Neuro: upper and lower limb examination Flashcards
what is babinski’s sign?
(or plantar response) +ve test if dorsiflexion of great toe on stimulation of sole of foot, and fanning out of toes= abnormal response if patient >6mnths, upper motor neurone lesion (pyramidal tract lesion)
stroke sole of foot from starting from lateral side and move in medially at the top. toes should plantarflex, dorsiflexion/extension is abnormal and is indicative of an UMN lesion e.g. stroke, MS, traumatic brain injury.
what is romberg’s test?
patient asked to stand unaided with arms by sides and close eyes. If they sway/lose balance, test=+ve, and indicates post. (dorsal) column disease/sensory ataxia- without coordination. If +ve, indicates absence of position sense in lower limbs (posterior column- conscious proprioception)
define an upper motor neurone lesion
lesion in neural pathway above anterior (ventral) horn of SC, or motor nuclei of cranial nerves. Interruption of descending motor pathways.
features characterising an upper motor neurone lesion e.g. stroke, MS
brisk reflexes (hypereflexia)- spastic hypereflexia increased tone in muscles (hypertonia) muscle rigidity no initial atrophy no fasciculations weakness more pronounced in extensor muscles in arms and flexor muscles in legs= pyramidal distribution of weakness pronator drift \+ve Babinski sign
define a lower motor neurone lesion
damage to a motor neurone or its axon to the muscle
features characterising a lower motor neurone lesion e.g. motor neurone disease, polio, guillain-barre syndrome
hyporeflexia or areflexia hypotonia, flaccid paralysis fasciculations atrophy early on weakness
tests of cerebellar function, and what happens if abnormal?
finger to nose touching: past pointing diadochokinesis: dysdiadochokinesis gait: ataxic- wide based gait heel to shin test: unable to perform effectively intention tremor
chief differential for signs of lower motor neurone lesion?
primary muscle disease- here symmetrical loss, reflexes lost later and no sensory loss.
what is tested for after inspecting the patient when performing an UL neurological exam.?
muscle tone: patient asked to go floppy, passively flex and extend limb, while also pronating and supinating forearm. check for rigidity/spasticity?
how can reflexes be reinforced if absent?
ask patient to clench their teeth on count of 3 when you use tendon hammer
should roll up clothing to visualise muscle that tendon reflex is for to observe muscle contraction as reflex action may not be very noticeable.
frequency of tuning fork for testing vibration?
128Hz
describe what happens in epilepsy, what causes it?
can experience recurrent seizures or fits= experience a short episode of symptoms- few s to a few min, that is due to nerves in the brain becoming too active, too electrically excitable, so the brain loses it’s ability to control the body e.g. when someone becomes really excited and hyperactive, and they may start running around and will try to tell you something but may not be able to get it out properly, and you can’t understand what they’re trying to tell you, so this is what is happening in the brain- brain controls everything we do, and it does this by having special cells- your nerves, which talk to one another to control the body, but in seizures, the nerves become overactive, so they’re trying to talk to one another but the nerves just can’t understand what they’re being told to do, so they don’t have any control and the brain loses its control over the body.
nerves not able to talk and listen to one another which they normally do by having electrical activity, now too electrically excitable, so they are setting off lots and lots of electrical impulses, too many too be understood, nerves are all talking to one another at once.
depending on which part of the brain these nerves become too active and excitable will determine your symptoms. may have abnormal movements, sensations- may smell something, may have a feeling of deja vu.
brain normally tells us to stay awake, so if lose control over that, we may lose consciousness.
tment of epilepsy?
can usually control symptoms well- control seizures
no cure, but with right type and dose of mediation, can stop seizures from happening
medicines given work by stabilising electrical activity in the brain, so stop nerves from all talking to each other at once so that the brain can regain control over what the body does.
Often only 1 medicine is needed to stop seizures from happening e.g. carbamazepine for focal/partial seziures- have associated aura usually, lamotrigine or sodium valproate for generalised tonic-clonic and absence- more common in children.
can try and avoid triggers to seizures e.g. watching TV, flashing lights, alcohol
The ketogenic diet is a diet very high in fat, low in protein and almost carbohydrate-free which can be effective in the treatment of difficult-to-control seizures in children.
Aromatherapy may help with relaxation and relieve stress, but have no proven effect on preventing seizures.
considerations in management of epilepsy, what do patients need to be aware of, concerns?
SUDEP- sudden death in epilepsy with a seizure, but this is very rare- don’t mention unless asked!
Some medicines for epilepsy interfere with the contraceptive pill. A higher-dose pill or an alternative method of contraception may be needed.
Tell your doctor if you intend to become pregnant. Pre-conception counselling is important for women with epilepsy. May or may not carry on with tment for epilepsy during pregnancy, seizures could cause damage to both mother and baby, but tments can themselves also cause damage to the fetus, lamotrigine probably safest as risk as no increased risk from baseline level.
if no underlying brain condition, outlook with medication for seizures is very good.
if had no seizures for 2-3 yrs, may do a trial with no medication, so may not need medication for life.
should be able to live a normal and active life, must be aware of driving restrictions- most notify DVLA and unable to drive for a year following a seizure.
differential diagnoses for epilepsy?
syncope e.g. vaso-vagal
cardiac arrhythmias
TIA- symptoms resolve completely within 24hrs
migraine
acute encephalopathy e.g. paracetemol OD
drop attacks- no confusion awards, or warning, no LOC
panic attacks- anxiety, may have tachcardia, sweating, hyperventilation
non-epileptic seizures
frequency of tuning fork for webers and rinne’s tests?
512 Hz or 256 Hz
*128Hz when testing vibration
what does rinne’s +ve mean?
test is normal- so AC>BC
rinne +ve result would occur for a normal ear, and 1 with sensori-neural hearing loss as sound conduction by both air and bone would be reduced as would affect common pathway for both air and bone conduction.
presenting symptoms of epilepsy?
Generalised seizures cause disturbance in consciousness. Generalised tonic-clonic seizure progresses through tonic (rigidity), clonic (movements) and postictal phases= altered consciousness stage after event, often associated with headache and drowsiness. Generalised tonic-clonic seizures often associated with tongue-biting and incontinence.
Patient may have amnesia for both the event and its exact circumstances.
Absence (petit mal) seizures cause an interruption to mental activity for <30 seconds. They rarely persist into adulthood.
Complex focal seizures may have features of:
Motor: automatism, lip-smacking, plucking at clothes, hair.
Sensory: transient paraesthesiae.
Autonomic: odd epigastric sensation-butterflies, nausea, abnormal taste or smell.
Psychiatric: unreality, déjà vu, fear.
symptoms related to seizures=
Sudden falls.
Involuntary jerky movements of limbs whilst awake.
Blank spells.
Unexplained incontinence of urine with loss of awareness, or in sleep.
Odd events occurring in sleep, eg fall from bed, jerky movements, automatisms.
Episodes of confused behaviour with impaired awareness.
Epigastric fullness sensation.
Déjà vu.
Fear.
Elation, depression.
Olfactory, gustatory, visual, auditory hallucinations.
what is Todd’s palsy?
temporary wkness after a focal seizure in motor cortex
what might an epileptic patient experience following a seizure?
headache
confusion
myalgia- if generalised tonic-clonic seizure
sore tongue
temporary wkness- Todd’s palsy
dysphasia- following focal seizure in temporal lobe
secondary causes of epilepsy?
stroke
SOL
cortical scarring e.g. due to previous head injury
hippocampal sclerosis e.g. after febrile convulsion
