Neurological Flashcards
Mnemonic for Cranial Nerve Names
On Old Olympus Towering Tops a Finn and German Viewed Some Hops
CN I
Olfactory
Test ability to identify familiar aromatic odors, one naris at a time
CN II
Optic
Test distant and near vision
Perform opthalmoscopic examination of fundi
CN III
Oculomotor
CN IV
Trochlear
CN VI
Abducens
CN V
Trigeminal
Inspect face for muscle atrophy and tremors
Palpate jaw muscles for tone and strength when clenches teeth
Test superficial pain and touch sesnation in each branch
Test corneal reflex
CN VII
Facial
Inspect symmetry of facial features with various expressions (eg. smile, frown, puffed cheeks, wrinkled forehead)
Test ability to identify sweet/salty tastes on each side of tongue
CN VIII
Acoustic
Hearing with whisper screening or audiometry
Compare bone and air conduction
Test for lateralization of sound
CN IX
Glossopharyngeal
CN X
Vagus
CN III, IV, VI
Occulomotor, Trochlear, Abducens
Test visual fields by confrontation and extinction of vision
Inspect eyelids for drooping
inspect pupils’ size for equality and their direct and consensual response to light and accommodation
Test extraocular eye movements
CN IX, CN X
Test ability to identify sour and bitter tastes on each side of tongue
Test gag reflex and ability to swallow
Inspect palate and uvula for symmetry with speech sounds and gag reflex
Observe for swallowing difficulty
Evaluate quality of guttural speech sounds (nasal, hoarse)
CN XI
Spinal accessory
Test trapezius muscle strength (shrug shoulders against resistance)
Test sternocleidomastoid muscle strength (turn head to each side against resistance)
CN XII
Hypoglossal
Inspect tongue in mouth and while protruded for symmetry, tremors, atrophy
Inspect tongue movement toward nose and chin
Test tongue strength with index finger when tongue is pressed against cheeck
Evaluate quality of lingual speech sounds (l, t, d, n)
Claasification of each CN by function
Sensory (S) Motor (M) Both (B)
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Distinguish between upper and lower neuron disease
Observe patient’s face when crying or laughing
Upper motor neurons (CVA, brain attack) = voluntary movements are paralyzed, but emotional movements spared
Lower motor neurons (Bell’s palsy) = all facial movements on affected side are paralyzed
Enhanced physiologic tremor
Seen with arms held extended, disappears at rest
Drug, alcohol withdrawal
Hyperthyroidism, hypoglycemia
Toxicity associated with medications (lithium, methylxanthines, valproate, tricyclic)
Essential tremor
Bilateral, symmetric Primarily hands, outstretched arms, intention tremor Head, trunk, voice, tongue Worsens with stress, fatigue; may improve temporarily with alcohol Progressive Usually absence of other neuro signs Lower limbs rarely affected No consistent pathology Autosomal dominant inheritance pattern
Intention tremor
Seen during intentional movement, writing, pouring, finger to nose test
Not at rest
Associated with cerebellar disorder, MS, alcohol
Resting tremor
Seen when limb at rest
Slow supination-pronation (pill-rolling) movements
Parkinson disease
Scoring Deep Tendon Reflexes
0 No response 1+ Sluggish, diminished 2+ Active, expected 3+ More brisk, slightly hyperactive 4+ Brisk, hyperactive, intermittent clonus
Stereognosis
Patient identifies a familiar object by touch
Two point discrimination
Needle/paper clip, alternately place one or two points simultaneously
Graphesthesia
Draw a letter or number on the body, ask to identfiy
Multiple Sclerosis (MS)
R/t infectious agents in susceptible individuals
Onset 20-40 y/o
Women > men
Subjective:
Fatigue; urinary frequency, urgency, hesitancy; sexual dysfunction; vertigo, weakness, numbness; blurred vision, diplopia, loss of vision; emotional changes; relapse of symptoms develop rapidly, takes weeks to recede
Objective:
Muscle weakness, ataxia; hyperactive DTR; parasthesia, sensory loss, vibration sense; intention tremor; optic neuritis; cognitive changes; MRI reveals brain lesions, spinal cord lesions (sometimes)
Encephalitis
Virus is transmitted esp WNV, Eastern equine encephalitis, Japanese encephalitis, HSV
Subjective:
Mild viral illness with fever; recovery stage followed by onset of lethargy, restlessness, mental confusion
Objective:
Altered mental status, confusion, stupor, coma; photophobia; stiff neck; muscle weakness, paralysis, ataxia
Meningitis
Infection colonizes, crosses the blood-brain barrier to CSF
Subjective:
Fever, chills; HA, stiff neck; Lethargy, malaise; vomiting; irritability; seizures
Objective:
AMS, confusion; nuchal rigidity; fever; Brudzinski, Kernig signs; petechiae, purpura; lumbar puncture and CSF to confirm
Intracranial tumor
Lesion displaces tissue and pressure, affects CSF circulation, function threatened
Peak primary brain tumors 65-79 y/o
Subjective:
Persistent HA; N/V (early morning); unsteady gait, impaired coordination; memory loss, confusion, reduced vision acuity, visual loss; behavior/personality change; seizure
Objective:
Vary by location of tumor; AMS, confusion, papilledema; cranial nerve impairment; aphasia; vision loss, nystagmus, hemianopia; gait disturbance, ataxia; MRI, CT
Pseudotumor cerebri
Intracranial HTN, mimics brain tumor
Impaired venous outflow, increases cerebral blood volume
Common in obese women 20-44 y/o
D/t metabolic d/o, infection, medications (oral contraceptives, acne), hematologic d/o, brain injury
Subjective:
Severe daily HA, throbbing; pain behind the eye; vomiting; short episodes blurred vision, double vision; whooshing behind ears
Objective:
Papilledema; inferior nasal vision field defect; decreased visual acuity; alert, unimpaired; absence of focal neurologic signs; CT, MRI - no cause of increased intracranial pressure
Mysathenia Gravis
Autoimmune disorder or neuromuscular junction involved with muscle activation; autoantibodies against acetylcholine receptors in the neuromuscular junction cause destruction and inflammatory changes in the postsynaptic membranes that lead to muscle dysfunction
Subjective:
Drooping eyelids; double vision; dysphagia, dysphonia; fluctuating fatigue, weakness; inability to work with arms raised above head; difficulty walking; symptoms worse later in day, improve with rest
Objective:
Ptosis, within 2 minutes of upward gaze; facial weakness when puffing cheeks; hypophonia; difficulty managing secretions; respiratory compromise; weakness of skeletal muscles without reflex, sensory, coordination abnormalities
Guillain-Barre Syndrome
Postinfections disorder following nonspecific GI, respiratory infection causes acute neuromuscular paralysis
Subjective:
Progressive weakness, more in legs; paresthesia; pain in shoulder, back, posterior thigh; double vision
Objective:
Distal weakness, bilateral; ataxia, progressing to flaccid paralysis; facial nerve weakness (Bells palsy), diplopia; dysphagia, respiratory distress; lumbar puncture reveals increased protein in CSF
Trigeminal Neuralgia (Tic Douloureux)
Recurrent paroxysmal sharp pain that radiates to one or more branches of the CN V
Small artery compresses CN V
Age 40-60 y/o
Subjective:
Sharp pain episode on one side of the face seconds to minutes; pain triggered by chewing, swallowing, talking, cold; several times daily or monthly
Objective:
Normal neuro findings; slight sensory impairment regions of pain; distribution of one or more division of facial nerve
Bell Palsy
Temporary acute paralysis or weakness one side of the face; acute inflammation of facial nerve CN VII eg. HSV leading to ischemia, demyelination, CNS lesions, structural lesions in ear or parotid gland; more common with DM
Subjective:
Rapidly progressive muscle weakness on one side; facial numbness
Objective:
Facial creases, nasolabial fold dissappear on affected side; eyelid will not close on affected side; eye may tear excessively; food/saliva pool; facial sensation intact
Peripheral Neuropathy
Disorder of PNS, results in motor and sensory loss, commonly DM, lipid metabolism d/o, vit B12, folate deficiency; neuropathy in Lyme disease; HIV; autoimmune etiology
Subjective:
Numbness, tingling, burning, cramping esp. hands or feet; night pain in one or both feet; unusual sensation of walking on cotton; burning sensation, hyperalgesia and allodynia (all sensation is painful)
Objective:
Reduced sensation in the foot with monofilament; loss of pain or sharp touch sensation to the mid-calf level; distal pulses diminished; decreased or no vibratory sensation below the knees; distal muscle weakness, can’t stand on toes/heels; skin ulceration
Cerebral Palsy (CP)
Permanent d/o of movement and posture development associated with nonprogressive (static) disturbances that occurred in fetal/infant brain
males > females
Subjective:
Delays in gross motor development that become more obvious with age; activity limitation, stiff joints and positioning; may have hearing, speech, language d/o; feeding, sucking difficulties; seizures
Objective:
Cognitive impairment, spastic CP (hypertonicity, tremors, scissor gait, toe walking); primitive reflexes, exaggerated DTRs; dyskinetic CP (involuntary slow writhing of extremities; exaggerated posturing, inconsistent muscle tone that varies during the day; ataxic; intention tremors; increased/decreased muscle tone (hypotonia as infant); instability, wide gait
Myelomengocele (Spina Bifeda)
Congenital vertebral defect (lumbar or sacral level) allows spinal cord contents to protrude
Folic acid deficiency in pregnancy, medications for seizures, acne
Subjective:
Loss or bowel control, constipation; loss or bladder control; mobility problems
Objective:
Exposed meningeal sac with fluid, nerves; sensory deficit, paralysis, weakness; hydrocephalus; hip, foot abnormalities; learning disabilities and perceptual motor skills
Shaken Baby Syndrome
Shaking causes the brain to move around in the skull, stretching, tearing nerve tissue, blood vessels, causing brain damage and subdural hematoma
Subjective:
Fever, irritability, lethargy, decreased food intake; apnea; seizure; LOC
Objective:
Altered LOC; seizure; bilateral retinal hemorrhages with retinal detachments; absence of visible trauma; CT shows subdural or subarachnoid hemorrage
Intrapartum Maternal Lumbosacral Plexopathy
Neuropathy can occur during late pregnancy and delivery; lumbosacral trunk compressed between maternal pelvic rim and fetal head leading to motor deficits in lower extremity
Subjective:
Intermittent pain radiates from the buttock to the leg; mother small; prolonged labor; pain subsides after delivery
Objective:
Pain radiates from the buttock of the affected extremity in lumbar 5 distribution; unilateral foot drop that may take weeks to resolve
Parkinson
Slowly progressive, degenerative neuro d/o in which deficiency of the dopamin neurotransmitter results in poor communication between parts of the brain that coordinate and control movement and balance
Hx encephalitis, drug use, CV disease; genetic, environmental, viral, toxic
> 50 y/o
Normal pressure hydrocephalus
Simulating degenerative disease, caused by noncommunicating hydrocephalus (dilated ventricles with intracranial pressure within expected ranges)
Slightly elevated baseline CSF; compression of brain tissue, decreased cerebral blood flow
Subjective:
Gait impairment; unsteady; forgetful; urinary frequency, incontinence
Objective:
Wide-based stance, short steps; no tremors; no sensory impairment; cognitive impairment; impaired memory recall (recent); CT, MRI reveal enlarged ventricles, not attributable to brain atrophy or congenital problem
Postpolio Syndrome (Progressive Postpoliomyelitis Muscular Atrophy)
Reappearance of neuro sx 10+ years later
Damaged neurons sent out axonal links to activate muscle fibers that had neurons killed by the polio virus; overloaded damaged neurons die over time, causing polio sx to recur
Subjective:
Increased pain sensitivity; fatigue; cold intolerance; difficulty swallowing, speaking; SOB; difficulty sleeping
Objective:
Focal, asymmetric muscle weakness, atrophy; fasciculatoins; dysphagia, dysarthria; sleep apnea, hypoventilation
Infants and children
Birth: brainstem and spinal cord control most reflexes (rooting, sucking, yawn, sneeze, hiccup, blink, withdrawal from pain)
Motor maturation from head down (cephalocaudal)
Developmental milestones
Older adults
Decrease in cerebral neurons but not always clinically significant
Velocity of nerve impulses slows
Risk factors for falls (pg. 552)
Basic Exam
Cranial nerve II-XII Proprioception & Cerebellar Function Romberg Sensory Function Deep Tendon Reflexes Sensory Function Superficial Reflexes Deep tendon reflexes
Proprioception & Cerebellar Function
Rapid alternating movements
Finger to nose
Heel to shin
Balance
Romberg
cerebellar function, vestibular function, sensory loss
Stand on one foot with eyes closed for 5 seconds
Gait
Sensory Function
Primary: superficial touch, pain, temp, pressure, vibration
Cortical: brain’s ability to interpret sensation (graphesthesia, point location, etc.)
Superficial Reflexes
Abdominal, plantar (Babinski normal to age 2) and cremasteric
Deep tendon reflexes
Bicep, brachioradialis, tricep, patellar, Achilles, clonus
Risk Factors for Falls in Older Adults
One or more falls in the past year
Past history of stroke
Neuro condition (Parkinson, dementia, peripheral neuropathy)
Disorder of gait or balance
Lower extremity weakness, sensory loss
Impaired vision
Assistive device (walker, cane, wheelchair)
Meningeal signs
Nuchal rigidity (check chin to chest)
Brudzinski sign
involuntary flexion of the hips and knees when flexing the neck
Kernig sign
Flex the leg at the knee and hip then attempt to straighten (+ when low back pain and resistance present)
Posturing
Decorticate posturing (flexion) Decerebrate posturing (extension
Spastic hemiparesis
Affected limb is stiff and extended with plantar flexion of the foot
Foot dragged, scraping toe or circled stiffly outward and forward
Affected arm remains flexed
Spastic diplegia (scissoring)
Short steps, dragging the ball of the foot across the floor
Thighs tend to cross forward on each other at each step due to injury to the pyramidal system
Steppage
Hip and knee are elevated excessively high to lift the plantar flexed foot off the ground
Dystrophic (waddling)
Legs are kept apart
Abdomen protrudes
Lordosis
Tabetic
Legs are positioned far apart, lifted high, forcibly brought down with each step
Cerebellar gait
Cerebellar ataxia
Patient’s gait wide-based
Staggering, lurching side to side accompanied by swaying of trunk
Sensory ataxia
Patient's gait is wide Feet thrown forward/outward Heels and then toes Watches ground positive Romberg
Parkinsonian
Stooped, body rigid
Short steps, shuffling, hesitation
Ataxia
Uncontrolled falling
Dystonia
Jerky, dancing movements, nondirectional
Antalgic limp
Limits the time of weight-bearing on affected leg to limit pain
