Lecture 10 Flashcards
1
Q
Where is the clinical neuro exam most helpful?
A
helpful in distinguishing between Upper Motor Neuron (UMN) lesion or Lower Motor Neuron (LMN) lesion.
2
Q
What are we looking at when talking about UMN?
A
- descending axons from cortex to brainstem or brainstem to spinal cord
- brain, spinal cord
3
Q
What are we looking at when talking about LMN?
A
- axons exiting the CNS and innervating peripheral targets
- motor divisions of cranial nerves
- exiting brain stem and spinal cord
4
Q
Will UMN lesions cause weakness?
Will LMN lesions cause weakness?
A
- yes
- yes
5
Q
Will UMN lesions cause atrophy?
Will LMN lesions cause atrophy?
A
- no
- yes
6
Q
Will UMN lesions cause fasciculations?
Will LMN lesions cause fasciculations?
A
- no
- yes
7
Q
- Will UMN lesions cause increased or decreased reflexes?
- Will LMN lesions cause increased or decreased reflexes?
A
- increased
- decreased
8
Q
Will UMN lesions cause increased or decreased tone?
Will LMN lesions cause increased or decreased tone?
A
- increased
- decreased
9
Q
What are the 6 main components of the clinical neurological exam?
A
- Mental Status
- Cranial Nerves
- Motor Exam
- Sensory Exam
- Reflexes
- Coordination/Gait
10
Q
What are the main components of the Mental Status Exam?
A
- Alertness/Arousal
- Orientation
- Memory
- Spatial Relations
- Apraxia
- Neglect and Constructions
- Sequencing tasks and frontal release signs
- Logic and abstraction
- Delusions and hallucinations
- Mood
11
Q
Mnemonic to remember cranial nerves.
A
Oh / Some Oh / Say Oh / Marry To / Money Touch / But And / My Feel / Brother Very / Says Good / Big Velvet / Brains Ah / Matter Heaven / More
12
Q
Our cranial nerves stem off of our ___________. What this means is that our CN can give us insight to any brain stem activity that is abnormal that may have not produced other symptoms.
A
brain stem
13
Q
Our cranial nerve exam is considered a ______ and can help to rule in/out any more serious pathologies that may have been missed.
A
screen
14
Q
What is CN1?
A
olfactory nerve
15
Q
Is the olfactory nerve often included in the cranial nerve screen? Why or why not?
A
-No, unless specific pathologies such as a subfrontal tumor are present the olfactory bulb and tract are sparred.
16
Q
With a CN1 test, we are testing for _________ and ___________.
A
- discrimination
- arousal
17
Q
When during our testing of CN1 would we be concerned about the olfactory nerve as opposed to a nasal disease?
This is when we would look further into CN1.
A
If the patient smells something that should be neutral (such as chocolate) and it is unpleasant or distorted.
18
Q
What is anosmia?
A
The loss of smell, either partial or total.
19
Q
What are some things that could cause impairements with the olfactory nerve?
A
- Parkinson’s
- Chronic meningeal inflammation
- Tumor in subfrontal region
- Heavy smoking
20
Q
What is CN2?
A
optic nerve
21
Q
The optic nerve has multiple roles in the vision system and therefore has multiple tests such as what?
A
- Visual Acuity
- Color Discrimination
- Field Cuts
- Pupillary Response to Light Accommodation
22
Q
What is visual acuity?
How do we test for visual acuity?
A
- how clear is patients vision
- Snellen chart (eye doctor chart)
23
Q
What is color discrimination?
A
example is color blindness
24
Q
- What are field cuts?
- How do we test field cuts?
A
- loss of vision
- patient sits in front of you and looks at your nose, using a color cap of a marker move slowly through each of the 4 quadrants from posterior to anterior and have them note when they can see the marker, repeat with other eye
25
What needs to be ruled out before ruling in visual field cuts.
neglect
26
Is visual neglect a result of damage to the optic nerve?
No, it is a result of damage to the parietal lobe
27
1
1
28
1
1
29
What is pupillary response to light accommmodation?
how well our eyes adjust in response to light (shining light into someones eyes should cause constriction)
30
- The pupillary response to light accommodation hits on _ cranial nerves, what are they?
- The ______ side of pupillary response is CN2, whereas the ________ side comes from CN3 (pupil constriction).
- 2, optic nerve (II) and occulomotor nerve (III)
| - afferent, efferent
31
CN3, 4, and 6 are all ______ nerves that innervate what muscles?
- motor
| - extraoccular muscles (EOMs)
32
- What nerve is CN3?
- What nerve is CN4?
- What nerve is CN6?
- 3 = occulomotor
- 4 = trochlear
- 6 = abducens
33
CN3 is important in pupil _________ (efferent limb), but is also important in what movements of the eyes?
- constriction
| - elevation, depression, adduction
34
CN4 is important in what movements of the eyes?
- depression
- intorsion
(down and in)
35
CN6 is important in what movements of the eyes?
abduction
36
The extraoccular muscles can all be tested with one test, which is called what?
BIG H test
37
What can be important to do before jumping into a BIG H test?
looking at the eyes at rest for dysfunction (if abducens nerve isn't firing properly, at rest the patient's eye can go into adduction because the muscles arent holding the eye in place).
38
With any of the 3 EOM nerves and a palsy associated with them, we will see a complaint of __________ from the patient.
double vision
39
Why do patients with palsies associated to CN3,4 or 6 present with double vision?
our eyes normally move in harmony with one another, in these patients they don't
40
If an individual has dysconjugate gaze in both eyes AND the same direction, is this indicative of a UMN or LMN lesion?
UMN
41
If an individual a dysconjugate gaze in both eyes BUT in different directions, is this indicative of a UMN or LMN lesion?
LMN
42
If an individual a dysconjugate gaze in one eye in a specific direction, is this indicative of a UMN or LMN lesion?
LMN
43
What nerve is CN5?
trigeminal nerve
44
CN5 is a _______ nerve, but is more known for its __________ signaling.
- mixed
| - sensory (afferent)
45
What are the 3 subdivisions of the trigeminal nerve?
- opthalmic (forehead and nose bridge)
- maxillary (cheeks and upper lip)
- mandibular (jaw and anterior part of tongue, also towards ears)
46
What are 3 tests performed to test for the trigeminal nerve function?
- light touch to face (sensory to V1, V2, and V3)
- bite strength
- corneal reflex
47
When is the corneal reflex test used?
With more unalert patients that can't participate in the first two tests (obtunded patients)
48
How is the corneal reflex test performed and what nerves are involved?
- touch a cotton ball to the white of the eyes (do they feel the swab, do they blink)
- CN5 and CN7
49
If a patient has total loss of sensory to the face, where may the lesion be occuring?
-ganglion or sensory root
50
Lesions in the _____ will result in a loss of light touch to the face, but pain and temperature are preserved.
pons
51
Pain and temperature loss, but light touch retainment is much more _________. What is this called?
- uncommon
| - associative anasthesia
52
What nerve is CN7?
facial nerve
53
CN7 is a ____ nerve most known for its motor innervation to muscles of ________________.
- mixed
| - facial expression
54
CN7 also has a sensory aspect and innervates the taste _________ for the anterior _/_ of our tongue.
- afferents (sensory)
| - 2/3
55
CN7 also has a function in the innervation of our secretomotor glands, including our _________ and __________ glands.
- lacrimal
| - salivatory
56
What are the methods to testing CN7?
- Observation
- Motor (smile, raise eyebrows, puff out cheeks, purse lips, close eyes tightly)
- Sensory (taste (typically don't test), secretomotor function)
- Reflexes (corneal reflex (w/CN5), nasopalpebral reflex)
57
- What is a complaint seen with the lacrimal gland?
| - How could we test this?
- dry eyes
| - have them inhale ammonia
58
-What is the way to test the salivatory gland?
-give them something spicy
59
How do we differentiate between a UMN vs a LMN lesion of CN7?
-forehead gets bilateral innervation, therefore patient with a UMN lesion will be forehead sparing, but a LMN lesion will result in full contralateral facial weakness.
60
What nerve is CN8?
vestibulocochlear
61
Our vestibulocochlear nerve innervates both structures involved in our _________ and ____________ systems.
- auditory
| - vestibular
62
What are the 2 tests used to test the auditory portion of CN8?
- Auditory
| - Weber and Rinne Tests
63
What is the vestibulo-ocular reflex (VOR)?
vestibular reflex that allows you to keep your eyes on target while your head is moving, without distorting the visual input along the way
64
What nerve is CN9?
| What nerve is CN10?
- glossopharyngeal
| - vagus
65
How do we test for CN9?
Palatine Activation
| -look for symmetry when patient has mouth open, uvula will deviate to uninvolved side
66
What test can we perform that involves both CN9 and CN10?
Gag reflex
- sensory = CN9
- motor (gag) = CN10
67
Patients with CN9 and 10 dysfunctions will also present with what that causes difficulty in speech production?
voice hoarseness
68
What nerve is CN11?
spinal accessory nerve
69
What muscles does CN11 innervate?
SCM and trapezius
70
How do we test for CN11 dysfunction?
MMTs
- shoulder shrug for upper trap
- bend and rotate for SCM
71
Patients with a CN11 UMN lesion will present with weakness where?
trapezius, SCM is spared
72
Patients with a CN11 LMN lesion will present with weakness where?
both SCM and trapezius
73
What nerve is CN12?
hypoglossal nerve
74
What does CN12 innervate?
tongue musculature
75
How do we test for CN12 dysfunction?
-ask patient to stick tongue out, look for tongue deviation
76
How do we determine CN12 UMN vs LMN lesions?
UMN lesion- tongue will deviate away
| LMN lesion- tongue will deviate towards
77
With CN12 LMN lesions we will also see what?
atrophy and fasciculations
78
THE MOTOR EXAM
THE MOTOR EXAM
79
What are the parts of the motor exam?
- Inspection at Rest
- Task Based Observation
- Tone Assessment
- MMT
80
What are we looking for when inspecting a patient at rest?
- Muscle Atrophy
- Fasciculations
- Hypertrophy
- Tremors
- Involuntary Movements
- Posturing
81
Patients with damage above/below the _____________ of the midbrain has significance to not only patient presentation (posturing) but also overall prognosis.
Red Nucleus
82
Patients with damage above the red nucleus will take on a _________ resting posture where they have full flexion of their UE and LE.
decorticate
83
Patients with damage below the red nucleus will take on a _________ resting posture where they have full extension of UE and LE.
decerebrate
84
When we see posturing, what is this a prognostic indicator of?
severe injury to NS, will probably not get better
85
What are the primary sensory pathways of the sensory exam?
- pain
- temperature
- vibration
- proprioception
- light touch/2pt discrimination
86
What is the scale for reflex testing?
```
0 = absent
1+ = trace
2+ = normal
3+ = brisk
4+ = non-sustained clonus
5+ = sustained clonus
```
87
- Abnormally increased reflexes are a result of _____ lesions.
- Abnormally decreased reflexes are a result of _____ lesions.
- UMN
| - LMN
88
________ is also a part of the neuro exam.
coordination
89
Deficits in any components of the neuro exam will inevitably lead to _____ disturbances.
gait
90
UMN and LMN lesions will present very _________ during functional tasks
differently
