Neuro Flashcards
Dangerous Headaches: Warning s/s
- Thunderclap headache (very severe headaches hat reaches max intensity in 1 min or less)
- “Worst headache of my life”
- First onset of headache at ≥ 50 yo
- Sudden onset of headache after coughing, exertion,s training, or sex (exertional headache)
- Sudden change in LOC
- Focal neuro sign s(e.g., unequal pupil size, hemiparesis, loss of function, poor gag reflex, difficulty swallowing, aphasia, sudden vision loss, vidual field defect)
- Head w/ papilledema (↑ ICP 2º to those listed here)
- “Worse-case” scenario of headaches r/o includes the following:
► Subarachnoid hemorrhage 9SAH) or acute subdural hemorrhage
► Leaking aneurysm or arteriovenous malformation (AVM)
► Bacterial meningitis
► Increase ICP
► Brain abscess
► Brain tumor
Subarachnoid Hemorrhage: General Overview
- Sudden and rapid onset of severe headache
- described as “the worse headache of my life”
- accompanied by N/V, neck pain or stiffness (+Brudzinski and/or Kernig signs)
- Photophobia
- visual changes (diplopia, visual loss)
- Rapid ↓ LOC
- Headache can be localized or nonlocalized in occipital area/neck
- may have seizures during acute phase
- VS: ↑ BP, ↑ temp, ↑ HR
Depending on source of bleed → focal neuro signs or no signs
- Usually caused by ruptured cerebral aneurysm or AVM
“Sentinel headache” → sudden intense headache
- can precede a spontaneous SAH by days to weeks
- An unenhanced CT scan can detect an SAH in approx 95% of pt within first 24 hours
- ~22% of patients die on same day
- MEDICAL EMERGENCY! CALL 911!!
Acute Bacterial Meningitis (In adults): General Overview
- Neonates, infants, and elderly are at ↑ risk
- Community-acquired is most commonly d/t Streptococcus pneumoniae (50%) and Neisseria meningitides (30%)
S/S
- Acute onset of high fever
- severe headache
- stuff neck (nuchal rigidity)
- meningismus w/ AMS
- Classic purple petechial rashes appear
- accompanied by N/V, photophobia
- Rapid worsening of sx → lethargy, confusion, and coma
If not treated, FATAL
Bacterial Meningitis is a MEDICAL EMERGENCY! Call 911!
Giant Cell Arteritis (Temporal Arteritis): General Overview
- Acute onset of headache, located on one temple of an older pt (avg 70 years)
- May c/o excruciating burning pain over affected temporal artery instead of headache
- affected temple has indurated, reddened, and cord-like temporal artery (tender and warm to touch) accompanied w/ scalp tenderness
- Abrupt onset of visual disturbances and/or transient blindness of affected eye (amaurosis fugax)
- may c/o jaw pain or jaw claudication (caused by artery obstruction)
- Marked ↑ ESR and CRP
- Hx of polymyalgia rheumatica (PMR) are at very high risk of developing this (30%)
- Headache may be accompanied by symptoms of PMR (fever, pain on shoulders/hips [polymyalgia], anorexia, weight loss)
***If left untreated → BILATERAL BLINDNESS!
Acute Stroke (Cerebrovascular Accident): General Overview
- Either Embolic (87%) or hemorrhagic (13%)
RF for embolization:
- afib, prolonged immobilization
- presents w/ acute onset of stuttering/speech disturbance
- on-sided facial weakness
- one-sided weakness of arms/legs (hemiparesis)
Hemorrhagic:
- poorly controlled HTN
- present w/ abrupt onset of a severe headache
- N/V
- nuchal rigidity (subarachnoid bleed)
Chronic Subdural Hematoma: General Overview
- Bleeding b/w dura and subarachnoid membranes of brain
- presents gradually
- sx may not show until a few weeks after injury
- hx of head trauma (falls, accidents)
- presents w/ hx of headaches and gradual cognitive impairment (apathy, somnolence, confusion)
- more common in alcoholics, elderly, and those on anticoagulation or aspirin therapy
Multiple Sclerosis: General Overview
- Adult female c/o episodic visual loss or diplopia (double vision)
- problems w/ balance and walking
- numbness and paresthesia on one side of face
- accompanied by urinary incontinence (75%) and/or bowel dysfunction (50%)
- reports that when bending neck forward/flexion, an electric shock-like sensation runs down the back (Lhermitte sign)
- Not emergent, but recognization of s/s important!
Neurological Testing:
1. Includes what components?
2. What mental status exams can be conducted for pts?
- mental status
- cranial nerves (CN)
- motor, reflex, and sensory exam
- mental status
- Folstein Min-Mental State Exam (MMSE)
- CN exam
- Folstein Min-Mental State Exam (MMSE)
Mini-Mental State Exam: Components
- Orientation (Name, age, address, job, time/date/season)
- Registration (Recite 3 unrelated words; distract pt for 5 mins, then ask pt to repeat works)
- Attention and calculation
- Spell world backward or indicate serial 7s (subtract 7 starting at 100)
- Language
- While speaking to pt, look for aphasia (impairment in language → difficulty speaking)
Cerebellar Testing
1. Definition
2. Types
- Cerebellum coordinates unconscious regulation of balance, muscle tone, and coordination of voluntary movements
- Gait
- Tandem gait
- Rapid alternative movements
- Heel-to-shin testing
- Finger-to-nose and finger-to-finger test
- Gait
** Clinical findings that are highly suggestive of damage to the cerebellum are ataxia, disequilibrium, as manifested by a wide-based gait, and muscular hypotonia
Cerebellar Testing: Gait
1. Definition
2. What indicates positive?
- Tell pt to walk to other side of room and back. If using walking aid (e.g., cane, walker), test pt w/ walking aid. Observe gait–is pt shuffling, scissoring, waddling, or swinging?
- POSITIVE: If acute cerebellar ataxia, pt will have a wide-based staggering gait
Cerebellar Testing: Tandem gait
1. Definition
2. What indicates positive?
- Tell pt to walk a straight line in normal gait, then instruct pt to walk in straight line w/ one foot in front of the other
- POSITIVE: if pt is unable to perform tandem walking, loses balance, and falls
Cerebellar Testing: Rapid alternating movements
1. Definition
2. What indicates positive?
- Pt to place hands on top of each thigh and move them (alternating between supination and pronation) as fast as possible
- POSITIVE: Pt unable to problems w/ rapid alternating movements (dysdiadochokinesia)
Cerebellar Testing: Heel-to-shin testing
1. Definition
2. What indicates positive?
- Pt in supine position w/ extended legs. Tell pt to place L heel on R knee and move it down the shin (repeat w/ R heel on L knee)
- POSITIVE: Unable to keep their foot on shin
Cerebellar Testing: Finger-to-nose and finger-to-finger test
1. Definition
2. What indicates positive?
- Pt to fully extend arm, then touch their nose of ask them to touch their nose, then extend arms and touch your finger
- POSITIVE: Unable or misses touching nose and/or finger to nose (dysmetria)
Proprioception: Romberg Test
1. Definition
2. What indicates positive?
- Pt to stand w/ arms/hands straight on each side and feet together w/ eyes open and observe. Next, instruct pt to close both eyes while standing in same position and observe
- POSITIVE: Positive if pt sways excessively, falls down, or has to keep feet wide apart to maintain balance. If abnormal → neuropathy or posterior column (of spine) disease
Cranial nerve Testing:
OOOTTAFAGVSH - “On Old Olympus Towering Tops, A Fin And German Viewed Some Hops”
CN I - Olfactory
CN II - Optic
CN III - Oculomotor
CN IV - Trochlear
CN V - Trigeminal
CN VI - Abducens
CN VII - Facial
CN VIII - Acoustic
CN IX - Glossopharyngeal
CN X - Vagus
CN XI - Spinal Accessory
CN XII - Hypoglossal
SSMMBMBSBBMM - “Some Say Marry Money But My Brother Say Big Boobs Matter Most”
CN I
Olfactory
- Use familiar cent (e.g., coffee, peppermint)
- Block one nostril at a time
CN II
Optic
- Visual field testing: Pt stands ~2 feet in front of examiner and covers their left (or right) eye. stretch arm so that it is in peripheral visual field and ask pt if they see 1, 2, or 3 fingers (all four quadrants)
- Stare straight ahead at about the same level as pt (examiner serves as the “control”)
CN III
Oculomotor
- CN III, CN IV, and CN VI are usually tested together; they control EOM
- First, look for ptosis
- Stand ~2 feet in front of pt as they fixate gaze on fingers of examiner’s hand
- Instruct pt to “follow my fingers” while observing for nystagmus (horizontal quick movements of eyes in one direction, alternates w/ slower movements of eyes i opposite direction; test pupillary function
CN IV
Trochlear
- CN III, CN IV, and CN VI are usually tested together; they control EOM
CN V
Trigeminal
- Provides sensory nerves to face
- Test sensation by lightly touching forehead are, cheek, and chin
- Trigeminal nerve has 3 branches: the ophthalmic (V1), cheek (V2), and jaw area (V3)
- Tell pt to close eyes when testing; ask if they feel sensation
** Herpes zoster infection (shingles) of CN V (5) ophthalmic branch → corneal blindness
*** Rash on tip of nose and temple area: RULE OUT shingles infection of trigeminal nerve involving the ophthalmic branch (V1)
CN VI
Abducens
- CN III, CN IV, and CN VI are usually tested together; they control EOM
CN VII
Facial
- Controls facial muscles that enable facial expression
- Tell pt to close eyelids tightly try to open eye lids manually
- Tell pt to look up and wrinkle forehead, then tell pt to smile
- Look for asymmetry and muscle atrophy
- Bell’s palsy is d/t inflammation of facial nerve (motor portion)
This affected side of face will not move and eyelid may not be fully close
CN VIII
Acoustic
- Hearing exam can be done by rubbing pt’s hair in front of ear
- Alternative: hold hand up as a sound screen then whisper a few numbers and ask pt if they heard the words
CN IX
Glossopharyngeal
- Both CN IX and X → control palate; usually tested together
- tell pt to open mouth, then yawn
- Observe for asymmetry; uvula should be midline
- Gag reflex can be tested by using tongue blade and lightly touching back of throat
- assess voice clarity (r/o dysarthria)
- Innervates movement of soft palate (ask pt to yawn or say “aah” to check voice clarity)
CN X
Vagus
- Both CN IX and X → control palate; usually tested together
CN XI
Spinal Accessory
- Controls shoulder shrug and head rotation
- Tell pt to shrug both shoulders; should be same level
- Then pt rotate head to left; place hand on pt’s left cheek and instruct to push against it
- tell pt to turn head to R side, then follow same procedure
- Check sternocleidomastoid muscle for atrophy or asymmetry
** The number reminds you of shoulders shrugging together
CN XII
Hypoglossal
- Controls tongue movement
- Pt to stick out their tongue and move it from side to side
- Look for atrophy and asymmetry
** Innervates tongue (midline, no atrophy)
Sensory System
1. Definition
2. Sensory tests
- Tell pt to close their eyes for tests
- Vibration sense
- Sharp-dull touch
- Temperature
- Vibration sense
Sensory System: Vibration sense
1. Definition
2. Positive
- Use 128-Hz tuning fork and tap lightly
- Then, place one end into distal joint of each thumb
- Pt should have eyes closed
- For testing feet, place tuning fork on tips of toes and several areas on sole of feet
- Go back and forth to compare one foot w/ the other
- Check for numbness or ↓ vibration sense
Important test of assessing severity of diabetic peripheral neuropathy - POSITIVE: if pt does not feel anything or have ↓ sensation
Sensory System: Sharp-dull touch
1. Definition
2. Positive
- Use sharp end of safety pin or toothpick for sharp touch testing
- For dull sensation → head to safety pin or eraser end of a pencil - POSITIVE: Pt unable to discriminate sharp from dull sensation or sense vibration; vibration sense is often the ealier to be affected in ds such as peripheral neuropathy (polyneuropathy), which can be result of diabetes and vit B12 deficiency anemia
Sensory System: Temperature
Test ability to differentiate hot or cold
Stereognosis
- Ability to recognize familiar object through sense of touch only
- Place a familiar object (e.g., coin, key, pen) on pt’s palm and tell pt to identify the object w/ eyes closed
Graphesthesia
Ability to Identify figures “Written” on skin
- “Write” a large letter or number on pt’s palms using fingers (pt’s eyes are closed)
Motor Exam: Extremities + Positive findings
- UE & LE
- Hands & Feet
- Pronator drift tests
UE: Pt to raise both arms in front them, then pronate and supinate. Tell pt to bend and extend forearms, then push against resistance provided by examiner
Hands: Perform full ROM w/ hands & fingers, w/ and w/out resistance (by examiner); dominant hand will be slightly larger d/t more muscle development
LE: while supine, tell pt to flex each hip, then raise each leg separately while examiner provides resistance; compare legs
Feet: Perform full ROM on toes and ankles; examiner provides resistance
Pronator drift test: Pt stretch out arms w/ palms facing up, w/ eyes open. Tell pt to close eyes. wait for 20-30 seconds. Then tap arms briskly downward. if POSITIVE, one arm goes downward or drifts
POSITIVE:
- In upper motor neuro diseases (stroke, amyotrophic lateral sclerosis [ALS], polio)
- In lower motor neuro lesions (neuropathy, polio, nerve root compression, radiculopathy), look for muscle weakness, muscle wasting/atrophy, and fasciculations
- Gross exam (legs) and fine motor movements (hands); test walking, using hands for manipulation/pincer grasp, jumping, and so forth
Reflexes
- Both sides should be compared w/ each other and should be equal
- 31 pairs of spinal nerve roots, named for their associated vertebral body
- Each pair exists at corresponding level, innervating distinct dermatomal distributions
