IDL Questions Flashcards
What is a presenting symptoms?
Why they have come to see the doctor
Includes anything else which comes up when screening for additional information at initiation of the session
What is an associated symptom?
Becomes apparent as we explore the presenting symptom.
Revealed independently or through questions.
Positive associated symptom: patient is experiencing the symptom
Negative associated symptom: patient is not experiencing the symptom
What is a red flag symptom?
Symptoms associated with a presenting complaint that may indicate a potentially serious or life threatening pathology.
What is important to note about headaches?
With a headache, the presence of any neurological symptom may indicate a potentially serious/life threatening condition.
What are red flag symptoms for headache?
Change in LOC and drowsiness = change in ICP
Fever, nausea, neck stiffness, photophobia = infection
Change in mood/personality = intracranial tumour
Weight loss = primary/metastatic tumours
Weight gain = tumour on pituitary gland
Issues with balance, coordination = tumour/stroke
What are the red flag features of a headache?
- New headache in older person (over 50 years)
- History of head trauma
- Sudden onset especially with no history of headache
- Severe + debilitating pain
- Features of raised ICP - worse with coughing/sneezing/bending over, wakes them from sleep, worse when waking up
How do you assess orientation to person, place and time?
Can you tell me your full name?
Where are you right now?
Roughly what time of day is it/what is todays date/what day is it/what month is it/what year is it?
What is assessed in the Glasgow Coma Scale?
Best eye response
Best verbal response
Best motor response
Describe the best eye response scale.
Open spontaneously - 4
Open in response to sound/stimulus - 3
Open in response to physical stimulus/pressure - 2
Do not open - 1
Closed by local factor (e.g. swelling/trauma) - N/A
Describe the best verbal response.
Orientated, converses normally - 5
Confused, disorientated - 4
Utters inappropriate words in response - 3
Incomprehensible sounds - 2
No sounds - 1
Factors interfering with communication (dysphasia) - N/A
Describe the best motor response.
Obeys commands - 6
Localizes to physical stimulus - 5
Flexion/withdrawal from physical stimulus - 4
Abnormal flexion to physical stimulus - 3
Extension to physical stimulus - 2
No movements in response - 1
Paralyzed/limiting factor (trauma) - N/A
What is important to note about the GCS?
BEST response
If patient if resting or sleeping - should be given opportunity to wake first
Cannot measure GCS in post ictal phase
Describe the different stimuli used in the GCS.
Voice/Sound stimulus - speak to patient to ask them to open their eyes
Physical stimulus: central stimulus e.g. trapezius pinch or supraorbital ridge
Describe the abnormal flexion to stimulus. - DECORTICATE RESPONSE
Slow stereotyped movement Forearms move across chest and are held close to body Hands pronate Elbows flex rigidly Thumb and fingers flex Legs extend Feet plantarflex
What is the decorticate response?
Abnormal flexion in response to physical stimulus
What is the decerebrate response?
Abnormal extension to stimulus
Describe the abnormal extension (DECEREBRATE RESPONSE)
Elbows extend Arms adduct and internally rotate at the shoulder Wrists flex Thumb and fingers flex Legs extend Feet plantarflex Less commonly the back arches
What is the lowest possible score for GCS?
3 = deep coma or death
What does a GCS score of 8 or less reflect?
Accepted definition of coma and suggests need for intubationn
What is the total GCS score used for and list the categories of severity.
Used prognistically
13-15 = mild head injury
9-12 = moderate head injury
3-8 = severe head injury (coma and intubation)
What factors may contribute/interfere with communication and ability to respond for GCS?
Deafness
Endotracheal tube
Physical injury to face
Neurological disability e.g. dysphasia
How do you apply supraorbital notch pressure?
Notify patient what youre doing
Thumb to apply pressure to one supraorbital notch
Initiate: mild pressure and increase pressure as needed
Apply pressure with increasing intensity for up to 10 seconds
Trapezius squeeze
Mild pressure, increase pressure with increasing intensity for 10 seconds
What do you look for when inspecting during motor exam?
Symmetry - compare both sides Use of limbs - function Posture of limb and trunk Gait Fasciculation Tremor Wasting or hypertrophy Scars Rash
What is tone
Resistance felt by the examiner when moving a joint passively through its ROM
Hypotonia and causes
Reduced tone
Lower motor neuron lesion e.g. trauma to peripheral nerve
Describe the different types of hypertonia.
Spasticity - dynamic response: greater at beginning of movement if movement is fast e.g. spastic catch (clonus is associated with spasticity)
Rigidity - increased tone with uniform resistance to movement (lead pipe or cogwheel). Leadpipe present throughout movement, cogwheel occurs if tremor is superimposed on increased tone (
What are the special tests examined as component of motor system?
Coordination
Deep tendon reflexes
What is hyperreflexia a sign of?
UMN lesion
Hyperthyroidism
What is hyporeflexia a sign of?
LMN lesion
Hypothyroidism
If a patient has normal tone, what would you expect to see as the knee is rapidly flexed?
Hell of the foot on that side should stay on the couch and drag up towards the buttocks
What would you find on examination of the motor system of the lower limbs if the person had a left upper motor neuron lesion?
Symptoms would affect the right leg:
- minimal muscle atrophy
- hypertonia
- hyperreflexia
- weakness
- may have associated sensory disturbance
What is clonus?
Series of rhythmic contractions in the muscle when the muscle and the tendon are suddenly stretched
What is the significance of clonus?
If it is not sustained (<6 beats) it may be physiological but if it is sustained it suggests UMN damage
What sensory modalities are tested in routine sensory examination?
Light touch: of least discriminatory value - as some fibres travel in the posterior columns, and some travel in the spinothalamic tract
Pain (and temperature) - fibres enter spinal cord and cross a few segments higher to ascend in the opposite ST
Vibration and joint sense - fibres enter spinal cord, ascend in posterior (dorsal) columns and cross in medulla
What is the difference between the sensory distribution of a nerve root and a peripheral nerve?
A dermatome = area of skin supplied by a sensory nerve root.
The sensory distribution of a peripheral sensory nerve crosses over different dermatomes.
Individual peripheral nerves are composed of multiple nerve roots
Why do we need to know the difference between the sensory distribution of a nerve root and a peripheral nerve?
We use the knowledge of dermatomal distribution (single nerve root) and the peripheral nerve distribution (from multiple nerve roots) to map sensory deficits and localize the lesion.
Sensory distribution of a nerve root is dermatomal.
Sensory distribution of a peripheral nerve will be made up of dermatomes of nerve roots that contribute to that peripheral nerve.
Name the 4 main patterns of sensory loss.
Global sensory loss: entire limb is affected e.g. stroke
Peripheral neuropathy: glove and stocking distribution e.g. diabetes
Dermatomal sensory loss e.g. compression of a single nerve root as it exits the spinal cord
What is dissociated sensory loss?
Loss of certain sensory modalities, but preservation of others e.g. loss of temperature and pain, but light touch is still intact
What is right monocular blindness and where is the lesion?
Right eye is blind
Left eye is normal
Right optic nerve
What is bitemporal hemianopia and where is the lesion?
Loss of temporal vision in both eyes
Lesion in optic chiasm
What is left homonymous hemianopia and where is the lesion?
Left side of both eyes affected
Lesion in the right optic tract
What is left upper quadrantanopia and where is the lesion?
Left upper quadrant in both eyes is affected
Lesion in lower fibres of the right optic radiation in the temporal lobe
What is the examination of the olfactory nerve?
CN1
Smell - test each nostril separately for smell
Optic nerve (II)
Visual acuity - Snellen’s Chart or near vision chart
Visual fields - confrontation with fingers
Fundoscopy
Oculomotor, trochlear, abducens
Observe: pupils, ptosis, strabismus
Eye movements: H and + sign with pen
Pupillary reflexes (light and accommodation)
Trigeminal nerve
Sensation - all 3 divisions with light touch, superficial pain
Corneal reflex
Motor - jaw opening
Jaw reflex
Facial Nerve
Facial movements - eyes tight, smile, puff cheeks
Vestibulocochlear (VIII)
Whisper test to screen hearing
Rinne and Webers tests
Glossopharyngeal, Vagus and Hypoglossal
Speech/articulation: 10, 12
Cough - 10
Movement of uvular: 10
Gag reflex (if problems with swallowing/regurgitation) 9 and 10
Appearance of tongue including abnormal movements 12
Power of tongue movements 12
Accessory VI
Trapezius and sternocleidomastoid muscle power
What is conductive deafness?
Abnormal conduction of sound anywhere from external auditory meatus to the stapes
Causes = otitis media, wax
What is sensorineural deafness?
Abnormal conduction of acoustic vibration and neural impulses by the cochlear and vestibulocochlear nerve respectively to the brain
Bilateral sensorineural deafness = exposure to noise and toxins e.g. gentamicin antibiotic
A cause of sudden unilateral sensorineural deafness = viral infection
Conductive hearing loss affecting left ear: what will I find in the Rinnes test and why?
Patient cannot hear L tuning fork when placed next to the L ear canal
Can hear tuning fork alongside R ear canal
Air conduction should be better than bone conduction, but air conduction through the external auditory meatus or middle ear (left) is impeded so conduction through the bone is better
Negative Rinne Test in Left Ear
Positive Rinne Test in Right Ear
Conductive hearing loss in L ear: Weber test findings and explanation.
Sound will be hear loudest in the affected ear (left)
Masking - if there is a problem conducting sound, there will be no masking of sound transmitted via bone/by environmental noise transmitted via external and middle ear
Occlusion - if sound cannot dissipate out of the auditory canal due to a conductive defect, this will cause increased cochlear stimulation and the sound will be louder on the affected side
Sensorineural deafness affecting left ear: Rinnes Test findings and why?
Provided hearing is good enough to hear the tuning fork - when the tuning fork is moved from the R mastoid process to outside R ear canal, it can be heard. Same thing for right ear.
Both air conduction and bone conduction will be reduced equally if there is a problem with the cochlear or 8th cranial nerve.
Positive Rinne’s test for both ears.
Sensorineural deafness in left ear: Weber test findings and why?
Sound will be referred to/heard loudest in normal ear.
Because sound cannot be transmitted as well by left cochlear/vestibulocochlear nerve.
Facial symmetry
Oculomotor, trigeminal, facial nerve (3,5, 7)
Ability to wrinkle forehead
Facial (7)
Ability to shut eyes tightly
Facial (VII)
Ability to puff out cheeks
Facial
Vagus - allows you to hold the air in your mouth and prevent air escaping through the nose
Cough
Vagus 10
Articulation
Facial
Vagus
Hypoglossal
7, 10, 12
Soft palate/uvular movement
Vagus
Gag reflex
Glossopharyngeal
Vagus
9,10
Tongue appearance and movement
Hypoglossal
12
Ability to shrug shoulders
Accessory = 11
Mouth drooping on one side
Facial nerve
Symmetry of forehead wrinkling
Facial
Cheek muscle wasting
Facial
Evidence of dribbling
Facial
Ptosis
Oculomotor
Unequal pupils
Oculomotor
Squint/strabismus
Oculomotor
Abnormal movement of eyes
Oculomotor
Trochlear
Abducens
Quality of speech
Facial, vagus, hypoglossal
Articulation
Facial, Vagus, hypoglossal
