Neurological Flashcards
What is the FAST test?
Detects symptoms of a stroke:
F: Facial weakness
A: Arm weakness
S: Speech problems
T: Time
How can you test facial weakness?
Can they smile? Has their face fallen on one side?
How can you test arm weakness?
Can they raise both arms and keep them there?
How can you test speech problems?
Can they speak clearly and understand what you say? Is their speech slurred?
What are neurological system symptoms?
- Headaches
- Vision, hearing
- Speech difficulties (dysphasia, dysarthria)
- Dizziness, vertigo
- Faints, fits, blackouts
- Weakness
- Numbness
- Coordination problems
- Walking, unsteadiness, falls
- Sleep disturbances
- Tremors
- Concentration
- Memory
A lot of patients will use the word ‘dizziness’ and ‘unsteadiness’. This is very broad. What can you ask them to be more specific?
Encourage patients to describe what they mean.
Ask specifically about sensation of movement; of the patient, of the room, of objects
Ask about causative factors; standing up, moving head, leaning over
What 3 steps should be taken during a neurological clinical examination?
- Assessment of conscious level
- Neurological examination of the limbs and cranial nerves
- Examination of other symptoms including CVS
How can conscious level be assessed using AVPU?
A: Alert
V: Responds to voice
P: Responds to pain
U: Unresponsive
What is GCS?
Glasgow Coma Scale
A neurological scale which aims to give a reliable and objective way of recording the state of a person’s consciousness.
What 3 aspects are tested in GCS?
- Eye opening
- Verbal response
- Motor response
What are the 4 criteria for eye opening in GCS?
- Spontaneous (best)
- To sound (e.g. asking/shouting)
- To pressure
- None (worst)
Where is pressure stimulation during testing eye opening applied in GCS?
Pressing on fingernail - with increasing intensity
If a patient is not able to open eyes e.g. due to swelling, what is recorded?
NT - not testable
What are the 5 criteria for verbal response in GCS?
- Orientated (best)
- Confused
- Words (not talking sensibly but instead in single words)
- Sounds (no recognisable words)
- None (worst)
What are the 6 criteria for motor response in GCS?
- Obey commands (best)
- Localising
- Normal flexion
- Abnormal flexion
- Extension
- None (worst)
How is motor response first tested in GCS?
Ask patient to perform a 2 step action:
Grasp and release your fingers with their hand
OR
Open mouth and stick out tongue
If a patient does not obey motor commands, a peripheral stimulus alone is inadequate to test motor response.
What is needed instead?
An addition central stimulus:
- Trapezius pinch
If not response then:
- Supraorbital notch
What is the trapezius pinch?
Place hand over patients shoulder and press fingers into muscle above shoulder blade with increasing intensity
For up to 10 seconds
What is the supraorbital notch?
Placing hand on forehead with a thumb over upper rim of orbit.
Feel for the notch in the supraorbital margin and apply pressure with increasing intensity for up to 10 seconds.
What are responses to supraorbital notch test?
Localising: patient reaches hand above their clavicle in attempt to move stimulus away
Non-localising: arm doesn’t reach above clavicle but does flex; this can be normal or abnormal flexion
Patient can extend arm instead: extension
Power grading for muscle contraction?
0 - No muscle contraction visible
1 - Muscle contraction visible, but no movement of joint
2 - Joint movement when effect of gravity eliminated
3 - Movement sufficient to overcome effect of gravity
4 - Movement overcomes gravity plus added resistance
5 - Normal power
What is the plantar reflex?
A reflex elicited when the sole of the foot is stimulated with a blunt instrument. The reflex can take one of two forms. In healthy adults, the plantar reflex causes a downward response of the hallux (flexion).
Red flags of meningitis?
- Neck stiffness
- Photophobia
How can diagnosis of meningitis be diagnosed?
Lumbar puncture to gain cerebral spinal fluid for gram stain and culture
This should be done immediately (also give antibiotics)
Red flags of a headache?
- History of trauma
- Fever/neck stiffness
- Seizure
- Wakes you up from sleep
- Reduced GCS/personality change
- Tenderness over temporal artery in patient > 50 years old
- Eye pain/red eye (glaucoma symptoms)
- Focal neurology
- First or worst headache e.g. ‘thunderclap’
- Triggered by cough, exercise or valsalvar
- Postural
What is a thunderclap headache?
A thunderclap headache is a severe headache that starts suddenly. This type of headache pain doesn’t gradually build in intensity. Instead, it’s an intense and very painful headache as soon as it starts. It’s frequently described as the worse headache of one’s life.
What is the Valsalva manoeuvre?
To do it, you breathe out strongly through your mouth while holding your nose tightly closed.
What is a postural headache?
A positional headache is a type of headache that gets worse when you stand up. The pain tends to subside once you lie down
What could a ‘thunderclap’ headache indicate?
Sub-arachnoid haemorrhage
What is a sub-arachnoid haemorrhage?
a life-threatening type of stroke caused by bleeding into the space surrounding the brain
What is cerebral venous thrombosis?
Cerebral venous thrombosis (CVT) is a blood clot of a cerebral vein in the brain.
Who is a cerebral venous thrombosis most common in?
Young women, smoking, oral contraceptive pill
4 potential diagnoses of an acute/sudden onset headache
- Sub-arachnoid haemorrhage
- Cerebral venous thrombosis
- Meningitis
- Temporal arteritis
Symptoms of meningitis?
Fever, neck stiffness, photophobia
What is temporal arteritis?
A condition where medium and large arteries, usually in the head and neck, become inflamed.
Primary vs secondary headache?
While primary headaches may cause significant daily pain and disability, they are not dangerous. Secondary headaches are caused by an underlying disease, like an infection, head injury, vascular disorders, brain bleed or tumours.
What can cause a cerebral abscess?
usually occurs when bacteria or fungi make their way into the brain, either through the bloodstream or from an infected area in the head, such as the ears or sinuses.
Mneumonic for cranial nerves?
Oh Oh Oh To Touch And Feel Very Good Velvet, Such Heaven
What is CN I?
Olfactory
What is CN II?
Optic
What is CN III?
Oculomotor
What is CN IV?
Trochlear
What is CN V?
Tigeminal
What is CN VI?
Abducens
What is CN VII?
Facial
What is CN VIII?
Vestibulocochlear
What is CN IX?
Glossopharyngeal
What is CN X?
Vagus
What is CN XI?
Spinal accessory
What is CN XII?
Hypoglossal
Function of the olfactory nerve?
Sensory - transmits sensory information about odours to the CNS where they are perceived as smell (olfaction).
Motor - none
How is the olfactory nerve tested?
Any recent changes to their sense of smell?
Function of the optic nerve?
Sensory - transmits sensory visual information from the retina to the brain
Motor - none
What 4 elements are there to the optic nerve test?
- Pupillary light reflexes to light and accommodation
- Visual acuity
- Visual fields
- Fundoscopy
What are the 2 pupillary reflexes that need to be tested?
Direct and consensual
How can the direct pupillary light reflex be tested?
- Patient looks straight ahead
- Shine torch into pupil
- Same pupil should constrict
How can the consensual pupillary light reflex be tested?
- Patient looks straight ahead
- Shine torch into pupil
- Looking if OTHER pupil constricts –> the contralateral pupil should constrict
What is visual acuity?
the clarity of your eyesight
How is visual acuity tested?
Using a snellen chart (a chart of letters or symbols)
- Patient covers one eye
- Read down chart
- Repeat on other eye
How can the visual field be tested?
Can the patient detect finger movements in all 4 quadrants of the visual field?
- Position yourself and patient an arms length apart at eyes level
- Patient covers one eye
- Cover your own eye (opposite eye)
- Move finger (watch video) and ask patient when they can see finger move
- Repeat this process for each visual field quadrant
- Repeat on other eye
If you are able to see the target but the patient cannot, this would suggest the patient has a reduced visual field.
What is fundoscopy?
Fundoscopy is performed to assess the optic disc for signs of pathology (e.g. papilloedema).
- Sit across from patient
- Use an ophthalmoscope to examine the retina at the back of the eye.
- Look through lenses to examine your eye.
What is the red reflex?
The red reflex refers to the reddish-orange reflection of light from the back of the eye, observed when using an ophthalmoscope
Function of the oculomotor (CN III), trochlear (CN IV) and abducens (CN VI) nerves?
Motor:
- Transmit motor information to the extraocular muscles to control eye movement and eyelid function
- The oculomotor nerve also carries parasympathetic fibres responsible for pupillary constriction.
How are the oculomotor (CN III), trochlear (CN IV) and abducens (CN VI) nerves tested?
- Get patient to look straight at you
- Get them to follow your finger with their eyes without moving their head
- Move your finger through the various axes of eye movement in a ‘H’ pattern.
Function of the trigeminal nerve (CN V)?
Transmits both sensory information about facial sensation and motor information to the muscles of mastication.
What are the 3 sub divisions of the trigeminal nerve?
1) Ophthalmic (V1)
2) Maxillary (V2)
3) Mandibular (V3)
Function of ophthalmic (V1)?
carries sensory information from the scalp and forehead, nose, upper eyelid as well as the conjunctiva and cornea of the eye.
Function of maxillary (V2)?
carries sensory information from the lower eyelid, cheek, nares, upper lip, upper teeth and gums.
Function of mandibular (V3(?
Carries sensory information from the chin, jaw, lower lip, mouth, lower teeth and gums.
Also carries motor information to the muscles of mastication.
How can the sensory component of all subdivisions of the trigeminal nerve be tested?
Ask the patient to close their eyes and say ‘yes’ each time they feel you touch their face. Ask if it feels the same on both sides?
Assess the sensory component of V1, V2 and V3 by testing light touch and pinprick sensation across regions of the face supplied by each branch.
What sensory subdivision of the trigeminal nerve supplies the forehead?
ophthalmic (V1)
What sensory subdivision of the trigeminal nerve supplies the cheek?
Maxillary (V2)
What sensory subdivision of the trigeminal nerve supplies the lower jaw?
(avoid the angle of the mandible as it is supplied by C2/C3): mandibular branch (V3)
How can the motor component of the trigeminal nerve be tested?
- Get patient to clench teeth
- Palpate their muscles in temples (temporalis) and cheeks (masseter)
- Ask the patient to open their mouth whilst you apply resistance underneath the jaw (pterygoid)
What is being assessed when inspecting the motor component of the trigeminal nerve?
Use the muscles of mastication to assess the motor component of V3
Function of the facial nerve (CN VII)?
Motor - transmits motor information to the muscles of facial expression
Sensory - responsible for the conveyance of taste from the anterior two-thirds of the tongue.
How can the motor aspect of the facial nerve be examined
Ask the patient to carry out a sequence of facial expressions whilst again observing for asymmetry:
- Raise eyebrows
- Close eyes
- Show teeth
- Puff out cheeks
Function of Vestibulocochlear nerve (CN VIII)?
Sensory - transmits sensory information about sound and balance from the inner ear to the brain
Motor - none
How can the Vestibulocochlear nerve be tested?
- Any recent changes in hearing?
- Whisper number into back of patients ear
- Ask them to repeat the number
- Repeat on both sides
Function of the glossopharyngeal (CN IX) nerve?
Motor - transmits motor information to the stylopharyngeus muscle which elevates the pharynx during swallowing and speech
Sensory - transmits sensory information that conveys taste from the posterior third of the tongue.
Function of the vagus (CN X) nerve?
Motor - transmits motor information to several muscles of the mouth which are involved in the production of speech
Sensory - transmits sensory information from the back of the throat which forms the afferent portion of the gag reflex
Why are the glossopharyngeal and vagus nerves assessed together?
Because of their closely related functions –> control movement in mouth and throat
How can the glossopharyngeal and vagus nerves be assessed?
- Ask patient to cough
* Look into patient’s mouth shining light and ask patient to say ‘ahh’
Function of the accessory nerve (CN XI)?
Motor - transmits motor information to the sternocleidomastoid and trapezius muscles (control movements in shoulders and neck)
Sensory - none
How can the accessory nerve be tested?
- Ask patient to shrug shoulders up and keep them there while you try push down on them
- Ask patient to turn head to one side then the other (added resistance)
Function of the hypoglossal nerve (CN XII)?
Motor - transmits motor information to the extrinsic muscles of the tongue
Sensory - none
How can the hypoglossal nerve be tested?
- Observe tongue: looking for muscle wasting etc
- Ask patient to stick tongue out and move it from one side to the other
- Ask patient to push tongue onto one side of cheek (and repeat) and keep it there while you add resistance
