Lecture 2 Flashcards
lesion to CN 4 causes:
- Extorsion: eye moves laterally
- Weakness looking down
- Verrtical diplopia that increases in you look down
- Head will tilt towards opposite die of lesion
CN4 lesion can be misdiagnosed as what?
Idiopathic torticollis
CN 4 is vulnerable to what?
DAMAGE D/T HEAD TRAUMA bc it wraps around the B.S
_________ is the most Common isolated CN palsy due to its long peripheral course.
Seen often in patients with:
1, subarachnoid hemorrhage,
2. late syphilis
3. trauma.
CN 6 (abducens)
CN 6 lesions result in:
- Esotropia/medial strabismus: the patient cannot look abduct the eye
- Horizontal diplopia
laterality of nystagmus is based on what?
fast beating part of the nystagmus.
when do we see a nystagmus?
What kind are there?
when a person has an extreme deviation of gaze.
Hortizontal, vertical and rotary
What causes nystagmus?
- due to impairment of vision at an early age
- labyrinth and cerebellar systems disorders
- drugs
Trigmeninal nerve does what?
- Sensory of face: use pinprick. if abnormal, conduct a temperature test with hot or cold stimuli
- Motor for mastication muscles (temporal ,masseter, pterygoids). move jaw side to side (lateral pterygoids) and clench (temporal and masseter)
- Corneal reflex: tests 5 and 7: feel cotton on eye, 7 will close it via the orbicularis oculi
CNS patterns of stroke –
- L cortical or thalamic lesion = _____
- L brain stem lesion =______
- L cortical or thalamic lesion=> R body and facial sensory loss
- L brainstem lesion=> L facial and and R body sensory loss
in trigeminal lesion, what way will the jaw deviate?
to the weak side because of the unopposed action of the opposite lateral pterygoid
Corneal blink reflex tests the ____ component of CN 5 and _____ component of CN 7
afferent of CN 5
efferent of CN 6
loss of corneal blink reflex can be seen in
acoustic neuromas, brainstem (pontine)
lesions etc
Blinking is absent in both eyes in CN ____ lesions
Blinking is absent on the side of weakness for CN ___ lesions
5
7
facial N does what?
- Motor for facial muscles, closes eyes and mouth
- taste for anterior 2/3 of tongue
- PArasympathetic secretion of saliva and tears
- Sensation of external ear
Inspect face during rest & conversation to note any asymmetry & observe any ticks or
other abnormalities
is testing what CN?
7
Bell’s Palsy (peripheral facial paralysis)
CN 7 lesion caused by unkown reasons in most cases.
affects BOTH upper & lower face causing widened palpebral fissure and increased nasolabial fold.
loss of taste,
hyperacusis (increases sensitivity to sound),
↑ or ↓ tearing
(supranuclear) central lesion
CN 7 lesion that affects mainly lower face muscles and is usually assx with hemiplegia (weakness on one side of the body).
This isimportant in determining if the weakness is central or peripheral in nature.
how to test CN 8
Cochlear: whisper test (if +, do webers and rhinne test)
vestibular: usually isnt done isolated. Usually tested with cerebellum
CN 8 (vestibular) lesions usually result in
- dysequillibrium
2. nystagmus
CN 8 (cochlear) lesions can result in
- Destructive lesions=>
- Irritative lesions =>
• Destructive lesions => sensorineural hearing loss. Ex. acoustic neuroma
• Irritative lesions => tinnitus (ringing in ears). Ex. Medications (aspirin, some
antibiotics etc)
CN 9 does what
- Motor – innervates the stylopharyngeus
muscle => elevates and widens the
pharynx when swallowing and phonation - Sensory – taste to the posterior 1/3 of
the tongue, sensation to the palate and
pharynx, skin of the external ear.
3 Afferent limb of the gag reflex
test CN 9
- Motor function & gag reflex of CN IX tested w/ CN 10 (gag reflex rarely tested in
primary care office setting – reserved for high index of suspicion) - Tasting – CN IX tested w/ CN VII (rarely tested in primary care office setting)
Afferent (sensory) part of gag reflex is CN ___.
efferent (motor) part is CN ____
9
10
Loss of the gag reflex is generally an indicator of lesion to _____
(and perhaps CN __)
ipsilateral CN 9
maybe 10
CN 10 (vagus) actions
- Motor – voluntary m for swallowing & phonation (pharynx and larynx ms except stylo)
- Sensory – sensation behind ear & part of external ear canal
- Parasympathetic – VISCERAL AFFERENT FIBERS to mucosa of eso => mid transverse colon AND to SMOOTH Ms => secretion of digestive enzymes, peristalsis, carotid reflex,
involuntary action of heart, lungs & digestive tract
test CN 10 (4 ways)
Testing:
1. listen to voice for hoarseness
(vocal cord), nasal tone (palatal
weakness)
- Check gag reflex
- Check for difficulty swallowing
(indicating either pharyngeal or
palatal weakness) - Inspect soft palate & uvula for symmetry. b/l lesion: fails to rise, u/l lesion: goes to normal side
Unilateral loss of soft palate and uvula symprret indicates an _____
CN X lesion.
ipsilateral
Pt has
Loss of gag reflex
• Loss of sensation in pharynx &
posterior 1/3 of tongue
• Slight dysphagia
where is the lesion
CN 9
Pt has
- Dysphonia
- Dysphagia
- Dyspnea
- Loss of gag or cough reflex
where is the lesion
CN 10
test CN 11
- look for fascilations of shoulders from behind
- Trapezius m: shrug shoulders against resistance. Weakness => ipsilateral shoulder droop.
- SCM: turn face against resitance. Lesion => problem turning head to opposite side
Trap weakness w/ atrophy & fasciculations =
peripheral N disorder
CN 12 actions
Motor –innerv all intrinsic and extrinsic tongue ms (except palatoglossus=> cn 10)
test CN12
protrude tongue and push into OPPOSITE cheek
CN 12 lesions cause
tongue will deviate to WEAK side and can t push tongue to opposite cheek
when inspecting motor system; what do we look at
- Body position & gait
- Involuntary movement – tremors, tics or fasciculations
- Muscle bulk – is the muscle wasting, atrophy
- Muscle tone – feeling the muscle resistance to passive stretch
- Muscle power: rate 0-5
muscle strength scale
- 0 = no muscle contraction
- 1 = barely detectable flicker or trace of contraction
- 2 = active movement W/O gravity
- 3 = active movement against gravity
- 4 = active movement against gravity & some resistance
- 5 = active movement against full resistance w/o fatigue
Neck and Upper extremity testing:
patient activates each muscle action against resistance
-Shrug shoulder– trapezius (CNXI) • F (C5,6) & E (C6,7,8) elbow • F & E wrist (C6,7) • Hand grip (C7,8,T1) • Abduct finger (C8,T1) • Opposition of thumb (C8,T1)
Low back and LE testing
Hip
- Flexion (L2,3,4 – psoas and iliacus),
- extension (S1 – glut max), adduction (L2,3,4)
- abduction (L4,5,S1)
Knee –
- Flexion (L4,5,S1,2 –hamstrings)
- extension (L2,3,4 –quads)
Ankle
- Plantar (S1 – gastrocnemius )
- dorsiflexion (L4,5 – tibialis anterior)
what dertmatomes should we test motor functions
- Biceps (C5-6)
- Triceps (C6-8)
- Quads (L2-4)
- Gastroc (L5-S2)
Upper Motor Neuron (UMN) will see a _____ pattern of weakness
Pyramidal: weak extensors in arms (EA), weak flexors in legs (FL)
FLEA= UMN lesion
pronartor drift tests what?
how to conduct?
UMN lesion (lesion to CST)
- Place arms out with palms up.
- If UMN lesion, forearm will move inward and down.
- Tapping on the arm should cause it retrun back to normal with the help of muscle stretnth, coordination and good position
Lower Motor Neuron (LMN) will see a _____ pattern of weakness
peripheral
weak flexors in arms (FA)
weak extensors in legs (EL)
____ MN lesion can cause muscle disease,where the muscle wastes, decreased tone and reflexes
LOWER
Coordination of muscle movement requires input from 4
systems:
- motor
- sensory
- vestibular
- cerebellar= rhythmic movement and steady posture
Cerebellar function
- Rapid alternating movements;
- Finger-to-nose
- Finger-to-finger
- Heel-to-shin
- rapidly pronate and supinate hand
- looks at dysmetria/dysataxia of voluntary movements
- position sense and function of both labyrinth and cerebellum
4.- tap heel on opposite patella and glideheel slowly along the
shin, look for accuracy and smoothness. repeat with eye closed
how to perform finger to finger
- have doc move finger in secveral places
- Then have doc keep finger still; tell pt to move finger up and bring it back down to the finger
- repeat with eye closed
bad on rapid alternating movements tells us we have
dysdiadokinesia
if pt cannot heel or toe walk
tests of plantar flexion and dorsi of ankles; thus,
+ for distal muscle weakness in legs OR CST weakness
Hop in place on one leg – tests _____ and _____ muscle strength, requires position
sense and cerebellar function
proximal and distal
Shallow knee bend on each leg– may reveal weakness of what
hip extensors
quads
or both
Romberg test – generally evaluated with gait and station but is a test of
______________
PROPIOCEPTION (sensory)
romberg test
Romberg Test tests position!!!
Patient stands with feet together and eyes open. Close both eyes for 30-60 seconds. Normal is minimal swaying.
If patient loses balance with
eyes open => cerebellar ataxia.
If pt loses balance with eyes closed, it is a positive
Romberg sign
______ – feet crossing over with toes dragged – often seen in cerebral palsy or multiple sclerosis
- _________ – high steppage, broad based – seen with posterior column damage and peripheral neuropathy
- ______ – small steps, feet do not leave ground, seen in frontal lobe processes and hydrocephalus
- ________ – gait is all over the place as if thepatient is falling, but does not fall, usual cause is psychogenic
- scissoring (CP or MS)
- sensory ataxia (PC damage or peripheral neuropathy)
- Magnetic (frontal lobe problems or hydrocephalus)
- Atasia-abasia (functional)
what are the 3 assymmetric gaits?
- Hemiplegic – usually due to UMN such as stroke. Gait is circumducted (leg
swing in a circular type pattern), ipsilateral arm swings less - Waddling pelvis – hips sway or “waddle” in a side to side type fashion dt muscle (myopathic) disease
3. Foot drop – unable to keep foot up during heel walk, can be due to UMN or LMN lesions (peroneal neuropathy or L5 radiculopathy)
Sensory evalulation involves testing for ____
dermatomes
testing for pain and temp involves the ________ tract . how?
Spinothalamic
- Pain: pinprick test. If abnormal, do temp test
- Temp: cold and hot test tubes
Propioception & vibration involves testing ______
posterior columns. How?
- Propioception/ postion: Grasp sides of
patient’s big toe between thumb and index
finger and move it through an arc. With
patient’s eyes closed as for response of “up”
or “down.” - Vibration: 128Hz tuning fork, place on
interphalangeal joints, malleoli
Light touch involves testing what pathways; how?
both PC and spinothalamic
Use a fine wisp of cotton. Compare 1 area w/ another & bilateral sides
Stereognosis
cant rexognize shapes of objects or those placed in hands
• Graphesthesia
cant recognize numbers written on palm
• Double simultaneous stimulation (extinction)
pt can feel 2 points touching them at once
Recognize and discuss what the dermatomal map indicates, specifically shoulder, thumb, little
finger, nipple, umbilicus, hallucis and little toe
Shoulder: C4 Thumb: C6 Little finger: C8 Nipple: T4 BB: T10 big toe: L5 Little toe: S1
BS lesion causes
ipsilateral sensory loss in face
contralateral sensory loss in body
______ reflexes indicate a lesion in the central nervous system.
______ reflexes indicate a lesion in the peripheral nervous
HYPERACTIVE: CNS
HYPOACTIVE: PERIPHERAL NS
DTR SCALE
Graded on a 0-4 scale
- 4+ = very brisk, hyperactive, w/ clonus (rhythmic oscillation b/w F & E)
- 3+ = brisker than average, possibly but not necessarily indicative of dz
- 2+ = average, normal
- 1+ = somewhat diminished, low normal
- 0 = no response
Biceps reflex – (\_\_\_) • Triceps reflex – (\_\_\_) • Brachioradialis reflex – (\_\_\_) • Patellar reflex – (\_\_\_\_) • Achilles reflex – (\_\_\_)
BICEPS: C5 TRICEPS: C7 BR: C6 PATELLA: L4 ACHILLES: S1
BABINKSI AND CLONUS ARE SIGNS OF ____ LESIONS
UMN
THERE ARE 3 SUPERFICIAL STIMULATION REFLEXES. WHAT ARE THEY?
- ABDOMINAL REFLEX: T10-T12, when you hit the abdomen, the BB should move to where you strike
- PLANTAR REFLEX: babinskie normal response of the toe should be plantarflexion. may persist in bbs
- ANAL REFLEX (S4/S5): touch areas around butthol and see if it contracts; lesion to cauda equina or sacral region
Postural tremor or kinetic tremor
usually due to _________
essential tumor
rolling pill tremor is d/t
BG disease (parkinsons)
tremor is
rhythmic osscilation of body part d/t contraction of an opposing muscle group and is the MOST COMMON MOVEMENT DISORDER
hemiplegia vs hemiparesis
hemiparesis-> weakness on one side of body
hemiplegia-> paralysis on one side of bdot
recognize the 5 levels of consciousness: Alertness, lethargy, obtundation, stupor, coma
Alert: speak to pt in normal tone and they should look at you and respond fully and appropriately
lethargy: speak to the pt LOUDLY; they should look at you, respond and fall asleep
obtundation: shake pt lightly as if they are asleep; alertness and interest is dereased; they open eyes, look at you adn respond but seem confused
stupor: pt has minimal awareness of self or env; apply a painful stimulus, causing the pt to arouse from sleep; may not resond
coma: apply repeated painful stimulus; the paint will not wake up
tremors can be resting (static), postural or intention
resting tremors: most ob at rest and can disappear with movement. Ex slow, fine pill rolling tremor in parkinsons
postural: tremors that occur when maintaing posture d/t hyperthyroidism, anxiety
intention: tremors thato ccur when VM and get worse with target. Ex. Cerebrallar lesion or MS
oral facial dysdokinesia
arrythmic movements ot tongue, jaw and face. less often involve LE
can be d/t pyshchotropic drugs
tic
repetiive coordinated movements that occur at irregular intervals
chorea
brief, rapid, jerky, irregular and unpredictable that occur at rest or during normal movement
UNLIKE TICS THAT RARELY REPEAT THEMSELVES
athetosis
twisting, slow movements that involve FACE and distal extremities
seen in CP
dystonia
similar to athetosis biut often involve larger groups of the body including trunk
