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
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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