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Neurology Clerkship > Neurological Examination of Sensation, Reflexes, and Motor Function > Flashcards

Neurological Examination of Sensation, Reflexes, and Motor Function Flashcards

1
Q

Type of primary sensation that refers to external stimuli, typically light touch, pain, and temperature, detected by various receptors in the skin

A

Exteroceptive sensation

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2
Q

Type of primary sensation that refers to stimuli from muscles, tendons, ligaments, and joints, in relation to position and movement of the body, limbs, and digits, and is important for balance and coordination

A

Proprioceptive sensation

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3
Q

Type of primary sensation that refers to internal stimuli affecting visceral organs, such as perception of a distended bladder

A

Interoceptive

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4
Q

Type of sensation that involves the simultaneous perception of several basic stimuli, further integrated and interpreted at the cortical level

A

Cortical (combined) sensation

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5
Q

Abnormal, spontaneous sensation, not provoked by stimuli, often described as tingling or “pins and needles”

A

Paresthesia

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6
Q

Uncomfortable, at times painful, hypersensitivity to non-noxious stimuli

A

Dysesthesia

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7
Q

What are the components of the exteroceptive sensation examination?

A
  1. Light touch (wisp of cotton, light stroke of the finger)
  2. Pain (broken cotton-swab stick, blunted safety pin)
  3. Temperature (cool metallic object)
  4. Vibration (128 Hz tuning fork), patient reports when the vibration is gone
    - Alternate from left to right
    - Move proximally
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8
Q

Define abnormally decreased vibration sensation.

A

If the tuning fork is still perceived to vibrate more proximally or at the same bony site (less valid with age, as this normally declines)

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9
Q

What are the components of the examination of proprioceptive sensation?

A

Test position sense by raising or lowering the patient’s finger or toe subtly a few degree at one joint; patient identifies the movement as “up” or “down”

If patient detects only large excursion of the joint, but consistently misses smaller movements, position sense is decreased. If even large joint movements are not detected, position sense is absent. May test proximally at wrists and ankles.

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10
Q

What is gnosis?

A

Object recognition

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11
Q

A lesion in the ___ or its connecting pathways produces a cortical sensory deficit in the contralateral body, while primary sensations may be relatively intact.

A

Parietal sensory cortex

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12
Q

What is the tactile recognition of familiar or common objects, such as a penny or paper clip in the palm of the hand, with the patient’s eyes closed?

A

Sterognosis

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13
Q

What is a deficit in stereognosis?

A

Astereognosis

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14
Q

What is the identification of numbers traced on the palm with the eyes closed?

A

Graphesthesia

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15
Q

What is a deficit of graphesthesia?

A

Agraphesthesia

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16
Q

What is the ability to perceive two tactile stimuli applied simultaneously to the same bilateral parts of the body with the eyes closed?

A

Double simultaneous stimulation

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17
Q

When bilateral tactile stimuli are given, the consistent failure to detect a stimulus on one side is due to what lesion? What is this called?

A

Contralateral parietal cortical lesion; extinction on double simultaneous stimulation

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18
Q

What is the ability to detect the simultaneous application of two sharp points separated by a minimal distance on the skin?

A

Two-point discrimination (fine touch)

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19
Q

How does a deficit in two-point discrimination appear?

A

Perceiving the two points as one point or failing to feel it at all

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20
Q

Although conveyed by the ___, two-point discrimination is usually considered a cortical sensation.

A

Posterior columns

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21
Q

Describe the progression of sensory loss in disorders of peripheral nerves.

A

Initial involvement of the larger, more myelinated sensory fibers causes impairment of position sense and vibration

Initial involvement of the smaller, less myelinated or unmyelinated sensory fibers produces early impairment of temperature and pain sensation

Eventually, if extensive and severe, all fibers and sensory modalities will be impaired.

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22
Q

Lesions of the posterior or dorsal columns cause what sensory deficits?

A

Deficits in position sense, vibration, and two-point discrimination

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23
Q

Presentation of lesions in the posterior (dorsal) columns of the spinal cord?

A

Deficits in position sense, vibration, and two-point descrimination

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24
Q

Isolated deficits in two-point discrimination associated with?

A

Contralateral sensory (parietal) cortex lesion

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25
Q

Lesions of the spinothalamic tract cause what deficits?

A

Deficits in pain and temperature

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26
Q

Absence of light touch sensation associated with?

A

Extensive lesions of the spinal cord or its dorsal roots (or in severe peripheral neuropathy or thalamic lesions) - because multiple spinal cord pathways convey light touch

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27
Q

Define mononeuropathy.

A

Sensation is decreased or lost in the territory of one peripheral nerve

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28
Q

Define polyneuropathy.

A

Aka peripheral neuropathy, sensation is decreased or lost in several peripheral nerves, creating a “stocking and glove” distal pattern of deficit

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29
Q

What are sensory impairments in the territory of one or more dermatomes from one or multiple root lesions.

A

Dermatomal deficits

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30
Q

Dissociation of sensation (loss of one modality with preservation of another) is characteristic of what type of lesion? Note that it is possible to occur in ___ lesions.

A

Spinal cord lesions (myelopathy); brain stem lesions

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31
Q

Define an intramedullary spinal cord lesion and describe the associated deficits.

A

Occur within the spinal cord parenchyma; cause a suspended or vestlike sensory loss and sacral sparing of sensory deficit

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32
Q

Define an extramedullary spinal cord lesion and describe the associated deficits.

A

Compress the spinal cord from outside, creating an initial sensory loss in sacral segments, progressing up “to a level” because of lamination of the STT

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33
Q

Hemisensory (hemibody) deficit of basic sensations on the R or L side of the body including the face is caused by what lesions?

A

Contralateral thalamic lesion or involvement of sensory pathways to the contralateral parietal lobe

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34
Q

Isolated or predominant deficits involving cortical or combined sensation typically occur on one side of the body and are usually do to what lesion?

A

Lesion in the contralateral parietal sensory cortex

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35
Q

Important dermatomal landmarks - C5

A

Lateral shoulder

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36
Q

Important dermatomal landmarks - C6

A

Thumb

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37
Q

Important dermatomal landmarks - C7

A

Index/middle fingers

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38
Q

Important dermatomal landmarks - C8, T1

A

Ring/little fingers

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39
Q

Important dermatomal landmarks - T4

A

Nipple

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40
Q

Important dermatomal landmarks - T10

A

Umbilicus

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41
Q

Important dermatomal landmarks - L3, L4

A

Anterior thigh

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42
Q

Important dermatomal landmarks - L5

A

Dorsal foot

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43
Q

Important dermatomal landmarks - S1

A

Lateral foot/sole

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44
Q

What is referred pain?

A

Pain perceived along a dermatome having sensory afferents from the same dorsal root level as the diseased internal organ

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45
Q

A heart attack may have referred pain along the inside of the left arm and forearm - dermatomes?

46
Q

An infection below the right diaphragm may cause pain at the R shoulder - dermatomes?

A

C3, C4, C5

47
Q

What is a quick, automatic, replicable motor response or muscle contraction provoked by a stimulus?

48
Q

Briefly describe the reflex arc that occurs when muscle stretch reflexes are tested with tendon tap.

A

Tendon tape causes passive stretching of the muscle and neuromuscular spindles -> activates 1a sensory nerve fibers (afferent arc) -> depolarization of alpha motor neurons (anterior horn cells) at that root level -> contraction of muscle fibers and a visible muscle twitch (reflex)

49
Q

Nerve roots tested by the biceps reflex?

50
Q

Nerve roots tested by the barchioradialis reflex?

51
Q

Nerve roots tested by the triceps reflex?

52
Q

Nerve roots tested by the finger flexors reflex?

53
Q

Nerve roots tested by the quadriceps (patellar) reflex?

A

L2, L3, L4

54
Q

Nerve roots tested by the Achilles reflex?

55
Q

Grade 0 reflex?

A

Reflex absent despite reinforcement

56
Q

Grade 1 reflex?

A

Reflex present only with reinforcement

57
Q

Grade 2 reflex?

A

Average reflex

58
Q

Grade 3 reflex?

A

Very brisk reflex without clonus

59
Q

Grade 4 reflex?

A

Reflex followed by repetitive jerking movements (clonus)

60
Q

List several broad reasons for decreased or absent reflexes.

A

Disorders disruption the afferent or efferent reflex arc (often occur in polyneuropathy or radiculopathy)

Healthy older adults may have absent ankle reflexes due to aging

61
Q

Broad cause of hyperreflexia?

A

UMN lesions, where the inhibitory effect on the local reflex circuit from the descending supraspinal tracts is lessened

62
Q

Asymmetrical hyperreflexia suggestions?

A

UMN (corticospinal tract) lesion

63
Q

What are cutaneous reflexes provoked by tactile stimuli to a localized area of skin or mucous membrane?

A

Superficial reflexes (exception - pupillary light reflex, where stimulation involves shining light into the pupil)

64
Q

The cranial nerve-mediated superficial reflexes are characteristically consensual - what does this mean?

A

Bilateral response to a unilateral stimulus

65
Q

List the 4 cranial nerve superficial reflexes.

A
  1. Pupillary
  2. Corneal
  3. Palpebral
  4. Gag (pharyngeal)
66
Q

What is the unilateral stimulus and associated afferent nerve + bilateral reflex and efferent nerve in the pupillary reflex arc?

A

Shine light -> CN II

CN III -> pupils constrict

67
Q

What is the unilateral stimulus and associated afferent nerve + bilateral reflex and efferent nerve in the corneal reflex arc?

A

Touch cornea -> CN 5

CN 7 -> eyes blink

68
Q

What is the unilateral stimulus and associated afferent nerve + bilateral reflex and efferent nerve in the palpebral reflex arc?

A

Touch eyelid/lash -> CN 5

CN 7 -> eyes blink

69
Q

What is the unilateral stimulus and associated afferent nerve + bilateral reflex and efferent nerve in the pharyngeal reflex arc?

A

Touch pharynx -> CN 9

CN 10 -> gag

70
Q

What is the abdominal reflex and what nerves are involved?

A

Stroking the skin over each quadrant -> local muscle contraction causing retraction or deviation of the umbilicus toward the stimulus; arcs at T7-T12 and upper lumbar spinal cord segments

71
Q

What is the cremasteric reflex and what nerves are involved?

A

Stroking up the inner thigh -> ipsilateral elevation of the testicle; arcs at L1, L2 spinal cord segments

72
Q

Babinski sign associated with what lesion?

A

UMN (corticospinal tract) lesion in adults

73
Q

What is the Hoffman’s sign?

A

Examiner lifts or supports the patient’s proximal middle finger and then flicks its distal phalanx downwards -> flexion of the fingers of that hand

74
Q

Define the stiffness felt by the examiner when the patient’s head is passively flexed anteriorly.

A

Nuchal rigidity

75
Q

Define Kernig’s sign.

A

Examiner feels resistance while attempting to fully extend the patient’s knee with the hip in 90 degrees of flexion

76
Q

Define Brudzinski’s sign.

A

Patient’s hips and knees flex after the examiner passively flexes the neck

77
Q

Define the straight leg raise maneuver.

A

Replication of radicular pain when the patient’s hip is passively flexed with the knee in extension suggests nerve root irritation or compression

78
Q

Pronator drift (slow pronation and downward drift of outstretched supinated arm) associated with?

A

Subtle proximal upper limb weakness from a corticospinal tract lesion

79
Q

Strength grade 0?

A

No movement

80
Q

Strength grade 1?

A

Flicker of movement

81
Q

Strength grade 2?

A

Movement only if gravity is eliminated

82
Q

Strength grade 3?

A

Movement only against gravity

83
Q

Strength grade 4?

A

Movement against partial resistance

84
Q

Strength grade 5?

A

Movement against full resistance

85
Q

Define monoparesis and monoplegia.

A

Monoparesis - partial limb weakness

Monoplegia - complete limb weakness

86
Q

Define paraparesis and paraplegia.

A

Paraparesis - bilateral partial lower limb weakness

Paraplegia - bilateral complete lower limb weakness

87
Q

Define quadriparesis and quadriplegia.

A

Quadriparesis - bilateral partial upper and lower limb weakness

Quadriplegia - bilateral complete upper and lower limb weakness

88
Q

Define hemiparetic and hemiplegic.

A

Partial or complete weakness of the upper and lower limbs on one side

89
Q

Typical cause of hemiparesis/hemiplegia?

A

UMN lesion in the ipsilateral spinal cord or contralateral brain or brain stem

90
Q

Typical myopathic pattern of weakness in muscle disease?

A

Involves the proximal limbs (shoulders and hips)

91
Q

Typical neuropathic pattern of weakness in polyneuropathy?

A

Involves distal limbs (feet and later the hands)

92
Q

Bilateral myelopathic weakness typically associated with?

A

Bilateral spinal cord lesion at the thoracic level

93
Q

Bilateral quadriparesis/plegia typically associated with?

A

Bilateral spinal cord lesion at the cervical level

94
Q

Define muscle tone clinically.

A

Resistance felt by the examiner when passively moving a patient’s limb

95
Q

What are the two types of hypertonicity?

A

Spasticity

Rigidity

96
Q

Define spastic hypertonicity.

A

Increased tone is unequal between agonist and antagonist muscles; especially increased tone in anti-gravity muscles (upper limb flexors, lower limb extensors)

Clasp-knife -> perceived resistance varies, lessens with movement

97
Q

Spasticity indicates what kind of lesion?

A

UMN lesion involving the pyramidal or corticospinal tract

98
Q

Define rigid hypertonicity.

A

Increased tone feels equal between agonist and antagonist muscles

Lead pipe rigidity 9constant resistance)

99
Q

Rigidity indicates what kind of lesion?

A

Lesion in extrapyramidal system

100
Q

What causes cogwheel rigidity?

A

Presence of tremor in addition to rigidity

101
Q

General causes of hypotonicity?

A

Afferent sensory or LMN lesions that interrupt the reflex arc of the muscle stretch reflex

102
Q

Define muscle atrophy.

A

Decreased bulk or wasting of a muscle

103
Q

General causes of muscle atrophy?

A

LMN lesions
Myopathies
Milder degrees may be seenin UMN lesions or from disuse

104
Q

What is a grossly observable, spontaneous twitch of a group of muscle fibers innervated by a single LMN?

A

Fasciculation; aka spontaneous discharge of a motor unit

105
Q

What is a motor unit?

A

LMN, axon, muscle fibers

106
Q

What is a spontaneous twitch of an individual muscle fiber, visible only in the naked muscles of the tongue?

A

Fibrillation

107
Q

Fibrillations or Fasciculations (which one) always indicate denervation?

A

Fibrillations

108
Q

Describe the clinical signs of UMN lesions.

A 
Weakness: more diffuse
Atrophy: mild, general
Atrophy vs. weakness: severe weakness with relatively mild atrophy
Fasciculations: never seen
Muscle tone: increased (spasticity)
Muscle stretch reflexes: increased
Clonus: may be present
Babinski sign: may be present
109
Q

Describe the clinical signs of LMN lesions.

A 
Weakness: more focal
Atrophy: severe, focal
Atrophy vs. weakness: severe atrophy with relatively mild weakness
Fasciculations: may be present
Muscle tone: decreased
Muscle stretch reflexes: decreased to absent
Clonus: never present
Babinski sign: absent
110
Q

Which aspects of UMN lesions are absent in the setting of spinal or neurogenic shock?

A

Increased muscle tone
Increased muscle stretch reflexes
Clonus
Babinski

Thus, in spinal shock, paralysis is initially accompanied by diffuse hypotonia and areflexia.

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