Module 2 Study Guide Flashcards
Cranial Nerve 1
1. Name
2. Type of nerve?
3. Function
4. Common abnormal findings
5. How is it assessed?
- The olfactory nerve
- This is a sensory nerve
- Controls sense of smell and interpretation of smell
- Lesion of the olfactory nerve, allergic rhinitis, smoking, old age, allergies, or inflammation.
- Making sure the nares are patent. Odor identification test.
Cranial Nerve 2
1. Name
2. Type of nerve?
3. Function
4. Common abnormal findings
5. How is it assessed?
- Optic nerve
- Sensory nerve
- Controls visual acuity, peripheral vision
- Decreased visual acuity, reduced peripheral vision. Optic neuropathy, retinal detachment, hemorrhage, stroke.
- Visual acuity test, visual field confrontation test, ophthalmoscope eye exam.
Cranial nerve 3
1. Name
2. Type of nerve?
3. Function
4. Common abnormal findings
5. How is it assessed?
- Oculomotor nerve
- Sensory and motor nerve
- Controls eye movements except laterally (toward ear on the same side and rotating the eyes downwards). Adjusts the shape of the lens to view objects at a distance or up close (accommodation). It also adjusts pupil width to allow more or less light in.
- Reduced eye movement, inability to accommodate, or pupillary dysfunction.
- View the pupils look for size, shape, symmetry, the pupillary response to direct and consensual light, the ability to accommodate. Having the patient follow an object through the six fields of cardinal vision.
Cranial nerve 4
1. Name
2. Type of nerve?
3. Function
4. Common abnormal findings
5. How is it assessed?
- Trochlear nerve
- This is a motor nerve
- The trochlear nerve has one job, it controls the superior oblique muscle of the eyes which allows you to look down.
- Inability or impaired ability to look down
- Assessed via the six cardinal fields of vision exam
Cranial nerve 5
1. Name
2. Type of nerve?
3. Function?
4. Common abnormal findings?
5. How is it assessed?
- Trigeminal nerve
- Motor and sensory nerve
- Plays a role in facial sensation, jaw movement, and blink reflex.
4. - Assessed via palpation of the facial muscles and jaw muscles. Exam of the patient’s ability to differentiate light touch on the forehead, cheeks, and chin. Assessment of the presence of the blink reflex.
Cranial nerve 6
1. Name
2. Type of nerve
3. Function
4. Common abnormalities
5. How is it assessed?
- Abducens nerve
- Motor nerve
- Has the job of moving the eyes laterally, toward the ear
- Inability or impaired ability to look laterally. This nerve is often the first affected by tumors of the area. Strabismus.
- Assessed via the six cardinal fields of vision.
Cranial nerve 7
1. Name
2. Type of nerve
3. Function
4. Common abnormalities
5. How is it assessed?
- Facial nerve
- Sensory and motor nerve
- Movement of the face’s muscles, speech, anterior 2/3 of the tongues ability to taste.
- Assessed via a series of facial expressions to test for muscle symmetry and control, listening to the patient’s speech, and doing a taste identification test.
Cranial nerve 8
1. Name
2. Type of nerve
3. Function
4. Common abnormalities
5. How is it assessed?
- Acoustic nerve
- Sensory nerve
- Hearing
- Lateralization, decreased air conduction, increased bone conduction
- Whisper test, weber test, Rinne test
Cranial nerve 9
1. Name
2. Type of nerve
3. Function
4. Common abnormalities
5. How is it assessed?
- Glossopharyngeal nerve
- Sensory and motor nerve
- Posterior 1/3 of the tongues ability to taste. Ability to swallow.
- Assessed along side the vagus nerve. Looks at ability to swallow. Taste test the tongues posterior 1/3.
Cranial nerve 10
1. Name
2. Type of nerve
3. Function
4. Common abnormalities
5. How is it assessed?
- Vagus nerve
- Sensory and motor nerve
- Has many functions in the parasympathetic realm. Plays a role in taste and speech.
Cranial nerve 11
1. Name
2. Type of nerve
3. Function
4. Common abnormalities
5. How is it assessed?
- Spinal accessory nerve
- Motor nerve
- Controls the muscle movement of the trapezius and sternocleidomastoid muscles.
- Palpation and motor movement of the involved muscles
Cranial nerve 12
1. Name
2. Type of nerve
3. Function
4.
5. How assessed?
- Hypoglossal nerve
- Motor and sensory nerve
- Tongue movement and speech
- Movement of the tongue and speaking
Chronic disorder characterized by recurrent, unprovoked electrical discharges of cerebral neurons?
Epilepsy
Progressive autoimmune disorder characterized by inflammation and degeneration of the myelin of the brain’s white matter?
Multiple sclerosis
Recurrent sharp paroxysmal pain that radiates into one or more branches of the fifth cranial nerve?
Trigeminal neuralgia
Acute inflammation of the brain and spinal cord, often due to a virus
Encephalitis
Inflammation of the meninges of the brain or spinal cord
Meningitis
A clinical syndrome of intracranial hypertension that mimics brain tumors
Pseudotumor Cerebri
Autoimmune disorder of the neuromuscular junction. Antibodies are directed to destroy acetylcholine receptors at the junction leading to decreased amounts of Ach available. Leads to muscles dysfunction.
Myasthenia Gravis
A sudden interruption of blood supply to a part of the brain or the rupture of a blood vessel, spilling its blood into spaces around the brain cells.
Stroke - ischemic then hemorrhagic
A condition where lesions occur in the white and gray matter with irreversible CNS damage. Onset age is 20-40, women are affected twice as often as men.
Multiple sclerosis
This causes displacement of tissue and pressure, affecting the cerebrospinal fluid circulation; function is threatened through compression and destruction of tissues.
Intracranial tumor
An autoimmune condition triggered by a bacterial or viral infection that damages the peripheral nerves, leading to denervation and atrophy
GBS
Excess cerebrospinal fluid (CSF) production or malabsorption of the CSF causes obstructed venous drainage of CSF. Obesity is a contributing factor. Most common in women of child bearing age
Pseudotumor Cerebri
Inflammatory reaction that compresses the facial nerve (CN7), such as in response to herpes simplex or herpes zoster viral infections. Facial nerve swelling and compression against the temporal bone, followed by demyelination occurs.
Bell Palsy
Sudden onset of numbness, weakness, confusion, trouble speaking or understanding speech, change in vision, loss of balance, or severe headache
What kind of data is presented here?
These are symptoms of a stroke or CVA
The data presented is subjective data
Objective data included - dysarthria, loss of balance
Drooping eyelids, double vision, difficulty swallowing or speaking, fluctuating fatigue or weakness, inability to work with arms raised above head, difficulty walking, symptoms are worse later in the day and improve with rest
Type of data presented?
These is subjective data describing MG symptoms
Objective data included - drooping eyelids, trouble speaking and swallowing (if assessed through an exam), trouble walking
History of recent illness, progressive weakness, starts in legs, paresthesia, pain in shoulder, back or thigh, double vision.
Type of data presented?
GBS
Subjective data
Fever, chills, headache, stiff neck, lethargy, malaise, irritability, seizures
Type of data?
This is subjective data describing the symptoms of meningitis
Objective data - if assessed through an exam - stiff neck. Seizures.
Persistent headache which may awaken the patient from sleep. Nausea and early morning vomiting. Unsteady gait, impaired coordination. Memory loss and confusion. Reduced vision acuity, vision loss, or diplopia. Behavior or personality changes. Seizures.
What kind of data is this?
This is subjective data describing the typical presentation of intracranial tumors.
Objective data included - unsteady gait, reduced vision, seizures
In children - irritability, lethargy, motor systems abnormalities, cranial nerve palsies, weight loss, growth failure, and precocious puberty.
What kind of data is this?
This is subjective data describing the typical child’s presentation of intracranial tumor.
Objective data included - cranial nerve palsies, growth failure
Fatigue, urinary frequency, sexual dysfunction, vertigo, blurred vision, emotional changes, relapsing and remitting symptoms
What kind of data is this?
This is subjective data describing the symptoms of MS. The most telling being the relapsing and remitting pattern.
Mild viral illness with fever, followed by lethargy and mental confusion
Type of data?
Subjective data describing the presentation of encephalitis.
AMS, confusion, stupor, coma, photophobia, stiff neck, muscle weakness, paralysis, and ataxia.
Which of the data presented is objective?
The data presented describes encephalitis.
Objective data - Coma, stiff neck (if through exam), paralysis, ataxia
Subjective data - AMS, confusion, photophobia, weakness
Tonic, clonic, postictal
Epilepsy
Facial creases and nasolabial folds disappear on affected side. Eyelid will not close. Lid sags, excessive tearing, food and saliva pool on affected side, facial sensation is intact
Seen with Bell’s palsy
Muscle weakness, ataxia, hyperactive DTR, paresthesia, optic neuritis, changes in cognition, MRI shows brain lesions
MS
Papilledema, cranial nerve impairment, aphasia, vision loss, gait disturbances, CT or MRI confirms diagnosis
Intracranial tumor
Elevated BP, altered LOC, weakness or paralysis, aphasia (receptive or expressive). CT or MRI confirm diagnosis
Stroke or CVA
Ptosis that develops within 2 minutes of upward gaze, facial weakness when puffing out cheeks, hypophonia, difficulty managing secretions, respiratory compromise, weak skeletal muscles without reflex, coordination abnormalities
MG - ptosis after two minutes upward gaze is common seen due to consumption of the Ach that is present or the use of the present Ach receptors. This leads to weakness quickly. Symptoms would worsen throughout the day.
The weakness with MG is most prominent in the eyes, face, speech, swallowing, and limb movements
AMS, confusion, nuchal rigidity, fever, (+) brudzinski and Kernig signs, LP and csf culture to confirm diagnosis
These are exam findings present with meningitis. An illness that affects the meninges of the CNS.
Brudzinski sign - patient laying supine. Support patients neck as you apply upward pressure, bringing their chin toward their chest. A positive sign would be involuntary flexion of the hips and knees as the body attempts to compensate for increased inflammation and irritation of the meninges.
Kernig sign - patient is laying supine. Have the patient bring their knee upwards toward their torso. After a little bit, have them straighten the leg back out. Severe stiffness of the hamstring makes straightening impossible.
A group of permanent disorders of movement and posture development associated with non-progressive disturbances that occurred in the developing fetal or infant brain
Cerebral Palsy
In children: fever, irritability, decreased food intake, difficulty breathing, seizure, loss of consciousness
Shaken baby syndrome
Condition is associated with excessive use of alcohol, medications used for seizures and acne, genetic factors, and pregnant person’s health conditions (folic acid deficiency, DM, and maternal obesity).
Myelomeningocele (Spina Bifida)
A slowly progressive, degenerative neurologic disorder in which motor function is primarily affected along with behavioral and cognitive problems
Parkinson Disease
Tremors occur initially at rest and with fatigue. Tremors improve with intended movement and sleep. Progresses to pill-rolling movements of fingers bilaterally and tremor of the head. Slowing of voluntary and automatic movements. Numbness, aching, tingling, and muscle soreness occur. Trouble swallowing and drooling.
Parkinson’s Disease
Destruction of neurons that transmit dopamine results in poor communication between parts of the brain that coordinate and control movement and balance. Onset 40-60 years old.
Parkinson disease
Plantar reflex
1. Type of reflex
2. Exam technique (expected findings)
3. Innervation
4. Abnormal findings
- Superficial
- Patient’s foot is stroked in an upward motion on the lateral surface of the foot then along the ball of the foot. This should cause a plantar flexion of the foot.
- Innervated by L5, S1, S2
- Dorsiflexion of the big toe (Babinski) or fanning of the toes.
Abdominal reflex
1. Type of reflex
2. Exam technique
3. Innervation
4. Abnormal findings
- Superficial
- Gently stroke either side of the abdomen next to the umbilicus. The lower and upper half of the stomach have different innervations.
- Upper - innervated by T8, T9, T10
Lower - innervated by T10, T11, T12
4.
Cremasteric reflex
1. Type of reflex
2. Exam technique
3. Innervation
4. Abnormal findings
- Superficial
- Stroke the inner thigh of male patient. The testicle and scrotum on that side will rise slightly.
- Innervated by T12, S1, S2
Biceps reflex
1. Type of reflex
2. Exam technique
3. Innervation
- Deep tendon reflex
- Support patients elbow with four fingers on one hand, wrap the thumb around over the AC area. Flex the elbow 45 degrees. Strike the top of the thumb. Should cause the patient’s elbow to flex.
- Innervated by C5 and C6
Brachioradial reflex
1. Type of reflex
2. Exam technique
3. Innervation
1, Deep tendon reflex
2. Support patients elbow with one hand. Have the arm flexed 45 degrees. Palpate the radial pulse and go proximal slightly. Strike the brachialradial tendon. Should cause the hand and wrist to supinate slightly.
3. Innervated by C5 and C6
Triceps reflex
1. Type of reflex
2. Exam technique
3. Innervation
- Deep tendon reflex
- The arm is support around the bicep region as the patient flexes their arm 90 degrees behind their them. The tricep muscle is struck causing the arm to extend.
- This muscle is innervated by C6, C7, and C8
Patellar reflex
1. Type of reflex
2. Examination technique
3. Innervation
- Deep tendon reflex
- Examined by having the patient sit with their thigh supported and their lower leg hanging off, unsupported. The patellar nerve will be struck (located slightly below the patella). This should cause an extension of the leg.
- Innervated by L2, L3, and L4
Achilles reflex
1. Type of reflex
2. Exam technique
3. Innervation
- Deep tendon reflex
- The patient’s ankle is held midline. The Achilles tendon is struck causing a plantar flexion of the foot.
- Innervated by S1 and S2
When should a clonus assessment be done? What does this look at? How is it done?
A clonus assessment should be done on all patients that present or are positive for hyperreflexia. The clonus exam is done by dorsiflexing the patient’s ankle for a bit. After awhile this can cause rhythmic oscillating movements known as clonus.
Protective sensation
- Protective sensation is an exam of the patients ability to determine sensation in their feet. This is an advanced skill.
- This exam should be done with all patients with diabetes or decreased sensation or with wounds on their feet.
- The exam is done by using a microfilament to apply generous pressure (until the microfilament bends) for 1.5 seconds over various spots of the sole of the foot.
- The patient is expected to be able to feel the sensation. The inability to feel the sensations is linked to diabetic neuropathy and other issues that can make it more likely the patient will sustain damage to their feet due to lack of sensation.
What are the meningeal signs? What are the different signs?
The meningeal signs are an advanced skill that looks at nuchal rigidity, normally associated with inflammation of the meninges.
1. Nuchal rigidity - assessed by having the patient lay supine. The provider will apply firm pressure behind the neck, lifting the head upwards so the chin goes towards the sternum. The inability of the chin to to be lifted toward the sternum without pain is a positive nuchal rigidity sign.
2. Brudzinski sign - the patient is laid supine. The head is lifted so the chin goes toward the sternum with the providers hands behind the patient’s head lifting. A positive sign is the involuntary flexion of the hips and knees. This flexion is due to the inflammation of the meninges and helps reduce the strain placed on them.
3. Kernig sign - the patient is laid supine. One knee is flexed so the leg is up toward the torso. After a couple seconds, the leg is attempted to be returned to the straight position. The inability of the leg to fully straighten is a positive kernigs sign.
Decorticate VS Decerebrate posturing
Decorticate posturing - a type of reflex that is present when a patient has damage to their corticospinal tract above the brainstem. Also known as flexor posturing.
Decerebrate posturing - a type of reflex that is present when a patient has damage to their brainstem. Also known as extensor posturing.
Rapid Rhythmic Alternating Movements
1. What is this exam assessing?
2. How is it performed?
3. Alternative?
Part of the exam for proprioception and cerebellar function.
Patient is asked to sit and pat their knees with their hands, alternating between palm and back of hand with an increase in speed gradually. An alternative method is to have the patient touch their thumb to each finger on the same hand in sequence with increasing speed. Assess hands separately.
Accuracy of movements
1. What is this exam assessing?
2. How is it performed?
3. Alternative?
Part of the exam for proprioception and cerebellar function.
Patient is asked to move their index finger from their nose to the provider’s finger and back. Assess the movement in each arm separately.
An alternative exam is to have the patient touch their index finger to their own nose, alternating between hands.
An alternative exam is the heel-to-shin movement.
Balance
1. What is this exam assessing?
2. How is it performed?
3. Alternative?
Part of the exam for proprioception and cerebellar function.
There are two different assessments making up the balance exam.
Balance - the initial exam of balance is the Romberg’s test. This exam is done by having the patient stand up, arms down to their side and feet together. The patient is instructed to close their eyes. Slight swaying is expected, complete loss of balance is a positive Romberg’s test identifying poor balance. This is most commonly associated with cerebellar ataxia, vestibular dysfunction, or sensory loss.
Gait assessed by having the patient remove their shoes and observing them walk around the room. Heel-toe walking (tandem gait) can overexaggerate any unexpected findings. Slight swaying is expected, not loss of balance.
What is examined during primary sensory function exam? Describe how these exams are performed.
- Superficial touch - assess various parts of the body with light touch using a cotton wisp. Have the patient close their eyes and identify where the light touch sensation is being applied.
- Superficial pain - use a broken tongue blade to assess various parts of the body with slight pressure. Have the patient close their eyes and identify where the pressure is being applied.
- Proprioception (position of joints) - assess the positioning of the great toe on each foot. Have the patient close their eyes and position the toe in various positions having the patient identify the changes.
- Temperature and deep pressure - performed only if there is abnormalities seen in superficial pain. Temperature is assessed through rolling test tubes filled with water (hot/cold) over different parts of the body and having the patient identify the location and temperature felt. Deep pressure is assessed through squeezing of the trap, calf, and bicep muscles.
- Vibration - place the tuning fork on various locations throughout the body, having the patient determine the location and level of the vibrations felt.
What are the cortical sensory functions? Describe each of these exams and how they are performed.
- Stereognosis - ability to recognize familiar objects with eyes closed.
- Two-point discrimination - used to evaluate how well the patient can identify multiple points of pressure applied in similar areas.
- Extinction phenomenon - touch multiple areas on the patient simultaneously. They should be able to feel both sensations.
- Graphesthesia - have the patient close their eyes. Using a blunt object, trace a familiar and easily recognizable design into their palm. Ask the patient to identify the tracing.
- Point location - with the patient’s eyes closed touch an area on the patient’s skin then withdraws the stimulus. Ask the patient to point where the stimulus was.
Timed get up and go test (TUG)
This is an assessment done to determine the level of mobility (balance, strength, and cerebellar function). Typically, this assessment is done on elderly people.
- Have the patient stand from a sitting position in a chair without using the arms
- Walk 10 feet
- Turn around
- Walk 10 feet back
- sit down in the chair without using the arms
This should take less than 12 seconds. Time over 12 seconds points to increased risk of falls, decreased mobility, and decreased gait.
