neuro Flashcards
why is it important to ask about neck stiffness in a general neurological hx?
meningism leads to resistance in neck flexion due to muscle spasm. in meninigits and subarachnoid haemorrhage
what is vertigo?
sensation of movement of self or surroundings, indicates a disturbance in the vestibular portion of the 8th nerve or brainstem
give some causes of unprovoked attacks of vertigo?
menieres disease (vertigo, tinnitus, deafness), vestibular neuritis and some ataxic syndromes
what can cause a decreased sense of smell?
usually upper resp tract infection
meningioma in olfactory groove
basal or frontal skull fracture
smoking, increased age
how can deafness be classified and the causes?
conduction deafness: wax, otitis media, ostosclerosis, pagets disease
neural: environmental exposure to noise, tumours, infection, menieres disease, drugs (aspirin, gentamicin)
give some neurological causes of incontinence.
spinal cord legions, spina bifida, MS, DM with autonomic involvement
what are the principle symptoms of lesions in sensory pathways below the thalamus?
paraesthesia, numbness, pain
what types of tremor indicate certain diseases?
resting=parkinsons
intention=cerebellar disease
action=anxiety, thyrotoxicosis
chorea (involuntary, jerky movements)=huntingtons
what neural problems can cause difficulties swallowing?
local oesophageal lesion pseudobulbar palsy (bilateral UMN lesion of IX, X and XII) or bulbar palsy (LMN lesion of IX, X, XII)
what causes dysarthria (difficulty articulating) and dysphasia (language defect)
lesions of lower cranial nerves or cerebellum, Parkinsons or local discomfort
lesions in dominant lobe
give some RF for cerebrovascular disease.
htn, hypercholesterolaemia, diabetes, ihd
what neurological sx does alcohol lead to?
tremor, halluconations, dementia, peripheral neuropathy, seizures, wernickes encephalopathy, korsakoffs psychosis
why is medication important in neurological hx?
tx previously tried
some drugs have toxic effects on ns e.g. isoniazid, phenytoin can cause peripheral neuropathys
some medications promote seizures
antiepileptic drugs can cause ataxia, diplopia tremor
what type of pain is present in different headaches/neurological disorders/
unilateral pain=migraine
bilateral=tension type headache
over temporal area=temporal arteritis
behind eyes/over cheeks and forehead=acute sinusitis
in the face=trigeminal neuralgia, temporomandibular arthritis, glaucoma, cluster headache, psychiatric disease
what may a severe headache of sudden onset be/
subarachnoid haemorrhage
what may be the cause of a progressive headache over weeks/mnths?
mass lesion
what is the likely cause of a headache of subacute onset?
inflammatory e.g. meningitis
what may a recurrent generalised headache with mnths/yrs of hx and associated with stress be?
tension headache
what causes should be considered in headaches of short duration?
sinusitis, glaucoma, miganious neuralgia
what may exacerbate headaches?
lying down/coughing/straining if mass lesion
photophobia in migraine
what does a very severe headache suggest?
subarachnoid haemorrhage, migraine or meningitis
when does vomiting usually accompany a headache?
if increased icp
is loss of consciousness a common feature of tia or stroke?
no, can occur if brainstem affected
how can headaches be associated with sudden onset weakness?
haemorrhagic stroke usually accompanied by a severe headache
mas lesions can cause similar events to tia and associated with headache
what is the association between visual disturbance and sudden onset weakness?
amaurois fugax (transient loss vision in one eye due to involvement of ipsilateral ophthalmic artery)
tia affected posterior circulation can lead to diplopia
brainstem infarction: diplopia or hemiparesis with crossed signs
what are some RF associated with sudden onset weakness?
AF: thromboembolic infarction
MI: cerebral embolism
coronary or peripheral vascular disease likely to have atherosclerosis of cerebral vessels
htn is a rf for cerebral haemorrhage
what medications are a rf for haemorrhagic stroke?
anticoagulants
what may situational or vasovagal syncope be provoked by?
fright, anxiety, postural changes, micturition, coughing
when may exertional syncope occur?
if obstruction to LV outflow by aortic stenosis or cardiac myopathy
what may preceed a collapse?
vasovagal syncope: nausea , dizziness, tinnitus, blurred/grey vision, sweating
palpitations or chest pain if arrhythmia
for hypoglycaemia: sweating, weakness, confusion
seizures may be preceded by an aura
why is the time of unconsciousness imortant?
vasovagal syncope =few s
cardiovascular syncope =brief but deeply unconscious and pale
fall without unconsciousness common in parkinsons
what is tongue-biting suggstive of?
tonic-clonic seizure
why is the time for recovery important in hx of collapse?
cardiac syncope: rapif, often with flushing
vaso-vagal episode:rapid and complete
generalised seizure: post-ictal drowsiness
why is history of cardiac disease important in collapse?
if due to arrhythmia may have hx of mi, cardiomyopathy or valvular disease
severe aortic stenosis associated with exertional syncope
what could collapse due to abdo pain be due to?
need to rule out ectopic pregnancy
why is hx diabetes important in collapse?
could be a hypoglycaemic episode if miss a meal/over exert
what can decreased visual acuity (snellens chart) be due to?
glaucoma, macular degeneration, diabetic retinopathy, cataracts
lesions affecting the optic nerve, chiasma, tract or cortex due to trauma, infection, of tumours
what nerve is affected in visual inattention?
II
what causes visual field loss?
CN II
unilateral=lesion of optic nerve or unilateral eye disease
bitemporal hemianopia=lesion in centre of optic chasm
homonymous hemianopia=lesion between optic tract and occipital cortex
what causes problems with the pupils response to light?
II
swinging test detects abnormality in afferent pathway e.g. due to optic atropy
what is an argyll robertson pupil?
will accomodate but not respond to light
what may abnormal eye movements be due to?
central lesion, muscular condition, III, IV or VI nerve palsy
diplopia=muscle weakness
nystagmus=MS, verstibular and cerebellar lesions, toxins
III=due to trauma->ptosis, down and out, fixed dilated pupil
IV=diplopia
VI=trauma or wernickes encephalopathy-> failure of lateral movement, convergent strabismus, diplopia
what does the pattern of sensory loss in V suggest?
total loss in all 3=lesion at level of ganglion orsensory root
in one=post-ganglionic lesion
which nerves cause a lack of corneal reflex?
abnormality in V or VII
what is an exaggerated jaw-jerk response seen in?
CNVII UMN lesion, psuedobulbar palsy
what leads to weakness of muscles of facial expression?
CNVII
LMN: all muscles on same side of lesion e.g. bells palsy
UMN: same side bus spares forehead. usually caused by tumour
what do combined lesions of CN IX and X lead to?
difficulty swallowing, nasal regurgitation, choking
what causes XI lesions?
unilateral: trauma to neck or base of skull
bilateral: motor neuron disease, Guillean Barre syndrome
what happens if there is a unilateral LMN lesion of XII?
tongue deviate towatds affected side
what happens if there us a UMN lesion of XII?
only noticeable when bilateral. small, immobile tongue
describe the MRC scale of power?
5=normal 4=reduced against resistance 3=movement against gravity but not resistance 2=movemetn when gravity eliminated 1=flicker of contraction 0=paralysis
what muscles and nerves are involved in hip flexion and extension?
iliop-psoas, L1 and 2
gluteus maximus, L5, S1 and 2
what muscles and nerves are involved in knee flexion and extension?
hamstrings, L5, s1 and 2
quadriceps, l2-4
what causes ankle dorsiflexion and plantar flexion?
tibialis anterior, l4 and 5
gastrocnemius and soleus, s1 and 2
what nerves are involved in the knee jerk reflex?
l3 and 4
what nerves are involved in the ankle jerk refelx?
s1-2
what nerves are involved in the plantar reflex?
l5, s1 and 2
what nerves supply the sensation to the different parts of the leg?
upper thigh=l2 anterior knee=l3 inner calf=l4 outer calf=l5 lateral foot=s1
what tuning fork should be used to asses sensation in limbs?
128Hz
give some common neurological patterns of gait disturbance.
spasticity=stiff and jerky on a narrow base
parkinsons=hesitation in starting, shuffling, freezing, festination, propulsion, retropulsion, decreased arm swing
cerebellar ataxia=broad-based, unstable, tremulous, leans towards more affected lobe
sensory ataxia=broad based and high stepping
distal weakness=affected leg liften high
proximal weakness=waddling
hemiplegia=plantar flexed foot with leg swung in lateral arc
what causes an arm drift?
UMN lesion: drift down, medial, pronation
cerebellar: upwards
loss proprioception
what muscles and nerves are in the abduction and adduction of the shoulder?
deltoid, C5-6
latissimus dorsi and pec major= C6-8
what muscles and nerves are involved in elbow flexion and extension?
biceps, c5-6
triceps c7
what causes wrist flexionand extension?
flexor carpi radialis and ulnaris: c6-8
extensor carpi radialis: c7-8
what muscles and nerves are involved in the different finger movements?
flexion=flexor digitorum profundus and superficialis, c7 and 8
extension=extensor digitorum, c7-8
abduction=dorsal interossi=c8, t1
adduction=palmar interossi, c8,t1
what nerves are involved in the biceps reflex?
c5 and 6
what nerves are involved in the triceps reflex?
c7 and 8
what nerves are involved in the supinator reflex?
c 5 and 6
what nerves supply sensation to which parts of the arms and hands?
outer upper arm=c5 lateral forearm and thumb=c6 middle finger=c7 little finger=c8 medial upper arm=t1
give 2 ways of assessing confusion?
abbreviated mental test score: /10, therefore quick
minimental test:/30
give the components of the abbreviated mental test.
age time (nearest hr) give address to recall at end year name of place identify 2 people e.g. doctors, nurses etc DOB year of first world war count backwards from 20 to 1
what is important in the timeline of a collapse/fall history?
before: what doing, room spining, trip/fall, chest pain/sob/palpitations, dizzy/altered vision, funny smells/taste, facial droop, trigger e.g. pain, prodrome (dizzy), colour change, recent health-infective sx
during: how long, where landed, seizure/abnormal movements, tongue biting, incontinence, vomiting,
after: recovery time, residual sx (chest pain, arm/leg weakness)
consequences: head injury, chest trauma, hips, wrists, ankles, long lie (myoglobin release from muscle breakdown->acute renal failure)
give some differnetial diagnoses for fall/collapse.
heart: ACS, aortic disruption, arrythmia, tachycardia, obstructive cardiomyopathy, valve disease, embolism
head: hypoxia, seizure, hyperventilation, hypoglycaemia, stroke
vessels: vasovagal, vasovalvar (increased pressure e.g. cough), AAA rupture, sepsis, postural hypotension
give some red flags for collapse/fall.
syncope during exertion/while supine
syncope with chest pain/abdo pain/back pain
fhx sudden death or inherited cardiac disease
known pacemaker/defibrillator
ongoing hypotension, bradycardia, tachycardia
clinical signs aortic stenosis, HOCM, HF, tamponade or dissection
ECG changes
what suggests a cardiac cause of collapse?
chest pain/palpitations, known ischaemic or valvular disease, preceded by increase in activity
what suggests postural hypotension is a cause of collapse?
change of position, may be immediately after anti-hypertensives/diuretics change in dose or time
what suggests seizure is cause of collapse?
abnormal movement, tongue biting, incontinence
what suggests sepsis is cause of collapse?
hx of being unwell, focal infective sx
what examination is done for fall/collapse?
airway: obstruction->hypoxia
breathing: hypoxic
circulation: shock, murmurs
disability: GCS and pupils, brief cranial nerve and neuro exam
exposure: temp, ABG, signs meningism, head trauma, alcohol intake
what is the san fransisco syncope score?
determines whether someone needs to go into hospital for a fall/collapse
what features in the hx are important in headache?
Site: Ask the patient to point. Unilateral/bilateral?
Onset: Sudden or gradual? Thunderclap?
Character: Throbbing? Like a tight band?
Radiation: Does the pain radiate?
Associated symptoms: Nausea/vomiting, altered conscious level, rash,
pyrexia, neck stiffness, photophobia, visual loss,
blurred vision, aura, tender scalp, malaise,
rhinorrhoea/lacrimation?
Timing: Constant/intermittent? Single/recurrent? Duration
of episodes. Worse at certain times of
day/month/year?
Exacerbating factors: noise, stress, bending, standing up, coughing,
sneezing, blowing nose, eating, combing hair,
bright or flashing lights, certain foods/drugs,
dehydration?
Relieving factors: analgesia, dark environment, lying down, rest
Severity: Scale (1-10)
what hx is important in altered consciousness?
Ask the patient to describe the episode in their own words.
Pay attention to:
Onset (gradual/sudden?),
Time of the day
What they were doing at the time?
Any pain, injections hot crowded rooms, emotional stress, prolonged standing,
How they felt before the episode
Associated symptoms: Dizziness, nausea, vertigo, aura, tachycardia, sweating, weakness,
paraesthesia, slurred speech, headache, tongue biting or incontinence, stiffening\jerking of
limbs, awareness and responsiveness during the episode, eyes-open or closed? Groans,
crying?
How long did it take to recover? Any amnesia, aggression, crying or weakness after the
episode? Feeling sad and crying after the episode
Previous episodes? If so whether they are like the current one?
Was the episode witnessed? If so what did the witness say? Can we contact them to get a
description?
what past medical hx is important?
Head/spinal trauma Metabolic/endocrine disorders e.g. diabetes Cancer (metastases?) Epilepsy Hypertension Atrial Fibrillation Heart diseases
what drug hx is important?
Anticonvulsants Drugs that interact with anticonvulsants / lower the seizure threshold Anticoagulants and anti-platelet drugs Analgesics Antihypertensives Antidepressants Insulin Recreational drugs
what social hx is important?
Alcohol consumption Smoking Recreational drugs Occupation Social activities/hobbies Home circumstances, level of independence
what fhx is important?
Diabetes Cerebral haemorrhage Cerebrovascular disease / stroke Ischaemic heart disease Migraine Epilepsy
what is rhombergs test?
The patient stands with feet together, arms outstretched in front of them and hands supinated.
If they cannot do this with the eyes open, it suggests a cerebellar lesion.
If the patient can maintain the position with the eyes open but loses balance when the eyes
are closed, this suggests loss of proprioception.
what is hemiplegic gait?
Arm adducted at the shoulder, flexed elbow and wrist, leg extended
and adducted at the hip, knee extended, and ankle plantar-flexed
The patient lurches his upper body toward the unparalysed side to elevate the pelvis
and swing the paralysed leg round. The plantar-flexed foot scrapes along the ground.
what is apraxic gait?
The gait is slow and shuffling. The stride length is markedly decreased. Can lose
balance while turning.
what is the gait like in parkinsons?
The gait is slow and shuffling. The stride length is markedly decreased. Can lose
balance while turning.
Gait in Parkinson’s disease: In addition to above, there is loss of arm swinging on
walking. The patient takes increasingly rapid steps forward to maintain an upright
posture (Festinant gait).
what is steppage gait?
Paralysis of the dorsiflexors of the ankle results in a “drop-foot”. The patient flexes the
knee and lifts the foot high to clear the toes from the ground. As it is returned to the
ground, there is a loud slapping noise.
Unilateral drop-foot suggests a common peroneal nerve palsy or spinal lesion.
Bilateral suggests generalised polyneuropathy.
what is ataxic gait?
This is a wide based gait. The feet are planted wide apart and patient
sways to one or both sides while walking. Attempting to walk heel-to-toe makes ataxic
gait more pronounced.
what is the MRC power grading?
5/5 = movement against gravity with full power against resistance
• 4/5 = movement against gravity with reduced power against resistance. Grades 4-, 4 and
4+ indicate reduced power but the presence of movement against slight, moderate and
strong resistance respectively.
• 3/5 = movement against gravity only without applied resistance
• 2/5 = muscle contraction with active movement only when gravity is eliminated
• 1/5 = flicker of muscle contraction seen, no movement
• 0/5 =no muscle contraction
what is rinnes test?
The vibrating tuning fork (512Hz) is held on the mastoid until the sound is no
longer heard. It is then held near the external acoustic meatus and the sound should continue
to be heard. In conductive hearing loss, bone conduction is better than air conduction and the
sound is not heard at the external acoustic meatus. In sensorineural hearing loss, both air and
bone conduction are decreased by a similar amount.
Rinne’s test (alternative method): The vibrating tuning fork is held on the mastoid then
immediately moved to the external acoustic meatus, whence, if conduction is normal it should
sound louder at the external acoustic meatus. If the sound is louder when the tuning fork is on
the mastoid, this indicates conductive hearing loss. In sensorineural hearing loss, both air and
bone conduction are decreased by a similar amount
what is webbers test?
A vibrating tuning fork (512Hz) is held against the forehead in the midline. The
vibrations are normally perceived equally in both ears because bone conduction is equal. In
conductive hearing loss, the sound is louder in the abnormal ear than in the normal ear. In
sensorineural hearing loss, the sound appears louder in the normal ear. The sensitivity of the
test can be increased by having the patient block their external ear canals with their index
fingers.
how can cerebellar dysfunction be assessed for?
Speech – assess for dysarthria by asking the patient to say repeating letters e.g.
“C,C,C,C” or “L,L,L,L” or tongue twisters e.g. “British Constitution” or “Baby
Hippopotamus”.
• Intention tremor and dysmetria (past-pointing = pointing beyond the examiners finger
in the finger-nose test)
• Nystagmus - coarse and slow; most noticeable on looking toward the side of the lesion
• Dysdiadochokinesis = difficulty controlling the rate, rhythm and force of movement. The
patient is abnormally slow and uncoordinated when attempting rapid hand movements,
e.g. alternately tapping the palm and dorsum of the right hand onto the back of the left
hand quickly and vice versa
• Ataxia (Lesions of the vermis cause truncal ataxia, lesions of the cerebellar
hemispheres cause ipsilateral limb ataxia)
• Stance: Wide based stance- Stand with feet wide apart.
• Gait- Inability to do heel to toe test
