Neuro Exam Flashcards

1
Q

What does A&O x3 mean

A
  • Patient is alert and orientated to person, place, and time
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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
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3
Q

Define persistent vegetative state

A
  • State lasting >1 yr for traumatic brain injury (TBI) and >3 mo for anoxic brain injury
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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
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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
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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)
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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
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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
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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
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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
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11
Q

Define verbal apraxia

A
  • Impairment of volitional articulatory control secondary to a cortical, dominant hemisphere lesion
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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
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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
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14
Q

Define global aphasia

A
  • Examine for marked impairments in comprehension and production of language
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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
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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
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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
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18
Q

Define hyperventilation

A
  • Increased rate and depth of respirations
  • Accompanies dysfunction of lower midbrain & pons
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19
Q

Define apneustic breathing

A
  • Abnormal respiration marked by prolonged inspiration
  • Accompanies damage to upper pons
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20
Q

What might an elevation in temperature indicate

A
  • May indicate infection, damage to hypothalamus or brainstem
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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
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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
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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
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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
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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)