Neuro A&P (Lauren's Part slide 68-132 🌭) Flashcards
Where is the lesion:
aphasia
Neglect (can’t attend to one side of body)
Hemianopia
UMN hemiparesis
Hemisensory of face and arm vs the leg
Cortex
Where is the lesion:
Dense hemiplegia (face, arm, and leg all equally affected)
Abnormal movements (chorea, ball is, tremor, cogwheeling)
Subcortical structures: Internal Capsule and Basal Ganglia
Where is the lesion:
Truncal ataxia and dysmetria
Midline cerebellum
Where is the lesion:
Limb ataxia and dysmetria
Hemisphere of cerebellum
Where is the lesion:
Ipsilateral CN palsies
Contralateral body deficits
“Crossed signs”
Brainstem
Where is the lesion:
Paraparesis
Bowel and Bladder involvement (rectal tone)**
Sensory level
Saddle anesthesia
spinal cord
Your patient has bilateral lower extremity weakness and bowel and bladder tone loss. What do you need to do immediately?
Give dexamethasone.
Cauda equina syndrome
If the test question says “Fasciculations” what is the answer
Lower motor neuron
Do lower motor neurons have any sensory function?
NO. Motor control only
Where is the lesion:
Fasciculation
No sensory involvement
Lower motor neuron
What are fasciculations?
Wiggly tongue
Wiggly things under the skin
Do peripheral nerves have motor and sensory?
Yes
Where is the lesion:
Stocking glove weakness and sensory loss
Diminished reflexes
Peripheral nerve
What is fatigability ?
Your muscles perform the task at first just fine, but they get tired right away if you keep doing it
If you start brushing your teeth but you cant finish because your muscles are too tired, what is that called?
Fatigability
If you see “Fatigability” in a test quesstion, what is the answer?
NMJ (neuromuscular junction)
Where is the lesion:
Fatigability
No sensory involvement
Normal DTRs
NMJ
Where is the lesion:
Proximal weakness
Symmetric
No sensory involvemnt
Muscle
What is the “setting” of a patient’s presentation?
Patient’s age and race
What is the “time course” of a patient’s presentation?
The onset and course
Ex: acute, subacute, chronic, progressive, stepwise, stable
Once you localize the lesion, you need to do VITAMIN CDE to come up with a list of differentials for what could have caused the lesion.
What does VITAMIN CDE stand for?
Vascular
Inflammatory
Trauma
Autoimmune
Metabolic
Infectious
Neoplastic
Congenital
Drugs
Epilepsy/seizures
(You would come up with Vascular things that could have caused a lesion. Then come up with Inflammatory things that could have caused it, etc)
What are the steps of a neurological examination?
Mental status (alert, coma, etc)
Neck/spine
Cranial nerves
Motor exam
Sensory exam
Reflexes
Coordination
Station and gait
Instead of describing your patient’s level of arousal as “stuporous” or “obtunded” etc, what should you do instead?
Just describe them.
“The patient opens eyes and turns to voice but is mute and obeys no verbal commands”
What are you looking for on the neck/spine part of the neuro exam?
Inspection
Auscultation
Nuchal rigidity
What are all the cranial nerves in order?
I forgot too
I. Olfactory
II. Optic
III. Oculomotor
IV. Trochlear
V. Trigeminal
VI. Abducens
VII. Facial
VIII. Vestibulocochlear
IX. Glossopharyngeal
X. Vagus
XI. Spinal accessory
XII. Hypoglossal
What is your favorite mnemonic to remember the cranial nerves in order. Here is mine
Oh Oh Oh To Touch And Feel Virgin Girls’ Vaginas And Hymens
What do you do to test cranial nerve II (Optic)
Visual acuity (just ask them to look at the clock or a Kleenex box)
Color vision (especially RED DESATURATION)
Visual fields
Fundoscopic exam
Pupils
What is red desaturation?
If someone is going to lose their color vision, red is going to be the color that usually is lost first.
She suggests you carry around a pen with a red cap and ask them if it looks more red in one eye vs the other
What is the fancy name for tunnel vision (losing peripheral vision)
Bitemporal hemianopia
What causes bitemporal hemianopia?
Pituitary adenoma
If someone has increased ICP, what will you see when you do a fundoscopic exam?
Papilledema
Emergency! Their brainstem could herniate
When you are doing the pupillary reflex, which cranial nerve receives the info from the light, and which one constricts the pupils?
Sees the light: CN II
Constricts the pupil: CN III
If you shine a light in someone’s left eye, and both pupils constrict, what can you assume about their cranial nerves?
Left CN II is intact
Right AND Left CN III are intact
(Normal response)
If you shine a light in someone’s Right eye, and neither pupil constricts, what can you assume about their cranial nerves?
Right CN II doesnt work
can’t say anything about CN III on either side
(In on II, out on III)
If someone has complete paralysis of their eyes and numbness on the top and middle part of their face, what is the problem
Something is wrong in the CAVERNOUS SINUS ***
What does CN V do?
Sensation to face
Muscles of mastication
Sensory limb of the corneal reflex (feeling the Q tip on the cornea)
When you do the corneal reflex test (touching their eyeball with a Q tip to see if they blink), which cranial nerves are you testing?
CN V: detects the Q tip
CN VII: blinks
Which cranial nerve closes your eyes
CN VII
What cranial nerve keeps the eyelids open
CN III
Which cranial nerve is damaged if you have PTOSIS (lack of eyelid opening)
CN III
What cranial nerve is damaged if you can not close your eyelids
CN VII
What is the vestibulo-ocular reflex?
Head rotates to right, eyes move to the left
Which cranial nerves are tested in the vestibulo-ocular reflex?
CN VIII (detects the Head movement)
CN VI and III move the eyes
What cranial nerves are tested with the gag reflex?
CN IX
CN X
(In on 9 out on 10)
You’re doing the vestibulo-ocular reflex test and you turn the patients head to the right, and his eyes follow.
Abnormal or normal?
Abnormal
BRAINSTEM DAMAGE
How do you test CN XI?
Sternocleidomastoid (head turning)
Trapezius (shoulder shrug)
If CN XII is damaged on the RIGHT, which side will your tongue deviate towards when you stick out your tongues
To the RIGHT
“LICK YOUR WOUNDS”
Which one is velocity dependent:
spasticity or rigidity
Spasticity
If someone has spasticity, where is the lesion?
UMN lesion
If someone has rigidity, where is the lesion?
Basal ganglia
I think thats what slide 95 means
When doing strength testing, do you start distally or proximally
Proximal
Which nerve roots:
Biceps reflex
C5, C6
Which nerve root:
Brachioradialis reflex
C6
Which nerve root:
Triceps reflex
C7
Which nerve root:
Patellar reflex
L4
Which nerve root:
Achilles’ tendon reflex
S1
Where is the lesion:
POSITIVE babinski sign
UMN
What is a positive babinski sign?
When you stroke the bottom of their foot their big toe point up
When you do the sensory exam, do you start distally or proximally?
Distal to proximal
What is dysmetria?
Inability to judge distance. Causes you to overshoot/undershoot when you do finger to nose test
What tests can you do to test coordination?
Finger to nose
Heel-knee-heel
Thumb tapping/ Toe tapping
Rapid alternating movements
Upper Motor Neuron or Lower motor neuron:
Spastic weakness
Upper motor neuron
Upper Motor Neuron or Lower motor neuron:
Hyper-reflexia
Upper motor neuron
Upper Motor Neuron or Lower motor neuron:
(+) Babinski
Upper Motor Neuron
Upper Motor Neuron or Lower motor neuron:
Flaccid weakness
Lower
Upper Motor Neuron or Lower motor neuron:
Hypo-reflexia
Lower
Upper Motor Neuron or Lower motor neuron:
Atrophy
Lower
Upper Motor Neuron or Lower motor neuron:
Fasciculations
Lower
Where is the lesion:
Face and arm are affected more than the leg
In the cortex, supplied by the Middle Cerebral Artery
Where is the lesion:
Leg is affected more than arm/face
In the cortex, supplied by the anterior cerebral artery
Where is the lesion:
Aphasia (cant talk)
Cortex
Where is the lesion:
Apraxia (can’t plan movements. Putting on a jacket or using scissors is hard)
Cortex
Where is the lesion:
Agnosia (unaware of deficits, unable to process sensory information)
Cortex
Where is the lesion:
DENSE unilateral motor or sensory deficit
Subcortical
Where is the lesion:
Face/arm and leg are equally affected
Subcortical
Where is the lesion:
Movement disorders
Subcortical
Aphasia
Cortex
⭐️⭐️⭐️⭐️
Neglect
Cortex
⭐️⭐️⭐️⭐️
Dense hemiplegia
Subcortical structures: internal capsule and basal ganglia
Chorea, Ballism, Tremor, Cogwheeling
Subcortical structures: Internal capsule and basal ganglia
Face/arm affected separately from leg
Cortex
Face/arm and leg equally affected
Subcortical structures: internal capsule and basal ganglia
Truncal vs limb ataxia and dysmetria
Cerebellum
⭐️⭐️⭐️⭐️
Cranial nerve palsies
Brainstem
“Crossed signs”
Brainstem
Bilateral leg involvement
Spinal cord
Bladder and bowel involvement
Spinal cord
Saddle anesthesia
Spinal cord
Sensory level
Spinal cord
Fasciculations
Motor neuron
⭐️⭐️⭐️⭐️
Distal weakness and sensory involvement in a stocking glove distribution
peripheral nerve
Areflexia or hyporeflexia
Peripheral nerve
Fatigability
NMJ
⭐️⭐️⭐️⭐️
Proximal weakness
Muscle
74 yr old male with vascular risk factors was brought into the ED with a sudden inability to speak and right sided weakness.
where is the lesion?
What is the setting?
What is the pathologic course?
Where: Left cortex (aphasia)
Setting: 74 yr old adult with vascular risk factors
Pathologic course: sudden
If you have a lesion in the RIGHT FRONTAL eye field, which way will your eyes look?
RIGHT
“Look at your lesion”
A 74 yr old male rolls in with sudden onset left sided weakness involving the face and arm. Language is preserved. He has a right gaze preference, and left sided neglect.
Where is the lesion
Right sided cortex in the MCA distribution
MCA does face and arm, ACA does leg
How would you figure out if a cortical lesion is in the ACA distribution or the MCA distribution.
ACA: leg is affected
MCA: face and arm are affected
Its probably a good idea to kind of look at homunculus man and get a general idea of where the body parts are
OK
What is left homonymous hemianopia?
Left half of visual field is lost in both eyes
75 yr old male rolls into the ED with sudden onset of right sided weakness.
On exam, language is normal, and he has a dense hemiparesis and hemisensory loss of the Face, arm, and leg.
Where is the lesion
Subcortical
LEFT side
68 yr old male with shaky hands and trouble walking that has worsened slowly over 4 years.
On exam, masked fancies, reduced eye blink, problems with smooth pursuit of eye movements, left greater than right hand tremor at rest, and shuffling gait.
What is the setting and pathologic course?
Where is the lesion?
Setting- 68yr old male
Course- progressive
Where: subcortical (Basal ganglia)
22 yr old male playing racquetball suddenly developed right neck pain, trouble swallowing (CN IX and X), right facial numbness and left body numbness.
Where is the lesion
Right brainstem
“Crossed signs”- left facial numbness and right body numbness
(Probably caused by a right vertebral artery dissection around the medulla)
Are all cranial nerve deficits an emergency?
Yes
65 yr old male with facial droop that has progressed over the last 2 days. He is unable to close his right eye, and has flattening of the nasolabial folds on the right side.
What’s wrong?
CN VII on the RIght
55 yr old ex-alcoholic present with progressive unsteady gait x 2 years. “My family still thinks I drink because I walk funny, but ive been sober for 5 years now”
On exam, he has spastic weakness, hyper-reflexia, absent proprioception and vibration up to the knees, a positive Romberg, and an ataxic gait.
Where is the lesion?
Dorsal column
(This is called subacute combined degeneration of the dorsal columns and lateral corticospinal tracts due to B12 deficiency)
Truncal ataxia and an ataxic gait
Central cerebellum
Bilateral leg weakness, sensory loss, and urinary retention and fecal incontinence. Absent rectal tone.
Spinal cord
Upper and lower motor neuron signs with diffuse Fasciculations is pathognomic for:
ALS
Mild spastic quadriparesis, quadriparesis, diffuse fasciculations, hyper-reflexia, and upgoing toes on plantar stimulation. No sensory loss.
What are the UMN signs:
What are the LMN signs:
What is this
UMN: spastic, hyperreflexia, babinski
LMN: fasciculations
This is pathognomic for ALS
39 year old male presents with 5 days of progressive bilateral buttock pain . The pain started suddenly after a coughing fit. Today he has developed numbness of his genitals, unable to urinate and constipation. On exam, saddle anesthesia and absent rectal tone.
Is this an emergency?
What do you need to do?
Where is the lesion?
This is a neurologic emergency
Give IV dexamathasone
Lesion is at end of spinal cord, either at conus medularis or cauda equina.
(Cough probably popped out a disc)
46 yr old female with Raynauds presents with worsening double vision, droopy eyelids and exercise intolerance over 6 months.
On exam, bilateral ptosis, unable to maintain sustained upgaze, develops double vision, and fatigable weakness.
Where is the lesion
NMJ.
This is myasthenia Travis
65 yr old diabetic with a hx of lung cancer and chemo has had numbness and tingling in bilateral feet that has worsened over 5 years.
On exam he has distal weakness in the legs, decreased reflexes, decreased sensation distally in both hands and feet, with downgoing toes to plantar stimulation 🧦🧤
Where is the lesion
Peripheral nerve
This is diabetic peripheral neuropathy
5 year old adopted boy just started school and he is having a lot of difficulty in PE class.
On exam, he has delayed speech, very large calves, proximal weakness, no sensory loss, waddling gait, and when you ask him to get up off the floor, he has to use his arms (Gower’s Sign)
Where is the lesion?
Muscle (“Proximal weakness”= muscle problem)
This is duchennes muscular dystrophy
