNS disease
How would the FNP assess primitive reflexes in the newborn? What would abnormal findings indicate?
- Moro reflex (startle reflex)
Manuever: hold the infant supine, supporting the head, back, and legs, abruptly lower the entire body about 2 feet - arms will abduct and extend, hands will open, legs will flex (infant may cry)
Ages: birth to 4 months
Abnormal finding:
- Persistence beyond 4 months = neurological disease (e.g. cerebral palsy)
- Persistence beyond 6 months strongly suggests it
- Asymmetric response = fracture of clavicle or humerus or brachial plexus injury
How would the FNP assess primitive reflexes in the newborn? What would abnormal findings indicate?
- Asymmetric tonic neck reflex
Maneuver: with the infant supine, turn head to one side, holding jaw over shoulder - arms/legs on side to which head is turned will extend while the opposite arm/leg will flex (repeat on other side)
Ages: birth to 2 months
Abnormal finding:
- Persistence beyond 2 months = asymmetric CNS development and sometimes predicts development of cerebral palsy
How would the FNP assess primitive reflexes in the newborn? What would abnormal findings indicate?
- Trunk incurvation (Galant) reflex
Maneuver: support the infant prone with one hand and stroke one side of the back 1cm from midline, from shoulder to buttocks - spine will curve toward the stimulated side
Ages: birth to 2 months
Abnormal finding:
- Persistence may indicate delayed development
How would the FNP assess primitive reflexes in the newborn? What would abnormal findings indicate?
- Landau reflex
Maneuver: suspend the infant prone with one hand - head will lift up and spine will straighten
Ages: birth to 6 months
Abnormal finding:
- Persistence may indicate delayed development
How would the FNP assess primitive reflexes in the newborn? What would abnormal findings indicate?
- Parachute reflex
Maneuver: suspend the infant prone and slowly lower the head toward a surface - arms and legs will extend in a protective fashion
Ages: 8 months and does not disappear
Abnormal finding:
- Delay in appearance may predict future delays in voluntary motor development
How would the FNP assess primitive reflexes in the newborn? What would abnormal findings indicate?
- Positive support reflex
Maneuver: hold the infant around the trunk and lower until the feet touch a flat surface - hips, knees, and ankles will extend, the infant will stand up, partially bearing weight, sagging after 20-30 seconds
Ages: birth or 2 months until 6 months
Abnormal finding:
- Lack of reflex suggests hypotonia or flaccidity
- Fixed extension and adduction of legs (scissoring) suggests spasicity from neurologic disease (e.g. cerebral palsy)
How would the FNP assess primitive reflexes in the newborn? What would abnormal findings indicate?
- Placing and stepping reflexes
Maneuver: hold infant upright as in positive support reflex; have one sole touch the tabletop - hip and knee of that foot will flex and the other foot will step forward (alternate stepping will occur)
Ages: birth (best after 4 days; variable age to disappear)
Abnormal findings:
- Absence of placing may indicate paralysis
- Newborns born by breech delivery may not have a placing reflex
What exam findings would be present in the newborn that has been exposed to maternal substance abuse or the infant experiencing neonatal abstinence syndrome?
Drug withdrawal from maternal substance use during pregnancy
- Irritability, jittery, tremors, hypertonicity, hyperactive reflexes
Neonatal abstinence syndrome
- Irritability, jittery, tremors, hypertonicity, hyperactive reflexes
- Poor feeding, seizures
