Neurology Flashcards
Neuro exam
Mental status Cranial nerves Deep Tendon Reflexes Tone Power Sensation Cerebellar Gait
Seizure investigations
EEG CT head CBC, lytes Medications- eg phenytoin levels LP (if new onset, fever, clinical signs)
Seizure history
- onset, chronology
- frequency- increasing, decreasing
- duration
- describe seizures: sequence of events, movements, salivation, tongue biting, incontinence, incontinence, aura (visual, smell)
- new symptoms: headache, vomiting, neuro deficits
- post itcal: headache, limb pain, todd’s paralysis
- medications: which ones, dose, how long, compliance
- Basic info: PMHx, PSHx, Meds, Allergies
Focused physical exam for a 60 year old female with acute confusion
vitals GCS Cranial nerve exam CNII- visual fields, fund CNIII- EOM CN II, III pupillary reflex, accommodation CN V facial sensation, clench teeth CN VII facial movements CN IX, X: gag, movement of palate CN VIII: hearing, CXI: sternocleidomastoid power, trapezius CXII: tongue
Power: arms, legs, hands Sensory: light touch, pin prick Reflexes Babinski Cerebellar: finger to nose, heel to shin Tone: cog wheeling Gait Balance (rhomberg)
Resp
Cardio
Abdomen
Infectious signs?
GCS
E
V
M
Eyes 4- spontaneous open 3- open to speech 2- open to pain 1- never
Verbal 5-oriented and converses 4- confused conversation 3- inappropriate words 2- incomprehensible sounds 1- none
Motor
6- obeys commands
5- localizes pain
4- withdraws to pain
3- decorticate position (abnormal flexion- arms adducted, flexed at elbows, wrist, feet in plantar flexion)
2- decerebrate position (abnormal extension- arms adducted, pronated, extended at elbow, flexed at wrist, plantar flexion)
1-none
Ddx neck pain and left arm weakness
- Musculoskeletal/muscular strain
- Disc degeneration, disk herniation
- Spondylosis (degenerative, osteoarthritis)
- cervical spondylytic myelopathy (degenerative changes narrowing the spinal canal)
- cervical radiculopathy (dysfunction of the spinal nerve root that may manifest with pain, weakness, reflex changes, or sensory changes)
- Malignancy
Red flags for neck pain/those who need imaging
History of recent significant fall or major trauma Unexplained weight loss Fever or chills History of cancer Immunosuppression Intravenous drug use Chronic steroid use Neurological signs or symptoms (arm clumsiness, gait difficulty, bowel or bladder dysfunction, Babinski's sign)
Neck Pain exam
Inspection: symmetry, erythema/bruising, atrophy (sternocleidomastoids), deformity,
Palpation: notes, masses, dorsal vertebral spines
Neck range of motion: flex, extension, rotation, lateral flexion
Shoulders/arms/hands
- inspection: symmetry, atrophy, deformity, skin lesions
- strength:
- Bicep flex: C5, C6
- Tricep ext: C6,7,8
- wrist extension: C6,7,8
- Grip: C7,8,T1
- Finger abduction: C8,T1, ulnar
- Opposition of thumb: C8,T1, median
- Sensation
- Deep tendon reflexes
Investigations
Indications for neck xray
- Age >50 years with new symptoms
- Constitutional symptoms (fevers, chills, unexplained weight loss)
- Moderate to severe neck pain lasting more than six weeks
- Progressive neurological findings
- Infectious risk (eg, injection drug use, immunosuppression)
- History of malignancy
Sensation of the hand
- median
- ulnar
- radial
Median: palmar surface of thumb, index, middle, thenar side of ring finger
Ulnar: 4th and 5th finger (dorsal and palmar)
Radial: dorsal surface of thumb, index, middle to PIP
Cervical radiculopathy management
- conservative therapy: soft collar, NSAIDS and acetaminophen
- if persistent symptoms then refer to neurosurgery, may ask for CT neck, may require surgery (decompressive laminectomy, anterior disectomy/graft fusion)
History for Carpel tunnel syndrome
age, occupation
-work done with hands
-onset, duration, chronology, time of day,
aggravating/relieving factors
-previous episodes, previous investigations
- associated symptoms: pain at night, diff opening jars, previous injuries
- functional limitations/work limitations
- neuro symptoms: pain, numbness, weakness in other areas, vision, headache, neck pain, nausea
Basic info: PMHx-diabetes, hypothyroid, rheumatoid artheritis, pregnancy, PSHx, meds, allergies,
Differential for carpal tunnel syndrome
carpal tunnel syndrome
cervical radiculopathy
brachial plexus injury
diabetic peripheral neuropathy
Investigations for carpal tunnel syndrome
Nerve conduction studies
Treatment for carpal tunnel syndrome
- wrist splint
- modified work
- local corticosteroid injection
- surgical decompression via flexor retinaculum release
Physical exam for carpal tunnel syndrome
Arm/wrist/hand
- strength: wrist extension (radial), finger abduction (ulnar), thumb opposition (median)
- reflexes
- sensation median, ulnar, radial distribution
Differential for 42 yo M found unconscious in street with GCS 11 and unilateral body weakness
Seizure, post itcal Stroke Intracranial hemorrhage Brain contusion Spinal cord injury
History of unconscious person
- sequence of events leading to collapse
- trauma?
- seizure?
- syncope?
- LOC?
- Injuries from fall
SAMPLE
To clear Cspine
Negative imaging
No distracting injuries
No tenderness on palpation of dorsal spinous processes
rotation to left and right not painful
Treatment of trauma patient who had loss of consciousness/unilateral weakness
- Vitals
- ABC’s (intubation if reps compromise, bolus is low BP), immobilize C-spine
- Trauma bloods: CBC, blood gas, lytes, liver enzymes, Cr
- Disability: GCS, pupils. If increased ICP- dilantin load, manitol, consult neurosurgery
- CT neck, CT head
Parkinson’s Disease
-features on exam
TRAP
Tremor: resting, pill rolling, suppressible with voluntary movement
Ridgitidy- cog-wheeling
Akinesia/bradykinesia
Postural instability: shuffling gait, retropulsion, falls
Other features:
mask like face
loss of arm swing
Parkinson’s disease
-features on history
drooling hypophonia micrographia dementia r/o depression
Physical exam for parkinson’s
Inspection: tremor, posture, face, decreased blinking
MMSE- short term memory, concentration, abstraction, micrographia
Neuro exam: CN Power DTR Sensation Tone Cerebellar Gait
Mini-mental status exam
- Orientation:
- year/season/month/date/ day of week
- place: country/province/city/hospital/floor - memory: 3 words -immediate and delayed recall
- Concentration: spell world backwards
- Language:
- comprehension: 3 step command
- reading: close our eyes
- writing: has to write 1 sentence
- repetition: no ifs, and, or buts
- naming: watch, pen
- spatial ability: 2 intersecting pentagons
Allen test
- compress ulnar and radial arteries at wrist
- have patient open and close hand to remove blood
- then release one side
- hand should pink up due to blood supply
- to demonstrate ulnar artery function
Head injury neuro exam
ABC-DE GCS, pupils SAMPLE history 2nd survey -log roll -spine
Neuro exam
- CN
- blood from ears and nose
- power upper and lower extremity
- reflexes
- sensation
Differential diagnosis for head injury
- concussion
- bleeds: subarachnoid, subdural, epidural, brain contusion
- seizure
- spinal cord injury
Management of head injury
CT head/neck
Neurosurgery consult
May need MRI to delineate injuries further
