Neuro Flashcards
All CNS lesions
Ipsilateral
Question asked
Is there is a neurologic problem?
Where is the neurologic problem?
What is the neurologic problem?
Increased ICP
Most defective finding
Papilledema
Type of lesion
Focal
Mass lesion
Infarction
Hematoma
Type of lesion
Multi focal
Multiple tumors, abscess
MS
Type of lesion
Diffuse
Toxic (metab encephalopathy)
Peripheral neuropathy
Myopathy
Is there is neurological problem?
3 findings
Meaningeal irritation
Increased intracranial pressure
Focal neurologic deficits
Irritation of the meninges by meningitis, subarachnoid hemorrhage, drugs and increase intracranial pressure
Meaningeal irritation
With the patient supine and the limbs extended, passively flex the neck
Brudzinski sign
Positive brudinzki sign
Flexion of the hips
With the patient supine, passively flex the hip to 90 degrees while the knee is flexed about 90 degrees
Kernig sign
Patient cannot place the chin on the chest
Nuchal rigidity
If patient with meningitis is awake
Sign are always positive
But if patient with meningitis has decreased level of consciousness
No positive signs
Obtunded that he cannot produce protective reflexes
Most common cause of meningitis
Infection
If patient has fever, automatically do the test for Meaningeal signs
CNS infection is always a differential diagnosis
Physical and neurological examination
Mental status exam - cerebral hemisphere
Cranial nerves - brainstem
Motor- corticospinal
Cerebellar - always ipsilateral
Reflexes - pathologic, superficial, deep tendon
Sensory - spinothalamic, posterior columnar
Meningeal signs
Central nervous system
Brain
Supratentorial
Diencephalon
Cerebral hemispheres
Thalamus
Basal ganglia
Central nervous system
Brain
Infratentorial
Brainstem
Cerebellum
Peripheral nervous system
Can best diagnose posterior fossa problems
MRI
Localize
What specific part
Lateralize
Right or left
Midline or diffused
Ipsilateral or contralateral
Symptoms that manifest contralateral to the lesion
Hemi paresis
Hemi sensory deficits
Symptoms that manifest ipsilateral to the lesion
Cerebellar problem
Cranial nerve deficits
Impaired position sense, vibration sense
Sudden onset
Within minutes, hours, days, weeks
Sudden onset
Cerebral infarction
Thrombolic
Embolism
Sudden onset
Cerebral hemorrhage
Most common cause is HPN
Subacute onset
More than 2 weeks but less than 3 months
Chronic onset
More than 3 months
Chronic onset
Neoplasm
Malignant
Glioblastoma
Patient will die after 6 months
Chronic onset
Neoplasm
Benign
Meningioma
Tumor will present for many years
Chronic onset
Abscess
Temporal nobe
Cerebellum
Chronic onset
Manifest within 6 months
Subdural hematoma
Chronic onset
Remnant of TB infection
Granuloma and cyst
Examination of cerebral function
Between frontal and parietal
Central sulcus
Examination of cerebral function
Between frontal and temporal
Lateral fissure
Examination of cerebral function
Sensory, cortical level function
Parietal
Examination of cerebral function
Vision
Occipital
Examination of cerebral function
Audition and memory
Temporal
Objective evidence of cerebral dysfunction
Seizure
Level of consciousness
Inability to maintain a coherent stream of thought or action
Diffuse infusion to brain
Confusion
Level of consciousness
Ability to sort out and stratify the many sensory inputs and potential motor output
Attention
Level of consciousness
Most common cause of confusion
Metabolic/ toxic derangement
Level of consciousness
Confusional state with excess sympathetic activity
Delirium
Most common cause of delirium
Febrile sates and dehydration
Level of consciousness
Ability to respond verbally and fending off
Drowsiness
Ask the sleeping pattern
Level of consciousness
Lethargy
Incomplete arousal to noxious stimuli
No response to verbal commands
Motor response purposeful
Stupor
Level of consciousness
Obtunded
Primitive and disorganized motor responses to noxious stimuli
No response to attempts at arousal
Light coma
Level of consciousness
Absence of response to noxious stimuli
Deep coma
Glasgow Coma Scale
Eye opening
4- spontaneous
3- verbal
2- painful
1- no response
Glasgow Coma Scale
Verbal
5- oriented and talks 4- disoriented and talks 3- inappropriate words 2- incomprehensible sounds 1- no response
Glasgow Coma Scale
Motor activity
6- verbal command 5- localizes pain 4- withdraws from pain 3- decorticate 2- decerebrate 1- no response
Full outline of unresponsive scale
Eye response
Motor
Brainstem reflex
Respiration
Mental status
Orientation
Time
Place
Person
Mental status
Attention
Ask patient to count backwards from 100 by 7
Stop after 5 correct answers
Mental status
Registration
Name 3 objects
Ask patient to repeat 3 objects
Mental status
Complex task
Give patient 3 step command
Mental status
Repetition
Repeat a sentence
Mental status
Recall
Usually dates
Recall
Type of memory
Recent
Remote
Immediate
Mental status
Reading
Follow written commands
Inability to understand the meaning
Agnosia
Types of agnosia
Trace letters/numbers on skin and palm with fingertips
Agraphesthesia/ agraphognosia
Types of agnosia
Inability to recognize faces in person or in photos
Prosopagnosia
Agraphognosia lesion
Contralateral parietal
Prosopagnosia lesion
Right or bilateral inferomedia temporo occipital region
Types of agnosia
Inability to locate , identify and orient one’s body parts
Autotopagnosia/ asomatognosia
Types of agnosia
Inability to be aware of his own bodily defect
Anosognosia
Ask patient to draw symmetrical figures
Seen in right parietal lesion
Unilateral neglect
Left sided hemispatial inattention
Sensory extinction, sensory inattention
Touch patient on one or both sides
Inattention to double simultaneous cutaneous stimuli
Inattention to double simultaneous cutaneous stimuli
Lesion
Right Parietal (common) / left parietal lesions
Word agnosia and word blindness
Left parietal lesion
Dyslexia and alexia
Inability to perform a voluntary act even though the motor, sensory, and mental status are intact
No motor weakness
Apraxia
Testing the apraxia
Instruct to do different tongue movement
Bucco-facial apraxia
If verbal instruction fails, try miming
Testing the apraxia
Ask the patient to demonstrate sequential acts
Ideomotor apraxia
Testing the apraxia
Draw geometric figures
Constructional apraxia
Testing the apraxia
Also know as Bruns apraxia
C3 and C4 commonly in right parietal lesion
Gait apraxia
Communication
Left hemisphere
Invest words and meaning
Communication
Right hemisphere
Prosody of speech (intonation, melody, pauses and phrasing)
Inability to understand or express words as symbols for communication even though the primary sensorimotor pathway to receive and express language and mental status are relatively intact
Aphasia
Types of aphasia
Need mo ito kabisaduhin nasa trans
Types of aphasia
Brocas
Can understand Motor Non fluent Expressive Left posterior inferior frontal operculum
Types of aphasia
Wernicke’s
Sensory
Receptive
Fluent
Types of aphasia
Conduction
Posterior parasylvian area
Types of aphasia
Frontally and superiorly toward stratum
Trans cortical motor
Types of aphasia
Parietal + temporal + thalamocortcial circuit
Trans cortical sensory
Types of aphasia
Entire parasylvian area
Global
Clinical manifestation of frontal lobe,
Bilateral hemiplegia ( quadriplegia)
Spastic bulbar (pseudobulbar palsy)
Decomposition of gait and sphincter incontinence
Inability to solve complex problem (prefrontal)
Clinical manifestation of temporal lobe
Korsakoff amnestic defect
Apathy and placidity
Hypermetamorphosia ( hypersexuality, hyperorality)
Clinical manifestation of parietal lobe lesion
Dysgraphia
Dyscalculla
Finger agnosia
Clinical manifestation of occipital lobe lesion
Loss of topographic memory and visual orientation
Hallucinations
Homonym outs hemianopsia
Made up of bags of small muscle fibers (intrafusal) has afferent and efferent axons that maintain constant tension
Muscle spindle
Only have efferent axons
Skeletal (extrafusal)
Pulls the perimysium and stretches the muscle spindle
Extension of joint
Relaxation of muscle spindle
Flexion of the joint
To maintain stretch sensitivity
JE- muscle spindle lengthens
JF- muscle spindle contracts
Reflexes
Upper ext- biceps and triceps
Lower ext - quads (knee jerk) and triceps surae reflex (ankle jerk)
Short convex sides
Taylor tomahawk hammer
Biceps reflex
C5, C6
Triceps reflex
C6-8
Patellar reflex, femoral nerve
L2-L4
Achilles reflex, tibial nerve
L5-S2
Lesion of various site of reflex arc
LMN lesion
Myopathy
Paralysis
Lesion of various site of reflex arc
LMN lesion
Denervation atrophy
Lesion of various site of reflex arc
Dorsal root lesion
Loss of sensation
Lesion of various site of reflex arc
Dorsal root lesion
LMN lesion
Myopathy
Absence of MSR
Superficial reflexes
Abdominal reflexes upper quadrant
T8T9
Superficial reflexes
Abdominal reflex lower quadrant
T11-T12
Superficial reflexes
Abdominal reflex
Beevor sign
Scrape skin toward umbilicus
Superficial reflexes
Cremasteric reflex
L1-L2
Superficial reflexes
Involves tapping the nail or flicking the terminal phalanx of the middle or ring finger
Hoffman’s
Positive when there’s flexion of terminal phalanx of thumb
Lesion in corticospinal tract
Superficial reflexes
Most important component: dorsiflexion of big toe and fanning of the rest
Babinski reflex
Corticospinal tract lesion
UMN paralysis
Superficial reflexes
Diagnostic reflex similar to the babinski reflex
To identify lesion of pyramidal tract
Chaddoks reflex
Superficial reflexes
Dorsiflexion of the big toe elicited by irritation downward of the medial side of the tibia
Oppenheim’s reflex
Lesion in pyramidal tract
Non localizing primitive reflex
Stroke proximodistally over the patients thenar eminence
Palmomental reflex
Non localizing primitive reflex
With patients eyes closed, tap philtrum several times
Snout relfex
Non localizing primitive reflex
Stroke patient palm from the hypothenar eminence toward junction of third and index finger
Grasp reflex
Non localizing primitive reflex
With patients eye closed stroke his lip from the center of the crevice to the sides
Sucking relfex
Increased ICP
Lateral rectus palsy secondary to abducens nerve
Diplopia with internal squint
Diplopia with internal squint
Test
Ask patient to look at one finger and move the finger to the right patent will see double vision
Increased ICP
Hypertension
Localized collection of pus
Bulging fontanelle
Separation of sutures
Rapid enlarging head size
Increased ICP
Very obvious
Shortened walking hours
Drowsiness
Deterioration in level of consciousness