neuro case histories Flashcards
where are upper motor neurons *
brain and spinal chord
where are lower motor neurons *
anterior horn cell, roots and plexuses to muscles
symptoms of upper motor neuron lesions *
REFLEXES - increased TONE - increased, spastic SENSATION POWER - reduced BABINSKI - extensor - when stroke foot toes curl upwards (should go down) WASTING - no FASCICULATION - no
symptoms of lower motor neuron lesions *
REFLEXES - reduced TONE - flacid SENSATION POWER - reduced BABINSKI - flexors or mute WASTING - yes FASCICULATION - yes
what can be inferred if neuro symptoms started occurring a year ago *
that the disease is slowly progressive
what can be inferred by the following symptoms - leg stiff drag feet cant carry things have appetite but losing weight slurred speech (dysarthria) sphincter function fine bilateral foot drop words grammatically correct tongue wastage swallow twice palate elevated poorly, gag reflex brisk, jaw jerk increased deep tendon reflexes brisk planter extensor superficial reflexes absent *
leg stiff - tone increased - upper motor neuron (umn)
drag feet - impaired gait - cerebellar or weak so cant lift leg properly
cant carry things - weak
have appetite but losing weight - problem is dysphagia - bulbar muscles not working correctly
slurred speech - bulbar muscles not working correctly
sphincter func - bowel and urinary func fine
bilateral foot drop - weakness of dorsiflexion = tripping
grammatically correct - doesn’t have dysphasia
tongue wastage - lower motor neuron (lmn)
swallow twice - weakness of muscles, wastage, exaggerated reflex
fasciculations - lmn
palate, gag and jaw jerk - umn
tendon reflexes - umn
planters - umn
superficial reflex - umn
anatomical part of nervous system effected - umn and lmn
what pathway is affected - corticospinal tract because no sensory involvement
why abdo reflex absent - that is seen in umn
significance of fasciculation - lmn
diagnosis - motor neuron disease
what is dysphasia *
substitute the wrong words
explain the 2 types of dysphasia *
receptive - pt cant understand what people are saying to them
expressive - understand what people are saying but you cant get words out
what are the deep tendon reflexes *
supinator biceps triceps knee ankle
what are superficial reflexes *
upper and lower abdominal reflexes
cremasteric reflex - in men
effect of umn on superficial reflexes *
they become absent
what are fasciculations *
involuntary abnormal contraction of all muscle fibres in a single motor unit and is random in time and place
how do fasciculations occur *
denervation leads to renervation by other neurons
effect is bigger than it should be
causes twitching and random firing
what is suggested by the following symptoms
- leg stiff
trips
leg jerk
r bicep and supinator reflex absent
tricep and finger jerk reflex exaggerated
which segment supplies the bicep, tricep and finger jerks
what is the expected ankle reflex
what is the expected plantar reflex
what is the diagnosis *
leg stiff - umn, spasticity trip - weakness/spasticity in leg - umn leg jerk - this is clonus - marker of spasticity - umn bicep and supinator reflex - lmn tricep and finger - umn
bicep - c5-6 tricep - c7 finger - c8-t1 ankle reflex - brisque plantar - extensor
diagnosis - disk prolapse that pushes on spinal cord at c5-6 and on root so have lmn effects at c5. below c5 all upper neurons are affected so have umn defects below
how can pain be interpreted *
it is localising
what is paraesthesiae *
unusual sensation
what is clonus *
rhythmic beating
what is rigidity *
as you bend the same amount of force is required thoughout and it applies the same amount of force back
what is spasticity *
more force you apply the more force is exerted back until it just gives
as move limb tone increases then suddenly gives
what can be interpreted from the following symptoms R arm is stiff even when arm is displaced slowly with both flexors and extensors involved R hand not working very well expressionless reflexes symettrical no weakness movements of r hand are slower than l increased tone in r leg
what symptoms are missing *
R arm stiff - rigidity
not weak and reflexes ok = not corticospinal tract
diagnosis - parkinsons
missing symptoms - tremor - because of problems with basal ganglia this is extrapyramidal
don’t blink
gait initiation failure - tilt forward to move their centre of gravity so that the fall triggers their walk, then they shuffle
micrographic handwriting
what is bradykinesia *
slow movement
how would you diagnose Parkinson’s *
DAT scan
variants of Parkinson’s disease *
idiopathic - lesions in nigro-striatal tract (strokes in same area have the same effect) lewy body disease MSAC MSA PSP
summarise the function of the first 10 cranial nerves *
cn1 smell
cn2 see - colour, field of vision, acuity,
cn3 eye movement, eyelid, pupil constriction
cn 4 superior oblique muscle of eye
cn5 jaw jerk, corneal sensation (reflex) and sensation to face
cn 6 - lateral rectus muscle
cn 7 - facial expression
cn 8 - hearing and balance
cn 9 and 10 - swallowing
where are the vertical and horizontal eye movement centres, what does this mean clinically *
centre of horizontal gaze - 6th nerve nuclei, in pons
vertical gaze - higher up - rostral interstitial nucleus of cajal
in different locations so can have damage to 1 without it affecting the other parts
where do the cranial nerves come off *
1 2 3 4 midbrain
5 6 7 8 pons
9 10 11 12 medulla
what can be interpreted from the following symptoms
- sudden double vision
ptosis of r eyelid
previous TIAs
conscious and not confused
R pupil deviated to r and down
R eye did not respond to caloric testing or in attempted convergance
pupillary responses intact
mild weakness in r arm and leg
deep tendon reflexes physiologic and symettrical in upper extremities, and increased in L lower extremity compared to R
L Babinski response
sensation normal
could articulate speech meaningfully
visual field full to confrontation
minor weakness in left corner of mouth when tried to grimace
palate elevated symettrically, corneal jaw jerk and gag reflexes are intact
tongue protruded on midline
shoulder shrug symettrical and of physiologic strength
mild weakness in l arm and leg, brisque reflex in l leg, plantor extensor, abdo reflex absent *
sudden - suggestive of vascular
ptosis - drooping of eyelid - could be horners, 3rd nerve palsy or myasthenia gravis
no dysarthria or dysphasia
pupil deviated to r and down - cn 6 and 4 working this movement is from superior oblique and lateral rectus
visual fields - cn 2 fine
pupillary reflex fine - this is surprising because this si part of the 3rd nerve function - happens because pupillomotor fibres to 3rd nerve run in discrete bundle along 3rd nerve not in nerve itself. stroke (medical 3rd nerve palsy) affect 3rd nerve = pupil dilation because no 3rd nerve controlled constriction. aneurism (surgical 3rd nerve palsy) damage motor fibres surrounding 3rd nerve but 3rd nerve is fine so still get pupil reflex
L mouth weakness - L facial nerve
palate, corneal, jaw jerk and gag - 5 8 9 10 11 12 ok
mild weakness in l arm and leg, brisque reflex in l leg, plantor extensor, abdo reflex absent - UMN in L
diagnosis - medical 3rd nerve palsy, l hemiparesis with umn symptoms, L facial nerve palsy
lesion is in the midbrain - oculomotor nerve here (cn3) affecting the ipsilateral side, and affecting contralateral corticospinal tract - fibres decussate further down
eitiology - stroke - because pupillary reflex
what is diplopia *
double vision
describe horners *
failure of sympathetic ns
have pupil constriction and enophthalmos
describe myasthenia gravis *
muscle disease with ach receptor causes fatigable weakness
what is a caloric test *
water injected into ear to stimulate the vestibular system
what can be determined from the following symptoms
weak R leg, R arm and L mouth and stiff R leg
high bp and ex smoker
dysarthria
cant move eye to L
increased tendon reflexes
*
weak R leg, R arm and L mouth and stiff R leg - umn
bp and smoker - vascular problem
dysarthria - cerebellar problem, hypoglossal problem with tongue, facial - half mouth not moving
cant move eye to l - problem with lateral rectus = 6th nerve palsy - 6th nerve nuclei is the centre for horizontal gaze
tone increased in R arm - umn r
tendon reflexes increased on r, normal on l - umn r
plantar extensor on r and plantar flexor on l - umn r
r upper extremity flexed, lower was extended - both resisted opposite movement - this is because of increased tone and means hemiparesis been around a long time because flexors stronger in upper limb, increased tone stronger in flexors in upper limbs and extensors in lower limbs. wrist bend down, elbow in and shoulder down. leg extension and plantar flexion stronger than leg flexion and dorsiflexion so leg straight
6 and 7 cn palsy on L hand side
upper motor neuron problem - spasiticity and weakness in R
lesion is in the pons
affects the pyramidal tract - contralateral hemiparesis
6th nuclei affected and facial nerve
what can be determined from the following symptoms - present with fall and imbalance
imbalance
headache
no neck trauma
father had vascular death young
poorly controlled dm
bruises on 1 foot
dysarthric
left beating nystagmus
L pupil smaller than R
diminished sensation to l side face and corneal reflex
L arm and leg ataxia, dysmetria, mild intention tremor
pinprick sensation was diminished in upper extremities on R*
imbalance - vestibulocochlear problem, brainstem or cerebellum (coordination)
headache - suggest haemorrhage
no neck trauma - if have neck trauma the layers of the arteries in neck could split and blood pools between the layers making lumen irregular = turbulent flow, if lumen blocked = stroke - but there is no trauma in this case
father death - family history of vascular problems
dm - retinopathy/neuropathy
bruises - maybe cant feel foot so it is weaker
dysarthric - problem with cerebellum, facial palsy, or tongue problem
L beating nystagmus - cerebellum not working properly
L pupil smaller than R - horner’s syndrome - no sympathetic stimulation
diminished sensation to l side face and corneal reflex- L trigeminal problem
L arm and leg ataxia, dysmetria, mild intention tremor - these are cerebellar signs
pinprick sensation - loss of pain reception on R - damage to spinothalamic tract is causing loss of pain reception on contralateral side
summary - balance - cerebellum problem, dysarthric - cerebellum, L beating nystagmus - cerebellum, horner’s - sns, loss of sensation to face and cornea - cn5, cerebellum signs, loss of pain sensation contralaterally - spinothalamic tract
diagnosis - lateral medullary syndrome - involve sns, trigeminal nerve, cerebellum and spinothalamic tract
describe ataxia *
clumsy arms and legs
cant control position and movement of limbs
describe dysmetria *
arm cant find place in space
it overshoots when you ask someone to lift arms up in front of them
describe intention tremor *
do finger-nose test
affected hand cant find nose without tremoring
what can be seen by asking a patient to rise their arms in front of them *
ataxia - affected arm drifts to 1 side
sensory athetosis - fingers look for place in space so drift to each other - happens when lost dorsal columns
weakness - arm drifts down
