Examination of the CNS Flashcards
Associated features of a migraine
- AURA: nausea/vomiting, photophobia and phonophobia
Where is a cluster headache pain located
Orbital or retroorbital - unilateral non-pulsatile
Pain location of temporal arteritis
Temple and scalp
Describe a neuro history taking
- Socrates (Sight, Onset, Character, Radiation, Association Symptoms, Time, Exacerbating factors + Severity)
- Does medication/posture/menstruation cycle help relief?
- Drug history (Excessive drug use can cause CNS problems e.g. phenytoin = ataxia and analgesics = headache)
- Family History (MND, Charcot-Marie-Tooth)
- Social History (How they cope? Can they work? Support circumstances? ALCOHOL and DIET? Recreational drug use )
Travelling and sexual history - Past Medical History
- Occupational History
How does diet contribute to CNS problems
Veggie = lack of B12
How does travelling cause CNS problems
- Lyme disease and Malaria
Three clinical presentations of a interior circulation stroke
- Hemiparesis
- Hemianopia
- Dysphasia
Three clinical presentations of posterior circulation stroke
- Ipsilateral cranial nerve palsy with contralateral deficit
- Bilateral deficit
- Eye movement deficit
- Cerebellar dysfunction
- Homonymous hemianopia
Three clinical presentations of lacunar stroke
ONE OF THREE:
- Pure sensory loss
- Pure sensory motor loss
- Ataxic hemiparesis
Describe initial physical examination of a near patient
- Assess consciousness level via GCS
- Signs of meningeal irritation (Neck stiffness, Kernig’s)
- Examine dysarthria and dysphagia
How is neck stiffness assessed
- Place hands on either side of the patient’s head
- Flex patient’s head gently until chin touches chest
- Ask patient to hold position for 10 seconds
- Positive: Spasming in neck muscles or neck is not being passively flexed
How is Kerning’s sign carrie out
- Flex legs to 90 degrees at both hip and knee with left hand placed over medial hamstrings
- Extend knee while hip is maintained in flexion
POSITIVE: Extension is resisted by spasming of hamstrings
How is patient speech assessed
- Listen to spontaneous speech
- Assess tongue: repeat ‘yellow lorry’
- Assess lips: repeat: baby hippopotamus
- Ask to count to 30 to assess fatigue
- Ask patient to cough and say AH - palate raising bilaterally
- Inspect mouth for loose-fitting dentures
How is dysphagia assessed (broca’s and wernicke’s assessment)
- Spontaneous speech
- Give patient a common object and ask to name it
- Give three-stage command (pick up paper, fold in half and place under a book)
- Repeat simple sentence
- Ask to read a passage
- Ask to write a sentence
Symptoms seen in frontal lobe damage
- Personality and behaviour changes
- Loss of emotional responses
- Cognitive impairment (attention and concentration effected)
- Dysphagia
- Urinary incontinence
- Primitive reflexes lost
- Seizures
Symptoms seen in temporal lobe damage
- Memory impairment
- Seizures
- Changes in smells
Symptoms seen in parietal lobe damage
- Cortical sensory impairment
- Dyslexia, dyscalculia
- Apraxia
- Sensory seizures
- Visuospatial disturbances
How is trigeminal nerve function assessed
SENSORY:
Ask patient to close eyes and say yes if they feel a light touch across trigeminal distributions
2. Repeat with neurological pin
3. Compare both sides
4. Nasal tickle test
MOTOR:
Inspect signs for wasting of muscle mastication
2. Ask patient to clench teeth
3. Ask patient to open jaw and see deviations of the jaw to one side or the other
CORNEAL REFLEX:
Ask to remove lenses
2. Depress lower eyelids and ask patient to look up
3. Touch lateral edge of cornea with damp cotton wool
4. Look for direct and consensual blinking
JAW JERK:
1. Let mouth hang loosely and place forefinger in middle between lower lip and chin
2. Tendon hammer under forefinger
CHECK BOOK
How is facial nerve assessed
- Inspect the face for asymmetry, differences in blinking and eye closure
- Watch for twitching
- Demonstrate yourself doing an action and get them to repeat
- Ask to raise eyebrows (frontal muscles
- Ask patient to screw eyes shut (orbiculares oculi)
- Ask patient to bare teeth (orbiculares iris)
- Ask patient to blow cheeks with mouth (buccinator)
Examination of the glossopharyngeal and vagus nerve
- Say AH and look at palate and uvula
- Ask patient to puff cheeks with lips closed (for cheeks to puff, palate must elevate and occlude nasopharynx - damage you should hear air escape through the nose)
- Ask patient to cough for strength
- Swallow test: Give three teaspoons of water and observe for absent swallowing or delayed cough
Examination of the accessory nerve
- Face patient and inspect sternomastoid muscles for wasting and hypertrophy
- Stand behind patient to inspect trapezius muscle for asymmetry
- Ask patient to shrug shoulders and apply downward pressure for strength
- Test power in left sternomastoid by asking patient to turn head to right while placing resistance and repeat for right
- Test both sternocleidomastoid muscles by asking patient to flex neck/ apply your palm to forehead as resistance
How is the hypoglossal nerve examined
- Ask patient to stick out their tongue and look for deviation
- Ask patient to move their tongue quickly from side to side
- Test power by asking patient to press tongue inside cheek while you press from outside
- Assess speech (yellow lorry)
- Assess swallowing with water swallow test
Outline the 6 stages of motor system lesion examinations
- Assessment of stance and gait
- Inspect and palpate muscles
- Assess tone
- Tets power and movement
- Examine reflexes
- Test coordination
How is stance assessed
- Ask patient to stand with feet close together and eyes open
CEREBELLAR ATAXIA: Swaying, lurching and struggling to stand in position - Ask patient to close their eyes and be prepared to steady them (swaying is common, falling is not)
- PULL test: inform you will push them forwards or backwards and should try maintain position
