Neuro Exam Flashcards
What can cause a person to feel anxious out of proportion to their circumstances?
Drugs, low vitamin levels, psychiatric issues, endocrine problems
What can cause a person to have mood problems or feel excessively sad?
Physiologic issues, exposure to chronic pain or illness, endocrine problems, social isolation, poor nutrition, inadequate sleep
What can cause a person to have problems with memory?
Physiological decline, dementia, trauma, psychiatric issues, drug reactions, ischemia, tumors, infection
What can cause isomnia?
Secondary to multiple physical or psychiatric problems, poor sleeping environment, daytime napping, early bedtimes, excessive time spent awake in bed
What can cause problems with staying awake (hypersomnia)?
Sleep apnea, narcolepsy
What can cause sleep disruption disorders?
Often occurs when traveling between time zones and with shift workers on rotating schedules, particularly nighttime workers
What are sleep disruptive behaviors?
Sleep terror disorder, sleep walking
What can cause sleepwalking in adults?
An organic brain syndrome, reactions to drugs, psychological disorders, and certain medical conditions
Feelings of going to pass out (syncope) are typically caused by what?
A malfunction from any number of causes to the brainstem or bilateral cerebral hemispheres
Feelings of movement (vertigo) are typically caused by what?
A malfunction of the vestibular apparatus (ear or brainstem)
Feelings of imbalance (ataxia) are typically caused by what?
A malfunction of the cerebellum, eyes, ears, or proprioceptors
Muscular weakness or paralysis could be caused by what?
A neuro problem (like a problem with cortex, basal ganglia, brainstem, cord, or peripheral nerve) or a muscle/tendon problem
What could cause abnormal sensations?
Pressure or injury to a nerve, ischemia, neuropathy, electrolyte imbalance, vitamin deficiencies, or medication reactions
What components make up the mental status examination?
Appearance and behavior, speech and language, mood, thoughts and perceptions, and cognitive function
What things should you look for when examining the appearance and behavior component of the mental status examination?
Facial expression, relationship to people and things, manner and affect, dress, grooming, and personal hygiene, posture and motor behavior, and level of consciousness
When observing manner and affect, what might you observe?
Anger, hostility, suspiciousness, or evasiveness in patients with paranoia; flat affect in schizophrenia or dementia; elation and euphoria of mania
How would you determine a patient’s level of consciousness is “lethargic?”
Speak to the patient in a loud voice. A lethargic patient appears drowsy but opens the eyes and looks at you, responds to questions, and then falls asleep
How would you determine a patient is “obtunded?”
Shake the patient gently as if awakening a sleeper. An obtunded patient opens the eyes and looks at you but responds slowly and is somewhat confused.
How would you determine if a patient is “stuporous?”
Apply a painful stimulus. A stuporous patient arouses from sleep only after painful stimuli, but verbal responses are slow or absent
How would you determine if a patient is “comatose?”
Apply a repeated painful stimuli. A comatose patient remains unarousable with eyes closed.
What should you look for when observing the speech and language component of the mental status examination?
Quantity, quality, rate and volume
When examining the quality of a person’s speech, what are you observing?
Their articulation of words and fluency/variability/clarity
What are circumlocutions?
Phrases or sentences are substituted for a word the person can’t think of
What is paraphasias?
Words are malformed, wrong, or invented
What are different things you might observe when looking at the rate and volume of a person’s speech?
Slow speech associated with depression, accelerated, loud speech associated with mania
A defect in Broca’s area could cause what?
Non-fluent aphasia
A defect in Wernicke’s area could cause what?
Fluent aphasia
What should you look for when observing the mood component of the mental status examination?
Assess mood by exploring the patient’s perceptions of their mood, and if you suspect depression, assess its depth and any associated risk of suicide
What is circumstantiality
Speech characterized by indirection and delay in reaching the point because of unnecessary detail, although components of the description have a meaningful connection
What is derailment?
Speech in which a person shifts from one subject to others that are unrelated or related only obliquely without realizing that the subjects are not meaningfully connected
What is flight of ideas?
An almost continuous flow of accelerated speech in which a person changes abruptly from topic to topic
What are neologisms?
Invented or distorted words, or words with new and highly idiosyncratic meanings
What is incoherence?
Speech that is largely incomprehensible because of illogic, lack of meaningful connections, abrupt changes in topic, or disordered grammar or word use
What is blocking?
Sudden interruption of speech midsentence or before the completion of an idea
What is confabulation?
Fabrication of facts or events in response to questions, to fill in the gaps in an impaired memory
What is perseveration?
Persistent repetition of words or ideas
What is echolalia?
Repetition of the words or phrases of others
What is clanging?
Speech in which a person chooses a word on the basis of sound rather than meaning
What are compulsions?
Repetitive behaviors or mental acts that a person feels driven to perform in order to produce or prevent some future state of affairs
What are obsessions?
Recurrent, uncontrollable thoughts, images, or impulses that a person considers unacceptable and alien
What are phobias?
Persistent, irrational fears, accompanied by a compelling desire to avoid the stimulus
What are anxieties?
Apprehensions, fears, tensions, or uneasiness that may be focused or free-floatin
What are feelings of unreality?
A sense that things in the environment are strange, unreal, or remote
What are feelings of depersonalization?
A sense that one’s self is different, changed, or unreal, or has lost identity or become detached from one’s mind or body
What are delusions?
False, fixed, personal beliefs that are not shared by other members of the person’s culture
What are you looking for when you examine the thoughts and perceptions component of the mental status exam?
Variations or abnormalities in thought process, abnormalities of thought content, insight and judgement, and abstract thinking
How can you usually assess judgement?
By noting the patient’s responses to family situations, jobs, use of money, and interpersonal conflicts
A concrete response when asking a patient what people mean when they use a proverb can be a sign of what?
Mental disability, delirium, dementia, or just a function of limited education
What are you looking for when you examine the cognitive functions component of the mental status exam?
Orientation, attention, memory, calculating ability, and constructional ability
What does orientation include?
Time, place, person
How can you test attention?
Recite a series of digits and ask the patient to repeat the numbers back to you
If vision and motor ability are intact, what does poor constructional ability suggest?
Dementia or parietal lobe damage
According to the Glasgow Coma Scale, patients with what scores are considered to be in a coma?
Scores between 3-8
What are the two cardinal DON’Ts when examining comatose or stuporous patients?
Don’t dilate the pupils and don’t flex the neck
What is the pathophysiology of a toxic-metabolic coma?
Arousal centers are poisoned or critical substrates are depleted
What is the pathophysiology of a structural coma?
A lesion destroys or compresses brainstem arousal areas, either directly or secondary to more distant expanding mass lesions
What would you expect to see in pupil examination of a patient in a toxic-metabolic coma?
Equal size, reactive to light. If they are pinpoint from opiates or cholinergics, you may need a magnifying glass to see the reaction
What would you expect to see in pupil examination of a patient in a structural coma?
Unequal or unreactive to light (fixed)
What do midposition, fixed pupils suggest?
Midbrain compression
What is the difference in level of consciousness in a toxic-metabolic vs structural coma?
In toxic-metabolic, level of consciousness changes after pupils change, but it changes before pupils change in a structural coma
What are examples of causes of toxic-metabolic comas?
Uremia, hyperglycemia, alcohol, drugs, liver failure, hypothyroidism, hypoglycemia, anoxia, ischemia, meningitis, encephalitis, hyperthermia, hypothermia
What are examples of causes of a structural coma?
Epidural, subdural, or intracerebral hemorrhage; cerebral infarct or embolus; tumor, abscess; brainstem infarct, tumor, or hemorrhage; cerebellar infarct, hemorrhage, tumor, or abscess
Bilaterally fixed and dilated pupils may be caused by what?
Severe anoxia
One fixed and dilated pupil suggests what?
Herniation of the temporal lobe
What does decerebrate posture result from?
Damage to the upper brain stem
What does decerebrate posture look like?
Arms are adducted and extended with wrists pronated and fingers flexed. Legs are stiffly extended and feet are plantarflexed
What does decorticate posture result from?
Damage to one or both corticospinal tracts
What does decorticate posture look like?
Arms are adducted and flexed with wrists and fingers flexed on the chest. Legs are stiffly extended and internally rotated with feet plantarflexed
How would you test CN I?
Test the sense of smell by presenting the patient with familiar nonirritating odors
Loss of smell occurs with what conditions?
Sinus conditions, smoking, aging, and cocaine use
What is anisocoria?
A difference of more than 0.4mm in the diameter of one pupil compared to the other, seen in up to 38% of healthy individuals
What should you look for when testing CN II and III?
Inspect size and shape of the pupils, identify any nystagmus, look for ptosis, and test pupillary reactions to light
What is Horner’s syndrome?
Results when cervical sympathetic pathway from hypothalamus is interrupted, lesion may be central, preganglionic, or postganglionic and may be primary or secondary to another disorder. Symptoms include ptosis, miosis, anhydrosis, and/or hyperemia
What is nystagmus?
An involuntary jerking movement of the eye, named for the direction of the quick component
What is nystagmus seen in?
Cerebellar disease (increases with retinal fixation), vestibular disorders (decreases with retinal fixation), and internuclear ophthalmoplegia (often from stroke or MS)
What is ptosis?
Drooping of the upper eyelids
How would you test CN III, IV, and VI?
Test the extraocular movements in the six cardinal directions of gaze, look for loss of conjugate movements in any of the six directions (causes diplopia), and check near response
How would you test CN V?
Test motor function by palpating temporal and masseter muscles while the patient bites down, test sensory by having the patient close their eyes and test the forehead, cheeks, and jaw on each side for sensation, and test corneal reflex
How would you test CN VII?
Have the patient raise their eyebrows, from, and smile with their teeth
How would you test CN VIII?
Assess hearing with the whispered voice test
If hearing loss is present in a patient, what should you determine about the hearing loss?
Whether it is conductive (from impaired “air through ear” transmission) or sensorineural (from damage to cochlear branch of CN VIII)
How would you test CN IX and X?
Listen to the patient’s voice, ask the patient to say “ah” or yawn as you watch the soft palate, and test gag reflex
What could cause hoarseness?
Vocal cord paralysis
What could cause a nasal voice?
Paralysis of the palate
What would unilateral absence of the gag reflex suggest?
Either a lesion of CN IX (afferent) or CN X (efferent)
How would you test CN XI?
Test the trapezius by having the patient shrug against restriction, test the SCM by having the patient turn into your hand (against restriction)
How would you test CN XII?
Listen to the articulation of the patient’s words, inspect the patient’s tongue, then, with the tongue protruded, look for asymmetry, atrophy, or deviation from the midline
What are tremors?
Rhythmic oscillatory movements, which can be roughly subdivided into three groups: resting (static), postural, and intention
What are resting (static) tremors?
Tremors that are most prominent at rest and may disappear with voluntary movement, as seen in parkinsonism
What are postural tremors?
Appear when the affected part is actively maintaining a posture, as those cause by hyperthyroidism or anxiety and fatigue
What are intention tremors?
Appear with movement and often get worse as the target gets closer, as those caused by diseases of the cerebellum
What are tics?
Brief, repetitive, stereotyped, coordinated movements occurring at irregular intervals, such as those caused by Tourette’s or drugs
What is chorea?
Brief, rapid, jerky, irregular, and unpredictable movements that seldom repeat themselves, such as those caused by Syndenham’s chorea (with rheumatic fever) and Huntington’s disease
What are athetoid movements?
Slower movements that are more twisting and writhing than choreiform movements and have a larger amplitude, most commonly involving the face and distal extremities. Causes include cerebral palsy
What are dystonic movements?
Similar to athetoid movements, but often involve larger portions of the body, including the trunk. Causes include drugs like phenothiazines
What are oral-facial dyskinesias?
Rhythmic, repetitive, bizarre movements that chiefly involve the face, mouth, jaw, and tongue, such as those caused by a late complication of psychotropic drugs like phenothiazines
What is muscular atrophy?
Refers to a loss of muscle bulk, or wasting
What do fasciculations with atrophy and muscle weakness suggest?
Disease of the peripheral motor unit
What is hypertrophy?
An increase in bulk with proportionate strength
What is pseudohypertrophy?
An increase in bulk with diminished strength, which can be seen in Duchenne Muscular Dystrophy
What is muscle tone?
The slight residual tension of a normal muscle with an intact nerve supply when it is relaxed voluntarily
How can you best assess muscle tone?
By feeling the muscle’s resistance to passive stretch
What is muscle tone spasticity?
Velocity-dependent increased tone that worsens at the extremes of range
What is muscle tone rigidity?
Increased resistance throughout the range of movement in both directions, not rate-dependent
What does decreased resistance when testing muscle tone suggest?
Disease of the peripheral nervous system or the acute stages of spinal cord injury
What is paresis?
Impaired strength
What is paralysis or plegia?
Absence of strength
What is muscle weakness observed in?
Peripheral nerve disease, CNS disease, muscular abnormalities, and other things like malnutrition
What would you tell a patient to do if you were testing for pronator drift?
Stand for 20-30 seconds with both arms straight forward, palms up, and with eyes closed
What is pronator drift indicative of?
It is both sensitive and specific for a corticospinal tract lesion originating in the contralateral hemisphere
Coordination of muscle movements requires integration of what?
The motor system, the cerebellar system, the vestibular system, and the sensory system
What is dysdiadochokinesis?
The inability to follow a movement quickly by its opposite, and movements are slow, irregular, and clumsy. Occurs in cerebellar disease
What is an ataxic gait?
A gait that lacks coordination, with reeling and instability
What could ataxia be caused by?
Cerebellar disease, loss of position sense, or intoxication
What is tandem walking?
Walking heel-to-toe in a straight line, which can show an ataxia that was not previously obvious
When observing gait, what should you look for?
Posture, balance, swinging of the arms, and movement of the legs
What is a positive Romberg sign?
If, when told to stand with feet together and eyes open and then close both eyes for 30-60 seconds without support, the patient stands fairly well with eyes open but loses balance when the eyes are closed
Would a patient with cerebellar ataxia have a positive Romberg sign?
No, because they have difficulty standing with feet together whether the eyes are open or closed
What is hyperreflexia seen in?
CNS lesions along the descending corticospinal tract
What is hyporeflexia seen in?
Diseases of spinal nerve roots, spinal nerves, plexuses, or peripheral nerves
What is reinforcement?
A technique involving isometric contraction of other muscles for up to 10 seconds that may increase reflex activity, used when a patient’s reflexes are symmetrically diminished or absent
What can cause a positive Babinski response?
A CNS lesion in the corticospinal tract. It can also be seen in unconscious states from drug or alcohol intoxication or in the postictal period following a seizure
What is asterixis seen in?
Liver disease, hypercapnia, and metabolic encephalopathy
What types of sensation should you test to evaluate the sensory system?
Pain and temperature (spinothalamic tracts), position and vibration (posterior columns), light touch, and discriminative sensations
What is analgesia?
Absence of pain sensation
What is hypalgesia?
Decreased sensitivity to pain
What is hyperalgesia?
Increased sensitivity to pain
