Neurologic Flashcards
When do you do a neuro exam
General screening
AMS, symptom specific (HA, vertigo, weakness)
Concern over a central or peripheral lesion and where it occured
What is included in the neuro exam in an adult pt
MSE Cranial nerves Sensory DTRs & Plantar reflex Cerebellar functioning Muscle strength Motor screening
What makes up the CNS (brain + cord)
Cerebrum Diencephalon Basal ganglia Thalamus Hypothalamus RAS Brain stem & medulla Cerebellum
What is the grey matter
Cell bodies
What is the white matter
Axons
What is the thalamus…sensory or motor
Sensory
What is the hypothalamus responsible for
Regulation of homeostasis, endocrine function, sex drive, and behavior
What is the RAS responsible for
Consciousness
What are the neurotransmitters of the sympathetic nervous system
Epinephrine
Norepinephrine
Dopamine
What are the neurotransmitters of the parasympathetic nervous system
Acetylcholine
What is CN-I
What is its function?
Olfactory nerve
Sensory: reception and interpretation of smells
What is CN-II
What is its function?
Optic nerve
Sensory: visual acuity and visual fields
What is CN-III
What is its function?
Oculomotor nerve
Motor: raise eyelids, most EOM
Parasympathetic: pupil constriction, lens shape
What is CN-IV
What is its function?
Trochlear nerve
Motor: downward, inward eye movement (SO)
What is CN-V
What is its function?
Trigeminal nerve
Motor: jaw opening and clenching, mastication
Sensory: 3 branches (opthalmic, maxillary, mandibular)
What is CN-VI
What is its function?
Abducens nerve
Motor: lateral eye movement (LR)
What is CN-VII
What is its function?
Facial nerve
Motor: facial expression muscles (except jaw), eye closure, mouth closure
Sensory: taste (anterior 2/3 of tongue)
Parasympathetic: secretion of saliva & tears
What is CN-VIII
What is its function?
Acoustic nerve
Sensory: hearing and equilibrium
What is CN-IX
What is its function?
Glossopharyngeal nerve
Motor: voluntary muscles for swallow and phonation
Sensory: nasopharynx, gag reflex, taste (posterior 1/3 of tongue)
Parasympathetic: secretion of saliva, carotid reflex
What is CN-X
What is its function?
Vagus nerve
Motor: voluntary muscles of phonation & swallow
Sensory: behind the ear, part of the external canal
Parasympathetic: secretion of digestive enzymes, peristalsis, carotid reflex, heart, lungs, digestive tract
What is CN-XI
What is its function?
Spinal Accessory nerve
Motor: turn head, shoulder shrug, some phonation
What is CN-XII
What is its function?
Hypoglossal nerve
Motor: tongue movement for speech, sound articulation, and swallowing
How many cervical nerve roots are there
8 (even though there are only 7 vertebrae)
How do spinal nerves innervate?
What do they form?
Innervate as individual dermatomes
Form peripheral nerves in plexuses with other nerve roots to innervate bodily regions
Which part of the nerve root is sensory & which part is motor
Anterior root = motor
Dorsal root = sensory
What does C3 innervate
Front and back of neck
What does C6 innervate
Thumb
What does C8 innervate
Pinky (5th finger)
What does T4 correspond to
Nipple line
What does T10 correspond to
Umbilicus
What does L1 correspond to
Inguinal region
What does S2/3 correspond to
Anogenital region
What does L4 innervate
Knee
What part of the hand does the radial nerve innervate
Back of the hand near the thenar space
What part of the hand does the median nerve innervate
Middle three digits anteriorly & posteriorly
What part of the hand does the ulnar nerve innervate
Lateral 5th digit
If there is a lesion above the cross-over in the motor cortex what will the symptom distribution be
Contralateral symptoms
If there is a lesion below the cross-over of the motor cortex what will the symptom distribution be
Ipsilateral symptoms
What is the basal ganglia for
Complex motor and movement pathways in deep grey matter
How do you identify an upper motor neuron (UMN) lesion.
What conditions may cause it
+ babinski
Increased DTRs
Muscular spasticity
Ex = MS, ALS
How do you identify a lower motor neuron (LMN) lesion.
What conditions may cause it
Decreased DTRs
Ipsilateral weakness
Decreased or absent muscle tone
Ex: nerve transection, polio, Guillan-Barre, ALS
What is a spinothalamic sensory pathway
What does it sense
Cross in the cord
Pain, temperature, crude touch
What is the posterior column of the sensory pathway
What does it sense
Cross in the medulla
Position, vibration, fine touch
What is a reflex
Involuntary response that may involve as few as 2 neurons, one sensory and one motor, across a single synapse
What can DTRs indicate
Level of spinal lesion
Electrolyte disturbances
Endocrine disturbances
UMN vs LMN disease
What do you look for regarding general appearance
Level of consciousness Facial features Hygiene/clothing Posture & motor activity Ht, Wt, build Vital signs
When evaluating CN-I what do you test
Nostril patency Identify odors (2)
When evaluating CN-II what do you test
Visual acuity
Visual fields
Fudoscopic exam
Lesion of the optic chiasm results in…
Bitemporal hemianopsia
Lesion of the optic tract results in…
Homonymous hemianopsia
When evaluating CN-III, IV, & VI what do you test
Pupillary response
EOMs
Nystagmus
Accommodation
Which type of nystagmus is worse…lateral or vertical
Vertical nystagmus
When evaluating CN-V what are you testing
Masseter strength
Temporalis strength
Corneal reflex
Pain and light touch sensation of the 3 branches
When evaluating CN-VII what do you test
Raise eyebrows Keep eyes closed against resistance Frown Show teeth & smile Puff out cheeks
What part of the face is affected during a central lesion (like CVA)
Lower face affected
If there is a CVA on the right side what will you see
Left side facial droop but may still have forehead wrinkle intact
When evaluating CN-VIII what do you test
Gross hearing
Weber
Rinne
What can cause conductive hearing loss
Disorders of the external ear
Disorder of the middle ear
What are the 2 MAIN causes of pure conductive hearing loss
AOM & cerumen impaction
What can cause sensorineural hearing loss
Disorders of the inner ear of brain
What is presbycusis
Sensorinerual hearing loss due to normal aging & related to high frequency loss
When evaluating CN-IX & X what do you test
Observe soft palate with phonation
Vocal quality
Swallowing
Gag reflex
What is the result of a unilateral vagus (CN-X) nerve lesion
Soft palate rise of the unaffected side only
What is the result of a bilateral vagus (CN-X) nerve lesion
No rise of the soft palate
Damage to what nerve is responsible for recurrent horseness
Recurrent laryngeal nerve (part of CN-X)
When evaluating CN-XI what do you test
SCM strength
Trapexius strength
When evaluating CN-XII what do you test
Protrude tongue
Tongue side to side
Speech articulation
If a lesion is a ________ lesion the tongue will deviate to the ________ side
Peripheral lesion
To the affected side
If a lesion is a _______ lesion the tongue will deviate to the _______ side
Cortical lesion
Unaffected side
What tongue manifestation is commonly seen with ALS
Atrophy of tongue d/t CN-XII lesion
What is 2 point discrimination good for
Good for peripheral lesions
The biceps DTR is associated with what nerve roots
C5 & C6
The triceps DTR is associated with what nerve roots
C6 & C7
The brachioradialis DTR is associated with what nerve roots
C5 & C6
The patellar DTR is associated with what nerve roots
L2, L3, & L4
The achilles DTR is associated with what nerve roots
S1
What are the grades of DTRs and what do they represent
0 = absent 1+ = hypoactive 2+ = NORMAL 3+ = hyperactive 4+ = hyperactive with clonus
What is clonus
Involuntary muscle contraction (often continuous)
What can you do/use to help illicit a DTR if having difficulty with pt
Use reinforcement such as pulling hands apart or clenching jaw
What part of the brain is responsible for coordination
Cerebellar function
What is dysmetria
Missing the mark in point to point movements
What are types/examples of cerebellar disease
Movement disorders (Parkinson’s, Huntington’s)
Cerebellar degeneration/atrophy (chronic alcoholism)
Cancers, genetic disease, CVA
What are the classic signs of cerebellar disease
Dysmetria, nystagmus (up & down, non-fatigueable), intention tremors
What are examples of involuntary movements
Tremors
Fasiculations
Chorea
What nerve roots are responsible for grasp strength
Lower cervical & T1
What is passive range of motion (PROMI)
Examiner provides the motion
What is active range of motion (AROMI)
Patient does the motion
What is ROM against resistance
Examiner provides resistance to the pt’s active motion (RAMI)
What are the MS grades and what do they mean
0/5 = no movement 1/5 = Visible muscle contraction w/o joint movement 2/5 = Movement at joint but not against gravity 3/5 = Movement against gravity but not against resistance 4/5 = Movement against resistance but less than normal 5/5 = Normal muscle strength
What muscles are mainly responsible for raising the arms
Deltoid and supraspinatous
What is ataxia
Inability to walk
What things are required to achieve balance
Require 2/3 of the following:
- ) visual confirmation of position
- ) non-visual confirmation of position (including proprioceptive and vestibular input)
- ) a normally functioning cerebellum
What is sensory ataxia
Polyneuropathy (DM, B12) encephalopathy + cerebellar diseases
What is a positive Romberg sign
What does it suggest
A loss of position with eyes closed
Suggests cerebellar disease
What does pronator drift suggest
Corticospinal damage (such as CVA)
What are examples of circumstantiality
Loose Associations Flight of ideas Neologisms Incoherence/ illogic Blocking Confabulation Perseveration Echolalia Clanging
What are examples of compulsions
Obsessions Phobias Anxieties Feeling of unreality Depersonalization Delusions
Which cranial nerve has ONLY sensory function
CN-I
What cranial nerve has motor, sensory, and parasympathetic functions
CN-VII
Which cranial nerves have ONLY motor functions
CN-IV, VI, XI, XII
Which cranial nerve is responsible for raising the eyelids
CN-III
The L side of pts face is paralyzed but he can wrinkle the L side of his forehead. Where is the lesion?
Right cerebral cortex
Which CN is responsible for chewing
CN-V
Which CN controls the corneal relex
CN-V
What CNs are involved in swallowing
CN-IX, X, & XII
Which CN has 3 sensory branches. What are they?
CN-V AKA Trigeminal Nerve
Ophthalamic, maxillary, & mandibular branches
Pt presents with tongue deviated to the left side. What CN is paralyzed
Left CN-XII
Pt presents with uvula deviated to the right side. What CN is paralyzed
Left CN-X
Pt has no sensation over the lateral aspect of the 5th finger. Which peripheral nerve is paralyzed?
Ulnar nerve
Which of the following is a test of discrimination:
Patting thighs, finger to nose, stereognosis, walking on heels
Stereognosis
What nerve roots are responsible for the triceps DTR
C6 & C7
A “normal” DTR is graded/noted as…
2+
What nerve roots control the abdominal reflex
T8 - T12
Upon exam you try to illicit an abdominal reflex however your pt doesn’t show one. Is this a normal or abnormal response
It is probably normal, many pts don’t exhibit this reflex
What are the 2 abnormal positions seen in comatose patients
Decorticate and decerebrate
What is decorticate rigidity
Upper arms flexed tight to the sides with elbows, wrists, and fingers flexed. Legs are extended and internally rotated while feet are plantar flexed
What does decorticate rigidity imply
Destructive lesion of the corticospinal tracts within or near the cerebral hemisphere
What is decerebrate rigidity
Jaws are clenched and neck is extended. Arms are adducted and stiffly extended at the elbows with forearms pronated and fingers and wrists flexed. Legs are stiffly extended at the kneeswith the fee plantar flexed
When does decerebrate rigidity occur
May be spontaneous or may be in response to external stimuli such as light, noise, or pain
What is decerebrate rigidity caused by
Caused by a lesion in the diencephalon, midbrain, or pons; although severe metabolic disorders like hypoxia & hypoglycemia can cause it
Which carries a better prognosis: decorticate or decerebrate rigidity
Decorticate
What are the 4 primitive reflexes? Who are they more common in
Rooting reflex, palmar grasp reflex, Moro reflex, & plantar reflex
More common in peds
At what age should the following reflexes go away (roughly, not exact):
Rooting reflex, palmar grasp reflex, Moro reflex, & plantar reflex
Rooting reflex = 4 months
Palmar grasp reflex = 6 months
Moro reflex = 2 months
Plantar reflex = 1 year
What does a persisting primitive reflex indicate
May indicate abnormal neurologic functioning
What is the glabellar reflex
What type of pt is it seen with
It is where you tap on the pts forehead a couple times. Normal pt may blink the first couple times then stop; abnormal will keep blinking with each tap
Common sign of Parkinson’s
Who is Wernicke-Korsakoff’s Syndrome seen in
Extremely malnourished alcoholics especially if they have thymine deficiency
If a pt presents with Wernicke-Korsakoff’s or is an extremely malnourished alcoholic what should you do first? What do you NOT want to do first
Never give them straight fluids first because you can make the condition worse. Need to give them a banana bag with thymine first
What is the classic triad of Wernicke-Korsakoff’s
Confusion (delirium), ophthalmoplegia, & ataxia
Which nerve is involved in carpal tunnel syndrome
Median nerve
Pt presents with pain and numbness on the ventral surface of the 1st 3 digits of the hand. What is this suggestive of
Carpal tunnel
What is the phalen’s test
Test for carpal tunnel; put backs of hands together and hold for 60 seconds; pain is positive carpal tunnel test
What is tinel’s sign
Percussion over the median nerve to test for carpal tunnel; pain or tingling in the fingers is a positive sign
Who is more at risk of developing carpal tunnel
Diabetics and pregnant women
Optic neuritis is commonly associated with what condition
MS
What is Kerning’s Sign
Pain and increased resistance to extending the knee with the hip flexed
What does bilateral kerning’s sign suggest
Meningeal irritation
What is Brudzinski’s Sign
Flexion of the hips and knees with passive flexion of the neck
What does a positive brudzinski’s sign suggest
Meningeal irritation
Altered mental status with a petichial rash is a BAD sign. What might it suggest?
Possible nisseria infection
What is a monofiliment & what is it used for
Small, thin structure/needle used to test multiple areas of the toes, forefoot, midfoot, and hindfoot for peripheral/diabetic neuropathy
What is an early sign of peripheral/diabetic neuropathy
Stocking/glove electric burning pain distribution
What is the classic triad of Parkinson’s
Rigidity, bradykinesia, & resting tremor
What is cogwheel rigidity
Difficulty moving the extremities
Parkinson’s pts also have a certain facial appearance…what is it?
Masked facies
What are the “on” and “off” periods of Parkinson’s
“off period” = symptoms are at their worst
“on period” = symptoms aren’t as bad
What are the upper motor neuron signs
Spastic weakness
Hyperactive reflexes
Extensor plantar reflexes (+Babinski)
Pronator drift (corticospinal)
What are the lower motor neuron signs
Flaccid weakness
Hypoactive reflexes
Muscle atrophy
Fasciculations
What are the extrapyramidal signs (seen in HD & PD)
Resting tremor, Rigidity
Postural deformity and instability
Slowed rapid alternating movements
What are the cerebellar signs (seen in B1 def)
Intentional tremor
Ataxia
Impaired rapid alternating movements (especially point to point movements)
What type of tremor is seen with benign essential tremor
Intention tremor
Guillain-Barre results mostly in UMN or LMN features/problems
LMN
ALS results mostly in UMN or LMN signs/problems
Mixture of UMN and LMN
