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H & P > Neurology > Flashcards

Neurology Flashcards

1
Q

Components of the brain

A
  • Cerebrum (R & L cerebral hemispheres)
  • Each hemisphere subdivided into lobes:
    frontal, parietal, temporal, occipital
  • Diencephalon
  • Brainstem (midbrain, pons, medulla)
  • Cerebellum
  • Deep brain nuclei
  • Tracts, fascicles, commissures
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2
Q

PNS fxn

A

Connects CNS to muscles & glands

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3
Q

PNS components

A
  • Cranial nerves & ganglia
  • Spinal nerves & dorsal root ganglia
  • Enteric nervous system
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4
Q

Frontal lobe

A
  • Higher order cognition
  • Motor planning, execution
  • Speech (expression)
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5
Q

Parietal lobe

A

Somatosensation

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6
Q

Occipital lobe

A

Vision

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7
Q

Temporal lobe

A
  • Audition
  • Speech (reception)
  • Hippocampus (memory)
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8
Q

Spinal cord components

A
  • Ascending & descending tracts

- Gray matter

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9
Q

Gray matter vs white matter

A
  • Gray matter = neuronal cell bodies

- White matter = neuronal axons

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10
Q

Cerebral cortex

A
  • Extensive outer layer of gray matter of the cerebral hemispheres
  • Largely responsible for higher brain fxns
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11
Q

Cerebellar cortex

A

Superficial gray matter of the cerebellum

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12
Q

Where do the 12 cranial nerves arise?

A
  • Brain (I & II)
  • Diencephalon
  • Brainstem
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13
Q

How many spinal nerves attach to the spinal cord?

A

31 pairs:

  • 8 cervical
  • 12 thoracic
  • 5 lumbar
  • 5 sacral
  • 1 coccygeal
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14
Q

Upper motor neurons

A
  • Nerve cell bodies that lie in the cerebral cortex & in several brainstem nuclei
  • Axons synapse w/ motor nuclei in the brainstem (for CNs) & in the spinal cord (for peripheral nerves)
  • Babinski sign present
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15
Q

Lower motor neurons

A
  • Nerve cell bodies in the spinal cord (anterior horn cells)
  • Axons transmit impulses through the anterior roots & spinal nerves into peripheral nerves
  • Terminate at the neuromuscular junction (interface btwn the nerve at the synaptic junction & the muscle fiber)
  • Connect brainstem & spinal cord to muscle fibers (bringing UMNs to muscles)
  • Axon terminates on an effector
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16
Q

What are the 3 motor pathways?

A
  1. Corticospinal tracts
  2. Basal ganglia system
  3. Cerebellar system
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17
Q

Through what 2 pathways does UMN control LMN?

A
  1. Pyramidal tract
    - Corticospinal tract
  2. Extrapyramidal tract
    - Reticulospinal
    - Vestibulospinal
    - Tectospinal
    - Rubrospinal tract
    - Corticobulbar tract
    - Corticorubral tract
    - Olivospinal tract
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18
Q

Extrapyramidal tract

A
  • Centers on the modulation & regulation (indirect control) of anterior (ventral) horn cells.
  • Modulates motor activity w/out directly innervating motor neurons
  • Can be involved w/ involuntary movements
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19
Q

Corticospinal tracts: Origin

A

Motor cortex of brain

- Travels into lower medulla –> crosses to contralateral side of the body –> synapses w/ anterior horn cells

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20
Q

Corticospinal tracts: Actions

A
  • Mediates voluntary & complicated delicate movements by stimulating selected muscle actions, inhibiting others
  • Inhibits muscle tone
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21
Q

Corticospinal damage

A

Diminished fxn below level of injury

  • Affected limb becomes weak or paralyzed
  • Skilled or delicate movements are poor when compared to gross movements s/a walking
  • Other effects depend on whether the damage is in UMN or LMN
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22
Q

LMN fxn

A
  • All voluntary movement depends upon excitation of LMN by UMN
  • The only neurons that innervate skeletal muscle fibers
  • Fxn as the final common pathway
  • Final link btwn CNS & skeletal muscles
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23
Q

UMN lesions

A
  • Damage above the crossover in the medulla –> motor impairment on contralateral side
  • Damage below the crossover –> motor impairment on ipsilateral side
  • Muscle tone is increased & deep tendon reflexes are exacerbated (due to loss of muscle tone inhibition)
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24
Q

LMN lesions

A
  • Damage = ipsilateral motor impairment (weakness or paralysis)
  • Muscle tone & reflexes are decreased or absent
  • Atrophy & fasciculations present
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25
Q

Basal ganglia system

A
  • Complex motor pathway

- Includes pathways btwn cerebral cortex, basal ganglia, brainstem & spinal cord

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26
Q

Basal ganglia actions

A

Maintain muscle tone & control body movements, esp. gross automatic movements s/a walking

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27
Q

Basal ganglia damage

A
  • Does not result in paralysis but causes:
    1. Changes in muscle tone (usually increased)
    2. Involuntary muscle movements
    3. Disturbances in posture & gait
    4. Slow or absent automatic movements (bradykinesia)
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28
Q

Cerebellar actions

A
  • Coordinates motor activity
  • Maintains equilibrium
  • Controls posture
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29
Q

Cerebellar damage

A
  • Impairs coordination, gait & equilibrium

- Decreases muscle tone

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30
Q

What do sensory impulses participate in?

A
  • Reflexes
  • Conscious sensation
  • Calibration of body position
  • Regulation of internal autonomic fxns

*BP, HR, RR

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31
Q

Sensory pathway fxn

A
  • Relay impulses from skin, muscles, viscera through peripheral nerves & posterior roots to enter spinal cord
  • Once inside spinal cord, impulses are transmitted to sensory cortex via:
    1. Posterior column pathway
    2. Spinothalamic tracts
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32
Q

Spinothalamic tracts

A
  • Sensory afferent fibers conducting light touch, pain, & temperature pass into the posterior horn of spinal cord & synapse w/ secondary neurons
  • Secondary neurons cross to contralateral side –> travel upward in the spinothalamic tracts to the thalamus
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33
Q

What does the thalamus do?

A

Transmits sensory impulses to cerebral cortex

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34
Q

Posterior columns

A
  • Sensory afferent fibers conducting discriminative touch, proprioception, & vibration pass directly into posterior columns of the spinal cord & don’t synapse w/ secondary neurons until they reach the medulla
  • Secondary neurons cross to contralateral side & travel to the thalamus
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35
Q

Spinothalmic tracts: Neurons (3)

A
  • 1st enters spinal cord
  • 2nd decussates in spinal cord & travels to thalamus
  • 3rd conveys info from thalamus to specific area of cortex
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36
Q

Posterior columns: Neurons (3)

A
  • 1st enters cord & ascends ipsilaterally
  • 2nd decussates in medulla & travels to thalamus
  • 3rd conveys info from thalamus to specific area of cortex
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37
Q

Spinocerebellar tracts

A
  • Conveys info re: unconscious proprioception to cerebellum
  • Proprioceptive to cerebellum
  • Posterior & anterior
  • Ipsilateral (does not decussate)
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38
Q

Spinocerebellar tract: Neurons (2)

A
  • Primary neuron from receptor to spinal cord

- Secondary neurons from spinal cord to cerebellar cortex

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39
Q

Myelopathy

A

Any functional disturbance &/or pathological change in the spinal cord
- UMN lesion

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40
Q

How is myelopathy characterized?

A
  • Increased tone, elevated reflexes
  • Proprioception changes
    • Romberg
  • Crossed findings (sensory & motor)
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41
Q

Radiculopathy

A

Disease of the nerve root

  • LMN lesion
  • Involve injury from pressure or other mechanical causes
  • Cervical roots C5-8 innervate upper extremities
  • Lumbosacral roots L3-S1 innervate lower extremities
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42
Q

How is radiculopathy characterized?

A
  • Loss of reflexes
  • Lancinating pain
  • Focal distributed weakness
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43
Q

Mononeuropathy

A

Damage to a single nerve or nerve group

- LMN lesion

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44
Q

How is mononeuropathy characterized?

A

Loss of movement, sensation, &/or other fxn

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45
Q

Examples of mononeuropathy

A
  • Carpal tunnel syndrome: median nerve compression

- Ulnar nerve compression

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46
Q

Median nerve compression

A
  • Sensory loss – 1st 3 ½ digits
  • Motor loss – thenar (abductor pollicus brevis, opponens)
  • Pain – nocturnal in 1st 3 ½ digits & forearm
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47
Q

Ulnar nerve compression

A
  • Sensory loss - 4th & 5th digits
  • Motor loss - hypothenar (abductor digiti minimi, 1st dorsal interosseous)
  • Pain - 4th & 5th digits & tenderness at elbow
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48
Q

Romberg test

A
  • Tests position sense (posterior columns)
  • Check Romberg before gait testing to avoid a fall
    1. Instruct pt to stand w/ feet together & eyes open
    2. Ask him/her to close eyes for 30-60 secs w/out support
  • Stand close to pt to prevent fall
  • Loss of balance = + Romberg = ataxia due to posterior column disease
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49
Q

Ataxia due to cerebellar disease

A

Results in difficulty standing w/ feet together, whether eyes or open or closed

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50
Q

Pronator drift

A
  • Test for contralateral corticospinal tract lesion (UMN)
    1. Pt should stand w/ arms extended outwards & palms up for 20-30 secs w/ eyes closed (pronation & downward drift of arm = +)
  • Detects subtle contralateral UMN lesion
51
Q

Mental status exam (MSE)

A
  • Begins when you 1st meet & continues throughout exam
  • Assessing “JOMAC” : Judgement, Orientation, Memory, Affect, Cognition
  • Formal testing only indicated when deficits are present
52
Q

MSE: Behavior & appearance

A
  • Grooming, dress, hygiene
  • Mood
  • Affect
53
Q

MSE: Orientation

A
  • Name
  • Place
  • Time
  • Situation
54
Q

MSE: Level of consciousness

A
  • Alert, lethargic, stuporous, comatose

- Responsive vs. non-responsive

55
Q

MSE: Recent memory

A

Recall 3 random words after 1 min

56
Q

MSE: Remote memory

A

Ask about well known events, dates, & locations

57
Q

MSE: Attention span/calculation

A
  • Serial 7s

- Spell WORLD (forwards & backwards)

58
Q

Cerebellar examination: Coordination

A
  • Assess for overall balance, equilibrium, & coordination of movement
  • Finger to nose
  • Heel to shin
59
Q

Finger to nose

A
  • Pt alternates touching the examiner’s finger, then his/her own nose
  • Detects dysmetria
60
Q

Heel to shin

A
  • Pt slides his/her heel of 1 foot down shin of other leg slowly & smoothly
  • Instruct pt to repeat 1 time, then switch legs in order to test cerebellar fxn bilaterally
61
Q

Cerebellar examination: Rapid alternating movements (RAMs)

A

Observe for speed & coordination while assessing 1 of the following:

  • Rapid pronation & supination of forearms
  • Touching fingertips to thumb
  • Tapping feet
62
Q

Cerebellar examination: Dysdiadochokinesia

A
  • Inability to do RAMs
  • Slow, but regular –> cerebral dysfunction
  • Fast, but irregular –> cerebellar dysfuntion
63
Q

Neuro exam: Sensory

A
  • Done in random fashion, on pts w/out specific sensory complaints
  • For those w/ sensory complaints, testing is performed in a methodical fashion
  • All testing is done w/ pt’s eyes closed
  • Pt must be alert & cooperative for reliable results
  • Start distally on each extremity & work proximally
  • Keep in mind underlying dermatomal patterns
64
Q

Important landmarks: Upper extremities

A
  • Thumb: C6
  • Middle fingers: C7
  • 5th digit: C8
65
Q

Important landmarks: Trunk

A
  • Nipple line: T4

- Umbilicus: T10

66
Q

Important landmarks: Lower extremities

A
  • Anterior thigh: L3
  • Anterior shin: L4
  • Top of foot: L5
  • Bottom of foot: S1
67
Q

Sensory exam: Light touch

A
  • Use cotton-tipped applicator to lightly touchskin
  • Instruct the pt to acknowledge when they feel the touch
  • Start distally, work proximally
68
Q

Sensory exam: Pain sensation

A
  • Check for sharp vs. dull by alternately using a cotton tipped applicator broken in 1/2
  • Start distally, work proximally
69
Q

Neuro exam: Reflexes

A
  • Involuntary defense mechanisms (involve as few as 2 neurons - 1 sensory afferent, 1 motor efferent)
  • Integrity of reflexes dependent upon intact afferent, synaptic, & efferent neurons
70
Q

Biceps reflex

A

C5-C6

- Indirectly tap biceps tendon to elicit forearm flexion

71
Q

Triceps reflex

A

C7-C8

- Tap triceps tendon to elicit forearm extension

72
Q

Patellar reflex

A

L3-L4

- Tap patellar tendon to elicit knee extension

73
Q

Achilles reflex

A

S1-S2

- Tap Achilles tendon to elicit plantar flexion

74
Q

Plantar response (Babinski)

A

L4-S1

  • Stroke lateral aspect of the sole from heel to ball of foot
  • Normal response = plantar flexion
  • Dorsiflexion of big toes = + response
  • Associated w/ CNS (UMN) lesion in corticospinal tract
75
Q

Clonus

A
  • Involuntary rhythmic oscillations btwn contraction & relaxation (e.g. btwn plantar & dorsiflexion)
  • Seen w/ hyperactive reflexes; consistent w/ UMN disease
76
Q

Brachioradialis

A

C5-C6

- Tap tendon/radium about 1-2+ inches above wrist to elicit forearm flexion & supination

77
Q

Involuntary movements

A
  • Tics
  • Oral-facial dyskinesias
  • Chorea
  • Athetosis
  • Myoclonus
  • Tremors
78
Q

Tics

A
  • Brief, repetitive twitching, usually of face or upper trunk
  • May see winking, grimacing, or shrugging
  • Causes: idiopathic, drugs, Tourette’s
79
Q

Oral-facial dyskinesias

A
  • Rhythmic, repetitive, bizarre movements of face, mouth, jaw, & tongue
  • Associated w/ psychotropic meds
80
Q

Chorea

A
  • Rapid, jerky movements of face, trunk & extremities

- Seen w/ Huntington’s disease

81
Q

Athetosis

A
  • Writhing, twisting movements of face, trunk & extremities
  • Seen w/ cerebral palsy
82
Q

Myoclonus

A

Brief, involuntary twitching of a muscle or a group of muscles

83
Q

Resting tremor

A
  • Most prominent at rest
  • Disappears w/ movement
  • Seen w/ Parkinson’s
84
Q

Postural tremor

A
  • Appears when actively maintaining posture (head or extremity)
  • Seen w/ benign familial tremor & hypothyroidism
85
Q

Intention tremor

A
  • Absent at rest; appears when reaching for target
  • Seen w/ aging, cerebellar disease & MS
  • May be familial
86
Q

Asterixis (aka. liver flap)

A
  • Abnormal tremor consisting of involuntary jerking movements, esp. in the hands
  • Assoc. w/ various encephalopathies
  • Can be a sign of hepatic encephalopathy (assoc. w/ cirrhosis)
87
Q

Disorders of muscle tone

A
  • Spasticity
  • Rigidity
  • Flaccidity
88
Q

Spasticity

A
  • Increased tone, worse w/ rapid movement

- Due to UMN disease; loss of tone inhibition

89
Q

Rigidity

A
  • Increased tone & resistance to movement; independent of rate of movement
  • Seen w/ basal ganglia disease
  • E.g. “cog-wheel” rigidity in Parkinson’s
90
Q

Flaccidity

A
  • Decreased tone

- Due to LMN disease (spinal cord or root injury)

91
Q

Seizure

A
  • Sudden disruption of the brain’s normal electrical activity - Accompanied by altered consciousness &/or other neurological & behavioral manifestations
92
Q

Status epilepticus

A
  • Life-threatening continuous series of generalized tonic-clonic seizures w/out return to consciousness btwn them
  • Tonic (rigid), clonic (uncontrolled jerking)
93
Q

Epilepsy

A

Recurrent seizures that may include repetitive muscle jerking (convulsions)

94
Q

Dementia

A
  • Irreversible state of cognitive impairment & short term memory loss
  • Related to organic brain disease, most commonly Alzheimer’s or multiple cerebral infarcts
  • At risk for delirium
95
Q

Delirium

A

Treatable acute state of cognitive impairment & confusion that may be related to illness, medications, or other causes

96
Q

Lethargy

A

Pt is sleepy, but will open eyes & respond before falling back to sleep

97
Q

Obtundation

A
  • Harder to arouse w/ verbal stimuli – may need to shake him/her
  • Responses are slower & tend to be confused; decreased interest in environment
98
Q

Stupor

A
  • Often cannot be aroused unless painful stimuli is applied
  • Voice & shaking ineffective
  • Lapse into unresponsiveness when stimuli cease; minimal awareness of self or environment
99
Q

Coma

A

Sustained loss of consciousness that does not reverse w/ internal or external stimulation

  • Associated w/ significant mortality (90% of people who survive awaken in 1st 3 days)
  • Does not respond to verbal or painful stimuli
  • Eyes closed & unarousable; no response to environment
100
Q

Causes of coma

A
  • Cardiac arrest
  • Overdose
  • Stroke
  • Cerebral edema
  • Metabolic conditions
  • Traumatic brain injury
  • Untreated status epilepticus
101
Q

Glasgow coma scale

A

Aims to give a reliable, objective way of recording the conscious state of a person

  • Eye opening
  • Motor response
  • Verbal response
  • Total score = E+M+V (15 = wide awake, 3 = deep coma)
  • Head injury: Score of < or = 8, or coma > 72 hrs = poor prognosis
102
Q

Other coma assessments

A
  • Posturing
  • Pupillary responses
  • Brainstem reflexes
  • Oculocephalic
  • Vestibulocochlear reflex
  • Respiratory patterns
103
Q

Abnormal posturing: Decerebrate rigidity

A
  • Abnormal extensor response
  • Jaws are clenched & neck extended
  • Extension of elbows & adduction of arms w/ forearms pronated
  • Legs extended & feet plantar flexed
  • Implies a lesion in the diencephalon or brainstem
  • Can occur w/ hypoxia or hypoglycemia
104
Q

Abnormal posturing: Decorticate rigidity

A
  • Abnormal flexor response
  • Flexion of elbows, wrists, fingers & adduction of arms
  • Legs extended & internally rotated, feet plantar flexed
  • Implies a destructive lesion of the corticospinal tracts near the cerebral hemispheres (brain damage)
105
Q

Brain herniation

A
  • A deadly consequence of very high ICP
  • Brain is squeezed across structures within the skull
  • Frequently present w/:
    ˚ Abnormal posturing
    ˚ GCS of 3-5
    ˚ 1 or both pupils dilated & fail to constrict
    ˚ Tx is urgent –> decompressive craniectomy
    ˚ Poor prognosis
106
Q

Oculocephalic reflex (“doll’s eyes”)

A
  • Hold pt’s eyes open & rotate his/her head side to side
  • Normal response: eyes move opposite of head
  • If eyes remain fixed & move in the same direction of the head movement = brainstem lesion (CN III – CN VIII)
    ˚ “Doll’s eyes absent”
107
Q

Vestibulocochlear reflex

A
  • Hold pt’s head at 300; lavage ear w/ ice-cold water
  • Normal response: Slow eye deviation toward ear (stimulus)
  • No response = brainstem lesion (CN III – CN VI)
108
Q

Alterations in mood

A

Mood: Internal emotional tone

  • Dysphoric: unhappy, depressed, dissatisfied
  • Euphoric: mild elation; exaggerated feelings of wellbeing
  • Anxious
  • Angry
109
Q

Alterations in affect

A

Affect: external range of expression, objective assessment of mood
- Full/normal: appropriate range of emotions
˚ “Affect congruent with mood”
- Blunted or restricted: moderately reduced range of affect
- Flat: absence of all or most affect
- Labile: multiple abrupt changes in affect

110
Q

Dysarthria

A
  • Problem w/ motor speech or articulation
  • Seen w/ bulbar or pseudobulbar palsy
  • Bulbar palsy: impairment CNs IX, X, XI & XII, which occurs due to a LMN lesion either at the medulla or from lesions of the lower cranial nerves outside the brainstem
  • Pseudobulbar palsy: impairment CNs IX-XII due to UMN lesions of the corticobulbar tracts in the pons
111
Q

Dysphonia

A
  • Weak or breathy voice
  • Vocal cords not well approximated
  • Seen w/ presbyphonia, vocal cord nodules, polyps, tumors, or paralysis
112
Q

Aphasia

A

Impairment of language ability

- Common w/ strokes, trauma, & mass lesions

113
Q

Receptive (Wernicke’s) aphasia

A

Comprehension not intact; fluent, but nonsensical speech

114
Q

Expressive (Broca’s) aphasia

A

Comprehension intact; unable to speak to varying degrees

115
Q

Global aphasia

A

Combination of receptive & expressive aphasia

116
Q

Apraxia

A

Inability to perform a learned motor act despite desire & physical ability to perform

  • Disorder of motor planning
  • May be seen w/ parietal lobe lesions
117
Q

Agnosia

A
  • Inability to recognize sensory stimuli
  • Any sensory modality can be affected (e.g. olfactory or auditory agnosia)
  • Associated w/ large parieto-occipital-posterior temporal lesion (CVA or dementia)
118
Q

Vibration (128 Hx tuning fork)

A
  • Place on bony prominence; ask what is felt & when it stops
  • If distal areas (e.g. fingers & toes) are normal, can assume proximal areas are also normal
  • Often the 1st sensation to be lost w/ peripheral neuropathy
119
Q

Proprioception

A
  • Move thumb up & down; ask pt to identify the direction.
  • Repeat w/ great toe
  • Technique: hold the sides of the digit
  • If distal areas (e.g. fingers & toes) are normal, can assume proximal areas are also normal
  • Can occur w/ MS or B12 deficiency due to posterior column disease
  • Can also occur w/ peripheral neuropathy
120
Q

Discriminative sensations

A
  • Test the ability of the sensory cortex to interpret sensations
  • These sensations also rely on touch & proprioception (Therefore testing discriminative sensations is only useful when touch & position sense are intact)
  • Sterognosis, graphethesia, 2-point discrimination
121
Q

Testing sensory cortex

A
  • Stereognosis: ask pt to identify common object placed in hand
  • Graphesthesia: draw a # (0-9, oriented to the pt) on his/her palm &/or dorsum of his foot & ask him/her to to identify it
  • 2 point discrimination: move 2 pins closer together until pt can only appreciate 1 point (Normal - Fingerpads < 5mm, Toes 3-8 mm)
122
Q

Tactile localization (aka “extinction” or “double simultaneous tactile stimulation”)

A
  • Simultaneously touch the pt on 2 separate sites
    on opposite sides of the body & ask what he/she feels
  • W/ a lesion of the R sensory cortex, the pt may not be able to recognize the stimulus on the L side of the body & vice versa
123
Q

Kernig’s sign

A
  • Supine - flex hip & knee, & attempt to straighten leg
  • Low back pain w/ maneuver = + = meningeal irritation
124
Q

Brudzinski’s sign

A
  • Supine - place hands behind neck & attempt to flex the neck toward the chest
  • Involuntary flexion of hips & knees = + = meningeal irritation

H & P (8 decks)

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