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Scientific Foundations > Neurological Examination > Flashcards

Neurological Examination Flashcards

1
Q

What are the three main components of the approach to neurological diagnosis?

A
  1. History
  2. Examination
  3. Investigations
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2
Q

What are the two main questions to consider when making a neurological diagnosis?

A
  1. Where is the lesion?
  2. What is the lesion?
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3
Q

What is the primary purpose of examining patients?

A

To localise pathology within the nervous system

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4
Q

For what other reasons might we examine patients?

A

▪️Evaluate function
▪️Monitor change
▪️Identify avenues for treatment
▪️Promote patient understanding
▪️Helpful if complaint is made
▪️Ritual

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5
Q

What is a myelopathy?

A

Abnormality/disease of the spinal cord

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6
Q

What is a radiculopathy?

A

Abnormality/disease of the nerve roots (leaving spinal cord in PNS)

Multiple = polyradiculopathy

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7
Q

What is plexopathy?

A

Abnormality/disease of the plexus

(bundles of nerves, either brachial or lumbar)

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8
Q

What is myopathy?

A

Abnormality/disease of the muscles

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9
Q

Examination should be….

A

Tailored to the clinical scenario

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10
Q

What are the three main elements of a standard neurological examination?

A
  1. Higher mental function
  2. Cranial nerves
  3. Motor and sensory examination of the limbs (including gait)
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11
Q

How many pairs of cranial nerves do we have?

A

12

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12
Q

What is the first cranial nerve (I)?

A

Olfactory nerve

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13
Q

When might be test the olfactory nerve and how?

A

▪️Rarely formally tested
▪️Might be relevant post-head injury or in patients with suspected PD as could be prodromal
▪️Formal test = UPSIT

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14
Q

What is the second cranial nerve (II)?

A

Optic nerve

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15
Q

How is visual acuity measured and what is the normal result?

A

▪️Snellen chart (opticians)
▪️6/6 - row 6 from 6 metres away

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16
Q

What elements of optic nerve function can we measure?

A

▪️Visual acuity
▪️Visual fields
▪️Pupillary reflexes (light, accommodation)
▪️Colour vision
▪️Fundoscopy - examination of fundus/retina

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17
Q

What is accommodation?

A

Pupils restrict when focuses on something close up

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18
Q

What is a healthy pupillary reflect to light?

A

They constrict

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19
Q

What can you infer about the location of a lesion if someone has complete loss of vision is one whole field (e.g. right)?

A

The problem is either in the eyes itself or early on in the optic nerve

(just behind the eye, after the optic chiasm)

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20
Q

What are the two main signs to look for when conducting a fundoscooy to look at the optic disk?

A

▪️Papilloedema (swelling of optic nerve head)
▪️Optic atrophy

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21
Q

What conditions might you see optic atrophy in?

A

Multiple sclerosis - optic nerve looks whiter and brighter where previously inflamed

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22
Q

What might papilloedema suggest?

A

Raised intracranial pressure

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23
Q

What are cranial nerves III, IV, and VI important for?

A

Eye movement

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24
Q

What two eye movements do you check for during exam?

A

▪️Pursuit movements (following finger)
▪️Saccadic movements (moving quickly to meet a target)

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25
Q

What is the fifth cranial nerve (V)?

A

Trigeminal nerve

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26
Q

What does the trigeminal nerve do?

A

▪️Sensation to the face
▪️Motor supply to muscles of mastication (chewing)

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27
Q

How do we examine the trigeminal nerve?

A

▪️Feel cotton wool or pinprick
▪️Strength and feel or muscles
▪️Corneal reflex
▪️Jaw jerk

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28
Q

What are the three branches of the trigeminal nerve?

A

▪️V1 - opthalamic
▪️V2 - maxillary
▪️V3 - mandibular

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29
Q

What is the seventh cranial nerve (VII)?

A

Facial nerve

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30
Q

What does the facial nerve do?

A

▪️Control muscles of facial expression
▪️Taste to front 2/3 of tongue

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31
Q

Where might damage be in the facial nerve pathway if someone has weakness in the whole of one side of the face?

A

The lower motor neuron

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32
Q

Where mignt damage be in the facial nerve pathway if someone has weakness at the bottom of one side of the face, but the top part is spared?

A

The upper motor neuron

(Top of the face receives bilateral supply which can protect it from damage)

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33
Q

What is the eighth cranial nerve?

A

Vestibulocochlear

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34
Q

What does the vestibulocochlear nerve control?

A

Hearing and balance

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35
Q

How can we examine the vestibulocochlear nerve?

A

▪️Screen hearing
▪️Vestibular function - assessment of gait and nystagmus

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36
Q

What can a tuning fork be used for?

A

Distinguishing sensorineural deafness from conductive deafness

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37
Q

What might nystagmus suggest?

A

▪️Vestibular problems (VIII cranial nerve)
▪️Cerebellar problems

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38
Q

What is the ninth cranial nerve (IX)?

A

Glossopharyngeal nerve

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39
Q

What is the tenth cranial nerve (X)?

A

Vagus nerve

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40
Q

What problems might arise from IX and X cranial nerve dysfunction?

A

Dysarthria and dysphagia

(speech articulation and swallowing)

41
Q

How can we test the IX and X cranial nerves?

A

▪️Say ‘aaah’ and look for palatal elevation
▪️Check gag reflex
▪️Check speech and swallowing
▪️Cough

42
Q

What does the glossopharyngeal nerve control?

A

▪️Taste to back 1/3 of tongue
▪️Pharyngeal sensation
▪️Gag reflex

43
Q

What does the vagus nerve control?

A

▪️Gag reflex
▪️Vocal cords

44
Q

What is the eleventh cranial nerve (XI) ?

A

Accessory nerve

45
Q

What does the accessory nerve control?

A

▪️Upper part of trapezius muscles
▪️Sternocleidomastoid muscles

46
Q

What is the twelth cranial nerve (XII)?

A

Hypoglossal nerve

47
Q

What does the hypoglossal nerve control?

A

Motor supply to the tongue

48
Q

How can you use tongue protrusion testing to determine location of a hypoglossal nevre lesion?

A

Tongue will often deviate to the side of the problem

49
Q

How can you examine hypoglossal nerve function?

A

▪️Observe tongue for wasting and fasciculation
▪️Tongue protrusion
▪️Power and speed of movement

50
Q

What might you see with damage to the left optic radiation?

A

Right hemianopia

51
Q

When might you see loss of a quadrant of visual field?

A

If optic radiation is lost within the parietal or temporal lobes

52
Q

What are the two main parts of limb examination?

A
  1. Motor
  2. Sensoryv
53
Q

What are the main elements of examining limb motor function?

A

▪️Observations
▪️Tone and clonus
▪️Power
▪️Reflexes
▪️Coordination
▪️Gait

54
Q

Where does the upper motor neuron originate and where does it cross over?

A

▪️From motor cortex
▪️Crossed over in pyramids of the medulla (pyramidal/corticospinal tract)

55
Q

Where does the spinal cord terminate?

A

At the L1 vertebra with the conus medullaris and L1 pedicle

56
Q

What is below the conus medullaris?

A

▪️Cauda equina
▪️Lower motor neurons

57
Q

How would pathology below the L1 vertebra/conus present?

A

As lower motor neuron signs

58
Q

How many pairs of nerve roots do we have?

A

31

59
Q

What is a myotome?

A

The spinal root supply of a muscle

(e.g. biceps are supplied by C5/6)

60
Q

What is a dermatome?

A

The region of skin supplied by a particular spinal root

61
Q

What is a plexus and what are the two main types?

A

▪️Structure where nerve roots come together, reorder, and project down to the limbs
, ▪️Brachial
▪️Lumbosacral

62
Q

What signs can you look for during observation in the motor examination?

A

▪️Wasting - loss of muscle bulk
▪️Fasciculation - twitches
▪️Abnormal movements (hypokinetic/Hyperkinetic)

63
Q

What might muscle wasting and fasciculation be a sign of?

A

Lower motor neuron pathology

64
Q

What are fasciculations?

A

Twitchy movements due to spontaneous contractions as the muscle loses its nerve supply

65
Q

What is tone?

A

The resistance to passive movement

66
Q

What are the two main types of increased muscle tone?

A

▪️Spasticity
▪️Rigidity

67
Q

How might spasticity present and what pathology does it suggest?

A

▪️Velocity dependent - worse when move limb quickly
▪️”Clasp-knife” - lots of resistance when try to extend which quickly gives way
▪️Sign of UMN lesion

68
Q

How might spasticity present and what pathology does it suggest?

A

▪️”Lead pipe” - same throughout whole range of movement
▪️Not velocity dependent - same however fast you move it
▪️Basal ganglia pathology

69
Q

What is ankle clonus?

A

▪️Multiple repetitive contractions (>2/3) in calf in response to flex of foot
▪️Often UMN sign alongside spasticity

70
Q

What do you use to grade motor power?

A

MRC grading (0-5)

71
Q

What are the most common patterns of weakness?

A

▪️Proximal
▪️Distal
▪️Pyramidal
▪️Focal

72
Q

What might a proximal pattern of weakness suggest?

A

Muscle disease

(muscles near the trunk)

73
Q

What might a distal pattern of weakness suggest?

A

Nerve disease

(hands and feet)

74
Q

What is a pyramidal pattern of weakness and what might it suggest?

A

Upper motor neuron pathology

More weakness of extensors in arms and flexors in legs

75
Q

What might a focal pattern of weakness suggest?

A

Damage to a single nerve root or peripheral nerve

76
Q

What happens when you strike a tendon?

A

▪️Sensory impulse sent to spinal cord
▪️Signal returns via LMN to muscle
▪️Kept in check by UMN

77
Q

How do muscles generate tone?

A

Constant activity of the reflex loop

(LMN and reflect arc stimulate each other)

78
Q

What is the role of the UMN in the reflex loop?

A

Inhibitory control

79
Q

What does a loss of reflex tell us about pathology?

A

LMN problem

80
Q

How might an UMN problem affect reflexes?

A

▪️Loss of inhibitory control of loop
▪️Exaggerated reflex

(explains spasticity in UMN lesions)

81
Q

What might loss of a single reflex suggest?

A

Problem with a specific nerve root

82
Q

What is the plantar response (babinski sign)?

A

Scratch bottom of foot and observe big toe

Normal = flexor response (toe goes down
Abnormal (UMN) = extensor response (toes fan up)

83
Q

Where might upper motor neuron damage occur?

A

▪️Brain
▪️Brainstem
▪️Spinal cord

84
Q

Where might lower motor neuron damage occur?

A

▪️Nerve root (anterior horn of spinal cord)
▪️Plexus
▪️Nerve

85
Q

What might you see on observation indicating UMN damage?

A

Contracture (limb pulled into weird position)

86
Q

What might you see on observation indicating LMN damage?

A

Wasting and fasciculation

87
Q

What is the difference between tone and power?

A

Tone = resistence to PASSIVE movement

Power = resistance to ACTIVE movement

88
Q

What are the main signs of UMN damage?

A

▪️Increased tone (spasticity)
▪️Decreased power
▪️Brisk reflexes
▪️Extensor plantar response

89
Q

What are the main signs of LMN damage?

A

▪️Decreased tone (flaccid)
▪️Decreased power
▪️Absent reflexes

90
Q

What are the main elements of examining limb sensory function?

A

▪️Observe
▪️Delineate boundaries of any sensory loss
▪️Light touch
▪️Pinprick
▪️Vibration
▪️Proprioception

91
Q

How can you test coordination and functioning of the cerebellar?

A

▪️Nystagmus and slurred speech (cranial nerve exam)
▪️Finger-nose test
▪️Rapid alternating movements (e.g. tap front and back of hand) (dysdiadochokinesis)
▪️Heel-shin test
▪️Gait

92
Q

What are the two signs of cerebellar dysfunction you might see with the finger-nose test?

A

▪️Dysmetria (missing target)
▪️Intention tremor (increases as approaches target)

93
Q

what gait disturbances might be observed in someone with cerebellar disease?

A

▪️Broad based gait
▪️Ataxia
▪️Fall to side of lesion

94
Q

What patterns of sensory loss might you see with radiculopathy?

A

Dematomal pattern - sensory loss to areas served by those nerve roots

95
Q

What patterns of sensory loss might you see with polyneuropathy and why?

A

Glove and stocking patterns

Usually longer nerves are first affected

96
Q

What patterns of sensory loss might you see with mononeuropathy?

A

Loss to area supplied by that nerve

E.g. median loss with carpal tunnel syndrome, common peroneal

97
Q

What are the main limitations of neurological examination?

A

▪️Hard to judge what is normal and abnormal (large range)
▪️May be affected by other factors (e.g. age, anxiety)
▪️”Hard” vs “soft” signs
▪️Bias
▪️Inter-rater reliability (subjective element)

98
Q

When is neurological examination most relevant in neuropsychiatry?

A

▪️FND - diagnosis and treatment
▪️Movement disorders (e.g. PD)
▪️Dementia (e.g. DLB vs AD)
▪️Acute/subacute cognitive and behavioural symptoms

Scientific Foundations (27 decks)

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