Neuro exam Ward Flashcards
1
Q
What are the components of the neurologic exam?
A
- mental status: level of alertness, appropriateness of responses, orientation of time and place
- cranial nerves: pupillary light reflex, fascial sensation and strength, gag reflex
- motor system: muscle strength testing, gait, and coordination testing
- sensory: pinprick, light touch, vibratory, proprioception
- reflexes: deep tendon reflexes and plantar response (Babinski)
2
Q
Describe abrupt or sudden onset/acute onset of neuro problem
A
Sudden onset of symptoms usually followd by gradual improvement is somewhat typical of cerebral hemorrhages, vascular diseases, and infections and head trauma
3
Q
Describe progressive neuro problem
A
Certain neoplasms and degenerative diseases of nervous system may cause a more linear progression of neurological symptoms and deficits.
In some degenerative diseases, pt’s symptoms such as minor memory disturbances, increased irritability, or mild personality changes may be unremarkable initially, but quite significant and apparent many years later
4
Q
Describe intermittent, relapsing episodes of neuro problem
A
Demyelinating diseases such as multiple sclerosis and certain vascular diseases often display a gradually deteriorating cycle of remission and symptoms
5
Q
Describe the components of mental status exam
A
- level of alertness: consciousness of pt (awake, alert, drowsy, lethargic, comatose, etc)
- appropriateness of response: insight to question and situation and ability to respond concretely to this versus tangential or confused demeanor
- orientation: knows date, place, self, situation
6
Q
Describe basic localization of cranial nerves
A
- Telencephalon: cerebral hemispheres (CN I)
- Diencephalon: rostral part of brainstem/paired structures on either side of 3rd ventricle (CN II)
- Mesencephalon: midbrain (CN III-IV)
- Metencephalon: pons (CN V)
- (Pontomedullary junction: CN VI-VIII))
- Myelencephalon: medulla (CN IX-XII)
7
Q
Summarize the functions of the cranial nerves
A
- I: Olfactory: smell
- II: Optic: visual acuity, visual fields, optic fundi, afferent limb of pupillary light reflex
- III: Oculomotor: extraocular movements (supplies medial rectus, inferior rectus, and inferior oblique), supplies levator palpebrae muscle (lifts eyelid), and is efferent limb of pupillary light reflex
- IV: trochlear: supplies superior oblique m, extraocular movements
- V: trigeminal: facial sensation: ophthalmic (V1, forehead), maxillary (V2, cheek), mandibular (V3, jaw); jaw movements (motor portion of nerve); corneal reflex (afferent/sensor limb)
- VI: abducens: supplies lateral rectus muscle, extraocular movements
- VII: facial: facial movements of expression, taste to anterior 2/3 of tongue
- VIII: vestibulocochlear: hearing (cochlear division), balance by vestibular devision
- IX: glossopharyngeal: swallowing, rise of palate and gag reflex (along with CN X)
- X: Vagus: gag reflex (with CN IX) and swallowing, phonation
- XI: spinal accessory: innervates upper trapezius and sternocleidomastoid muscle (SCM) (shoulder shrug and neck movements, head turning to opposite side)
- XII: hypoglossal: innervates intrinsic tongue muscles
8
Q
Describe testing of olfactory CN I
A
- use non-irritating, familiar odors (cinnamon, coffee, vanilla)
- have pt compress one nostril and sniff through other. Pt should be able to discern odors on each side
- loss of smell can occur with smoking, chronic sinus disease, head trauma, aging, Parkinson’s disease, cocaine use
- loss of sense of smell indicates ipsilateral lesion
9
Q
Describe testing of Optic CN II
A
- test visual acuity with Snellen eye chart (pt stands 20 feet from chart)
- inspect fundi: locate optic disc, check for papilledema, pallor, or atrophy. Inspect retina for hemorrhages or exudates, spontaneous venous pulsations, hypertensive vascular changes, trace arteries and veins peripherally
- visual field test: pt in front of examiner. One eye covered during testing, patient to count fingers held up testing all 4 quadrants, also test blink response to lateral threat
- color vision (usually only done by ophthalmology)
- pupillary light reflex (tests CN II and III)
- lesions to optic nerve anterior to chiasm cause ipsilateral blindness
10
Q
Describe testing of pupillary light reflex
A
- Tests CN II and III (afferent/sensory component CNII, efferent/motor component CNIII)
- shine light into eye and watch for pupillary constriction
- direct light reflex: stimulated pupil constricts
- consensual (indirect) reflex: opposite pupil constricts (along with stimulated pupil)
- light stimulus is given to one eye. CN II sends stimulus to brainstem/midbrain where it is transferred to CNIII to produce constriction in both eyes
11
Q
What is opticokinetic nystagmus?
A
- normal physiologic response to fixating on a moving target
- asymmetric loss can be due to frontal or parietal lesion on side to which tape is moving
12
Q
Describe testing of oculomotor CNIII
A
- check eyelid for ptosis (drooping of eyelid that does not clear upper margin of pupil)
- check pupil shape and symmetry
- reactivity to light (pupillary light reflex) and near reaction
- near reaction: reaction when gaze shifts from a far to a near object. As the object approaches, the pupils constrict with associated convergence of eyes (eyes move medially/nasally) and accommodation (thickening of lens by ciliary muscles). Helps to bring object into clear focus
13
Q
Describe cardinal signs of gaze
A
- CNIII: adduction, downward gaze (aided by CNIV), elevation of eye
- CNIV: inward rotation, downward and lateral movement
- CNVI: lateral movement of eye
14
Q
What are some findings with CN III lesions?
A
- ptosis (drooping of eyelid past upper margin of pupil) due to levator palpebrae weakness
- pupillary dilation or asymmetry: due to disruption of parasympathetic fibers. If severe, will see a fixed/dilated pupil
- position change of eye: “down and out” pupil due to weakness of extraocular muscles (MR, IO, IR, SR)
15
Q
Describe compressive brainstem lesions related to CNIII
A
- hematomas: subdural or epidural
- large strokes, abscesses, tumors
- space occupying or expanding masses may cause brain to herniate through various dural openings in cranium. Initially, pupilloconstrictor fibers of CNIII causing dilation and fixation of pupil. Second effect is on somatic efferent fibers that supply extraocular muscles which then cause external strabismus (“down and out” of eye)
- aneurysms: areas of weakened arterial blood vessel walls causing dilation of arterial segment of internal carotid artery or posterior communicating artery generally within cavernous sinus causes similar findings as brainstem (uncal) herniation. Key difference is level of consciousness is preserved with aneurysms (prior to rupture) and is abnormal in herniation syndromes.
- diabetes mellitus: can cause extraocular muscle weakness but often spares puilloconstrictor fibers
16
Q
Describe CN IV Lesions
A
- due to its long course around brainstem, CN IV is vulnerable to head trauma. Lesions result in:
- extorsion of eye (eye position drifts laterally)
- weakness of downward gaze (due to weakness of superior oblique muscle)
- vertical diplopia: increases when looking down
- head tilting: to opposite of lesion. Can be misdiagnosed as idiopathic torticollis
17
Q
Describ CN VI lesions
A
- most common isolated CN palsy due to its long peripheral course. Seen often in pts with subarachnoid hemorrhage, late syphillis, and trauma. Lesions result in:
- convergent (medial) strabismus (esotropia): inability to abduct eye. Due to lateral rectus muscle weakness
- horizontal diplopia: maximal separation of images when looking toward paretic lateral rectus muscle
18
Q
Describe testing of trigeminal CN V
A
- check facial sensation in forehead (VI), cheek (V2), and chin (V3) to pinprick, light touch, and hot/cold
- check motor function: check lateral jaw movements (lateral pterygoids), jaw clenchgin (temporal and masseter muscles)
- check corneal reflex (tests CN V and VII): lightly touch cotton wisp to cornea which should result in contraction of orbicularis oculi muscle (blink)
19
Q
Describe trigeminal lesions
A
- decreased sensation of face and mucous membranes
- loss of corneal reflex
- weakness of muscles of mastication
- jaw deviation toward weak side (due to unopposed action of opposite lateral pterygoid muscle)
20
Q
Describe corneal (blink) reflex
A
- protective reflex involving CN V (afferent limb) and CN VII (efferent limb)
- ask pt to look up and away from examiner
- take cotton wisp and approach opposite side of pt’s line of vision and touch cornea. Pt should blink in response.
- loss of blink reflex indicates lesion of CN V or VII. Can be seen in acoustic neuromas, brainstem (pontine) lesions, etc
21
Q
Describe the functions of Facial CN VII
A
- Motor: facial expressions, eye and mouth closure
- sensory: taste for salty, sweet, and bitter substances to anterior 2/3 of tongue
- parasympathetic: secretion of saliva and tears
- general sensation: of external ear
22
Q
Describe lesions of CN VII
A
- paralysis of muscles of facial expression (upper and lower portions of face) seen as a widened palpebral fissure and increased nasolabial fold (Bell’s Palsy)
- loss of corneal reflex (efferent limb)
- hyperacusis: increased sensitivity to sound
- crocodile tears syndrome: due to abberant regeneration of nerve after trauma. Pt sheds tears when chewing
23
Q
Clinical note of Bell’s Palsy?
A
- peripheral facial paralysis
- can be caused by trauma or infection, but in most cases, is idiopathic (unknown)
24
Q
Clinical note about bilateral facial palsies?
A
Can occur in Miller-Fisher variant of Guillain-Barre Syndrome
25
Clinical note of supranuclear (central) facial palsy?
- spares upper face and usually is associated with hemiplegia (weakness to one side of body)
- important in determining if weakness is central or peripheral in nature
26
Describe testing for hearing (cochlear division) of vestibulocochlear CN VIII
-check for hearing loss of hearing by whisper test or finger rub in each ear. If present, do Weber and Rinne tests
27
Describe Weber test
- performed on pts with unilateral hearing loss
- test for lateralization of sound
- place tuning fork (256 or 512 Hz) on vertex of skull or on forehead after striking fork between thumb and index finger
- ask pt where sound can be heard (one or both ears). In normal individuals, the sound is heard equally in both ears.
- In conductive hearing loss seen with occlusion of ear (cerumen impaction, perforation of eardrum, otosclerosis), the sound lateralizes to impaired ear
- in sensorineural hearing loss (nerve damage), the sound lateralizes to good (unaffected) ear
28
Describe Rinne test
- compares air to bone conduction (AC to BC)
- in normal individuals, air conduction is greater than bone conduction
- place vibrating tuning fork to mastoid bone
- when pt can no longer hear sound, quickly place tuning fork close to ear canal and ask if sound can be heard again ("U" of fork should face forward)
- In conductive hearing loss, bone conduction is heard as long or longer than it is through air. (BC>AC). Negative Rinne's test
- In sensorineural hearing loss, air conduction is greater than bone conduction (AC>BC). Positive Rinne test. AC and BC are both diminished in sensorineural hearing loss which keeps ratios same as normal hearing person (AC>BC)
29
Vestibular division of CN VIII lesions result in:
- dysequilibrium (imbalance)
| - nystagmus: rapid involuntary and rhythmic movement (or oscillation) of eye
30
Cochlear division of CN VIII lesions result in:
- destructive lesions lead to sensorineural hearing loss. Ex: acoustic neuroma
- irritative lesions can cause tinnitus (ringing in ears). Ex: medications (aspirin, some antibiotics, etc)
31
Describe functions of glossopharyngeal nerve CN IX
- motor: innervates stylopharyngeus muscle which elevates and widens pharynx on swallowing
- sensory: taste to posterior 1/3 of tongue, sensation to palate and pharynx, skin of external ear
- afferent limb of gag reflex
32
Describe testing for gag reflex
- tests CN IX (afferent/sensory) and X (efferent/motor)
- use a cotton tipped applicator to lightly touch posterior pharynx. This should elicit gag response.
- test each side individually
- Loss of gag reflex is generally an indicator of ipsilateral CNIX (perhaps CN X)
33
Lesions of IX result in
- loss of gag reflex
- loss of sensation in pharynx and posterior 1/3 tongue
- slight dysphagia
34
Describe what vagus X innervates. Describe testing
- innervates muscle of pharynx (except stylopharyngeus) and larynx
- visceral afferent fibers from mucosa of esophagus to mid-transverse colon and lining of respiratory system (larynx to alveoli)
- parasympathetic to smooth muscle to same areas
- listen to voice for hoarseness (vocal cord) and nasal tone (palatal weakness)
- check gag reflex
- check for difficulty swallowing (indicating either pharyngeal or palatal weakness)
- ask pt to open mouth and say "ah" and look for symmetric elevation of soft palate, midline uvula position, and medial movement of each side of posterior pharynx.
- unilateral loss indicates ipsilateral CN X lesion
35
Lesions of X result in
- dysphonia
- dyphagia
- dyspnea
- loss of gag or cough reflex
36
Describe cranial and spinal divisions of spinal accessory nerve CNXI
- cranial division: (accessory portion) innervates muscles of larynx (via recurrent laryngeal nerve) except the cricothyroid muscle.
- spinal division: (spinal portion) innervates trapezius muscle (with cervical root C2) and sternocleidomastoid muscles (with cervical roots C3 and C4)
37
Describe testing of SCM and trapezius for CN XI
- SCM: test by having pt attempt to turn head against mild resistance. (Contraction of left SCM turns head to right and vice versa).
- Paralysis of SCM results in difficulty turning head to opposite side
- Trapezius: test by having pt shrug shoulders against resistance
- weakness of trapezius from CN XI lesion results in ipsilateral should droop
38
Describe hypoglossal CN XII
- innervates all intrinsic and all extrinsic tongue muscles (except palatoglossus CNX)
- test by having pt protrude tongue and push tongue into opposite cheek
- CN XII lesion results in tongue deviation to weak side and inability to push tongue to opposite cheek
39
Describe evaluating speech
- listen to pt speak
- evaluate if speech pattern is normal
- types of speech disturbances
- dysarthria (slurred speech)
- dysphasia (partial or complete impairment of ability to communicate)
- apahasia (inability to get words out or understand what is being said)
40
Describe evaluation of motor system
- inspection: muscle bulk. If normal bulk or atrophy
- muscle tone: feeling muscle's resistance to passive stretch
- involuntary movements: tremors, tics, dyskinesias
- muscle power: graded on 0-5 scale
- body position: upright, anteroflexed, leaning
- try to determine if abnormality is central or peripheral in origin
41
Describe scale for grading muscle strength
0: no muscle contraction detected
1: evidence of slight contractility, no joint movement
2: active movement of body part with gravity eliminated
3: complete range of motion against gravity but not resistance
4: complete range of motion against gravity with some resistance. Movement at joint with some effort.
5: complete range of motion against gravity with full resistance. No movement at joint.
42
Describe neck and upper extremity testing of motor system
- pt activates each muscle action against resistance
- neck: flexion/extension, side to side
- shoulder shrug: trapezius (CNXI)
- shoulder abduction, flexion, extension: deltoid (C5)
- elbow: flexion (C5, C6) and extension (C6, C7, C8)
- wrist: flexion and extension (C6, C7)
- hand grip (C7, C8, T1)
- finger abduction (C8, T1)
- opposition of thumb (C8, T1)
- flexion, extension, and lateral bending of spine
43
Describe motor system testing of hip, knee, ankle
- hip:
- -flexion: psoas and iliacus (L2, L3, L4)
- -extension: gluteus maximus S1
- -adduction (L2-4), abduction (L4-5, S1)
- knee
- -flexion: hamstrings (L4-5, S1-2)
- -extension: quadriceps (L2-4)
- ankle
- -plantar flexion: gastrocnemius (S1)
- -dorsiflexion: primarily tibialis anterior (L4-5)
44
Describe examination of spinal nerves and motor responses
- Motor dermatomes
- Biceps (C5-6)
- Triceps (C6-8)
- Quadriceps (L2-4)
- Gastrocnemius (L5-S2)
45
Describe weakness in upper motor neuron (UMN)
- hypertonia, hyperreflexia
- pyramidal pattern of weakness (weak extensors in arms and weak flexors in legs)
- pronator drift (arms held extended for up to 2 minutes; arm drifts down and supinates)
46
Describe weakness in lower motor neuron (LMN)
- wasting, fasciculation, decreased tone, or decreased reflexes
- peripheral pattern of weakness (weak flexors in arms, weak extensors in legs)
- muscle disease: wasting, decreased tone, or decreased reflexes
- neuromuscular junction: fatiguable weakness, normal or decreased tone, normal reflexes
- functional: normal tone, reflexes and muscle bulk, but erratic power (give-away weakness)
47
Describe what sensory system testing tests for
- pinprick and temperature: spinothalamic tract
- proprioception, 2-point tactile discrimination and vibratory: posterior columns
- light touch: both pathways
- discriminative sensations: depend on above sensations and cortex
48
Describe dermatomes and examples
- band of skin innervated by sensory root of a single spinal nerve
- helps localize lesions to specific level
- can be individual variations
```
Shoulder (C4)
Radial aspect of forearm and thumb (C6)
Little finger (C8)
Nipple (T4)
Umbilicus (T10)
Hallucis (L5)
Little toe (S1)
```
49
Descrbe testing sensory system
- pain: use broken cotton tipped applicator or tongue depressor
- temperature: often omitted if pain sensation is normal. Use test tube filled with hot and cold water
- light touch: fine wisp of cotton. Compare one area with another
- vibration: 128 Hz tuning fork, place on interphalangeal joints, malleoli
- proprioception (position): grasp sides of pt's big toe between thumb and index finger and move it through an arc. With pt's eyes closed as for response of "up" or "down"
50
Define sterognosis, graphesthesia, two-point discrimination, double simultaneous stimulation (extinction)
- Stereognosis: ability to identify shapes of objects or recognizing objects placed in hand
- graphesthesia: ability to identify numbers written on palm
- two-point discrimination: ability to distinguish being touched by one or two points
- double simultaneous stimulation (extinction): ability to feel two locations being touched simultaneously
51
Describe patterns of sensory loss
- single nerve: loss limited to distribution of single nerve
- root or roots: loss is in different nerve distributions with a common root. C5-7 common in arms. L4-5, S1 common in legs
- spinal cord: complete transverse lesion, hemisection of cord, central cord, posterior column, anterior spinal syndrome
- brainstem: crossed findings with ipsilateral loss in face and contralateral in body
- thalamic: hemisensory loss of all modalities
- cortical loss: intact primary sensations, but loss of cortical sensations
- functional loss: non-anatomical distribution
52
Summarize UMN vs LMN lesions
```
UMN lesions (CNS):
Hemiparesis
Parapareiss
Hemianesthesia
Hyperreflexia
Babinski sign (positive)
```
```
LMN lesions (PNS)
Weakness in isolated muscle or muscle group
Hyporeflexia
Early muscle atrophy
Negative Babinski sign (normal)
```
53
Describe deep tendon reflex testing
- test each area by having pt sit or lie in relaxed position
- place extremities in a symmetric and relaxed position
- strike tendon briskly and quickly and observe speed, force, and amplitude of response
- response of each tendon is recorded based on rating scale of 0-4
54
Describe grading system for deep tendon reflexes
0: no response
1: diminished, low normal
2: average, normal
2+: more brisk than normal but no spread
3: brisk, spread to involve movement across more than one joint
4: hyperactive with clonus
55
Describe hyper/hypo active reflexes and lesions
Hyperactive reflexes indicate lesion in CNS
| Hypoactive reflexes indicate lesion in PNS
56
What are the commonly tested reflexes?
```
Biceps (C5*, C6)
Triceps (C6, C7*)
Brachioradialis (C5, C6*)
Patellar (L2, L3, L4*)
Achilles (S1)
```
57
Describe Babinski sign
Critical sign of UMN dysfunction.
Abnormal when sole of foot is scratched from heel toward toes and across transverse arch.
Great toe extends, and remainder spread
58
What is clonus?
UMN sign
Abnormal pattern of neuromuscular activity characterized by rapidly alternating involuntary contraction and relaxation of skeletal muscle.
Should test for this if reflexes are hyperactive
59
What are frontal lobe release reflexes?
Rooting, grasping, glabellar, and palmo-mental
60
Describe abdominal reflex
Superficial tendon reflex
T10-12
Test all four quadrants
Stroking abdomen causes umbilicus to move toward area of stimulation
61
Describe cremasteric reflex
Superficial tendon reflex
afferent L1, efferent L2
Stroking inner thigh causes scrotum to rise on stroked side
62
Describe anal wink reflex
Superficial tendon reflexes
S4, S5
Useful for cauda equina or lesions that affect sacral region
Touch areas around perirectal region and note if contraction
63
Coordination of muscle movement requires input from what 4 systems?
- motor system: for strength
- cerebellar system: for rhythmic movement and steady posture
- vestibular system: for balance and coordinating eye, head, and body movement
- sensory system: for position sense
64
Describe coordination (cerebellar) testing
- finger to nose: evaluate for dysmetria/dysataxia of voluntary movements
- heel to shin: tap heel on opposite patella and glide heel slowly along shin
- rapid alternating movements: rapid pronation and supination of hand. Seen in frontal and cerebellar damage
- Saccades: tests contralateral cerebral hemisphere through PPRF with a cerebellar component
65
Describe gait and station
- evaluate the pt's ability to rise from chair with arms folded may indicate proximal muscle weakness if unable to perform this task
- arm swing: should swing freely when ambulating
- width of gait: narrow or wide based
- toe walking: may indicate distal muscle weakness
- Hell walking: can be a sensitive test for corticspinal tract lesions (CNS) or indicate distal muscle weakness
- tandem walking: may reveal imbalance not previously noted
- Romberg test: generally evaluated with gait and station but is a test of proprioception (sensory test)
66
Describe Romberg test
- often performed with gait and station evaluation
- test of proprioception (sensory system)
- pt stands in front of examiner with his back to examiner. Pt is asked to place his feet together and stretch arms fully out to side. Examiner should guard pt against falling. Pt then is asked to close his eyes. Pt should be able to maintain balance.
67
Describe symmetrical gaits
- Parkinsonian: anteroflexed posture, festinating (difficult to start/stop), small steps, en bloc turns (many steps to turn around), decreased arm swing (usually bilateral)
- Scissoring: feet crossing over with toes dragged. Often seen in cerebral palsy or multiple sclerosis
- Sensory ataxia: high steppage, broad based. Seen with posterior column damage and peripheral neuropathy
- Magnetic: small steps, feet do not leave ground. Seen in frontal lobe processes and hydrocephalus
- Astasia-abasia (functional): gait is all over the place as if pt is falling but does not fall. Usual cause is psychogenic
68
Describe asymmetrical abnormal gait
- hemiplegic: usually due to UMN such as stroke. Circumducted gait (leg swing in a circular type pattern), decreased arm swing ipsilateral to affected leg
- waddling pelvis: usually indicates myopthic (muscle) disease (myopathy). Hips sway or waddle in a side to side type fashion
- foot drop: unable to keep foot up during heel walk, can be due to UMN or LMN lesions. Usual LMN lesion is peroneal neuropathy or L5 radiculopathy
69
Describe tremor testing
- tremor: test for postural or resting tumor
- postural tremor or kinetic tremor: usually due to essential tremor
- resting (pill rolling) tremor: indicates basal ganglia disease (Parkinson's)
70
What is Kernig's sign?
Pt supine.
Flex thigh then straighten leg.
Pt will experience pain in neck
71
What is Brudzinski's sign?
Pt supine
Lift pt's head
Knees will come up in response
72
Describe postures in coma
- decorticate: both arms flexed. Legs stiff and extended. Lesion usually above brainstem in thalamus
- decerebrate: arms are extended. Legs stiff and extended. Usually indicates brainstem lesion in midbrain
73
Symptoms from problems in special systems?
- vestibular: nystagmus, vertigo, vomiting, postural impairment, disequilibrium
- cerebellar: dysmetria, dysdiadochokinesia, ataxia, intention tremor, slurred speech, asthenia
- pyramidal: spastic paralysis/paresis, hyperreflexia, hypertonia, babinski
- extrapyramidal: dyskinesia, resting tremor
- cortical: hemi-dyasthesia, hemiplegia, hemiparesis, apraxia, aphasia, cognitive/behavioral
74
Describe gait and station
- evaluate the pt's ability to rise from chair with arms folded may indicate proximal muscle weakness if unable to perform this task
- arm swing: should swing freely when ambulating
- width of gait: narrow or wide based
- toe walking: may indicate distal muscle weakness
- Hell walking: can be a sensitive test for corticspinal tract lesions (CNS) or indicate distal muscle weakness
- tandem walking: may reveal imbalance not previously noted
- Romberg test: generally evaluated with gait and station but is a test of proprioception (sensory test)
75
Describe Romberg test
- often performed with gait and station evaluation
- test of proprioception (sensory system)
- pt stands in front of examiner with his back to examiner. Pt is asked to place his feet together and stretch arms fully out to side. Examiner should guard pt against falling. Pt then is asked to close his eyes. Pt should be able to maintain balance.
76
Describe symmetrical gaits
- Parkinsonian: anteroflexed posture, festinating (difficult to start/stop), small steps, en bloc turns (many steps to turn around), decreased arm swing (usually bilateral)
- Scissoring: feet crossing over with toes dragged. Often seen in cerebral palsy or multiple sclerosis
- Sensory ataxia: high steppage, broad based. Seen with posterior column damage and peripheral neuropathy
- Magnetic: small steps, feet do not leave ground. Seen in frontal lobe processes and hydrocephalus
- Astasia-abasia (functional): gait is all over the place as if pt is falling but does not fall. Usual cause is psychogenic
77
Describe asymmetrical abnormal gait
- hemiplegic: usually due to UMN such as stroke. Circumducted gait (leg swing in a circular type pattern), decreased arm swing ipsilateral to affected leg
- waddling pelvis: usually indicates myopthic (muscle) disease (myopathy). Hips sway or waddle in a side to side type fashion
- foot drop: unable to keep foot up during heel walk, can be due to UMN or LMN lesions. Usual LMN lesion is peroneal neuropathy or L5 radiculopathy
78
Describe tremor testing
- tremor: test for postural or resting tumor
- postural tremor or kinetic tremor: usually due to essential tremor
- resting (pill rolling) tremor: indicates basal ganglia disease (Parkinson's)
79
What is Kernig's sign?
Pt supine.
Flex thigh then straighten leg.
Pt will experience pain in neck
80
What is Brudzinski's sign?
Pt supine
Lift pt's head
Knees will come up in response
81
Describe postures in coma
- decorticate: both arms flexed. Legs stiff and extended. Lesion usually above brainstem in thalamus
- decerebrate: arms are extended. Legs stiff and extended. Usually indicates brainstem lesion in midbrain
82
Symptoms from problems in special systems?
- vestibular: nystagmus, vertigo, vomiting, postural impairment, disequilibrium
- cerebellar: dysmetria, dysdiadochokinesia, ataxia, intention tremor, slurred speech, asthenia
- pyramidal: spastic paralysis/paresis, hyperreflexia, hypertonia, babinski
- extrapyramidal: dyskinesia, resting tremor
- cortical: hemi-dyasthesia, hemiplegia, hemiparesis, apraxia, aphasia, cognitive/behavioral
