Neuro exam PNS Flashcards
If a patient comes in with motor signs what are the 4 main pathologies?
UMN lesion (pyramidal tract and spinal chord)
LMN lesion (spinal chord nerves)
Cerebellar pathology
Basal ganglia pathology (ie Parkinsons)
Damage to which nerve causes carpal tunnel?
Median
What position should the patient be in for a upper limb exam?
45 degrees on couch or sitting with their legs off the couch
What position should the patient be in for a lower limb exam?
Lying on the couch 45 degrees
What may you see on general inspection for an upper limb exam?
Wheelchair Catheter (could be due to neurological cause) Muscle wasting Neurofibromas Ptosis
What acronym is used to remember how should should inspect a patient for an upper limb exam and what does it mean?
SWIFT
Scars
Wasting of muscles
Involuntary movements (chorea, myoclonus, tardive dyskinesia)
Fasciculations
Tremor (resting, intention tremor, postural tremor)
Also look for specific signs eg neurofibromas
Look at the face for hypomimia, ptosis, ophthalmoplegia
What is hypomimia and when is it seen?
Reduced facial expression often seen in Parkinson’s
How do you test for pronator drift?
Ask the patient to put their arm out in front of you with the palm up, close their eyes and get them to hold it there for 30 secs/ as long as they can
If a patients arm goes down slightly and pronates when testing for pronator drift where may their lesion be?
Right side (UMN lesion causing pronator drift)
What happens to upper limb and lower limb flexors and extensors in UMN lesion?
Upper limb: flexors are stronger than extensors (resulting in pronation of the arm)
Lower limb: extensors are stronger than flexors
What does pronator drift test for?
Upper motor neurone lesion
Where do you test for tone in the upper limb? How?
Shoulder
Elbow
Wrist
Ask them to be floppy, circumduction of shoulder, flexion/extension of elbow and flexion/extension of the wrist
What is the difference between spasticity and rigidity?
Spasticity is velocity dependant ie if you do the movement faster the hypertonia will reduce but rigidity is not velocity dependant so the hypertonia will remain
What type of rigidity is seen in the upper limb in Parkinsonism? Describe what it means
Cogwheel rigidity= everytime you attempt a movement it doesn’t work/ gets stuck
What are the ways to test for power in the upper limb?
Shoulder abduction Shoulder adduction Elbow flexion Elbow extension Wrist flexion Wrist extension Finger abduction Thumb abduction
How should you apply resistance when testing for power in the upper limb?
Use the same part of the arm the patient is using eg when testing for shoulder abduction use your whole arm as they are too but when testing for finger abduction only use your fingers as thats what they will use
How is power reported?
MRC= muscle power scale
Describe the MRC and what trick can be used to remember it?
0= no movement 1= flicker of movement 2= active movement (not against gravity) 3= active movement against gravity 4= active movement against gravity and resistance 5= normal power
If you remember that 3 is movement against gravity then you can work up and down to figure out the rest
What reflexes do you test for in the upper limb?
Biceps
Triceps
Supinator
How do you test for the biceps reflex?
Find the biceps tendon
Strike the tendon hammer onto YOUR finger
How do you test for the triceps reflex?
Find the triceps tendon
Strike the tendon hammer on the patients skin directly
How do you test for the patient’s supinator reflex?
Find the tendon and strike the tendon hammer onto YOUR finger
Observe the brachioradialis muscle
What track is responsible for light touch?
Mainly dorsal column
What track is responsible for pin prick/ pain?
Spinothalamic tract
What track is responsible for vibration?
Dorsal column
What track is responsible for proprioception?
Dorsal column
What signs are seen in Brown sequard syndrome and explain them? What is it?
Damage to half the spinal chord
You will see ipsilateral motor weakness and loss of vibration and proprioception
Contralateral loss of pain and temp
This is because the spinothalamic tract crosses at the level of the vertebra (so lesion in the spinal cord causes contralateral signs) but the dorsal column crosses at the level of the medulla (so lesion in the spinal cord has ipsilateral effects)
What is mononeuropathy?
Loss of sensation in the area a nerve applies eg radial nerve
What is radiculopathy?
Sensory loss in area supplied by the nerve root eg C5 dermatome
What sensory loss will occur when there is spinal cord damage?
Sensory loss at and below the level of involvement
What type of sensory loss will occur if there is a thalamic lesion?
Contralateral sensory loss
What type of sensory loss will occur if there is peripheral neuroapthy?
Symmetrical sensory loss ie glove and stocking
What typically gives glove and stocking sensory loss?
Diabetic neuropathy
Chronic alcohol use
How do you test for sensation in the upper limb?
Close their eyes and say yes when they can feel something
Touch C5, C6, C7, C8 and TI alternating between sharp end and blunt end or cotton wool
How do you test for vibration in the upper limb?
Use a 128 Hz tuning fork and vibrate it
Place it on the most distal bony prominence ie interphalangeal joint of the thumb and ask the patient to close their eyes
Stop the fork vibrating by touching it and ask the patient to tell you when it stops vibrating
What do you do if a patient is unable to identify when vibrations stop when testing for vibration in the upper limb?
Move the tuning fork up their arm and repeat ie from IPJ of thumb to wrist to elbow and see if they can tell at those joints
How do you test for proprioception in the upper limb?
First show the patient how you will move their thumb up and down with their eyes open and ask them to close their eyes and say when you move it up and down
When moving their thumb hold it on the SIDES
What should you do if a patient fails the test for proprioception?
Move up their limb ie go from thumb to wrist to elbow and see if they can identify proprioception there
What 2 tests are done for coordination in the upper limb?
Rapid alternating movement test
Finger nose test
What does the rapid alternating movement test look for when examining the upper limb?
Cerebellar pathology
Dysdiadokokinesia
Also seen in MS
How do you ask he patient to do the rapid alternating movement test?
Ask them to hold out their left hand palm up and then slap their right hand onto it, then turn the right hand over and slap it on and keep going as fast as they can
Then ask them to repeat with the hands the other way around
How do you do the finger nose test?
Ask the patient to touch their nose with their finger and then hold out your finger and ask them to touch their finger to yours. Get them to do this multiple times and move your finger around
What does the finger nose test look for? Explain it
Intention tremor- this is a tremor that gets worse as the patient approaches the object
How may a patient fail a finger nose test?
Intention tremor
Pass pointing- where they overshoot when trying to point to your finger
What pathology is a failed finger nose test suggestive of?
Ipsilateral cerebellar pathology (if tremor is only present on one hand)
Bilateral cerebellar pathology (if tremor is present on both hands)
What acronym is used to remember clinical signs a patient with cerebellar pathology may have?
DANISH Dysdiadochokinesia Ataxia Nystagmus Intention tremor Slurred speech (dysarthria) Hypotonia (heel/shin test)
What is nystagmus?
Flickering eye movements in one eye
What additional tests might you want to do for the PNS aside from upper and lower limb exam?
Mini mental state exam
Assess gait and balance
What are some common gait abnormalities?
Ataxic Parkinsonian High stepping Waddling Hemiparetic Spastic paraparesis
What does cerebellar ataxia look like?
Legs far apart as they can’t tell where they are/ poor balance
What does sensory ataxia look like?
Stomping on the ground as they can’t really feel their feet
What does a Parkinsonian gait look like?
Shuffling and festinating gait (where they appear to shuffle in a rushed way)
They may also freeze and get stuck
What is a hemiparetic gait?
One leg is stiff and so the other one swings around it in an arc
What usually causes a hemiparetic gait?
UMN lesion
What does spastic paraparesis look like? What might cause it?
Both legs are stiff so they have to swing around in arcs when walking
Caused by a problem that affects both sides of the brain eg cerebral palsy
What senses are needed to maintain balance?
2/3:
Proprioception
Vision
Vestibular function
How do you do Rombergs test?
Ask the patient to stand still and spot them by their sides with your arms and ask them to close their eyes and observe them
What is Romberg’s test used to identify and how does it identify it?
It is used to identify if a patient has cerebellar or sensory ataxia
Sensory ataxia= the patient will become wobbly when they close their eyes as they don’t have proprioception so when vision is knocked out they are left only with vestibular function which is not enough to maintain balance
Cerebellar ataxia= the patient will already be wobbly and will not get worse after their eye shuts as they do not have a sensory priblem
What may causes sensory ataxia?
Peripheral neuropathy
B12 deficiency
Diabetes
Menieres
Where do you test for tone in the lower limb?
Hip
Knee
Ankle
How do you test for tone in the legs
Tell them to let their leg go floppy
Flap their leg
Lift their leg and the knee and let it drop
Circumduct their ankle and then push it back for clonus
Where do you test for power in the lower limb?
Hip flexion Hip extension Hip abduction Hip adduction Knee flexion Knee extension Ankle dorsiflexion Ankle plantar flexion Big toe extension Big toe flexion
What reflexes do you test for in the lower limb?
Knee
Ankle
Plantar
How do you do the plantar reflex test on the lower limb?
Using a blunt object drag it from the ankle end to their toes on the lateral aspect of the foot
What is the normal and abnormal response to the plantar reflex?
Normal= toes move down Abnormal= big toe moves up and other toes fan out
Remember in babies the opposite is normal
What will you see on inspection of limbs in UMN lesion?
No fasciculations or wasting
What will you see on inspection of limbs in LMN lesion?
Fasciculations and wasting
What will happen to tone in UMN lesion?
Hypertonia
What will happen to tone in LMN lesion?
Hypotonia
What will happen to power in UMN lesion?
Reduced- usually pyramidal weakness
What will happen to power in LMN lesion?
Reduced
What will the plantar reflex be in UMN lesion?
Up going plantars (babinski +ve)
What will the plantar reflex be in LMN lesion?
Normal plantars
How do you test for sensation in the lower limb?
Fine touch with cotton wool in dermatomes
Pin prick test (alternate sharp and blunt)
How you test for vibration in the lower limb?
128 Hz tuning fork in IPJ of big toe and stop and ask them to tell you when it stops
How you test for proprioception in the lower limb?
Get them to close their eyes and hold their big toe on the sides with your fingers, move it up and down and tell them to tell you when you do so
How do you test for coordination in the lower limb?
Heel shin test, ask them to bend their leg at the knee and bring their right heel on their left knee and then run it down their left shin and back up to the knee etc and repeat the other way around
Why may a patient fail the heel shin test?
Cerebellar pathology (more likely if their power was normal) Weakness in legs
