Exam 4: Neuro Flashcards

Question

Moro Reflex (Startle Reflex) What age? How to assess? What would abnormal findings indicate?

Answer 1

Birth to 4 mo * Hold the infant supine, supporting the head, back, & legs. * Abruptly lower the entire body about 2 ft. * The arms will abduct & extend, hands will open, & legs will flex. Infant may cry. Persistence **\> 4 mo** suggests **neurologic disease** (e.g., CP); **\> 6 mo** **strongly suggests** it. **Asymmetric response** suggests **fracture** of clavicle or humerus or brachial plexus injury.

Answer 2

Meningitis

Answer 3

Hypoglossal Tongue symmetry, position, & movement * Listen to word articulation * Inspect tongue lying on floor of mouth (atrophy, fasciculations) * Protrude tongue (asymmetry, atrophy, deviation from midline?) * Tongue side to side (symmetry of mvmt) Tongue atrophy and fasciculations are present in **ALS** and **past polio**. In a **unilateral cortical lesion**, the protruded tongue deviates away from the side of the cortical lesion. In CN XII lesions, the tongue deviates to the weak side.

Answer 4

Primarily S1 * If pt is sitting: partially dorsiflex the foot at the ankle. Patient relax. Strike the Achilles tendon. * If pt is lying down: flex 1 leg at both hip and knee and rotate it externally so that the lower leg rests across the opposite shin. Then dorsiflex the foot at the ankle and strike the Achilles tendon. Watch and feel for plantar flexion at the ankle and note the speed of relaxation after muscular contraction.

Answer 5

Subtle neonatal behaviors may indicate withdrawal from nicotine if the mother smoked during pregnancy such as: * fine tremors * persistent irritability * poor self-regulation

Answer 6

Are most prominent at rest and may decrease/disappear w/ voluntary movement. Common relatively slow, fine pill-rolling tremor of parkinsonism, about 5/second.

Answer 7

* Autoimmune collagen vascular disease * History of preeclampsia * Gestational diabetes * Pregnancy-induced HTN

Answer 8

1. Flex the pt’s leg at both the hip and the knee 2. Then slowly extend the leg and straighten the knee. Discomfort behind the knee during full extension is normal but should not produce pain. **+ test**: **Pain and increased resistance** to knee extension. Suggests meningeal inflammation from **meningitis or subarachnoid hemorrhage**.

Answer 9

L5, S1 * With a key or the wooden end of an applicator stick, stroke the lateral aspect of the sole from the heel to the ball of the foot, curving medially across the ball. * Closely observe movement of the big toe, normally plantar flexion. * Some pts withdraw from this stimulus by flexing the hip and the knee. **Dorsiflexion of the big toe** is a **positive Babinski response**, arising from a **CNS lesion affecting the corticospinal tract**. The Babinski response can be transiently positive in unconscious states from drug or alcohol intoxication and during the postictal period following a seizure. A marked Babinski response is **occasionally** accompanied by **reflex flexion at hip and knee.**

Answer 10

Mass lesions (brain tumors, abscess)

Answer 11

1 year: ∼12% 10 year stroke: 19% 10 year death: 43%

Answer 12

Birth to 6-8 mo * Touch the sole at the base of the toes. * Toes will curl. Persistence of reflex **\> 8 mo** suggests **pyramidal tract dysfunction**.

Answer 13

Contralateral leg weakness

Answer 14

Sudden: * Numbness or weakness of the leg, arm, or face * Confusion or trouble understanding * Trouble seeing in one or both eyes (partial loss of vision, homonymous hemianopsia, asymmetric pupils, loss of light reaction) * Trouble walking, dizziness, loss of balance or coordination * Motor and sensory deficits * Ataxia, diplopia, and dysarthria * Severe headache with no known cause * Acute symtomatic seizures

Answer 15

1. Neck Mobility/Nuchal Rigidity 2. Brudzinski Sign 3. Kernig Sign

Answer 16

Facial * Observe infant crying & smiling; note symmetry of face. Congenital facial nerve palsy can result from birth trauma or developmental defects.

Answer 17

Oculomotor * Pupillary reactions to light * Near response (constriction and accommodation) * EOM * Convergence of the eyes * Identify any nystagmus, diplopia, ptosis Abnormalities: Anisocoria, abnormal constriction-CN III palsy, ptosis + opthomoplegia – intracranial aneurysm (awake), transtentorial herniation (comatose); if anisocoria worsens in darkness, the small pupil has abnormal dilation-Horner syndrome (unequal pupils and worsens in darkness, nothing to do for it, just monitor by optho) and simple anisocoria

Answer 18

* Contralateral face weakness, * arm \> leg weakness, * sensory loss, * visual field loss, * apraxia, * aphasia (left MCA), or * neglect (right MCA)

Answer 19

Acoustic * Whispered voice test * If fail whisper test: * Rinne (air & bone conduction) * Weber (lateralization) **Excess cerumen, otosclerosis,** and **otitis media** cause conductive hearing loss. **Presbyacusis** from aging from sensorineural hearing loss. Vertigo with hearing loss and nystagmus –Meniere disease.

Answer 20

Birth (best after 4 days; variable age to disappear) * Hold infant upright. * One sole touch tabletop. * The hip & knee of that foot will flex & the other foot will step forward. * Alternate stepping will occur. **Absence** of placing may indicate **paralysis**. Newborns born by breech delivery may not have a placing reflex.

Answer 21

Trigeminal 1. Corneal reflexes 1. Touch cornea w/ cotton. 2. Jaw movements 1. Clench teeth 2. Open & move jaw side to side 3. Facial sensation 1. Pain on forehead, cheeks, & chin. Eyes closed. 2. If detect sensory loss, confirm using temperature sensation. Unilateral jaw weakness: **pontine lesions** Bilateral weakness: **bilateral hermispheric dz** Stroke: ipsilateral facial and body sensory loss from **contralateral cortical or thatlmic lesions** Blinking absent on both side with **CN V lesions**

Answer 22

Birth to 2 mo * Support the infant prone w/ one hand & stroke one side of the back 1cm from midline, from shoulder to buttocks. * The spine will curve toward the stimulated side. **Absence** suggests a **transverse spinal cord lesion or injury**. **Persistence** may indicate **delayed development**.

Answer 23

Are absent at rest, appear with movement and often get worse as the target gets closer. * Cerebellar disorders (multiple sclerosis)

Answer 24

Neglect or inattention to the opposite side of the body

Answer 25

This is mainly a test of *position sense*. * Pt 1st stand with feet together & eyes open, then close both eyes for 30-60 sec. w/o support. * Note the pt’s ability to maintain an upright posture. Normally any swaying is minimal. In ataxia from dorsal column disease and loss of position sense, vision compensates for the sensory loss. The pt stands fairly well with eyes open but **loses balance when they are closed, (a positive Romberg sign)**. In **cerebellar ataxia**, the pt has difficulty standing with feet together whether the eyes are open or closed.

Answer 26

Swallow & Gag * Observe coordination during swallowing. * Test for gag reflex. Dysphagia, or difficulty in swallowing, can occasionally be due to injury to cranial nerve IX, X, and XII.

Answer 27

Cardiovascular causes of death (including stroke)

Answer 28

3 to 4.5 hours

Answer 29

1st make sure there is no injury or fracture to the cervical vertebrae or cervical cord (radiologic eval). Then, with pt supine, place your hands behind the pt’s head and flex the neck forward, if possible until the chin touches the chest. **Neck stiffness with resistance to flexion** could indicate **acute bacterial meningitis** or **subarachnoid hemorrhage**.

Answer 30

Optic * Visual acuity * Inspect the optic fundi and discs * Visual fields by confrontation- each eye separately then both together * Pupillary reactions to light * Near response Stroke: partial loss of vision, visual field defect

Answer 31

Subarachnoid Hemorrhage

Answer 32

is often preceded by an aura or prodrome, and is highly likely if 3 of the 5 “POUND” features are present: **P**ulsatile or throbbing **O**ne Day duration, or lasts 4 to 72 hours if untreated **U**nilateral **N**ausea or vomiting **D**isabling or intensity causing interruption of daily activity.

Answer 33

1. Raise both eyebrows. 2. Frown. 3. Close both eyes tightly so you can’t open them. Test muscular strength by trying to open them. 4. Show both upper and lower teeth. 5. Smile. 6. Puff out both cheeks. Blinking absent one the side of weakness in lesions of CN VII. Flattening of the nasolabial fold and drooping of the lower eyelid suggest facial weakness **Bells palsy** (upper & lower face)

Answer 34

Abducens * EOM * Convergence of the eyes Identify any nystagmus (may be associated with cerebellar dz), diplopia, ptosis

Answer 35

* Dysphagia * Dysarthria * Tongue/palate deviation * and/or ataxia with crossed sensory/motor deficits (= ipsilateral face with contralateral body)

Answer 36

Contralateral visual field loss

Answer 37

Birth to 6 mo * Suspend the infant prone w/ one hand. * The head will lift up, & the spine will straighten. **Persistence** may indicate **delayed development**.

Answer 38

* Stimulate one side or simultaneously stimulate corresponding areas on both sides of the body. Ask where the patient feels your touch. * Normally both stimuli are felt. * With **lesions of the sensory cortex**, only one stimulus may be recognized. The stimulus to the side opposite the damaged cortex is extinguished.

Answer 39

Extraocular Movements * Observe how well the infant tracks your smiling face (or a bright light) & whether the eyes move together.

Answer 40

1. Stereognosis 2. Number identification (graphesthesia) 3. Two-point discrimination 4. Point localization 5. Extinction

Answer 41

Birth to 3-4 mo * Place your fingers into the infant’s hands & press against the palmar surfaces. * The infant will flex all fingers to grasp your fingers. Persistence of **palmar grasp** reflex **\>4 mo** suggests **pyramidal tract dysfunction**. Persistence of **clenched hand \>2 mo** suggests **CNS damage** (esp if fingers overlap the thumb)

Answer 42

Oculomotor deficits and/or ataxia with crossed sensory/motor deficits Complete basilar artery occlusion— “locked-in syndrome”

Answer 43

African Americans * Prevalence: black vs white men: 4.2% vs 2.2%; black vs white women: 4.7% vs 2.5% * Mortality per 100,000: black vs white men: 55 vs 36; black vs white women: 47 vs 36

Answer 44

Motor * Test rooting reflex. * Test sucking reflex (watch infant suck breast, bottle, or pacifier) and strength of suck.

Answer 45

Increase | (estimated to range from 6% to 28%)

Answer 46

C6, C7 * Pt sitting or supine. * Flex the pt’s arm at the elbow, w/ palm toward the body, and pull it slightly across the chest. * Strike the triceps tendon w/ a direct blow directly behind and just above the elbow. * If difficult for the pt to relax, support the upper arm and ask the pt to let the arm go limp (“hung up to dry”). Then strike the triceps tendon. Watch for contraction of the triceps muscle and extension at the elbow.

Answer 47

If the pt’s reflexes are symmetrically diminished or absent, use reinforcement, a **technique involving isometric contraction of other muscles** for up to 10 seconds that may **increase reflex activity**. Ex: To reinforce the arm reflexes, ask pt to clench teeth or squeeze both knees together. If leg reflexes are diminished or absent, ask the pt to lock fingers and pull one hand against the other. Tell the pt to pull just before you strike the patellar or Achilles tendon.

Answer 48

Modifiable risk factors: * HTN, smoking, dyslipidemia, DM, weight (obesity), diet/nutrition, physical inactivity, heavy alcohol use, cocaine or illicit drug use. Disease specific risk factors: * A.Fib, CAD, OSA, patent foramen ovale, carotid or vertebral/basilar artery dissection, hypercoagulable states

Answer 49

* Briefly touch a point on the patient’s skin. Then ask the patient to open both eyes and point to the place touched. * Normally a person can do so accurately. * **Lesions of the sensory cortex** impair the ability to localize points accurately.

Answer 50

If the reflexes seem hyperactive, test for ankle clonus. * Support the knee in a partly flexed position. With your other hand, dorsiflex and plantar flex the foot a few times while encouraging the pt to relax, then sharply dorsiflex the foot and maintain it in dorsiflexion. Look and feel for rhythmic oscillations between dorsiflexion and plantar flexion. **Normally** the ankle does not react to this stimulus. There may be a few clonic beats if the patient is tense or has exercised. Sustained clonus points to **CNS disease**. The ankle plantar flexes and dorsiflexes repetitively and rhythmically. Clonus must be present for a reflex to be graded 4.

Answer 51

Trochlear * EOM * Convergence of the eyes * Identify any nystagmus, diplopia, ptosis Binocular diplopia in CN IV neuropathy-MG, trauma, thyroid ophthalmopathy

Answer 52

Very difficult to test

Answer 53

**F**ace drooping **A**rm weakness **S**peech difficulty **T**ime to call 911

Answer 54

Spinal Accessory * Look for atrophy or fasiculations * Shrug shoulders against hands * Turn head to side against hand Trapezius weakness w/ atrophy & fasciculations points to a peripheral nerve disorder. In trapezius muscle paralysis, the shoulder droops, & scapula is displaced downward & laterally. Observe the contraction of the opposite SCM muscle & note the force of the mvmt against hand. A supine patient w/ bilat. weakness of the SCM has difficulty raising head off pillow.

Answer 55

Acoustic * Test acoustic blink reflex (blinking of both eyes in response to a loud noise). * Observe tracking in response to sound.

Answer 56

* Using the 2 ends of an opened paper clip, or 2 pins, touch a finger pad in 2 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 \<5 mm on the finger pads). * **Lesions of the sensory cortex** increase the distance between two recognizable points.

Answer 57

L2, L3, L4 * Patient may sit or lie down to flex knee. * Briskly tap the patellar tendon just below the patella. Note contraction of the quadriceps with extension at the knee. Placing your hand on the patient’s anterior thigh lets you feel this reflex.

Answer 58

They appear when the affected part is actively maintaining a posture. * fine rapid tremor of hyperthyroidism * the tremors of anxiety and fatigue * benign essential (and often familial) tremor

Answer 59

* With the blunt end of a pen or pencil, draw a large number in the patient’s palm. * A normally abled person can identify most numbers. * **Graphanesthesia =** The inability to recognize numbers, indicates a **lesion in the sensory cortex.**

Answer 60

**A**ge ≥60 years, initial **B**lood pressure ≥140/90 mm Hg, **C**linical features of focal weakness or impaired speech w/o focal weakness, **D**uration 10-59 minutes or ≥60 minutes, and **D**iabetes.