OHCEPS - The Nervous System Flashcards

Question

Dysphonia is?

Answer 1

Defective volume - huskiness,

Answer 2

1. Laryngeal disease 2. Laryngeal nerve palsy 3. Rarely muscular disease such as myasthenia gravis. 4. May also be psychological.

Answer 3

Defect of language, NOT JUST SPEECH, so reading and writing may also be affected - some patients attempt to overcome speaking difficulties with a notepad and a pen only to be bitterly disappointed.

Answer 4

Patient is unable to speak or understand speech at all. | Broca and Wernicke affected.

Answer 5

1. Lesion in Broca (frontal lobe) - involved in language production. 2. Understanding remains intact. 3. Unable to answer questions appropriately. 4. Speech is non-fluent, broken with abnormal word ordering. 5. Unable to repeat sentences.

Answer 6

Anterior, motor, or Broca's dysphasia.

Answer 7

1. Lesion in Wernicke - Problems understanding spoken or written language (dyslexia) and problems with word-finding. 2. Unable to understand commands or questions. 3. Speech is fluent with lots of meaningless grammatical elements. 4. May contain meaningless words. 5. Unable to repeat sentences. 6. Patients are often unaware of their speech difficulty and will talk nonsense contentedly --> although may become frustrated with other people's lack of understanding!!!

Answer 8

Posterior, sensory, or Wernicke's dysphasia.

Answer 9

Describes a severe form of receptive dysphasia containing only meaningless words (neologisms) and sounds.

Answer 10

The supplementation of one word with another.

Answer 11

1. Lesions in the arcuate fasciculus and/or other connections between the 2 primary language areas. 2. Patient can comprehend and respond appropriately. 2. Unable to REPEAT A SENTENCE.

Answer 12

1. All language function is intact EXCEPT for naming of objects. 2. Caused by lesion in angular gyrus. 3. Patient may function with "circumlocution" --> eg says "that thing that I write with" if unable to say "pen".

Answer 13

With the abbreviated mental test score (10 points).

Answer 14

1. Date of birth 2. Age 3. Time 4. Year 5. Place 6. Head of state --> Who is the prime minister --> NAME is required. 7. WWII --> What year did the WWII started? 8. 5-minute recall --> Tell the patient an address (often 42 West street is used) and ask them 5min later to recall it. 9. 20-1 --> Backward counting from 20 to 1. 10. Recognition --> What job do I do? (doctor) and "What job does this man/woman do?" (nurse) --> BOTH must be correct to score a point.

Answer 15

1. Fibers arise in the mucous membrane of the nose. 2. Axons pass across the cribriform plate to the olfactory bulb. 3. Olfactory tract runs backwards below the frontal lobe + projects, mainly, in the uncus of the ipsilateral temporal lobe.

Answer 16

Olfactory epithelium also contains free nerve endings of the 1st division of CN V.

Answer 17

Take a nearby odorous object (coffee, chocolate) and ask the patient if it smells normal.

Answer 18

A series of identical bottles containing recognizable smells are used. The patient is asked to identify them. Commonly used agents: 1. Coffee 2. Vanilla 3. Camphor 4. Vinegar --> Test EACH nostril separately + determine if any loss of smell is uni- or bilateral.

Answer 19

Usually NASAL, not neurological.

Answer 20

1. URI 2. Trauma 3. Smoking 4. Old age 5. Parkinson 6. Less commonly tumors of the ethmoid bones or congenital ciliary dysmotility syndromes.

Answer 21

1. Mucous-blocked nostril. 2. Head trauma 3. Subfrontal meningioma

Answer 22

1. Peppermint 2. Ammonia 3. Methanol stimulate the FREE TRIGEMINAL ENDINGS so are not as a good test of CN I.

Answer 23

Optic nerve begins

Answer 24

A Snellen's chart.

Answer 25

1. In good light, the patient should stand 6m away from the chart. 2. Each eye is tested in turn and the patient is asked to read the chart. 3. The number above each line indicates the distance at which a person with normal sight should be able to read it. 4. Record the line reached - allow max of 2 errors/per line. 5. Indicate results as: distance from chart/distance it should be read eg 6/36.

Answer 26

1. Count Fingers held in front of their face (CF) 2. See hand movements (wave your hand). 3. Perceive light --> CF, HM, PL, or NPL (not perceive light).

Answer 27

1. Not tested routinely. | 2. Tested using Ishihara plates.

Answer 28

The area that the eye can see without moving is NOT CIRCULAR --> Eyebrows and nose obstruct superiorly and nasally whereas there is no obstruction laterally.

Answer 29

1. Sit opposite the patient, 1m, eyes levels. 2. Test first for gross defects + visual neglect with both eyes open. 3. Raise your arms up to the sides so that one hand is in the upper right quadrant of your vision and one in the upper left. 4. Ask patient to look directly at you ("look at my nose"). 5. Move one index finger and ask the patient, while looking straight at you, to point to the hand which is moving. 6. Test with the right, left, and with both hands. 7. Test the lower quadrants in the same way. 8. If VISUAL NEGLECT is present --> patient will be able to see each hand moving individually but reports seeing only one hand when BOTH are moving.

Answer 30

1. Like much of the neurological exam, gross defects can be seen without the patient's cooperation (confused or drowsy). 2. Test for response to "menace" by bringing your hand in sharply from the side, stopping just short of hitting the patient in the eye. 3. If your hand can be seen, the patient will BLINK. 4. Test vision on the left and the right side.

Answer 31

Confusing term --> Constricted visual field, giving the impression of looking down a pipe or tunnel.

Answer 32

1. Glaucoma 2. Retinal damage 3. Papilledema 4. Often "functional"

Answer 33

Caused by papilledema.

Answer 34

Blindness in one eye caused by devastating damage to the eye, its blood supply, or optic nerve.

Answer 35

A hole in the visual field (macular degeneration, vascular lesion or, if bilateral, toxins). If bilateral may indicate a very small defect in the corresponding area of the occipital cortex (MS) !!!

Answer 36

Nasal half of BOTH retinas, and therefore, the temporal half of each visual field is lost (damage to the center of the optic chiasm such as a pituitary tumor, craniopharyngioma, suprasellar meningioma).

Answer 37

The nasal half of each visual field is lost (very rare).

Answer 38

1. May be left or right. 2. Commonly seen in stroke patients 3. Right OR Left side in both eyes is lost. 4. If the macula is spared --> lesion in the optic radiation. 5. If the macula is NOT spared --> lesion in the optic tract.

Answer 39

Corresponding quarters of the vision is lost in each eye .

Answer 40

Lesion in TEMPORAL LOBE.

Answer 41

Lesion in the parietal lobe.

Answer 42

It is often worth dilating the pupil by instilling a few drops of mydriatic - 1% tropicamide or 1% cyclopentolate - into the inferior conjunctival sac. With a little practise one often finds that this is not necessary for a routine exam.

Answer 43

If they have a history of angle closure glaucoma or episodes of seeing haloes around lights at night-time.

Answer 44

1. Performed in a dimly lit room. 2. Ask patient to focus on distant object + keep eyes still. 3. Look through the ophthalmoscope (OS) 30cm away from the patient and bring the light in nasally from the temporal field to land on the pupil. 4. Dial up a hypermetropic (plus) lens on the OS to focus on the corneal surface + move in as close as possible to the patient's eye --> By gradually decr. the power of lens --> examine cornea, iris, and lens in turn. 5. Continue to decr. power of the lens until you can sharply focus on the retinal vessels. 6. It is often best to pick up one of the vascular arcades in the periphery and track them in towards the optic disc. 7. Take time to look carefully - esp. where the arteries cross veins. 8. Ask the patient to look directly into the light of the OS to gain a view of the vascular region.

Answer 45

1. Healthy disc is pale pink/yellow and round or slightly oval in shape. 2. Margins between disc and surrounding retina should be crisp and well defined --> Occasionally a surrounding ring is present which may be slightly lighter or darker in color. 3. At the centre of the disc is the physiological cup. It appears paler in color compared to the rest of the disc.

Answer 46

1. Located temporally from the optic disc. 2. This is the region with the maximum concentration of cones. 3. At the centre of the macula is the fovea --> tiny pit DEVOID OF BLOOD VESSELS and responsible for fine resolution. 4. Disease involving the macula and fovea can cause devastating visual loss.

Answer 47

1. The central retinal artery/vein enter and leave the globe in the center of the optic disc. 2. Veins appear larger and darker in color in comparison to the arteries. 3. Spontaneous venous pulsations are seen in many normal eyes. 4. Arterial pulsations should NOT be visible in normal eyes.

Answer 48

View the macula by directing the light on the most sensitive part of the eye. This can often be unpleasant for the patient and will lead to more marked miosis and a restricted view.

Answer 49

1. Raised, swollen, enlarged. 2. Disc often appears darker in color 3. Margins of the disc are blurred and become indistinct from the adjacent retina. 4. Retinal vessels can be seen arching down from the raised disc towards the peripheral retina. 5. In severe cases --> Retinal hemorrhage may be seen around the disc.

Answer 50

Swelling of the optic disc due to INCR. INTRACRANIAL PRESSURE. Not all optic disc swelling is papilledema.

Answer 51

1. Space occupying lesions --> Malignancy, subdural hematoma, cerebral abscess. 2. Subarachnoid hemorrhage --> Commonly associated with vitrous hemorrhage. 3. Chronic meningitis 4. Idiopathic intracranial HTN 5. Malignant HTN 6. Ischemic optic atrophy

Answer 52

1. Physiological cup is incr. in respect to the rest of the disc. 2. Retinal vessels kink sharply as they emerge over the rim of the cup. 3. Hemorrhages may be present.

Answer 53

Most commonly one of the various types of glaucoma.

Answer 54

Pale optic disc due to loss of nerve fibers in the optic nerve head.

Answer 55

1. Ischemic optic neuropathy 2. Optic neuritis 3. Trauma 4. Optic nerve compression

Answer 56

1. Depends on its location within the various layers of the retina. 2. Deep hemorrhages appear as "dots" due to the close packing of the cells in this region. 3. More superficial hemorrhages in the nerve fiber layer appear as more widespread "blotches".

Answer 57

1. DM 2. HTN 3. Subarachnoid hemorrhage 4. Blood dyscrasias 5. Systemic vasculitis 6. Valsalva maneuver 7. Trauma 8. Bacterial endocarditis (known specifically as Roth spots)

Answer 58

1. Large areas of ischemic white retina associated with sudden catastrophic visual loss. 2. Calcific, cholesterol or fibrin-platelet emboli can often be seen occluding the retina artery/branch.

Answer 59

Either embolic or thrombotic (remember giant cell arteritis also).

Answer 60

1. Large, widespread flame-shaped hemorrhages --> stormy sunset. 2. Gradual onset painless blurred vision and visual loss. 3. Optic disc swelling may be present.

Answer 61

1. Blood dyscrasias 2. DM 3. Glaucoma

Answer 62

1. UNILATERAL optic atrophy 2. Contralateral papilledema 3. Central scotoma 4. Anosmia (variable) 5. Systemic symptoms --> Headache, dizziness, vertigo, vomiting.

Answer 63

1. Meningioma of optic nerve, olfactory groove or sphenoid wing. 2. Frontal lobe tumor.

Answer 64

1. Sphincter pupillae muscle | 2. Dilator pupillae muscle

Answer 65

Found in the iris at the margin of the pupil. | Innervated by PNS fibers --> Constricts the pupil (miosis).

Answer 66

Radially arranged smooth muscle --> Innervated by SNS --> Dilates pupil (Mydriasis).

Answer 67

1. Afferent fibers leave the eye in the optic nerve and separate in the midbrain to synapse with the 3rd nerve nuclei. 2. Efferent pathway fibers then travel to synapse in the ciliary ganglion before innervating the sphincter pupillae.

Answer 68

1. Inspect both pupils in good light - is there a discrepancy in size (anisocoria) or shape? --> Present in 25% of normal population. 2. May be secondary to previous ocular inflammation disease, trauma, or surgery.

Answer 69

Must determine which of the pupils is the correct size: 1. Pathologically constricted pupil is more obvious in dim light as the normal pupil dilates. 2. A pathologically large pupil will be more apparent n bright illumination when the normal pupil will constrict.

Answer 70

Assess the AFFERENT limb of the pupillary light pathway: 1. Shine light in the normal eye and both pupils constrict --> consensual response in the affected eye is intact. 2. Swing the light to the affected eye and both pupils dilate --> afferent drive to cause constriction of the pupils from the affected eye is reduced in comparison to that of the unaffected eye. 3. Swing the light back to the normal eye and both pupils constrict.

Answer 71

Ask the patient to focus on a distant object and then look immediately to your index finger held 30cm in front of their face. --> normal will be for the pupils to constrict in response to convergence and accommodation.

Answer 72

1. Midbrain lesions caused by neurosyphilis target the more dorsally located fibers that subserve the light response. 2. Ventrally located fibers responsible for accommodation are spared.

Answer 73

Small irregular pupil that accommodates but does NOT react to light.

Answer 74

1. Neurosyphilis | 2. DM

Answer 75

1. Denervation of the Iris and ciliary body due to ciliary ganglionitis (although some would dispute this!). 2. Associated loss of tendon reflexes is seen in some patients and is termed Holmes-Adie syndrome.

Answer 76

Unilateral dilated pupil --> Accommodates and relaxes very slowly and shows absent or depressed light reflex --> Supersensitive to 0.1% pilocarpine (causing constriction).

Answer 77

1. Usually IDIOPATHIC and predominates in young adult females (2:1). 2. May also follow iridoplegia or ocular trauma.

Answer 78

1. Unilateral miotic pupil with partial Ptosis (due to paralysis of Muller's muscle - a small smooth muscle in the upper lid. 2. Movement of the upper lid should be intact as the levator muscle is supplied by the oculomotor nerve. 3. Variable interruption of sudomotor innervation to the ipsilateral side of the face. 4. Sweating is absent if the lesion occurs proximal to the carotid plexus, after which the sudomotor fibers separate.

Answer 79

1. Protracted course of the sympathetic pathway makes it vulnerable to disruption at many different points. 2. Congenital - often associated with an alternation in Iris pigment (heterochromia). 3. Injury or surgery to the neck. 4. Multiple sclerosis 5. Cevernous sinus disease 6. Neoplasia involving the mediastinum, cervical cord or the apex of the lung. 7. Infarction - secondary to occlusion of the basilar or posterior inferior cerebellar artery. 8. Thoracic aortic aneurysm 9. Syringomyelia or syringobulbia

Answer 80

Avulsion of the C8 and T1 roots.

Answer 81

1. Levator palpebrae superioris 2. Superior rectus 3. Medial rectus 4. Inferior rectus 5. Inferior oblique

Answer 82

PNS supply to the constrictor (sphincter) pupillae of the Iris and ciliary muscle.

Answer 83

Lies anterior to the aqueduct of the midbrain.

Answer 84

Accessory PNS nucleus --> Lies posterior to the oculomotor nucleus. Fibers pass anteriorly, through the cavernous sinus, entering the orbit through the superior orbital fissure.

Answer 85

Superior oblique

Answer 86

1. Lies Inferiorly to that of the oculomotor and has connections with the cerebral hemispheres, visual cortex and nerves III, VI, VIII. 2. Fibers pass POSTERIORLY and immediately crooks one another. 3. They then travel through the cavernous sinus, entering the orbit through the superior orbital fissure.

Answer 87

1. Lies beneath the 4th ventricle. 2. Connects with the nuclei of the III and IV through MLF. 3. Emerges from the pons and travels through the cavernous sinus to enter the orbit through the superior orbital fissure.

Answer 88

1. Inspect position of the lids --> Epicanthic folds prominent? Ptosis? 2. Look at the position of the eyes in neutral gaze. 3. Asymmetrical position suggests strabismus (squint) and this should be assessed with the cover test. 4. Ask patient to follow your index finger in vertical, horizontal, and oblique planes - avoiding extremes of gaze. 5. Is nystagmus present? 6. Diplopia? Ask the patient. 7. Eyes should follow smoothly the moving target (pursuit) --> often interrupted with saccades in Parkinson/Huntington.

Answer 89

1. Now hold up your index finger on one side of their head and your thumb on the other - in their temporal visual fields. 2. Ask the patient to look quickly between finger and thumb --> Should be accurate, smooth, rapid.

Answer 90

Ask the patient to look from a distant object to a near object --> the eyes should converge smoothly and equally in association with accommodation and pupil constriction.

Answer 91

1. Weakness of the levator muscle in myasthenia gravis. 2. CN III palsy 3. Disruption of the insertion of the levator muscle into the tarsal plate of the lid either through surgery or trauma.

Answer 92

One eye is directed towards the target, the other is turned laterally.

Answer 93

The other eye is turned medially.

Answer 94

1. Non paralytic | 2. Paralytic

Answer 95

1. Seen in childhood | 2. Both eyes have a full range of movement but only one of the eyes is directed towards the target of fixation.

Answer 96

Movement of one or more of the extraocular muscles is decreased due to disease of the muscle, a nerve palsy, or a physical obstruction to movement in a particular direction --> tethering, trauma, or neoplasm.

Answer 97

Used for further analysis of non-paralytic squint: 1. Patient sits in front of you. 2. Present a fixation target in front of them (top of your pen for example). 3. Ask them to cover their right eye. 4. Closely observe the uncovered left eye --> One of three is possible: a. Eye doesn't move at all --> normal. b. Eye moves nasally to fixate --> Divergent squint c. Eye moves temporally to fixate --> Convergent squit Repeat covering the left eye.

Answer 98

Using a syntophore in eye clinics.

Answer 99

Should always involve a detailed assessment of the cornea, lens, vitreous and retina to exclude opacities and abnormalities.

Answer 100

Oscillating movements of the eyes.

Answer 101

Type of jerk nystagmus (to and fro movements are of different velocities).

Answer 102

Caused by disease in the labyrinth or its central connections.

Answer 103

Is away from the side of the lesion.

Answer 104

1. Often horizontal and rotatory components. | 2. Usually only present in the acute phase of labyrinthine disease.

Answer 105

1. The velocity of the movements is the same in BOTH directions. 2. Often a congenital condition associated with deceased visual acuity.

Answer 106

1. Cerebrovascular disease | 2. Multiple sclerosis

Answer 107

Patients with acquired nystagmus will often complain of continual movement of their visual environment, which is NOT the case with congenital nystagmus.

Answer 108

This is a normal response of the eye when trying to follow a moving object - when looking from the window of a train.

Answer 109

Lesions of the deep parietal lobe when drum rotation is towards the affected hemisphere.

Answer 110

The fast phase is upwards.

Answer 111

1. Brainstem disease | 2. Intoxication with alcohol and a number of other drugs including phenytoin.

Answer 112

The fast phase is downwards.

Answer 113

1. In toxic states and Demyelinating diseases. | 2. Herniation of cerebellar tissue through the Foramen magnum as seen in Chiari malformation.

Answer 114

The fast phase is towards the direction of action of the affected muscle.

Answer 115

In dysfunction of extraocular muscles secondary to intrinsic weakness or nerve palsy.

Answer 116

When assessing nystagmus try to avoid the extremes of lateral gaze (I.e. Not >30 degrees) --> This will elicit end-point nystagmus - a physiological response not to be confused with a pathological process.

Answer 117

1. Pupil dilated and response to neither light nor accommodation. 2. All the extraocular muscles are paralyzed except for the lateral rectus and the superior oblique. 3. Unopposed action of these cause the eye to look DOWN AND OUT.

Answer 118

COMPLETE ptosis.

Answer 119

1. DM (pupil sparing) 2. Lesions involving the superior orbital fissure. 3. Cavernous sinus disease 4. Aneurysm of posterior communicating artery 5. Weber syndrome (associated CONTRALATERAL hemiplegia)

Answer 120

1. Paralysis of the superior oblique causes the eye to elevate when adducting. 2. Patient complains of Diplopia and will have difficulty looking downwards and inwards on the affected side. 3. Patient may try to compensate for this by tilting their head away from the side of the lesion --> Ocular torticollis.

Answer 121

1. Trauma 2. Surgery 3. DM 4. Atherosclerosis 5. Neoplasia

Answer 122

1. Paralysis of the lateral rectus muscle means the eye cannot be abducted from the midline and the unopposed action of the medial rectus leaves the eye deviated NASALLY at rest. 2. Patient complains of Diplopia in horizontal gaze. 3. Lesions in the 6th nerve nucleus also involve the lateral gaze centre and lead to gaze paresis.

Answer 123

1. DM 2. Atherosclerosis 3. MS 4. Neoplastic lesions 5. Raised intracranial pressure leading to compression of the nerve on the edge of the petrous temporal bone (a false localizing sign). 6. Trauma 7. Surgery

Answer 124

All 3 nerves involved in Oculomotor control along with sympathetic fibers to the Iris and the ophthalmic and maxillary divisions of the trigeminal nerve pass through here.

Answer 125

1. Carotid-cavernous fistula 2. Expanding pituitary tumor 3. Cavernous sinus thrombosis - associated with proptosis and injection of conjunctival vessels (chemosis) 4. Aneurysm

Answer 126

1. A complex range of Ophthalmoplegias can result from any compressive lesion located within the orbit. 2. Proptosis may be present with variable optic nerve involvement. 3. Many lesions may directly impinge upon the extraocular muscles as well as the innervating nerves.

Answer 127

1. Transmits all the nerves supplying the extraocular muscles along with the ophthalmic division of the trigeminal nerve. 2. Inflammation or a lesion at the superior orbital fissure leads to Tolosa-Hunt syndrome.

Answer 128

A complex unilateral ophthalmoplegia associated with anesthesia over the forehead and ocular pain.

Answer 129

This is interruption of the MLF, connecting the nuclei of cranial nerves III and VI on opposite sides.

Answer 130

1. Impaired adduction in the IPSILATERAL eye in unilateral lesions -nystagmus is often seen in the abducting eye. 2. Bilateral lesions often cause vertical nystagmus and impaired vertical pursuit. 3. Convergence remains intact. 4. Patient will complain of horizontal Diplopia due to impaired adduction on the affected side - not due to nystagmus in the abducting eye.

Answer 131

1. Cerebrovascular disease | 2. Multiple sclerosis.

Answer 132

The PPRF is responsible for conjugate eye movements in horizontal gaze.

Answer 133

1. Failure of horizontal eye movements towards the side of the lesion - Horizontal gaze paresis. 2. An ipsilateral Internuclear ophthalmoplegia if the lesion extends to involve the MLF. 3. Preservation of vertical gaze. 4. Contralateral deviation of the eyes in the acute phase.

Answer 134

1. Vascular disease 2. Demyelinating disease 3. Neoplasia

Answer 135

Lesions occurring in the dorsal midbrain involve the vertical gaze centre - hence also known as dorsal midbrain syndrome.

Answer 136

1. Impaired upward gaze in both eyes resulting in convergence, retraction of the globe into the orbit and nystagmus. 2. Light-near dissociation of the pupils - The near reflex is intact but response to light is poor.

Answer 137

1. Demyelinating disease 2. Vascular disease affecting the dorsal midbrain 3. Enlarged 3rd ventricle

Answer 138

Facial sensation in 3 branches: V1, V2, V3.

Answer 139

Muscles of mastication.

Answer 140

Inspect the patient's face --> Wasting of the Temporalis will show as hollowing above the zygomatic arch.

Answer 141

1. Ask patient to clench their teeth and feel both sides for the bulge of the Masseter and Temporalis. 3. Ask the patient to open their mouth wide --> The jaw will deviate towards the side of the V lesion. 3. Again ask them to open their mouth but provide resistance holding their jaw closed with one of your hands.

Answer 142

1. Assess light-touch for each branch and ask the patient to say 'yes' if they can feel it. 2. For each branch, compare left to right. Ignore minor differences. 3. Test pin-prick sensation at the same spots using a sterile pin. 4. Temperature sensation is not routinely tested - Consider only if abnormalities in light touch and pin-prick are found. 5. Use specimen tubes or other small containers full of hot or cold water.

Answer 143

1. Wasting of muscles 2. Loss of ALL sensory modalities 3. Loss of light touch only 4. Loss of light-touch in V only 5. Loss of pin-prick only 6. Loss of sensation in a muzzle distribution (nose, lips, anterior cheek)

Answer 144

1. Long-term V palsy 2. MND 3. Myotonic dystrophy

Answer 145

V ganglion lesion (herpes zoster?)

Answer 146

With loss of sensation on ipsilateral side of the body --> contralateral parietal lobe (sensory cortex) lesion.

Answer 147

Lesion at sensory root pons.

Answer 148

Along with contralateral side of the body --> ipsilateral brainstem lesion.

Answer 149

Damage to the lower part of the spinal sensory nucleus --> syringomyelia, demyelination.

Answer 150

1. Explain to the patient what is about to happen as this could appear rather threatening! 2. Ask the patient to let their mouth hang loosely open. 3. Place your finger horizontally across their chin and tap your finger with a patella hammer. 4. Feel and watch jaw movement --> Should be a light closure but this varies widely in normal people.

Answer 151

``` Afferent = V1 Efferent = VII ```

Answer 152

1. Ask the patient to look up and away from you. 2. Gently touch the cornea with a wisp of cotton wool. 3. Bring this in from the side so it cannot be seen approaching. 4. Watch both eyes. A blink is a normal response. - -> No response = Ipsilateral V1 palsy. - -> Lack of blink on one side only = VII palsy. 5. Watch out for contact lenses! --> Will give reduced sensation - Ask the patient to remove them first.

Answer 153

1. Note the sensory distribution! The angle of the jaw is NOT supplied by V3 but by the great auricular nerve (C2, C3). 2. When testing the corneal reflex, touch the cornea (overlies the iris), not the conjunctiva (overlies the sclera).

Answer 154

1. External auditory meatus 2. Tympanic membrane 3. Small portion of skin behind the ear. 4. Special sensation: Taste anterior 2/3 of tongue.

Answer 155

1. Muscles of facial expression | 2. Stapedius

Answer 156

PNS supply to lacrimal glands.

Answer 157

1. Nucleus lies in the pons - nerve leaves at the cerebellopontine angle with VII. 2. Nerve gives off a branch to the stapedius at the geniculate ganglion while the majority of the nerve leaves the skull via the stylomastoid foramen and travels through the parotid gland.

Answer 158

1. Look at the patient's face at rest. Look for asymmetry in the nasolabial folds, angles of the mouth and forehead wrinkles. 2. Ask the patient to raise their eyebrows ("look up!") and watch the forehead wrinkle. 3. Attempt to press their eyebrows down and note any weakness. 4. Ask the patient to "close your eyes tightly". 5. Ask the patient to blow out their cheeks. Watch for air escaping on one side. 6. Ask the patient to bare their teeth. "Show me your teeth!" Look for asymmetry. 7. Ask the patient to pursue their lips. "Whistle for me!" Look for asymmetry. The patient will always smile after whistling.

Answer 159

A failure to smile when asked to whistle is usually due to emotional paresis of the facial muscles and is synonymous with Parkinsonism.

Answer 160

This should be examined briefly if only VII examined - can be done as part of VII if examining all the cranial nerves.

Answer 161

Rarely tested outside specialist clinics. 1. Each side is tested separately by using cotton buds dipped in the solution of choice applied to each side of the tongue in turn. 2. Be sure to swill the mouth with distilled water between each taste sensation. 3. Test: sweet, salty, bitter (quinine), and sour (vinegar).

Answer 162

1. Will cause loss of facial movement on the ipsilateral side but with preservation of forehead wrinkling. 2. Both sides of the forehead receive bilateral nervous supply. Unilateral --> CVA etc. Bilateral --> Pseudobulbar palsy, motor neuron disease.

Answer 163

Will cause loss of all movement on the ipsilateral side of the face.

Answer 164

1. Deemyelination 2. Tumors 3. Bell's palsy 4. Pontine lesions 5. Cerebellopontine angle lesions

Answer 165

1. Sarcoidosis 2. GBS 3. Myasthenia gravis

Answer 166

Idiopathic unilateral LMN VII paresis.

Answer 167

Unilateral paresis causes by herpes at the geniculate ganglion --> look for herpes rash on the external ear.

Answer 168

1. Bell's phenomenon is the upward movement of the eyeballs when the eye closes. 2. This occurs in the normal state but can be clearly seen if the eyelids fail to close due to VII palsy. 3. VII palsy does NOT cause eyelid ptosis. 4. Longstanding VII palsy can cause fibrous contraction of the muscles on the affected side resulting in more pronounced nasolabial fold (the reverse of the expected findings). 5. BILATERAL VII palsy will cause a sagging, expressionless face and is often missed.

Answer 169

1. Hearing | 2. Balance/Equilibrium

Answer 170

Originates in the organ of Corti --> Passes though the internal auditory meatus to its nucleus in the pons --> Fibers pass to the superior gyrus of the temporal lobes.

Answer 171

Arises in the utricle and semicircular canals --> Joins the auditory fibers in the facial canal --> Enters the brainstem at the cerebellopontine angle and ends in the pons and cerebellum.

Answer 172

1. Enquire first about symptoms. 2. Hearing loss/changes or balance problems. 3. Peripheral vestibular lesions cause ataxia during paroxysms of vertigo but not at other times.

Answer 173

Test each ear separately - Cover one by pressing on the tragus or create white-noise by rubbing your fingers together at the external auditory meatus.

Answer 174

1. Whisper a number into one ear and ask the patient to repeat it. 2. Repeat with the other ear. 3. Be careful to whisper at the same volume in each ear (the end of expiration is best) and at the same distance (about 60cm).

Answer 175

1. Tap a 512Hz tuning fork and hold adjacent to the ear (air conduction). 2. Then apply the base of the tuning fork to the mastoid process (bone conduction). 3. Ask the patient which position sounds louder. Normal --> Air conduction > Bone conduction = Rinne's positive. In neural (or perceptive) deafness, Rinne's test will remain positive. In conductive deafness --> Bone > Air.

Answer 176

1. Tap a 512Hz tuning fork and hold the base against the vertext or forehead at the midline. 2. Ask the patient if it sounds louder on one side. - -> Neural deafness --> Tone is heard better in the intact ear. - -> Conductive deafness --> Tone is heard better in the affected ear.

Answer 177

1. Ask the patient to stand facing you, arms outstretched. 2. Ask them to march on the spot, then close their eyes (continue marching). 3. Watch! - -> Patient will gradually turn toward the side of the lesion - sometimes will turn right around 180.

Answer 178

A test for benign positional vertigo (BPV). Do NOT test those with known neck problems or possible circulation impairment.

Answer 179

1. Warn the patient about what is to happen. 2. Sit the patient facing away from the edge of the bed such that when they lie back their head will not be supported (over the edge). 3. Turn their head to one side and ask them to look in that direction. 4. Lie them back quickly - Supporting their head so that it lies about 30 degrees below the horizontal. 5. Watch for nystagmus --> affected ear will be lowermost. 6. Repeat with the head turned in the other direction.

Answer 180

1. NO nystagmus = normal. 2. Nystagmus, with a slight delay (10sec) and fatiguable (can't be repeated successfully for 10-15min) = BPV. 3. Nystagmus, no delay, no fatigue = Central vestibular syndrome.

Answer 181

1. Pharynx 2. Middle ear 3. Special sensation: Taste on posterior 1/3 of tongue.

Answer 182

Stylopharyngeous musclee

Answer 183

Parotid gland

Answer 184

Originates in the medulla --> Passes through the jugular foramen.

Answer 185

1. Tympanic membrane 2. External auditory canal 3. External ear 4. Also proprioception from thorax and abdomen

Answer 186

1. Palate 2. Pharynx 3. Larynx

Answer 187

Carotid baroreceptors

Answer 188

Originates in medulla and pons, leaves the skull via jugular foramen.

Answer 189

1. Ask the patient to open their mouth and inspect the uvula (use a tongue depressor if necessary) --> Central or deviated to one side? If so, which side? 2. Ask the patient to say "aah". Watch the uvula --> Should move upwards centrally. Does it deviate to one side?

Answer 190

``` Afferent = IX Efferent = X ```

Answer 191

1. With the patient's mouth open wide, gently touch the posterior pharyngeal wall on one side with a tongue depressor or other sterile stick. 2. Watch the uvula (it should lift up). 3. Repeat on the opposite side. 4. Ask the patient if they felt the 2 touches - and was there any difference in sensation?

Answer 192

1. Ask the patient to cough - normal character? Gradual onset/sudden? 2. Listen to the patient's speech - note volume, quality and whether it appears to fatigue (quieter as time goes on). 3. Test shallow.

Answer 193

1. Moves to one side = X lesion on the opposite side. 2. No movement = muscle paresis. 3. Moves with "aah" but not gag and decr. pharyngeal sensation = IX palsy

Answer 194

1. Gradual onset of a deliberate cough = vocal cord palsy. 2. 'Wet', bubbly voice and cough palsy (X palsy). 3. Poor shallow and aspiration = combined IX and X or lone X lesion.

Answer 195

1. Cranial part --> from nucleus ambiguus in the medulla. 2. Spinal part --> from the lateral part of the spinal cord down to C5 as a series of rootlets. 3. These join together and ascend adjacent to the spinal cord, passing through the foramen magnum to join with the cranial portion of the accessory nerve. 4. It leaves the skull via the jugular foramen. 5. Cranial portion joins with the X. 6. Spinal portion innervates SCM and the upper fibers of the trapezii. NOTE --> Each cerebral hemisphere controls IPSILATERAL SCM and the CONTRALATERAL trapezius.

Answer 196

1. Cranial portion cannot be tested separately. 2. Inspect the SCM - Look for wasting, fasciculations, hypertrophy, and any abnormal head position. 3. Ask the patient to shrug their shoulders and observe. 4. Ask the patient to shrug again, using your hands on their shoulders to provide resistance. 5. Ask the patient to turn their head to each side, first without and then with resistance (use your hand on their cheek).

Answer 197

1. Isolated lesions are very rare. 2. Bilateral weakness --> wasting caused by muscular problems or motor neuron disease. 3. Unilateral weakness --> Trapezius and SCM same side --> suggests peripheral neurological lesion. 4. Unilateral weakness --> Trapezius and SCM of opposite sides --> usually seen with hemiplegia suggests an UMN lesion IPSILATERAL to the weak sternomastoid.

Answer 198

1. Remember that the action of the SCM is to turn the head to the OPPOSITE SIDE --> Poor head turning to the LEFT indicates a weak RIGHT SCM. 2. When providing resistance to head turning, be sure to press against the patient's cheek. Lateral pressure to the jaw can cause pain and injury, particularly in the elderly and frail.

Answer 199

Muscles of the tongue.

Answer 200

Nucleus lies on the floor of IV ventricle --> Fibers pass ventrally, leaving the brainstem lateral to the pyramidal tracts --> Leaves the skull via the hypoglossal foramen.

Answer 201

1. Ask the patient to open wide and inspect the tongue on the floor of the mouth --> Look for size and evidence of fasciculation. 2. Ask the patient to protrude the tongue --> Look for deviation or abnormal movements. 3. Ask the patient to move the tongue in and out repeatedly, then side-to-side. 4. To test subtle weakness, place your finger on the patient's cheek and ask them to push against it from the inside using their tongue.

Answer 202

Will cause fasciculations on the affected side and a deviation towards the AFFECTED side on protrusion. --> ALSO there be a weakness on pressing the tongue away from the affected side.

Answer 203

Will rarely cause any clinically obvious signs.

Answer 204

Will give a small, globally weak tongue with reduced movements.

Answer 205

Will ALSO produce a small, weak tongue.

Answer 206

Trombone tremor --> Can be caused by: 1. Cerebellar disease 2. Extra-pyramidal syndromes 3. Essential tremor

Answer 207

1. Rippling movements may be seen if the tongue is held protruded for long periods. 2. This is normal and should NOT be mistaken for fasciculations.

Answer 208

1. Any walking aids or abnormal gait? 2. Shake hands - abnormalities of movements? Strength? Relaxation? 3. Any abnormal movements when sitting? 4. Any obvious weaknesses (eg hemiplegia)? 5. Does the patient have good sitting balance?

Answer 209

1. Abnormal positioning - Due to weakness or contractures. 2. Wasting 3. Fasciculation (irregular contractions of small areas of muscle). 4. Make a point of inspecting the shoulder girdle, small muscles of the hand, quadriceps, anterior compartment of lower leg and ankle. 5. Look at the foot for contractures or abnormalities of shape.

Answer 210

1. Aim is to test the resting tone in the limbs. This takes practise and the feel of normal, incr. or decr. tone can only be taught through experience. 2. Telling the patient to relax usually has the OPPOSITE effect! 3. They can be distracted by a counting task or told to relax the limb "as if you're asleep". 4. Light conversation is a generally successful ploy. 5. You should also repeat the following manoeuvres at different speeds and intervals to catch the patient at an unguarded moment.

Answer 211

Take the patient's hand in yours (as if shaking it) and hold their elbow with your other hand. From this position you can: 1. Pronate/supinate the patient's forearm. 2. Roll the patient's wrist through 360 degrees. 3. Flex and extend the patient's elbow.

Answer 212

With the patient lying flat, legs straight, hold onto the patient's knee and roll it from side to side.

Answer 213

With the patient in the same position, put your hand behind the patient's knee and raise it quickly. Watch the heel - it should lift from the bed/couch slightly if tone is normal.

Answer 214

Holding the foot and the lower leg, flex and dorsiflex the ankle.

Answer 215

1. Normal tone --> Slight resistance in movement. 2. Decr. tone --> "Flaccid" due to LMN or cerebellar lesions or myopathies. 3. Incr. tone --> Spasticity, rigidity, Gegenhalten, myotonia, dystonia.

Answer 216

Clasp-knife rigidity - The limb appears stiff. With incr. pressure, there is sudden "give" and the limb moves. --> UMN lesions.

Answer 217

The limb is equally stiff through all movements.

Answer 218

An extrapyramidal sign, caused by a tremor superimposed on a rigid limb. The limb moves in a stop-go halting fashion.

Answer 219

Paratonia - Seen in bilateral frontal lobe damage and catatonic states. Tone incr. with incr. pressure from the examiner. --> The patient appears to be resisting movement.

Answer 220

A slow relaxation after action. When asked to make a fist, the patient is unable to release it quickly and will be slow to let go of a hand-shake (eg myotonic dystrophy).

Answer 221

The limb or head has an abnormal posture that looks rather uncomfortable.

Answer 222

Examiner should demonstrate each movement, mirroring the patient.

Answer 223

Medical Research Council power classification: 5 --> Normal power 4 --> Movement against resistance but not normal 3 --> Movement against gravity, but not against resistance 2 --> Movement with gravity eliminated (eg can move leg side-to-side on bed but not lift it). 1 --> Contractions but no movement seen. 0 --> No movement.

Answer 224

C5: Ask the patient to abduct their arms and elbows bent. "Arms up like a chicken!". Ask them to hold still as you attempt to push their arms down.

Answer 225

C6, C7: | The patient should hold their arms tightly to their sides with elbows bent. You attempt to push their arms out.

Answer 226

C5, C6: The patient should hold their elbows bent and supinated in front of them. Hold the patient at the elbow and wrist and attempt to extend their arm. "Don't let me straighten your arm!"

Answer 227

C7: Patient holds position above as you resist extension at the elbow by pushing on their distal forearm/wrist. "Push me away!"

Answer 228

C6, C7: With arms supinated, the patient should flex the wrist and hold as you attempt to extend it by pulling from your own wrists.

Answer 229

C6, C7: | The opposite manoeuvre to that above. The patient holds their hand out straight and resists your attempts to bend it.

Answer 230

C8: Ask the patient to squeeze your fingers or BETTER ask the patient to grip your fingers palm-to-palm and resist your attempts to pull their hand open.

Answer 231

C7, C8: Ask the patient to hold their fingers out straight - you support their wrist with one hand and attempt to push their fingers down with the side of your hand over their 1st interphalangeal joints.

Answer 232

T1: | Ask the patient to splay their fingers out and resist your attempts to push them together.

Answer 233

T1: Holding the patient's middle, ring, and little finger with one hand and their index with the other, ask the patient to pull their fingers together. OR place a piece of paper between their out-stretched fingers and ask them to resist your attempts to pull it away.

Answer 234

A useful test of subtle weakness. Patient is asked to hold their arms outstretched in front, palms upwards and eyes closed. If one side is weak, the arm will pronate and slowly drift downwards.

Answer 235

L1, L2, L3: With the lower limbs lying on the bed/couch, the patient is asked to raise each leg, keeping the knee straight. Examiner can oppose the movement by pushing down on the thigh just above the knee. "Stop me from pushing down!"

Answer 236

L5, S1: Ask the patient to keep their leg pressed against the bed as you attempt to lift it - either with a hand beneath the calf or the ankle. "Stop me lifting your leg up!"

Answer 237

L4, L5, S1: Ask the patient to move their leg out to the side as you oppose the movement with a hand on the lateral thigh. "Stop me pushing your legs together!"

Answer 238

L2, L3, L4: With the legs central, put your hand on the medial thigh and attempt to pull the leg out to the side against resistance. "Don't let me pull your legs apart!"

Answer 239

L5, S1: 1. Take hold of the patient's knee with one hand and their ankle with the other and flex the leg to about 60 degrees. 2. Patient may think you want them to resist this so often a quick instruction "bend at the knee" is required. 3. Ask the patient to bend their leg further ("stop me straightening your leg out") and oppose the movement at their ankle.

Answer 240

L3, L4: 1. With the patient's leg in the position above, ask the patient to extend their leg ("push me away", "straighten your leg out") as you oppose it. 2. Alternatively, attempt to bend the patient's leg from a straightened starting position.

Answer 241

S1, S2: With the patient's leg out straight and ankle relaxed, put your hand on the ball of the foot and ask the patient to push you away. "Push down and stop me pushing back!".

Answer 242

L4, L5: 1. From the starting position above, hold the patient's foot just above the toes and ask them to pull their foot backwards. 2. Patients may often attempt to move their entire leg here so "cock your foot back and stop me pushing your foot down" with an accompanying hand gesture helps.

Answer 243

Reflex is absent or decreased.

Answer 244

Reflexes are increased or 'brisk'.

Answer 245

C5, C6: 1. With the patient seated, lie their arms across their abdomen. 2. Place your thumb across the biceps tendon and strike it with the tendon hammer. 3. Watch the biceps for contraction.

Answer 246

C5, C6: 1. The muscle tested is actually the brachioradialis. 2. With the patient's arms lying loosely across their abdomen, put your fingers on the radial tuberosity and tap with the hammer. 3. The arm will flex at the elbow. 4. If brisk, the fingers may also flex.

Answer 247

C7: 1. Taking hold of the patient's wrist, flex their arm to 90 degrees. 2. Tap the triceps tendon about 5cm superior to the olecranon process of the ulna. 3. Watch the triceps.

Answer 248

C8: 1. This is only present if tone is pathologically increased. 2. With your palm up and the patient's arm pronated, lie the fingers on yours. 3. Strike the back of your fingers. 4. The patient's fingers will flex.

Answer 249

L3, L4: 1. With the patient's leg extended, use one hand behind their knee to lift their leg to 60 degrees. 2. Tap the patella tendon and watch the quadriceps. 3. If brisk, proceed to testing for clonus here.

Answer 250

1. With the patient's leg extended , place your thumb and index finger over the superior edge of the patella. 2. Create a sudden downward (toward the feet) movement, and HOLD. 3. Watch the quadriceps. 4. Any beat of clonus here is abnormal.

Answer 251

S1, S2: 1. With the hip flexed and externally rotated and the knee flexed to 90 degrees, hold the foot and tap the Achilles tendon. 2. Watch the calf muscles for contraction/ankle flexion. 3. Alternatively, with the leg extended and relaxed, place your hand on the ball of the foot and strike your hand with the hammer.

Answer 252

If the reflex is ABSENT, it can sometimes be elicited by asking the patient to perform a 'reinforcing' action which acts to increase the activity of neurons in the spinal cord. --> Short-lived, however you should aim to test the reflex in the first 10sec of the reinforcement.

Answer 253

For upper limb reflexes --> Ask the patient to clench their teeth. For lower limb reflexes --> Ask the patient to lock their fingers together, pulling in opposite directions.

Answer 254

``` 0 = Absent +/- = Present only with reinforcement 1+ = Decr./less than normal 2+ = Normal 3+ = Brisk/more than normal ```

Answer 255

1. Children 2. Elderly 3. Multiparous patients 4. Those who had abdominal surgery 5. Obese

Answer 256

1. Patient should be lying on their back, relaxed, abdomen exposed. 2. Using an orange stick or similar, stroke each of the 4 segments of the abdomen, in a brief movement towards the umbilicus. 3. As each segment is stroked, the abdominal muscles will reflexly contract. 4. Summarize the findings diagrammatically using a simple 2x2 grid and indicating the presence or absence of a response by marking "+" and "-" respectively. (+/- for intermediate response).

Answer 257

Upper --> T8-T9 | Lower --> T10-T11

Answer 258

L1, L2: 1. With the male patient standing and naked from the waist down, you should lightly stroke the upper aspect of their inner thigh. 2. The ipsilateral cremaster muscle contracts and the testicle will briefly rise.

Answer 259

L5, S1, S2: 1. Patient should be lying comfortably, legs outstretched. 2. Warn the patient that you are about to touch the sole of their foot. 3. Stroke the patient's sole. 4. You should stroke from the heel, up the lateral aspect of the sole to the base of the 5th toe. If there is no response, the stroke can be continued along the ball of the foot to the base of the big toe. 5. Watch the big toe for its INITIAL movement. - -> NORMAL is FLEXION of the big toe. - -> UMN lesions will DORSIFLEX the big toe --> THIS IS THE BABINSKI RESPONSE !!!

Answer 260

1. Down Arrow for plantar flexion. 2. Up Arrow for dorsiflexion. 3. - for an absent response.

Answer 261

If the leg is withdrawn and the heel moves in a "ticklish" reaction, this is called a "withdrawal" response and the test should be repeated.

Answer 262

A rhythmical contraction of a muscle when suddenly stretched - a sign of HYPERREFLEXIA due to UMN lesion.

Answer 263

1. With the patient lying on the bed, knee straight and thigh slightly externally rotated, suddenly dorsiflex the foot. 2. More than 3 beats of clonus - as long as the foot is dorsiflexed - is ABNORMAL.

Answer 264

1. These are reflexes seen in the newborn. 2. May still be present in a few normal adults. 3. They return somewhat in the elderly but are seen mainly in frontal lobe disease and encephalopathy. Not routinely tested, unless looking specifically for frontal lobe signs or Parkinson's disease.

Answer 265

1. Using your index finger, repeatedly tap (gently) the patient's forehead between the eyebrows. 2. If normal, the patient will blink only in the first 3 or 4 taps.

Answer 266

1. You should stroke the patient's palm, using sharp firm pressure from the radial side to the ulnar. 2. Watch the patient's chin. 3. If the reflex is present, there will be a contraction of the ipsilateral mentalis seen in the neck and chin.

Answer 267

1. Gently stroke your fingers over the patient's palm in a radial-ulnar direction, telling the patient NOT to grip your hand. 2. If present, the patient will involuntarily grasp your hand and seemingly refuse to let go.

Answer 268

1. With the patient's eyes closed, gently tap their lips with your fingers or (very cautiously) with a patellar hammer. 2. An involuntary puckering of the lips is a positive reflex.

Answer 269

1. With the patient's eyes closed, gentle stimulation at the corner of their mouth will result in a suckling action at the mouth. 2. The patient's head may also turn towards the stimulus.

Answer 270

The are of skin supplied by the sensory neurons corresponding to each spinal level can be mapped out - each segment called a dermotome.

Answer 271

1. Posterior columns | 2. Spinothalamic tract

Answer 272

1. Light touch 2. Proprioception 3. Vibration 4. Stereognosis (ability to recognize an object by touch) 5. Weight discrimination 6. Kinesthesia (perception of movement)

Answer 273

1. Pain | 2. Temperature

Answer 274

1. C7 --> Covers the middle finger. 2. T4 --> lies at the level of the nipples. 3. T10 --> Lies over the umbilicus

Answer 275

1. With the patient's eyes closed, touch their skin with a wisp of cotton wool and ask them to say "yes" when it is felt. 2. The interval between each touch should be irregular and unpredictable! 3. In practice, a gentle touch with the finger is often used. HOWEVER, this risks testing pressure not light touch sensation. It is also harder to ensure equal force is applied in all areas. 4. (!) DO NOT, as many do, make tiny stroking movements on the skin - this stimulates hair fibres, and again, is not a test of light touch. 5. (!) BE AWARE of areas where decr. sensation is expected (foot calluses etc.). 6. After testing each limb/body area, double check with the patient "did that feel the same all over?" and explore any areas of abnormal sensation more thoroughly before moving on.

Answer 276

1. A subtle but often clinically important sign of parietal lobe dysfunction. 2. Patient feel stimulus on the affected part - but NOT when there is competition from a stimulus on the opposite side.

Answer 277

1. Ask the patient to close their eyes and tell you if they feel a touch on their left or right - use any body part - commonly hands and feet as a quick "screen". 2. Touch the right hand, then the left hand, then both. 3. The touches should be repeated randomly to confirm the result.

Answer 278

In a right sided parietal lesion, the patient will feel both left and right stimuli but when BOTH sides are touched, they will not be able to feel the stimulus on the left.

Answer 279

A 128Hz tuning fork (compare with CN VIII) is used.

Answer 280

1. Ask the patient to close their eyes, tap the tuning fork and place the base on a bony prominence - ask if the patient can feel the vibration. 2. If "yes", confirm by taking hold of the tuning fork with your other hand to stop the vibration, after asking the patient to tell you when the vibration ceases. 3. As always, compare left to right and work in a systematic fashion, testing bony prominences.

Answer 281

1. Finger tip 2. Wrist 3. Elbow 4. Shoulder 5. Anterior superior iliac spine 6. Tibial tuberosity 7. Metatarsophalangeal joint and toes

Answer 282

1. With the patient's eyes closed and leg relaxed, grasp the distal phalanx of the big toe from the sides. 2. While stabilizing the rest of the foot, you should move the toe up and down at the joint. 3. Ask the patient if they can feel any movement - and in which direction. 4. Flex and extend the joint, stopping at intervals to ask the patient whether the toe is "up" or "down". 5. If proprioception is absent, test other joints, working proximally.

Answer 283

1. The toe is gripped from the sides - If held incorrectly, pressure on the nail may suggest the toe is pressed down and so on. 2. Normal proprioception should allow the patient to identify very subtle movements which are barely visible.

Answer 284

A further test of joint position sense. When proprioception is lost in the limbs, patients can often stand and move normally as long as they can see the limb in question. 1. Ask the patient to stand - and you stand facing them. 2. Ask the patient to close their eyes. 3. If there is loss of proprioception, the patient will lose their balancee and fall - if so, catch them with care, asking them to pen their eyes again immediately if they haven't already done so.

Answer 285

Use a disposable pin or safety pin - NOT a hypodermic needle as these break the skin - a line of tiny wounds up a patient's arm or weeping edema up a shin is an infection risk and very embarrassing!

Answer 286

1. Test as you would for light touch, gently pressing the pin on the skin. 2. Test each dermatome in a systematic way, mapping out abnormalities. 3. On each touch, ask the patient to say whether it feels sharp or dull. 4. Occasionally test the patient's reliability as a witness with a negative control by using the opposite (blunt) end of the pin.

Answer 287

1. This is not routinely tested outside specialist clinics. 2. May be evident from history (accidental burns). 3. When tested, test tubes or similar vessels containing hot and ice-cold water are used - and each dermatome tested as above. 4. Remember to ensure that exterior of the tube is dry.

Answer 288

1. Ask the patient to touch the end of their nose with their index finger. 2. Hold your own finger out in front of them - at arm's reach from the patient - and ask them to then touch the tip of your finger with theirs. 3. Ask them to move between their nose and your finger. 4. Look for intention tremor (worse as it approaches the target) and "past-pointing" (missing the target entirely). 5. The test can be made more difficult by moving the position of your finger each time the patient touches their nose.

Answer 289

1. Should be demonstrated to the patient. 2. Ask the patient to repeatedly supinate and pronate their forearm keeping the other arm still such that they clap their hands palm-to-palm, then back-to-palm and so on. 3. Alternatively, ask them to mimic screwing in a light bulb.

Answer 290

Slow and clumsy - This is inability to perform rapidly alternating movements.

Answer 291

1. From a resting (arms at their side) position, the patient should be asked to quickly abduct their arms and stop suddenly at the horizontal. 2. In cerebellar disease --> there will be a delay in stopping and the arm will oscillate about the intended final position.

Answer 292

1. Pull on the patient's flexed arms (as if testing elbow flexion power) and suddenly let go. 2. If lacking coordination, the patient will hit his/herself in the face. 3. This test does little for doctor-patient trust and rapport and is rarely performed for obvious reasons (!)

Answer 293

1. With the patient sitting, legs outstretched, ask them to slide the heel of one foot up and down the shin of the other leg at a moderate pace. 2. A lack of coordination will manifest as the heel moving side to side about the intended path. 3. In sensory - as OPPOSED to cerebellar - ataxia (lack of proprioception), patients will perform worse with their eyes closed.

Answer 294

1. The patient taps your hand with their foot as fast as possible. 2. The NON-dominant side performs poorly in normal individuals.

Answer 295

Muscles of the anterior forearm, EXCEPT flexor carpi ulnaris, and LOAF (lateral 2 lumbricals, opponens pollicis, abductor pollicis brevis, flexor pollicis brevis).

Answer 296

1. Thumb 2. Anterior index and middle fingers 3. Some of the radial side of the palm

Answer 297

1. Weakness and wasting of the thenar eminence. 2. With the hand lying flat, palm up, hold your pen above the thumb and ask the patient to move their thumb vertically to touch it ("pen-touching test") - they will not be able to. 3. Often power is good here despite symptoms and obvious carpal tunnel syndrome!

Answer 298

Perform Ochsner's Clasping Test for weakness of flexor digitorum superficialis - ask the patient to clasp their hands together. If a lesion is present, the index finger will fail to flex!

Answer 299

All the small muscles of the hand EXCEPT LOAF + Flexor carpi ulnaris.

Answer 300

1. Ulnar side of the hand. | 2. Little finger and half of ring finger.

Answer 301

Hard to test. There may be visible wasting of the small muscles of the hand with clawing of the fingers --> extension at the phalangeo-metacarpal joints and flexion at the interphalangeal joints.

Answer 302

Ask the patient to grasp a piece of paper between their thumb and forefinger. Alternatively, ask them to make a fist. --> Thumb is unable to adduct so will flex instead.

Answer 303

1. Triceps 2. Brachioradialis 3. Extensors of the hand

Answer 304

A small area over the anatomical snuff box - hard to test.

Answer 305

1. Look for wrist drop. 2. If not obvious, ask the patient to flex at the elbow, pronate the forearm and extend the wrist (you may need to demonstrate). 3. Wrist weakness will become clear.

Answer 306

The lateral aspect of the thigh.

Answer 307

There may be some sensory loss as indicated but, in practice, this is very hard to test.

Answer 308

Anterior and lateral compartments of the leg.

Answer 309

The dorsum of the foot and the anterior aspect of the leg.

Answer 310

1. "Foot-drop" with corresponding gait. Weakness of foot dorsiflexion and eversion. Preserved inversion. 2. In an L5 lesion, there will be a similar deficit but will also display a weakness of inversion, hip abduction and knee flexion.

Answer 311

Quadriceps femoris.

Answer 312

Medial aspect of thigh and leg.

Answer 313

1. Weakness of knee extension is only slightly affected - hip adduction is preserved. 2. Stretch: With the patient lying prone, abduct the hip, flex the knee and plantar-flex the foot. 3. The stretch is positive if pain is felt in the thigh/inguinal region.

Answer 314

All the muscles below the knee and some hamstrings.

Answer 315

Posterior thigh, ankle and foot.

Answer 316

1. Foot drop and weak knee flexion. 2. Knee jerk reflex is preserved but ankle jerk and plantar response are absent. 3. Stretch test: with the patient lying supine, hold the ankle and lift the leg, straight to 90 degrees. Once there, dorsiflex the foot. 4. If positive, pain will be felt at the back of the thigh.

Answer 317

A test for nerve compression. Commonly used for carpal tunnel syndrome. 1. Percuss the nerve over the site of possible compression - at the wrist, gently tap centrally near the flexor palmaris tendon. 2. If the nerve is compressed, the patient will experience tingling in the distribution of the nerve on each tap.

Answer 318

Ask the patient to walk a few meters, turn and walk back to you. Note especially: 1. Use of walking aids. 2. Symmetry 3. Size of paces 4. Lateral distance between the feet 5. How high the feet and knees are lifted. 6. Bony deformities 7. Disturbance of normal gait by abnormal movements --> You may want to consider asking the patient to: 1. Walk on tip-toes --> Inability = S1 or gastrocnemius lesion. 2. Walk on their heels --> Inability = L4/L5 lesion - foot drop.

Answer 319

One side will be obviously weaker than the other with the patient tilting pelvis to lift the weak leg which may swing out to the side. Gait may be unsafe without the use of walking aid.

Answer 320

If both legs are spastic (cerebral palsy, MS), toes drag on floor, trunk sways from side-to-side, and legs cross over on each step.

Answer 321

1. Flexed posture with small, shuffling steps. 2. No or little arm-swing. 3. Difficulty starting, stopping and turning. 4. Gait seems hurried ("festinant") as legs attempt to prevent body falling forwards.

Answer 322

1. Broad based (legs wide) gait with lumbering body movements and variable distance between steps. 2. Difficulty turning - be there to catch them!

Answer 323

1. Loss of proprioception. 2. Patient requires more sensory input to be sure of leg position so lifts legs high (high-stepping) and stamps feet down with a wide-based gait - may also watch legs as they walk. 3. Romberg's sign positive.

Answer 324

1. Weakness of proximal lower limb muscles. 2 Patient fails to tilt pelvis as normal so incr. rotation to compensate - also at the shoulders. 3. May also see incr. lumbar lordosis.

Answer 325

1. L4-L5 lesion, sciatic, or common peroneal nerves. 2. Failure to dorsiflex the foot leads to a "high-stepping" gait with incr. flexion at the hip and knee. 3. If bilateral, may indicate peripheral neuropathy.

Answer 326

1. Usually frontal lobe pathology such as normal pressure hydrocephalus or cerebrovascular disease. 2. Problems with gait even if all other movements may be normal. 3. Patient may appear frozen to the spot and unable to initiate walking. 4. Movements are disjointed once walking.

Answer 327

Diffuse cortical dysfunction - Upright posture, small steps with a normal arm-swing.

Answer 328

The cause will normally be obvious from the history. The patient limps with an asymmetrical gait due to painful movement.

Answer 329

1. Gait problems will be variable and inconsistent, often with bizarre and elaborate consequences. 2. May fall without causing injury. 3. Often worse when watched.

Answer 330

A number of conditions provoking painful extensor muscle spasm: 1. Bacterial and viral meningitis 2. Subarachnoid hemorrhage 3. Parkinsonism 4. Raised intracranial pressure 5. Cervical spondylosis 6. Cervical lymphadenopathy 7. Pharyngitis

Answer 331

1. Lie the patient flat 2. Taking their head in your hands, gently rotate it to the sides in a "no" movement, feeling for stiffness. 3. Lift the head off the bed and watch the hips and knees - the chin should easily touch the chest.

Answer 332

When the head is flexed by the examiner, the patient briefly flexes at the hips and knees - a test for meningeal irritation.

Answer 333

1. Further test for meningeal irritation. 2. With the patient lying flat, flex their hip and knee, holding the weight of the leg yourself. 3. With the hip flexed to 90 degrees, extend the knee joint so as to point the leg at the ceiling. 4. If positive, there will be resistance to leg straightening (caused by hamstring spasm as a result of inflammation around the lumbar spinal roots) and pain felt at the back of the neck.

Answer 334

1. A test for an intrinsic lesion in the cervical cord (not meningeal irritation). 2. When the neck is flexed as above, the patient feel an electric shock-like sensation down the centre of their back.

Answer 335

Damage ABOVE the level of the anterior horn cell - anywhere from the spinal cord to the primary motor cortex.

Answer 336

1. No muscle wasting (although will have disuse atrophy in long-term weakness). 2. Incr. tone --> Spasticity (clasp-knife) due to stretch reflex hypersensitivity. 3. Typical pattern of weakness is termed "pyramidal": - Upper limbs: weak abductors and extensors. - Lower limbs: weak adductors and flexors. 4. Incr. tendon reflexes and clonus - Up-going plantar response.

Answer 337

1. Muscle wasting. Fasciculations. 2. Decr. tone. 3. Flaccid paralysis 4. Decr. tendon reflexes. Plantar response may be down-going or absent.

Answer 338

Mono --> One limb is affected. Hemi --> One side of the body (Left or right). Para --> Both LOWER limbs affected. Quadriplegia --> All 4 limbs affected.

Answer 339

Damage to anterior horn cells, medulla, spinal tracts: 1. UMN/LMN pattern of weakness. 2. Fasciculations almost always present. 3. Reflexes normal or incr. until later in the disease. 4. Plantar response is up-going. 5. External ocular muscles almost never involved. 6. No sensory disturbance (distinguishing the presentation from a poluneuropathy).

Answer 340

1. Pattern of symptoms comprising an akinetic/rigid syndrome. 2. Number of causes including drug-induced and other intracranial pathologies. 3. Diagnosis is often inaccurate and there NO SINGLE TEST. 4. Triad of: Resting tremor + Bradykinesia + Rigidity.

Answer 341

1. Mask-like and expressionless facies. 2. Little blinking 3. Positive glabellar tap reflex.

Answer 342

1. Flexed posture with decr. arm swing. 2. Gait is "festinant" meaning "hurried" often in small, shuffling steps with feet barely lifted off ground. 3. Slow to start and difficulty stopping.

Answer 343

Incr. tone with cogwheel or "lead-pipe" rigidity.

Answer 344

Pill-rolling flexion at the thumb and forefinger at 4-8Hz.

Answer 345

Extrapyramidal dysarthria, soft, quiet, and hesitant speech. | You may have to wait some time for the answer to a question!

Answer 346

Writing is small and neat "micrographia".

Answer 347

Motor restlessness with a feeling of muscle quivering and an inability to remain in a sitting position.

Answer 348

Slow, writhing involuntary movements often with flexion, extension, pronation, and supination of the fingers and wrists.

Answer 349

Intermittent spasm of muscles around the eyes.

Answer 350

1. Non-rhythmical, dance-like, spasmodic movements of the limbs or face. 2. Appear pseudo-purposeful (the patient often hides the condition by turning a spasm into a voluntary movement - eg the arm suddenly lifts up the patient pretends they were adjusting their hair).

Answer 351

Repetitive, automatic movements that stop only during sleep.

Answer 352

Dyskinetic movements often of the face (lip-smacking, twisting of the mouth). --> Often a side effect of neuroleptic therapy.

Answer 353

Markedly increased tone often with spasms causing uncomfortable-looking postures.

Answer 354

Violent involuntary flinging movements of the limbs on one side - rather like severe chorea.

Answer 355

Brief, shock-like movement of a muscle or muscle-group.

Answer 356

1. Writhing limb movements (often finger/arm) much like athetosis but caused by a loss of proprioception. 2. The arm returns to the normal position when the patient notices it straying.

Answer 357

Continuous quivering and rippling movements of muscles at rest like a "bag of worms". Facial myokymia: especially near the eyes.

Answer 358

1. Repetitive, active, habitual, purposeful contractions causing stereotyped actions. 2. Can be suppressed for brief periods with effort.

Answer 359

Rhythmical contraction of the head. May be either "yes-yes" or "no-no" movements.

Answer 360

Repetitive, alternating movements, usually involuntary.

Answer 361

Also known as Brown-Sequard syndrome: 1. Motor --> Below the level of the lesion, UMN pattern of weakness on IPSILATERAL side. 2. Sensory --> Below the level of the lesion: a. CONTRALATERAL loss of pain and temperature. b. IPSILATERAL loss of light-touch, vibration sense, and proprioception. c. Light touch may remain intact as some fibres travel in the spinothalamic tract.

Answer 362

Loss of vibration sense and proprioception on BOTH sides below the level of the lesion.

Answer 363

Also known as posterolateral column syndrome - often due to B12 def. 1. Loss of vibration sense and proprioception on both sides below the level of the lesion. 2. UMN weakness in lower limbs, ABSENT ankle reflexes. 3. + Peripheral sensory neuropathy, optic atrophy and dementia.

Answer 364

1. Loss of pin-prick and temperature sensation below the lesion. 2. INTACT light-touch, vibration sense, and proprioception.

Answer 365

1. Loss of pain and temperature sensation over the neck, shoulders, and arms in a "cape" distribution. 2. Intact vibration sense, proprioception, and light touch. 3. Atrophy and areflexia in the arms. 4. UMN weakness in the lower limbs. 5. Look also for scoliosis due to weakness of paravertebral muscles.

Answer 366

1. Signs are IPSILATERAL. 2. Nystagmus 3. Speech is staccato, scanning. 4. Decr. tone, drift and tremor in limbs (upper especially) 5. Finger-nose testing may reveal intention tremor and past-pointing. 6. Dysdiadochokinesis 7. Rebound 8. Pendular jerks - best seen in the knee. Test the tendon reflex at the knee as normal. If "pendular", the extensor response will continue to several beats. 9. Poor sitting balance. 10. Ataxic gait.

Answer 367

1. Sensory and visual inattention. 2. Visual field defects 3. Agnosias (lack of sensory perceptual abilities) 4. Apraxias - inability to perform movements or use objects correctly. 5. Gerstmann's syndrome

Answer 368

1. Hemi-neglect - patient ignores on side of their body. 2. Asomatagnosia - patient fails to recognize own body part. 3. Anosagnosia - patient is unaware of neurological deficits. 4. Finger agnosia - patient is unable to show you different fingers when requested (eg show me your index finger). 5. Astereognosis - Inability to recognize an object by touch alone. 6. Agraphaesthesia - inability to recognize letters or numbers when traced on the back of the hand. 7. Prosopagnosia - Inability to recognize faces (test with family members or famous faces from a nearby magazine).

Answer 369

1. Ideational apraxia 2. Ideomotor apraxia 3. Dressing apraxia

Answer 370

Unable to perform task but understands what is required.

Answer 371

Performs task but makes mistakes (puts tea into kettle and pours milk into cup).

Answer 372

Inability to dress correctly - test with a dressing gown. | One of a number of apraxias named after the action tested.

Answer 373

1. Right-left dissociation. 2. Finger agnosia 3. Dysgraphia 4. Dyscalculia (test with serial 7s).

Answer 374

Memory loss - confabulation (invented stories and details).

Answer 375

1. Primitive reflexes 2. Concrete thinking (unable to explain proverbs - eg ask to explain what "a bird in the hand is worth two in the bush" means). 3. Loss of smell sensation. 4. Gait apraxia.

Answer 376

1. Muscle disease causes a weakness similar to that of LMN lesions with NO SENSORY LOSS. 2. Tendon reflexes are reduced or absent.

Answer 377

Characterized by continued, involuntary muscle contraction after voluntary effort has ceased.

Answer 378

A defect of skeletal muscle Cl channels caused by a trinucleotide repeat, usually. Becomes evident age 20-50.

Answer 379

1. Distal limb weakness. 2. Weak sternomastoids - evident by weakness of neck flexion with normal power on neck extension. 3. Weak facial muscles - expressionless face. 4. Test by shaking the patient's hand - they may be unable to let go!

Answer 380

1. Frontal baldness 2. Cataracts - look for thick glasses 3. Mild intellectual impairment 4. Cardiomyopathy 5. Hypogonadism 6. Glucose intolerance

Answer 381

Tap the patient's thenar eminence, this will cause contracion and very slow relaxation of abductor pollicis brevis.

Answer 382

Autoimmune disease with antibodies against ACh receptors.

Answer 383

1. Complex palsies - including extraocular muscles. 2. Weakness is proximal and often includes the eyelids (ptosis) and muscles of mastication. 3. Weakness increases with USE. Patients report incr. severity of symptoms at the end of the day. 4. In the early stages, will feel tired as they expend extra energy in performing routine tasks. 5. Friends may notice ptosis.

Answer 384

Test for fatiguability: 1. Ask the patient to look to the ceiling and hold the position. Watch for ptosis. 2. Ask the patient to hold their arms above their head - or out to the sides - watch for incr. weakness.

Answer 385

1. Bilateral - frontal, temporal. 2. Sensation of tightness radiating to neck and shoulders. 3. Can last for days. 4. No associated symptoms.

Answer 386

1. Sudden, dramatic onset "like being hit with a brick". 2. Occipital initially - may become generalized. 3. Associated with neck stiffness and sometimes photophobia.

Answer 387

1. Frontal, felt behind the eyes or over the cheeks. 2. Ethmoid sinusitis is felt deep behind the nose. 3. Overlying skin may be tender. 4. Worse on bending forwards. 5. Lasts 1-2 weeks. Associated with coryza.

Answer 388

1. Diffuse, spreading from the temple - unilateral. 2. Tender overlying temporal artery (painful brushing hair). 3. Jaw claudication while eating 4. Blurred vision - can lead to loss of vision if severe and untreated.

Answer 389

1. Generalized 2. Associated with neck stiffness and signs of meningism. 3. Nausea, vomiting, photophobia 4. Pruritic rash is caused by septicemia, not meningitis per se

Answer 390

1. Rapid onset, usually felt over one eye. 2. Associated with a blood-shot, watering eye, and facial flushing. 3. May also have rhinorrhea (runny nose). 4. Last for a few weeks at a time.

Answer 391

1. Generalized headache, worse when lying down, straining, coughing, on exertion or in the morning. 2. Headache may wake the patient in the early hours. 3. May be associated with drowsiness, vomiting, and focal neurology.

Answer 392

1. Unilateral - rarely crossed the midline. 2. Throbbing/pounding headache. 3. Associated with photophobia, nausea, vomiting, and neck stiffness. 4. May have preceding aura.

Answer 393

1. Eye-witness account? State of clothing - loss of continence? 2. Look for alert necklace/bracelet. Look in the wallet, purse etc.

Answer 394

1. Is the airway patent? Should the patient be in the recovery position? 2. Measure RR, note pattern of breathing. Is O2 needed? 3. Cyanosis? Feel pulse. Listen to chest. Measure HR, BP.

Answer 395

Look for injury, petechial hemorrhage, evidence of IVDA.

Answer 396

1. Watch! Is the patient still or moving? All 4 limbs moving equally? 2. Any abnormal movements - fitting, myoclonic jerks? 3. Test tone and compare both sides. 4. Squeeze the nail bed to test the response to pain (all 4 limbs).

Answer 397

Lesion ABOVE the brainstem: 1. Flexion + Internal rotation of the arms. 2. Extension of the lower limbs.

Answer 398

Lesion in the MIDBRAIN: 1. Extension at the elbow 2. Pronation of the forearm 3. Extension at the wrist 4. Extension of the lower limbs

Answer 399

1. Attempt to wake the patient by sound. 2. Ask their name. 3. If responsive, are they able to articulate properly? 4. Note the best response. 5. Be aware of possible dys- or aphasia which may cause an inappropriate response in an otherwise healthy individual. 6. Score level of consciousness according to GCS.

Answer 400

1. Do NOT examine if there may have been trauma. | 2. Test for meningeal irritation - these signs decr. as coma deepens.

Answer 401

Inspect for signs of trauma and facial weakness. Test pain sense.

Answer 402

Bruising behind the ear = base of skull fracture.

Answer 403

1. Look for CSF leakage or bleeding. 2. Test any clear fluid for glucose (positive result = CSF). 3. Inspect eardrums.

Answer 404

1. Look for cuts on the tongue (seizures), corrosive material around the mouth. 2. Smell breath for alcohol or ketosis. 3. Test the gag reflex - absent in brainstem disease or deep coma.

Answer 405

1. Pupils - measure size in mm. Are they equal? 2. Test direct and consensual light responses. 3. Pupils incr. with atropine, TCAs, amphetamine. 4. Pupils decr. with morphine, metabolic coma. 5. Test corneal reflex. 6. Fundi --> look especially for papilloedema and retinopathy.

Answer 406

1. Take the patient's head in your hands and turn in from side-to-side. 2. The eyes should move to stay fixed on an object - indicates INTACT BRAINSTEM.

Answer 407

``` A brief but thorough exam. Look especially for: 1. Trauma 2. Fractures 3. Signs of liver disease 4. Added heart sounds ```

Answer 408

1. Test urine 2. Capillary glucose 3. Temperature

Answer 409

Objective score of consciousness. A. Eye opening (max 4 points) 4 - Spontaneously open 3 - Open to (any) verbal stimulus 2 - Open in response to painful stimulus 1 - No eye opening at all B. Best verbal response (max 5 points) 5 - Normal 4 - Conversing but disoriented and confused 3 - Inappropriate words (random words, no conversation) 2 - Incomprehensible sounds (moaning etc) 1 - No speech at all C. Best motor response (max 6 points) 6 - Obeying commands (raise your hand) 5 - Localizing to pain (moves hand towards site of stimulus) 4 - Withdraws to pain (pulls hand away from stimulus) 3 - Abnormal flexion to pain (decorticate posture) 2 - Abnormal extension to pain (decerebrate posture) 1 - No response at all

Answer 410

Narrow the exact meaning down without appearing aggressive or disbelieving. This term is used by different people to describe rather different things.