Neuro Exam Flashcards
1
Q
What does A&O x3 mean
A
- Patient is alert and orientated to person, place, and time
2
Q
Define the levels of alertness
A
- Alertness: pt responds appropriately, opens eyes, respond fully/appropriately to stimuli
- Lethargy: pt appears drowsy, can open eyes, respond to examiner but falls asleep easily
- Obtundation: pt can open eyes/look at examiner but responds slowly & is confused
- Stupor: pt can be aroused from sleep only with painful stimuli, verbal responses are slow or absent
- Coma: state of unconsciousness from which can not be aroused; no response to external stimuli
- Unresponsive wakefulness syndrome (AKA vegetative state): return of sleep/wake cycles, normalization of HR/BP/respiration/digestion, & lack of cognitive responsiveness
- Minimally conscious state (MCS): severely altered consciousness with minimal but definite evidence of self or environmental awareness
3
Q
Define persistent vegetative state
A
- State lasting >1 yr for traumatic brain injury (TBI) and >3 mo for anoxic brain injury
4
Q
Describe the Glascow Coma Scale (GCS)
A
- Relates consciousness to 3 elements of response: eye opening, motor response, & verbal response
- Score ranges from 3-15: severe brain injury = 1-8; moderate brain injury = 9-12; minor brain injury = 13-15
5
Q
Describe the coma recovery scale-revised
A
- Examines multiple domains including auditory, visual, motor, verbal, communication, & arousal
- Includes brain stem reflexes such as pupillary light reflex, corneal blink reflex, spontaneous eye movements, oculocephalic reflex, & postural response
- Recommended for moderate to sever TBI and stroke
6
Q
How would you assess memory
A
- Immediate recall: name 3 items previously presented after a brief interval (5 mins)
- Recent memory: recall of recent event (what did you have for breakfast)
- Remote memory: recall of past events (where were you born)
7
Q
What are the different kinds of attention and how to assess them
A
- Attention span: ability to recall 7 digits in order presented
- Sustained attention: ability to attend to task without redirection
- Divided attention: ability to shift attention from one task to another
- Focused attention: ability to stay on task in presence of distractors
- Ability to follow commands
8
Q
Describe the mini-mental state examination (MMSE)
A
- Screening for cognitive dysfunction
- Looks at orientation, registration, attention & calculation, recall and language
- Max score of 30; 21-24 = mild; 16-20 =-4 moderate; ≤15 = severe impairment
9
Q
Describe the scoring of Rancho Los Amigos levels of cognitive function (LOCF)
A
- Assess cognitive recovery from TBI
- (1) no response
- (2/3) decreased response levels
- (4/5/6) confused levels
- (7/8) appropriate
10
Q
Define nonfluent aphasia/Broca’s aphasia/expressive aphasia
A
- Central language disorder in which speech is typically awkward, restricted, interrupted, and produced with effort
- Result of lesion in 3rd frontal convolution of left hemisphere
11
Q
Define verbal apraxia
A
- Impairment of volitional articulatory control secondary to a cortical, dominant hemisphere lesion
12
Q
Define dysarthria
A
- Impairment of speech production resulting from damage to the central or peripheral nervous system
- Causes weakness, paralysis, or incoordination of the motor-speech system
13
Q
Define fluent aphasia/Wernicke’s/receptive aphasia
A
- Examines comprehension
- Central language disorder in which spontaneous speech is preserved & flows smoothly while auditory comprehension is impaired
- Result of lesion in posterior 1st temporal gyrus of left hemisphere
14
Q
Define global aphasia
A
- Examine for marked impairments in comprehension and production of language
15
Q
Define conduction/association aphasia
A
- Result of damage to the arcuate fasciculus that connect Wernicke’s and Broca’s areas
- Causes word finding issues & problems with repeating phrases
16
Q
Normal vital responses to exercise
A
- HR increases in direct proportion to intensity of exercise
- SBP increases while DBP remains the same or slightly decreases
17
Q
Define Cheyne-Strokes respiration
A
- Period of apnea lasting 10-60 secs followed by gradually increasing depth and frequency of respirations
- Accompanies depression of frontal lobe and diencephalic dysfunction
18
Q
Define hyperventilation
A
- Increased rate and depth of respirations
- Accompanies dysfunction of lower midbrain & pons
19
Q
Define apneustic breathing
A
- Abnormal respiration marked by prolonged inspiration
- Accompanies damage to upper pons
20
Q
What might an elevation in temperature indicate
A
- May indicate infection, damage to hypothalamus or brainstem
21
Q
Signs and symptoms of meningeal irritation/brain infection
A
- Impaired neck mobility: Kernig’s sign and Brudzinski’s sign
- Irritability, visual discomfort with bright light
- Altered level of consciousness
- Severe HA, nausea, and vomiting
- Altered vital signs, high fever
- Generalized weakness
22
Q
Signs and symptoms of increased intracranial pressure (ICP)/cerebral edema and brain herniation
A
- Altered level of consciousness
- Altered vital signs: increased SBP, widening pulse pressure & bradycardia, irregular respirations (bradypnea = <12 breaths per min), elevated temperature
- HA
- Vomiting secondary to irritation of vagal nuclei (CN X)
- Pupillary changes (CN III signs)
- Papilledema at entrance to eye
- Progressive impairment of motor function
- seizure activity
23
Q
How to assess sensation
A
- Test superficial and proprioceptive sensations first: pain, discriminate touch, vibration, & proprioception
- Test combined sensations after determining superficial & proprioceptive touch is intact: apply stimulus in random/unpredictable order and avoid summation
24
Q
What are the combined cortical sensations
A
- Stereognosis: ability to identify familiar objects placed in hand
- Tactile localization: ability to identify location of a touch stimulus on the body
- Two-point discrimination: ability to recognize one or two blunt points applied to the skin simultaneously
- Barognosis: ability to identify similar size/shaped objects placed in hand with different gradations of weight
- Graphesthesia: ability to identify numbers, letters, or symbols traced on skin
- Bilateral simultaneous stimulation: ability to identify simultaneous touch on the two sides/segments of the body
25
How is screening for loss of protective sensation typically examined
- Typically examined with monofilaments (5.07 for DM/foot) and/or the ability to detect sharp from dull
26
Define homonymous hemianopsia
- Loss of half of visual field in each eye
- Contralateral to the side of a cerebral hemisphere lesion
27
Define bitemporal hemianopsia
- Loss of outer half of both the right and left visual field resulting in a loss of peripheral vision
- Occurs with damage at the optic chiasm
28
Define anosognosia
- Severe denial, neglect for lack of awareness of severity of condition
- Determine whether patient shows severe impairments in neglect & body scheme
29
Define body scheme disorder (somatognosia)
- Have patient identify body parts or their relationship to each other
30
How to examine for spatial relations syndrome
- Figure-ground discrimination: pick out an object from an array of objects (brake on wheelchair)
- Form constancy: pick object out of similarly shaped but different sized objects (large box out of multiple boxes)
- Spatial relations: duplicate pattern of 2-3 blocks
- Position in space: demonstrate different limb positions (put arm overhead)
- Topographical disorientation: determine if patient can navigate a familiar route on their own
- Depth & distance imperceptions: can pt judge depth/distance (stair navigation)
- Vertical disorientation: can pt accurately identify when something is upright
31
Define agnosia
- Inability to recognize familiar objects with one sensory modality while retaining ability to recognize same object with other sensory modalities
-Doesn't recognize object by sight but recognizes it by sound
32
Define apraxia
- Inability to perform voluntary, learned movements in the absence of loss of sensation, strength, coordination, attention, or comprehension
- Correlates with damage to the pre lateral frontal cortex & somatosensory association cortex
33
Define ideomotor and ideational apraxia
- Ideomotor: pt cannot perform the task on command but can do the task when left on own
- Ideational: pt cannot perform the task at all, either on command or on own
34
Signs of spastic hypertonia
- Clasp knife response: marked resistance to PROM suddenly gives way
- Clonus: maintained stretch stimulus produces a cyclical, spasmodic contraction
- Hyperactive cutaneous reflexes/positive Babinski's sign: DF of great toe with fanning of other toes ins response to stroking up the lateral side of the sole of the foot
- Hyperreflexia: increased deep tendon reflexes (DTRs)
35
Is flaccidity seen in UMN lesions
- Seen initially after suprasegmental/UMN lesions (brief period of spinal shock in SCI, cerebral shock in stroke)
- Decreased or no resistance to PROM
- After brief period then become spastic
36
Grading for modified Ashworth scale for spasticity
- (0) no increase in muscle tone
- (1) slight increase in tone, minimal resistance at end of ROM
- (1+) slight increase in tone, minimal resistance though less than half of ROM
- (2) more marked increase in tone, through most of ROM, affected part easily moved
- (3): considerable increase in tone, passive movement difficult
- (4): affected part rigid in flexion or extension
37
Difference between rigidity and spasticity
- Spasticity is velocity dependent
- Rigidity is increased resistance to PROM that is independent of the velocity of movement
38
Describe cogwheel versus lead pipe rigidity
- Lead pipe: uniform throughout the range
- Cogwheel: interrupted by a series of jerks
39
Describe decerebrate rigidity/posturing
- Seen in comatose pts with brainstem lesions b/w the superior colliculus & the vestibular nucleus
- Results in increased tone & sustained posturing in rigid extension of all 4 limbs & trunk/neck
40
Describe decorticate rigidity/posturing
- Seen in comatose pts with lesions above the superior colliculus
- Results in increased tone & sustained posturing of upper limbs in flexion & the lower limbs in extension
41
Signs of UMN lesiosn
- Hypertonia
- Spasticity
- Hyperreflexia, clonus
- Babinski's sign and Hoffman's sign
- Muscle spasms
42
Signs of LMN lesions
- Hypotonia, flaccidity
- Hyporeflexia
- Fasciculations (muscle twitching)
- Muscle atrophy
43
Describe the different types of reflexes
- DTRs: normally occurring reflexes in response to stretch of muscle
- Superficial cutaneous reflexes: normally occurring reflexes in repose to noxious stimulus (light scratch) applied to skin
- Primitive spinal reflex: Babinski's sign
- Midbrain/cortical reactions: protective extension, optical righting
44
Extrapyramidal disorders/basal ganglia dysfunction could have the presence of what involuntary movements
- Tics: spasmodic contractions of specific muscles, commonly involving face, head, neck, or shoulder
- Chorea: relatively quick twitches or "dancing" movements
- Athetosis: slow, irregular, twisting, sinuous movements, occurring especially in UEs
- Tremor: continuous quivering movements; rhythmic, oscillatory movement observed at rest
- Myoclonus: single, quick jerk
45
Define intention tremors
- Seen in cerebellar disorders
- Occurs when voluntary movement is attempted
46
Difference between passive and active restraint with strength testing
- Passive: soft tissue changes restrict ability to move (contractures)
- Active: spastic muscles restrict ability to move
47
Clinical issues with strength testing in PNS, LMN lesions
- Myopathies: typically see proximal weakness of extremities
- Neuropathies: typically see distal weakness of extremities
- Myasthenia gravis: produces decremental strength losses that are more pronounced with repetitive testing
48
Standardized tests and measures for fine motor coordination
- Jebsen-Taylor Hand Function Test
- Minnesota Rate of Manipulation Test
- Purdue Pegboard
49
Define dyssnergia
- Impaired ability to associate muscles together for complex movement
50
Define dysmetria
- Impaired ability to judge the distance or range of movement
51
Define dysdiadochokinesia
- Impaired ability to perform rapid alternating movements (RAM)
52
What are the 3 systems that play a part in balance control
- Visual system: visual acuity, depth perception
- Somatosensory system:proprioception, cutaneous sensation
- Vestibular system: observe balance with changes in head position/movement
53
What are the 6 conditions of the sensory organization test (SOT)
- 1: eyes open, stable surface
- 2: eyes closed, stable surface
- 3: visual conflict, stable surface
- 4: eyes open, moving surface
- 5: eyes closed, moving surface
- 6: visual conflict, moving surface
54
What is the grading scale for postural sway
- Scaled from 1 being minimal sway to 4 being a fall
55
Describe the clinical test for sensory interaction in balance (CTSIB)
- Tests the same 6 conditions as the sensory organization test (COT) but uses a medium-density foam instead of a moving platform
56
Describe the modified CTSIB
- Assesses balance but only in 4 conditions involving eyes open versus eyes closed and on stable ground versus foam
57
Define static, dynamic, versus functional stability limits/balance
- Static: ability to maintain COM in varied stance when BOS does not change
- Dynamic: ability to exert control of COM when BOS is changing
- Functional stability limits: ability to move COM as far as possible in mediolateral/anteroposterior direction within BOS
58
Which direction do patients push in Pusher's syndrome
- They push towards their weak side
59
What are the different postural strategies for maintaining balance
- Ankle: ankle muscles & leg/foot proprioception utilized to maintain balance
- Hip: hip & lower trunk muscles maintain balance by shifting COM using hip motions (flexion/extension)
- Stepping: rapid step(s) taken to realign COM within BOS
- Suspensory: bending the knees to lower the COG (center of gravity)
60
Difference between anticipatory and reactive postural control/balance
- Anticipatory: ability to shift COM before a specific voluntary movement
- Reactive: response to external perturbations & ability to bring COM back within BOS by use of postural strategies
61
Define perturbations
- Can include force against the COM (push/pull) or displacement of the BOS (using a moveable surface such as a platform, ball, or equilibrium board)
62
Describe the functional balance grades
- Normal: ability to maintain steady balance w/o hand hold support; accepts max challenge & can shift weight easily at full ROM
- Good: ability to maintain balance w/o hand hold support, limit postural sway; accepts moderate challenge; can pick something off the floor
- Fair: ability to maintain balance with hand hold support, may require occasional min A; accepts minimal challenge, can maintain balance while turning head
- Poor: require hand hold support & mod-max A; unable to accept challenge
- Absent: unable to maintain balance
63
Define ataxia
- Wide based gait with uncoordinated movements
- Typically improved with looking down in polyneuropathies
64
Define hemiplegic gait
- Gait is altered following stroke
- Gait is typically slow & asymmetrical with decreased stance time & push off on stroke-affected side
- Stroke affected side UE and LE move as a unit rather than with a dissociating arm swing from the LE on forward progression
65
Define festinating/Parkinson gait
- Characterized by freezing with initiation/termination and short, rapid steps once gait starts
66
Define myopathic gait
- Pelvic girdle and proximal muscle weakness results in hyperlordosis & compensated Tredenlenburg on weight bearing limb
67
Advantages and disadvantages of a head CT
- Advantages: Take minimal time, helpful following trauma/hemorrhagic stroke, & good visualization of osseous tissue & larger cortical lesions
- Disadvantages: Limited visualization of small/ischemic lesions, & pt has exposure to radiation
68
How soon should TPA (clot busting drug) be administered following a non-hemorrhagic stroke
- Within 3-4 1/2 hours of thromboembolic stroke
69
Head MRI is the primary method of examination for what pathologies
- Tumors
- Demyelination
- Vascular abnormalities
70
Advantages and disadvantages of a head MRI
- Advantages: superior visualization of almost all tissue & no exposure to radiation
- Disadvantages: cost, time, & movement artifact if patient moves
71
Define a PET scan (postion emission tomography)
- Neuroimaging technique in which radioisotopes are inhaled or injected and emissions are measured with a gamma ray detector system
72
Advantages and disadvantages of a PET scan
- Advantages: allows physiological mapping for biochemical analysis, tool for imaging cerebral blood flow and brain metabolism to assist in screening/Dx of tumors, dementia, stroke, & seizure
- Disadvantages: lacks detailed resolution as compared to CT/MRI; less accurate in detecting small or slow growing tumors; radiation exposure
73
Describe a diffuse tensor imaging (DTI)
- Form of MRI
- Allows visualization of axons and pathways
- Advantages: useful fro imaging mild TBI & assessing disruption of association/projection fibers, no radiation exposure
- Disadvantages: cost and processing time of images
74
Advantages and disadvantages of a functional MRI
- Looks at hemodynamics/changes in deoxygenated hemoglobin
- Advantages: provides good spatial resolution to identify active areas of the cortex
- Disadvantages: delayed (3-5 secs) temporal resolution making it difficult to directly relate timing of events
75
Advantages and disadvantages of a carotid.vertebral artery doppler US
- A: useful for imaging lumen or carotid/vertebral arteries to analyze flow & detect plaques in arteries; low cost; take minimal time
- D: limited visualization of structures surrounding the arteries/veins
76
Define nerve conduction velocity
- Distance between/w 2 points divided by the difference between.w the corresponding latencies, expressed as meters/second (m/s)
77
When is prolonged distal latencies and decreased conduction velocities seen
- Seen in peripheral neuropathies characterized by demyelination
78
When is slowed conduction velocities seen
- Seen with focal compression/disease of longer segments of peripheral nerve
79
When is reduced amplitudes seen
- Result of damage to axons & typically seen in more chronic and/or moderate to severe compression neuropathies, radiculopathies, or polyneuropathies that target axons
80
What does EMG (electromyography) detect
- Detects electrical activity arising from muscles during needle insertion, resting, minimal and maximal muscle recruitment
81
What EMG sign is a hallmark of denervated or diseased muscles
- At rest the muscle should be quiet
- Spontaneous EMG activity at rest is a hallmark sign of denervated or diseased muscles
82
When do abnormal spontaneous EMG activity typically occur
- Typically occur 7-21 days after peripheral nerve injury/compression & correlates with Wallerian degeneration
83
What is an electroencephalography (EEG)
- Measures electrical activity of the brain
- Specific wave forms are analyzed & correlated to normal, abnormal, or sleep cycles
- Provides key info on the timing & firing (temporal resolution) or neurons in the brain
84
Purposes of a lumbar puncture
- Insertion of spinal needle below the level of L1-L2
- Withdraw CSF for chemical analysis & cytological exam
- Measure intracranial pressures & spinal fluid dynamics
- Injection of contrast medium for radiological exam
- Injection of therapeutic agents
85
Complications of a lumbar puncture
- Severe HA caused by CSF leakage (relieved by lying down)
- Infection
- Epidural hematoma
- Uncal herniation
86
Pathological CSF findings
- Increased pressure occurs with intracranial tumors, abscesses, meningitis, inflammatory processes, subarachnoid hemorrhage, cerebral edema, & thrombosis of venous sinuses
- Decreased pressure occurs with leaking CSF, subarachnoid block circulatory collapse, severe dehydration
- Changes in color/appearance
- Elevated proteins may indicate tumors or inflammation
- Elevated CSF specific protein (oligoclonal bands) seen in CNS inflammatory diseases (eg. MS)
