NEURO Flashcards
Bradykinesia
Finger Tapping
Hand Movements
Pronation-Supination
Toe taps
Often very asymetrical - PC one limb. so test both sides
Rated by the MDS UPDRS
Dont memorise scoring.
Impact of Bradykinesia
Hypomimia (facial expression)(mask)
Hypophonia (soft voice)
Short steps, shuffling gait
Micrographia
Rigidity
Hypotonia and Hypertonia
Spasticity and Rigidty
Paratonia and Myotonia (less common)
Increased resistance to passive movement
Do not learn the rating tool.
Determine between spasticity and rigidty
Distribution
Clinical Context
Associated signs
Effect of Velocity- spasticity worse with speed, better when slower but rigidity is present regardless
Synkeinesis- move another part of body and rigidity gets worse.
Tremor
RESTING At completely relaxed state, slow tremor will come out.
Look at speed- physiological will be fast, pathological will be slow.
Upper limbs in parkinsons, pill rolling.
Re-emergent- same muscle joints and frequency but error at rest, reduces/ disappears at movement.
Essential/action
leaves at movement, occurs at sustained postures.
Scale based on amplitude- do not learn.
Cogwheel rigidity
Rigidity and tremor superimposed.
Jumps in movement of the wrist
feeling the tremor
Gait
Reduced velocity
Reduced cadence
Reduced stride length
Asymmetric stride length
Reduced arm swing
Freezing in Gait
Motor blocks during walking:
gait initiation, turning, passing through a doorway, threshold, line on floor- zebra crossing
Postural instability
Pull test and theyll fall back- normal response is to shuffle to regain balance.
Camprocormia- bending forward
Pisa syndrom- titling
Striatal hand/foot- flexion at PIP , relax at DIP
RBD
Rem Sleep Behaviour Disorder
Act out your dreams
Kicking, flailing
Early feature
Cranial Nerve exam
INTRODUCTION
Introduce yourself
Explain examination.
Obtain consent
Offer chaperone + explain supervisor will re-examine (for ophthalmoscopy)
Clean hands
Position your patient sitting and sit opposite them
Cranial Nerve
GENERAL INSPECTION
Facial asymmetry
Eye related signs
Medical aids – glasses, eye patch, hearing aids, pen and paper for communication
Hearing aids
Fasciculations
Scars
back of ear – acoustic neuroma
craniotomy
in front of ear – parotid gland tumour, may have associated ipsilateral facial nerve palsy
Tracheostomy, nasogastric or PEG tubes
Cranial Nerve Exam
OLFACTORY NERVE (CN I- SENSORY)
“Do you have difficulty with your sense of taste or smell?”
Cranial Nerve Exam
OPTIC NERVE (CN II- SENSORY)
VISUAL ACUITY: Snellen chart (with and without glasses)/ counting fingers, hand movements, light/ dark
COLOUR VISION: Ishihara plates
VISUAL INATTENTION
VISUAL FIELDS
CENTRAL VISION
BLIND SPOT
Cranial Nerve Exam
OCULOMOTOR (CN III- MOTOR), TROCHLEAR (CN IV- MOTOR) and ABDUCENS (CN IV SENSORY+MOTOR)
EYE MOVEMENTS; including commenting on squints, nystagmus
PUPILS
Inspection
Test reaction to LIGHT (Direct and consensual)
Test ACCOMODATION
Cranial Nerve Exam
OPTIC NERVE (CN II- SENSORY)
FUNDOSCOPY/OPTHALMOSCOPY – covered in P year
Cranial Nerve Exam
TRIGEMINAL (CN V- MOTOR + SENSORY)
Dab different areas of face, both sides, with cotton wool (sensory) - compare with sensation over sternum
V1 (Ophthalmic)
V2 (Maxillary)
V3 (Mandibular)
Motor component:
Clench teeth (masseter and temporalis muscles)
Open mouth against resistance (pterygoid muscles- jaw deviation)
Push jaw to one side (pterygoid weakness)
Jaw jerk and corneal reflex (with permission from supervisor
Cranial Nerve
FACIAL (CN VII- MOTOR+SENSORY)
Look for asymmetry
“Raise your eyebrows – keep them there, don’t let me push them down”
“Screw your eyes up tight – keep them closed, don’t let me open them”
“Smile – show me your teeth”
“Purse your lips together, don’t let me pull them apart”
Sense of taste in anterior 2/3 of the tongue (sensory)
Cranial Nerve exam
VESTIBULOCOCHLEAR NERVE (CN VIII- SENSORY)
Crude hearing (whisper a number) from 60cm whilst masking the sound in the other ear. Test both ears
If they cannot hear this perform tuning fork tests using a 512 Hz fork
Rinne’s test
Weber’s test
Cranial Nerve Exam
GLOSSOPHARYNGEAL NERVE (CN IX- SENSORY+MOTOR) AND
VAGUS NERVES (CN X- SENSORY+MOTOR)
Oral cavity
Look at the tongue , uvula and palate.
Gag reflex (with permission from supervisor)
Swallow (with permission from supervisor)
Cranial Nerve
ACCESSORY NERVE (CNXI- MOTOR)
Shrug shoulders
Turn head against resistance
Cranial Nerve
HYPOGLOSSAL (CN XII- MOTOR)
Wasting and fasciculation of tongue
Protrude tongue: Deviation of tongue towards side of pathology
Move tongue from side to side
Motor Neurone
General Inspection
SWIFT
Scars, Wasting, Involuntary Movements, Fasciculations, Tremor
When speaking to pt for intro see if they hoarseness in voice and full face movement
Motor Neuron
Balance: Trunk and Gait
TRUNK
With patient sitting up
Instability; Romberg’s test
Truncal ataxia
GAIT
Look for abnormalities:
Asymmetry
Wide based gait
Poor coordination
Scissoring gait
Waddling gait
High stepping gait
Gait apraxia
Shuffling gait
Hysterical gait
Ask patient to turn around
En-block turning
Heel to toe walking
Walk on heels
Walk on toes
Motor Neurone
Its not IPPA its….
Tone
Power
Coordination
Sensory Reflex
Upper body Tone
Clasp knife rigidity
Lead pipe rigidity
Cog-wheel rigidity
Hypotonia
Flaccid tone
Hold the patients hand with one hand (like shaking hands) and the elbow with the other
Move elbow and wrist randomly, including a mixture of rotational and flexion/extension movements and assess the extent and timing of any resistance
Compare with other side
Upper Body power
Shoulder Abduction (C5- axillary nerve)
Elbow Flexion (C5/C6 -musculo-cutaneous nerve)
Elbow Extension (C7/C8 -radial nerve)
Wrist Extension (C6/C7 -radial nerve)
Finger extensors (C6/C7 -radial nerve)
Finger flexion/grip (C8)
Abductor pollicis brevis/thumb abduction (median nerve)
Dorsal interossei/finger abduction (ulnar nerve)
MRC Grade 5
Upper body coordination
Dysdiadochokinesia (cerebellar disease)
Finger-nose (cerebellar disease, dysmetria, intention tremor, past-pointing)
Upper body reflex
Reflexes
Biceps (C5)
Triceps (C7)
Supinator (C6)
Lower body tone
Roll leg
Lift knee and drop it
Clonus
Examine both legs and compare findings
Lower leg power
Power
Hip Flexion (L2/3 -femoral nerve)
Hip Extension (L4/5 -inferior gluteal nerve)
Knee Extension (L3/4 -femoral nerve)
Knee Flexion (L5/S1 -sciatic nerve)
Ankle Dorsiflexion (L4/5 -deep peroneal nerve)
Plantar-flexion (S1/2 -tibial nerve)
Foot inversion (L4 -tibial nerve/deep peritoneal nerve)
Foot eversion (L5/S1 -superficial peroneal nerve)
Big toe Extension (L5 -deep peritoneal nerve)
Lower limb coordination
Co-ordination triangle - intention tremor/past pointing in cerebellar disease
Lower llimb reflex
Reflexes
Knee (L3)
Ankle (S1)
Plantar reflex (dorsiflexion of big toe/fanning of other toes -UMN lesion)
Sensation
If no reported abnormalities- start distally and include all dermatomes
If there are reported abnormalities- start from area of abnormality & map it out
Test following modalities:
Light touch
Pain
Vibration sense
Position sense
Temperature, if appropriate
Sensation exam
Pattern / approach to testing – as for upper limbs
Test following modalities:
Light touch
Pain
Vibration sense
Position sense - including Romberg’s test
Temperature – if appropriate
Arm dermatome
lower limb dermatome
