Neuro Flashcards
Motor Cortex Function
Movement
Frontal Lobe function
Judgement, foresight, and voluntary movement
Broca’s area function
motor aspect of speech production
Frontal Lobe function
smell
Temporal Lobe function
hearing
Occipital lobe function
primary visual area
Wernicke’s area function
Speech comprehension
Cerebellum function
coordination, balance
Sensory cortex function
pain, heat, and other sensations
5 segments of the spinal cord
- cervical (c1-8)
- Thoracic (T1-12)
- Lumbar ( L1-5)
- Sacral (S1-5)
- Coccygeal
Cauda Equina location
L1-2 -
nerve roots fan out
Motor root location
ventral (anterior)
Sensory root location
dorsal (posterior)
Sympathetic NS location and general function
Fight or Flight (T1-L3) - lateral gray of spinal cord
releases noradrenaline -
increases HR, RR, dilates pupils
Peripheral nerve amounts and locations
31 pairs
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
makeup of a spinal nerve
motor fiber (ventral) and sensory fiber (dorsal) merge to form the spinal nerve
Parasympathetic components
Basal metabolism
slows HR, RR, constricts pupils
Acetylcholine is the neuro T of the psns
Sympathetic System origin
Thoracic/Lumbar
Parasympathetic system origin
Brain/Sacral
Common concerning symptoms of the Nervous system
Headache
Dizziness or vertigo
Generalized, proximal, or distal weakness
Numbness
Abnormal or loss of sensations
Loss of consciousness, syncope, or near-syncope
Seizures
Tremors or involuntary movements
Detection of the three Ds
delirium, dementia, and depression
Health promotion- preventative awareness
Stroke and TIA prevention
Reduction of peripheral neuropathy
Neuro physical exam assessment questions
- Is the mental status intact?
- Are the right and left side findings the same? (symmetrical)
- If the findings are asymmetrical, or abnormal otherwise - are the causative lesions in the CNS or PNS?
***! - ALWAYS ASK IF AN ASYMMETRY IS NORMAL FOR THE PT.
Organize thinking into five nervous system related categories
- mental status
- speech and language
- cranial nerves
- motor and sensory system
- reflexes
Mental Status ROS
Level of consciousness
Speech
Orientation
Current events knowledge
Judgment
Vocabulary
Abstraction
Memory-immediate recall, recent and remote
Language-fluency, comprehension, repetition, naming, reading, writing
Calculation
Object recognition
Emotional responses
Praxis
Mood and affect
Higher intellectual function-knowledge, abstraction, judgment, insight, reasoning
Aphasia
loss of speech comprehension
Dysarthria
difficulty controlling the muscles used for speech
(Disorder of speech)
Speech requires formulation of articulation and pronunciation. This involves the bulbar muscles and the physical ability to form words.
Manifests as slurred, slow speech
Dysphonia
difficulty in speaking from a physical disorder of the mouth, throat, tongue, or vocal cords
(disorder of speech, phonation difficulties, hoarsness)
Speech exam
Recite a short phrase for Pt. to repeat
ex. No ifs ands or buts
Dysphagia
Disorder of language, difficulty in comprehending or speaking as a result of cerebral dysfunction
Language Processes
Semantics - selection of words to be spoken
Syntax - formulation of appropriate sentence phrases
Orientation components
Person, time, place and situation
Judgement Assessment
(Simple question that the answer is obvious)
What would you do id you saw someone being attacked?
Abstraction assessment
Ask patient to interpret:
How is an apple and an orange alike?
Vocabulary assessment
Varies based on education level and diversity.
Ask something like, What do you use a pen for?
and should be asked in order of increasing difficulty like: car, ability, dominant, voluntary, telescope
Emotional assessment q’s
Any mood changes?
How are your spirits?
Are you depressed?
[Response-appropriate, abnormal, or flat]
Mini mental state exam categories
- Orientation
(year, day month, where they are) - Registration
(name three objects. ask patient to repeat them- repeat until they learn them all) - Attention and calculation
(serial 7s, spell a word backwards - Recall
(ask for the 3 items from before) - Language
(name pencil and watch
Repeat “No ifs ands or buts”
Follow a 3 stage command - take this paper in your hand, fold it in half, and out it on the floor
Read and obey “CLOSE YOUR EYES”
Write a sentence
Copy the design shown
Cerebellar Function- assessment tests
Gait
Finger-to-nose assessment
Heel-to-shin
Rapid alternating movements(RAM)
Romberg
Gait-definition and assessment procedure
The manner of walking or running.
Walk straight ahead and then return on tiptoes and then walk on heels then tandem walk one foot touching the toes of the other.
Posture, balance and arm swing.
Hop on one foot.
Gait Disturbance
Ataxic
Choreiform
Diplegic
Hemiplegic
Myopathic
Neuropathic
NPH
Parkinson
Trendelenburg
Ataxic gait
An unsteady, staggering gait is described as an ataxic gait because walking is uncoordinated.
Usually multifactorial
Increases with age and most are due to sensory deficits.
Choreiform (Hyperkinetic)
Involuntary movements that are superimposed on gait without balance difficulties.
Usually due to Huntington’s chorea.
Diplegic (Scissor)
Patients have involvement on both sides with spasticity in lower extremities worse than upper extremities.
Cerebral Palsy
Hemiplegic
Gait in which the leg is stiff, without flexion at knee and ankle, and with each step is rotated away from the body, then towards it, forming a semicircle.
Causes-CVA, CP, Parkinson
Myopathic (Waddle)
A particular way or manner of moving on foot: a person who ran with a clumsy, hobbling gait. No weight bearing on the affected side.
Seen in myopathies
Neuropathic (Steppage)
Steppage gait is a form of gait abnormality characterized by foot drop due to loss of dorsiflexion.
The foot hangs with the toes pointing down, causing the toes to scrape the ground while walking, requiring someone to lift the leg higher than normal when walking.
Neuropathies
Normal Pressure Hydrocephalus
Gait caused by Normal Pressure Hydrocephalus
3W’s
Wet -Incontinent
Wobbly-Gait unsteady
Wacky-Demented
Parkinson’s Gait
Slow shuffling gait (festinating)
Stuck to the floor (freezing)
Decreased to absent arm swing
Trendelenberg Gait
Abnormal gait associated with a weakness of the gluteus med.
It is characterized by the dropping of the pelvis on the unaffected side of the body at the moment of heel strike on the affected side.
In this deviation the pelvic drop during the walking cycle lasts until heel strike on the unaffected side and is accompanied by an apparent lateral protrusion of the affected hip.
The person also shortens the step on the unaffected side and displays a lateral deviation of the entire trunk and the affected side during the stance phase of the affected lower limb.
This gait is one of the more common gait deviations.
Finger to nose
Rapidly points finger to nose and then to examiners finger, move smoothly and assess quickness. Switch hands and repeat.
Heel to Shin
Lay on back and slide heel of one extremity down the shin of the other and switch sides.
tests cerebellar function and dyssynergia
RAM-Diadochokinesia
Alternate rapidly supination and pronation of hands. Toe tapping, finger to thumb.
Compare RT to LT, but remember there will be some mild difference (ie RT hand faster in RT dominant)
Rhomberg
Stand in front of examiner with feet together with heels touching, extend arms with palms facing upwards. (eyes closed)
Positive if pt sways and have to move feet for balance.
Pronator drift-one of the arms drift down and fingers flex.
Testing joint position sense
Somatosensory configuration
The sensory information is mostly somatosensory: touch, temperature, pressure and pain (“somato” = “body”).
Axons in these nerves tend to cross to the opposite side of the spinal cord so that sensation-in and control-of the right side of the body are in the left brain, and vice versa.
Within the spinal cord axons ascend-from and descend-to the brain in well-segregated tracts: for crude touch, for pain&temperature, for motor control, and for proprioception&kinesthesia (muscle, tendon & joint position as well as muscle tension and movement information).
Motor Terms
Paresis: weakness
Plegia: no movement
Hemi: half
Quad: all 4.
Praxis-ability to perform a motor activity.
Apraxia is the inability to perform a voluntary movement in the absence of deficits in motor strength, sensation or coordination.
Motor neurons configuration
Upper Motor Neurons (UMN) are formed from fibers from the corticospinal tracts.
UMN synapses with LMN in the ant horn of the spinal cord
The motor root leaves the cord anteriorly to join the sensory root and becomes the spinal nerve
UMNs v LMNs
Motor Evaluation
Tone-residual tension in a voluntary relaxed muscle and is assessed by resistance to passive movement.
Bulk- size
Strength-graded
It is also important to assess for involuntary movements such as tremors, tics or fasciculation; noting their location, rate, amplitude, intention, quality, rhythm, and relation to posture.
Motor GRading
0/5-absent-no contraction
1/5-Trace-slight contraction noted
2/5-weak-movement sideways(no gravity)
3/5-Fair-Movement against gravity-(up)
4/5-Good-Movement against gravity with some resistance
5/5-Normal-Movement against gravity with full resistance
Sensory-Spinothalamic tracts
Fibers responsible for pain, temperature and crude touch (light touch without localization)
Synapse quickly with secondary neurons in the posterior horn of the spinal cord and then cross to travel contra-laterally to the brain
Secondary-Posterior Columns
Fibers responsible for position, vibration detection, along with fibers for fine touch go directly to the posterior columns
These fibers travel ipsilaterally up to the lower medulla then synapse with secondary neurons and cross to the contralateral side and travel to the thalamus
Secondary- Posterior column damage
If there is solely posterior column damage; a person will have a wide range of sensation, but will lose position and vibration sense inferior to the level of damage
Sensory configuration
At the thalamic level. Crude sensations are felt (pain, temperature, pleasant, unpleasant);
For full sensation the fibers synapse with a third group of neurons (thalamic level) and travel to the sensory cortex of the brain.
Sensory definitions
Paresthesias-a sensation of pricking or tingling on the skin having no objective cause and usually associated with injury or irritation of a sensory nerve or root.
Numbness-Ask meaning, different meaning to different people.
Dysthesia- Abnormal, unpleasant sensation to touch.
Pain-abnormal unpleasant senation.
Sensory descriptors
Light Touch
Pain
Vibration Sense
Proprioception
Tactile Sense
Discriminative sensations
2 point
stereognosis (identify objects with eyes closed)
graphesthesias (identifying shapes traced in hand- parietal lobe problem)
point localization
Dorsal sensory root locations upper extremity
C2 and C3 - Posterior head and neck
C4 and T2 - Adjacent to each other in the upper thorax
Nipple - T4 or T5
Umbilicus - T10
Upper extremity
C5 - Anterior shoulder
C6 - Thumb
C7 - Index and middle fingers
C 7/8 - Ring finger
C8 - Little finger
T1 - Inner forearm
T2 - Upper inner arm
T2/3 - Axilla
Dorsal sensory root locations lower extremity
Lower extremity
L1 - Anterior upper-inner thigh
L2 - Anterior upper thigh
L3 - Knee
L4 - Medial malleolus
L5 - Dorsum of foot
L5 - Toes 1-3
S1 - Toes 4,5; lateral malleolus
S3/C1 - Anus
Light Touch
Touch patient with gauze or cotton to distal toes and fingers
Sensory deficits are often distal if absent then work proximal until patient can feel and repeat on opposite side(determine sensory level)
If specific area c/o numbness etc, check that area
Pain test
Safety pin/break cotton applicator go to area to show patient the difference between sharp and dull to establish baseline and then begin distal.
Close eyes.
Determine sensory level.
Vibration
128 HZ tuning fork
Start distal and go proximal over bony prominence
Close eyes
Patient tells you when it stops vibrating and determine sensory level.
Proprioception + how to test
Position sense
Have patient close eyes and then move distal digit (toe /finger) up and down and patient will tell you up or down. If can’t tell move proximal.
Tactile Localization
Double stimulation
Eyes closed
Touch right and left sides and patient tells you where you touched them
Two-point Discrimination
Paper clip and place 3 mm apart and keep moving closer until patient feels only 1 point (<2 mm felt as one point)
Reflexes
Reflex arc, involuntary
Some only involve sensory and motor nerves with one synapse.
To fire, all of the components must work. The afferent nerve (sensory), the synapse (in the anterior horn of the spinal cord) and the efferent nerve (motor, in the anterior horn).
Reflexes grading
0-absent
1+-decreased
2+-normal
3+-increased
4+-hyperactive
Deep tendon reflex locations
Biceps-C5-6
Brachioradialis-C5-6
Triceps-C6-8
Patellar-L2-4
Achilles-S1-2
Bicep tendon reflex testing procedure
Biceps- The patient should relax and pronate the forearm midway between flexion and extension. Place the thumb firmly on the biceps tendon. Strike the hammer on the examiner’s thumb. Observe for contraction of the tendon and flexion at the elbow (C5-C6)
Brachioradialis tendon reflex testing procedure
Brachioradialis The arm is rested on the patient’s knee and held in semiflexion and pronation. Strike the styloid process of the radius about 1-2 inches above the wrist. Observe for flexion at the elbow and simultaneous supination of the forearm (C5-C6).
Triceps tendon reflex testing procedure
Triceps-Flex the patient’s elbow and pull the arm toward the chest. The elbow should be midway between flexion and extension. Tap the tendon above the insertion of the ulna’s olecranon process 1-2 inches above the elbow. Observe for prompt contraction of the triceps with extension of the elbow (C6- C8)
Patellar tendon reflex testing procedure
Patellar Tendon-This is also known as the knee jerk.
The patient should sit with the legs dangling off the side of the table. Place your hand on the quadriceps muscle. Strike the patellar tendon firmly with the base of the reflex hammer. Contraction of the quadriceps should be felt and extension of the knee will be observed (L2-L4).
Achilles tendon reflex testing procedure
Achilles Tendon-This is also known as the ankle jerk.
It is elicited by having the patient sit with the feet dangling off the side of the bed. The leg should be flexed at the hip and knee.
The examiner should dorsiflex the patient’s foot. Strike the Achilles tendon just above its insertion on the posterior aspect of the calcaneus with the wide angle of the reflex hammer. This can also be done with the patient lying supine. Observe for plantar flexion at the ankle (tests nerve roots at S1-S2).
Superficial Reflexes
Abdominal: lie supine and run an applicator stick quickly horizontally lateral to medial toward umbilicus. (upper T8-10 and lower T10-12)
Normal-contraction of abdominal muscles deviating towards stimulus
more superficial reflexes
Cremateric: rub the inner thigh with applicator stick. (S2-3)
Normal-elevation of testicle on the same side.
Anal-pucker around examiner finger (S2-4)
Clonus
A series of involuntary, rhythmic, muscular contractions and relaxations.
A one or two beat clonus may not be abnormal
Glascow Coma Scale
Special Tests
Meningeal
Asterixis
Doll’s Eyes
Straight Leg Raise
Patrick’s Test
Waddell’s
Babinski
Hoffman
Meningeal signs
Brudzinski: hand behind head and flex neck forward until chin touches chest.
Positive: hips and knees flex
Kernigs: Flex pts leg at the hip and knee and then straighten knee.
Positive: patient resistance to maneuver
Asterixis-Liver flap
Pt has hands cocked up and fingers spread.
Positive: brief, non-rhythmatic flexion of the hands and fingers.
No movement is normal.
Hepatic encephalopathy.
Doll’s Eyes + indication
Vestibulo-occular reflex
Turn pts. Head and eyes move in opposite direction to remain fixed on an object.
Negative-eyes remain fixed in mid position.
Cerebellar damage.
Doll’s Eyes Positive test
Positive if comatose pt’s eyes remain focused on an object despite head movement. When the patient’s head is turned, the eyes move in the opposite direction as though still looking at a stationary object (Positive Doll’s eyes).
If this is positive, the reason for coma is above the brainstem. In an alert person, we suppress this reflex.
In a comatose patient with brainstem damage, his eyes remain fixed in mid position
Babinski
To evoke the Babinski reflex, the sole of the foot between the heel and the toe is firmly stroked with a hard tool or a thumb.
In infants, this could cause the big toe to extend, pushing outwards, and often the small toes will accompany it in a splaying motion.
Infants demonstrate the reflex because their brains are not fully mature, so the protections which prevent this reflex are not yet present.(up to 2yrs)
Hoffman sign
Hoffman’s sign is a neurological sign in the hand which is an indicator of problems in the spinal cord. It is associated with a loss of grip.
The test for Hoffman’s sign involves tapping the nail on the third or forth finger.
A positive Hoffman’s is the involuntary flexing of the end of the thumb and index finger - normally, there should be no reflex response.
Implications of a positive Hoffman
Hoffman’s sign is an indicator of a number of neurological conditions including Cervical Spondylitis, other forms of spinal cord compression and Multiple Sclerosis.
In MS, a positive Hoffman’s sign is usually caused by lesions in the motor nerve pathways on or above the place in the spinal cord where the nerves that control the hands exit (C5).
CN I Function
Olfactory - smell
CN II Function
Optic Nerve - visual acuity, visual fields, ocular fundi
CN III Function (with CN II also)
Oculomotor - pupillary reaction
CN III, IV, and VI function
(Oculomotor, trochlear, abducens)
extra-ocular muscle movements, and opening eyes
CN V Function
Trigeminal - Facial sensation, movements of the jaw, and corneal reflexes
CN VII Function
Facial Nerve - Facial movements and gustation
CN VIII Function
Vestibulocochlear nerve - Hearing and balance
CN IX, and X Functions
Glossopharyngeal, Vagus - Swallowing, elevation of the palate, gag reflex and gustation
V,VII,X,XII functions
Trigeminal, Facial, Vagus, Hypoglossal-
Voice and speech
CN XI Function
Accessory - Shrugging the shoulders and turning the head
CN XII Function
Hypoglossal - Movement and protrusion of tongue
Olfactory Nerve pathway
Sensory receptors in the nasal mucosa are stimulated by odors.
These stimuli are detected by the olfactory bulb.
Nervous impulses then travel through the olfactory tract to terminate in the anterior perforated substance.
These intimate connections with the entorhinal cortex, amygdala, hippocampus and other parts of the limbic system.
Olfactory nerve testing
Test each side separately with eyes closed.
Use nonirritating substance as this could trigger pain receptors.
Use familiar smells.
Compare strength of smell.
Often omitted unless trauma or complaint.
Irregular Olfactory Nerve manifestations
Anosomia-colds, rhinitis, tumors
Hypersomia- hysterics, cocaine addicts
Parosmia-olfactory hallucinations, hysterics, seizures, schizophrenia and uncinate gyrus lesions.
Cacosmia- unpleasant odors- decomposition of tissue
Optic nerve Tests
Visual Acuity-OS,OD,OU
Visual Fields
Fundoscopic Examination
Pupil Diameter
Pupillary Response
Accomendation
Oculomotor nerve functions
Pupil Diameter
Pupillary Response
Accommodation
Motor to four eyeball muscles
Injury to nerve causes dilated pupil and ptosis
“fixed and dilated”
CN III Pathway
The superior division supplies the levator palpebrae superioris and superior rectus muscles.
Theinferior division supplies the medial rectus, inferior rectus and inferior oblique muscles.
Optic and oculomotor pupillary functions
Normal pupils are equal in size and shape and are situated in center of iris
Pupillary size varies with intensity of light is about 3-4 mm
Miosis-<2mm
Mydriasis->5mm
Aniscoria-pupillary asymmetry
CN II & III: Light reflex
Dim Lights
Fix gaze on opposite wall to eliminate accomendation
Shine bright light obliquely into each pupil
Look for both direct (same eye) and consensual (opposite eye) reaction
Record pupil size and shape
CN II & III: Accommodation
Hold finger about 10 cm from patient’s nose
Alternate looking into distance and at finger
Observe pupillary response
Trochlear nerve function
Innervates superior oblique muscles
Trigeminal branches function
V1-Opthalmic
V2-Maxillary
V3- Mandible
Trigeminal Testing 1
Palpate Masseter muscle while biting down.
Check sharp and dull sensation and if abnormal then warm and cold and vibration.
Check next to nose and chin. Have them close their eyes. Corneal Reflex.
Trigeminal Test procedures
Abducens Nerve Function
to contract the lateral rectus which results in abduction of the eye.
Facial Nerve Testing + CVA analysis
Check for asymmetry.
Puff cheeks, smile, close eyes and attempt to open.
Peripheral-if whole side is paralyzed.
Central-(CVA)- if forehead is spared.
Sensory from anterior 2/3 of tongue
Motor to muscles of facial expression
Parasympathetic to salivary and lacrimal glands
Injury causes facial droop, dry eyes, dry mouth
How to interpret CN VII damage
When the whole side of the face is paralyzed the lesion is peripheral.
When the forehead is spared on the side of the paralysis, the lesion is central (e.g., stroke). This is because a portion of the VII cranial nerve nucleus innervating the forehead receives input from both cerebral hemispheres. The portion of the VII cranial nerve nucleus innervating the mid and lower face does not have this dual cortical input.
Hyperacusis (increased auditory volume in an affected ear) may be produced by damage to the seventh cranial nerve. This is because the seventh cranial nerve innervates the stapedius muscle in the middle ear which damps ossicle movements which decreases volume. With seventh cranial nerve damage this muscle is paralyzed and hyperacusis occurs.
Furthermore, since the branch of the seventh cranial nerve to the stapedius begins very proximally, hyperacusis secondary to seventh cranial nerve dysfunction indicates a lesion close to seventh cranial nerve’s origin at the brainstem
CN VIII Testing
Whisper test or rub fingers together.
Weber
Rhinne
Glossopharyngeal function
Voice
Gag Reflex
Uvula deviation
Sensory posterior 1/3 of tongue, auditory tube, pharynx
Parasympathetic to parotid gland
Vagus Nerve function
Voice
Gag Reflex
Uvula deviation towards unaffected side
Sensory larynx, pharynx, heart, lungs
Motor to larynx, pharynx, heart, lungs
Accessory Nerve Function and tests
Innervates muscles of larynx and pharynx.
Innervates muscles of Trapezii and SCM.
Check for asymmetry of trapezius.
Shrug shoulders.
Push head laterally against hand.
Hypoglossal Function + Tests
Controls three of four tongue’s extrinsic muscles.
Genioglossus, Styloglossus, Hyoglossus
Palatoglossus is Vagus.
Check for tongue deviation-
towards peripheral lesion and away from central
Tongue atrophy.
Tongue fasiculations.
