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Physical Diagnosis > PD Neuro Part 1 > Flashcards

PD Neuro Part 1 Flashcards

1
Q

Concerning neuro symptoms

A 
Changes in mood, attention, or speech
Changes in memory, orientation, insight, or judgement
Delirium or dementia
Headache
Pain
Dizziness or vertigo
Weakness
Numbness/loss of sensation
Syncope
Seizures
Tremors or involuntary movement
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2
Q

Areas of neuro exam

A 
Mental status
Cranial nerves
Motor system
Sensory system
Reflexes
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3
Q

Mental status exam

A

Total expression of a person’s emotional responses, mood, cognitive functioning, and personality
Determined throughout interview

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4
Q

Mental status exam appearance and behavior

A

Grooming
Emotional status
Body language

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5
Q

Mental status exam emotional stability

A

Mood and feelings

Thought processes

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6
Q

Mental status exam cognitive abilities

A

State of consciousness
Memory
Attention span
Judgement

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7
Q

Mental status exam speech and language

A 
Voice quality
Articulation
Comprehension
Coherence
Aphasia
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8
Q

Prep for mental status exam

A

Make patient comfortable and secure
Make it easy for patient to talk freely
Trust, confidentiality, desire to help

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9
Q

Difficult to separate … from … history

A

Separate medical from psychiatric history

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10
Q

History for MSE

A 
ETOH use
Drug abuse
Recent medications
Suicidal thoughts/attempts
Homicidal/unusual behavior
History of mental illness
Previous hospitalizations
Prior visits to practitioners
Family history
Birth and developmental hx
School record
Work experience
Antisocial behavior/legal problems
Marital hx
Interpersonal relationships
Home life
Military hx
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11
Q

Describing speech

A 
Soft
Loud
Stuttering
Hesitancy
Accent
Enunciation
Rate
Relationship to motor activity
Delay
Coherency
Disorganized speech
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12
Q

Delusion

A

Abnormalities in the content of thought

False beliefs which cannot be explained, including by patient’s cultural background

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13
Q

Types of delusion

A 
Persecutory
Jealousy
Sin or guilt
Gradiose
Religious
Somatic
Reference
Being controlled
Mind reading
Thought broadcast
Thought insertion
Thought withdrawal
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14
Q

Hallucinations

A

Abnormalities in perception, which occur in the absence of some identifiable external stimulus

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15
Q

What sensory modality are affected by hallucinations?

A 
All:
Hearing
Sight
Smell
Taste
Touch
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16
Q

What must a patient describe about hallucinations?

A

Must describe an actual, specific perception

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17
Q

Questions for suicidal homicidal ideation

A

Very important to remember these questions in all psychiatric examinations
Ask directly about thoughts of self harm or harming others
Do you have a plan?

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18
Q

Risk factors for suicide

A 
Hx of mental DO
ETOH or drug abuse
Major physical illness
Job loss
Relationship loss
Lack of support system
Impulsive behavior
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19
Q

Activities of daily living dependent on…

A

Patient’s mental status

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20
Q

Basic ADLs

A 
Bathing
Dressing
Toileting
Feeding
Ambulating
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21
Q

Instrumental ADLs

A 
Housekeeping
Grocery shopping
Meal preparation
Managing medications
Communication skills
Money management
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22
Q

Glasgow Coma Scale

A

Used to quantify consciousness when a patient has altered level due to head trauma or hypoxic event
Developed to predict mortality and for emergency assessment of consciousness

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23
Q

What two brain components do we assess with a GCS?

A

Cerebral cortex and brainstem

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24
Q

3 factors of GCS

A

Eye opening - 4 points
Verbal response - 5 points
Motor response - 6 points

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25
Q

Max and min GCS

A

3-15

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26
Q

Eye opening

A

4 - spontaneously
3 - speech
2 - pain
1 - none

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27
Q

Verbal response

A 
5 - orientated
4 - confused
3 - inappropriate
2 - incomprehensible
1 - none
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28
Q

Motor response

A 
6 - obeys commands
5 - localizes pain
4 - withdraws from pain
3 - flexion to pain
2 - extension to pain
1 - none
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29
Q

Unexpected levels of consciousness

A 
Confusion
Lethargy
Delirium
Stupor
Coma
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30
Q

Confusion

A

Inappropriate responses to questions
Decreased attention span
Decreased memory

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31
Q

Lethargy

A

Drowsy, falls asleep easily

When aroused, responds appropriately

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32
Q

Delirium

A

Confusion accompanied by agitation or hallucinations
Inappropriate reactions to stimuli
Confusional state characterized by disturbance of consciousness, impaired attention, and change in cognition

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33
Q

Stupor

A

Arousable for short periods by questions or painful stimuli

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34
Q

Coma

A

Motionless

Unresponsive to stimuli

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35
Q

Mini mental state exam

A

Standardized method for grading the cognitive state of patients

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36
Q

Max score for mini exam

A

30

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37
Q

Depressed patients without dementia score for mini exam

A

24-30

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38
Q

Score of 20 or less on mini exam

A

Dementia
Delirium
Schizophrenia
Affective disorder

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39
Q

Components of mini mental status exam

A

Orientation: season, D/M/Y, day, city, state, hospital
Registration - name 3 objects, have pt repeat
Attention/calculation - serial 7s
Recall - repeat 3 objects
Language - pt says “no ifs, ands, or buts about it”
Pt follows 3 step command

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40
Q

Dementia

A

Syndrome of failing memory and impairment of other intellectual functions, behavioral abnormalities, and personality changes
Chronic progressive deterioration of the brain
Usually related to obvious structural diseases of the brain tissue
Most causes non-reversible

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41
Q

Dementia symptoms

A

Insidious onset
Cognitive impairment - permanent and progressive
Agnosia
Speech/language -disordered, rambling, incoherent, struggles to find words
Mood and affect - depressed, apathetic, uninterested
Delusions
NO hallucinations

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42
Q

Agnosia

A

Loss of ability to recognize persons, objects, etc

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43
Q

Types of dementia

A 
Alzheimer's
Vascular dementia - multi-infarct dementia
Lewy body dementia
Alcohol induced
Parkinson's
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44
Q

Delirium

A

Confusional state characterized by disturbance of consciousness, impaired attention, and change in cognition
Confusion accompanied by agitation or hallucinations
Inappropriate reactions to stimuli

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45
Q

Etiology of delirium

A 
Hypoxia or hypercapnea
Sepsis
Uremia
Electrolyte imbalance
ETOH withdrawal
Meds
Brain injury
Liver failure
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46
Q

Is delirium curable?

A

Yes - reversible if treating underlying problem

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47
Q

Delirium symptoms

A 
Acute onset
Duration - hours to days
Anxiety, intense
Decreased memory
Decreased attentiveness
Decreased consciousness
Delusions/hallucinations - visual, auditory, tactile
Mood/affect - rapid mood swings, fearful, suspicious, agitated
Disturbed sleep
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48
Q

Depression

A

Common psych illness
Symptoms range from mild to psychotic
Episodic or persistent

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49
Q

Causes of depression

A

Grief

Reaction to medical DO

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50
Q

Symptoms of depression

A

Mood and affect - extreme sadness, anxious, irritability
Somatic c/o - decreased appetite, HA, constipation, fatigue
Speech - slow/sluggish, slow to respond
Cognitive - c/o memory loss, inability to concentrate

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51
Q

CNS

A

Brain and spinal cord

Main network of coordination and control of body

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52
Q

PNS

A

Carries info to and from the CNS
Motor and sensory nerves
Ganglia

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53
Q

How is the CNS protected?

A

Skull
Vertebrae
Meninges
CSF

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54
Q

3 layers of meninges

Produce and drain…

A

Dura mater
Arachnoid mater
Pia mater
Produce and drain CSF

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55
Q

Where does CSF circulate?

A

Between an interconnecting system of ventricles in the brain and around the brain/spinal cord

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56
Q

Arteries to brain

A

2 internal carotid
2 vertebral
1 basilar

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57
Q

Veins draining brain

A

Venous sinuses that empty into the internal jugular veins

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58
Q

4 major regions of brain

A

Cerebrum
Cerebellum
Brainstem
Diencephalon

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59
Q

Brainstem

A

Medulla oblongata
Pons
Midbrain

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60
Q

Diencephalaon

A

Thalamus
Hypothalamus
Pituitary

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61
Q

Brain tissue colors

A

Gray or white

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62
Q

Gray matter

A

Made up of neuronal cell bodies

Rims surface of cerebral hemispheres forming cerebral cortex

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63
Q

Deep clusters of gray matter

A

Basal ganglia
Thalamus
Hypothalamus

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64
Q

White matter

A

Consists of neuronal axons coated with myelin, allows nerve impulses to travel faster

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65
Q

Lobes of cerebrum

A

2 hemispheres each divides into 4 lobes

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66
Q

Frontal lobe

A

Motor cortex - voluntary mvmt
Speech formation
Areas for emotions, affect, drive, self-awareness
Autonomic response related to emotional stress

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67
Q

Frontal lobe area for speech

A

Broca’s area

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68
Q

Parietal lobe

A

Processes sensory data
Interpretation of tactile sensations - pain, temp, texture
Visual, gustatory, olfactory, auditory sensation
Comprehension of written words, proprioception, recognition of body parts

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69
Q

Occipital lobe

A

Primary vision center and interpretation of visual data

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70
Q

Temporal lobe

A

Responsible for perception and interpretation of sounds
Speech area - comprehension of spoken word and written language
Integration of taste, smell, and balance, as well as behavior, emotion, and personality

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71
Q

Temporal lobe area for speech comprehension

A

Wernicke’s

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72
Q

Cerebellum

A

Aids the motor cortex of cerebrum in the integration of voluntary movement
Processes sensory info from eyes, ears, touch receptors, musculoskeleton
Utilizes sensory data to control muscle tone, equilibrium, and posture

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73
Q

Brainstem

A

Pathway between cerebral cortex and spinal cord

Control involuntary functions

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74
Q

Components of brainstem

A

Medulla oblongata
Pons
Midbrain
Diencephalon

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75
Q

What structures arise from brainstem?

A

Nuclei of the 12 cranial nerves arise from these structures

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76
Q

Cranial nerves

A

Peripheral nerves that arise from brain instead of spinal cord
Motor and/or sensory function

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77
Q

4 CN with parasympathetic functions

A

III, VII, IX, X

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78
Q

Basal ganglia

A

Pathway and processing station between motor cortex and upper brainstem

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79
Q

Autonomic nervous system

A

Regulates internal environment of body
Person has no voluntary control
2 divisions - balance the impulses of the other

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80
Q

Sympathetic nervous system

A

Prods body into action during time of physiologic and psychologic stress

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81
Q

Parasympathetic nervous system

A

Conserves body resources and maintain day-to-day body functions (digestion and elimination)

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82
Q

Spinal cord

A

Extends from medulla to L1-L2
Conus medullaris
Cauda equina
Sensory, motor, autonomic impulses between brain and body

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83
Q

Level of cauda equina

A

L4

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84
Q

White matter tracts of SC

A

Ascending and descending tracts

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85
Q

Gray matter of SC

A

Butterfly shape with anterior and posterior horns

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86
Q

Descending spinal tracts originate in…

A

Brain

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87
Q

Pyramidal tract

A

Great motor pathway that carries impulses for voluntary movement

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88
Q

Ascending spinal tracts

A

Mediate various sensations

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89
Q

Posterior dorsal column

A

Carry fibers for discriminatory sensations of touch, deep pressure, vibration, position of joints, stereognosis, +2 point discrimination

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90
Q

Spinothalamic tracts

A

Carry fibers for crude touch, pressure, temp, and pain

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91
Q

… Motor neurons make up the descending pathways from brain to spinal cord

A

Upper motor neurons

92
Q

Lower motor neurons originate… and terminate…

A

Originate in anterior horn

Terminate in muscle fibers

93
Q

How many pairs of spinal nerves?

A 
31 pairs
8 cervical
12 thoracic
5 lumbar
5 sacral
1 coccygeal
94
Q

Spinal nerves arise… and exit…

A

Arise from SC and exit at each intervertebral foramen

95
Q

Dermatome

A

Sensory and motor fibers of each spinal nerve supply and receive information in a specific body distribution

96
Q

Formation of nerve plexus

A

Anterior branches of several spinal nerves combine

97
Q

Spinal nerve separates into…

A

Ventral and dorsal roots

98
Q

Ventral root

A

Motor fibers carry impulses from SC to the muscles and glands of the body

99
Q

Dorsal root

A

Sensory fibers carry impulses from the sensory receptors of the body to the SC

100
Q

Impulses from dorsal root travel…

A

Up to brain for interpretation

Initiate reflex action when it synapses immediately with motor fiber after a stimulus

101
Q

Reflex arc

A

Dependent upon intact afferent nerve fibers, functional synapses in SC, intact motor nerve fibers, functional NMJ, and competent muscle fibers

102
Q

When upper motor neurons are damaged above the cross over of its tracts in the medulla, motor impairment develops on what side?

A

Contralateral

103
Q

In damage below the cross over, motor impairment occurs on what side?

A

Ipsilateral

104
Q

How many pairs of peripheral nerves?

A

12 pairs

105
Q

Where do peripheral nerves arise from?

A

Brainstem/diencephalon

106
Q 
Where do these nerves arise from?
I-II
III-IV
V-VIII
IX-XII
A

I-II diencephalon
III-IV midbrain
V-VIII pons
IX-XII medulla

107
Q

Motor and sensory innervation of the head and neck

A

Voluntary muscles
Visceral motor
General sensation
Special sensation

108
Q

Name cranial nerves

A 
I Olfactory
II Optic
III Oculomotor
IV Trochlear
V Trigeminal
VI Abducens
VII Facial
VIII Vestibulococchlear
IX Glossopharyngeal
X Vagus
XI Spinal accessory
XII Hypoglossal
109
Q

Which senses are not routinely tested?

A

Taste and smell are not routinely tested unless abnormality suspected

110
Q

Prep for sensory testing

A

Patients eyes are closed

111
Q

Sensory testing

A

Light touch

Sharp versus dull

112
Q

Light touch

A

Light strokes of cotton swab or brush/monofilament

Ask for when and where stimulus was felt

113
Q

Sharp versus dull

A

Tests superficial pain
Broken tongue blade, paper clip
Alternate sharp and dull testing in unpredictable fashion
Ask pt if they feel sharp versus dull and location

114
Q

CN I

A 
Special sense of olfaction
Anosmia 
Patient closes eyes
Make sure both nares are patent
Occlude one nostril and test smell with familiar, non offensive odor
Test opposite using different odor
115
Q

Causes of anosmia

A 
Nasal disease
Allergies
Trauma
Smoking 
Aging
116
Q

CN I skull fracture

A

Tearing of fibers crossing cribiform plate

CSF rhinorrhea

117
Q

How to distinguish between rhinorrhea and CSF

A

CSF is salty

118
Q

CN I Frontal lobe mass

A

Tumors or abscess

Leads to compression

119
Q

CN I damage to primary cortical olfactory area

A

Temporal lobe

Masses or seizures may present with olfactory hallucinations

120
Q

CN II motor or sensory

A

Sensory

121
Q

CN II

A

Visual acuity and visual field testing portion of eye exam

Fundoscopic exam for direct visualization

122
Q

CN III motor or sensory

A

Motor

123
Q

CN III

A

Raise eyelids
Extraoccular movements
Parasympathetic - pupillary constriction, changes in lens shape

124
Q

CN IV motor or sensory

A

Motor

125
Q

CN IV

A

Downward, inward eye movement

Extraocular movements

126
Q

CN V motor or sensory

A

Motor and sensory

127
Q

CN V motor

A

Jaw opening/clenching
Chewing
Mastication

128
Q

CN V sensory

A 
Cornea
Iris
Lacrimal glands
conjunctivae
Eyelids
Forehead
Nose
Nasal and oral mucosa
Teeth
Tongue
Ear
Face 
Scalp
129
Q

Divisions of trigeminal

Sensory or motor

A

V1 - opthalmic (sensory)
V2 - maxillary (sensory)
V3 - mandibular (both)

130
Q

Testing CN V motor

A

Observe face for muscle atrophy, jaw deviation, fasciculations
Have pt clench teeth as you palpate masseter and temporalis is muscles

131
Q

What condition are you suspicious of with fasiculations?

A

ALS

132
Q

Testing CN V sensory

A

Test each division (All 6) for light touch, sharp versus dull

Test corneal reflex

133
Q

What would we test if normal CN V sensory function is impaired?

A

If impaired, test temp sensation using test tubes filled with hot or cold water in all 6 divisions and compare

134
Q

Who do we test corneal reflex in?

A

Comatose patients

135
Q

What is the normal response for corneal reflex?

A

Blink when cotton wisp touches cornea

136
Q

What two CN need to be intact for the corneal response?

A

CN V and VII

137
Q

Which branch of trigeminal is dangerous to be infected with herpes zoster?

A

V1 - risk of blindness

Opthalmic emergency!

138
Q

Trigeminal neuralgia

A

Unilateral pain syndrome, usually limed to 1 division of Cn V
Hot lancinating pain can be debilitating
Ofte associated with trigger - light touch, chewing, sneezing

139
Q

Cause of tic douloureux

A

Idiopathic

140
Q

Most common patient with CN V neuralgia

A

Over 60

141
Q

Neuro exam with tic douloureux

A

Unrevealing

142
Q

Treatment for trigeminal neuralgia

A 
Carbamazepine (Tegretol)
Gabapentin (Neurontin)
Pregabalin (Lyrica)
Microvascular decompression
Gamma Knife
143
Q

CN VI motor or sensory

A

Motor

144
Q

CN VI

A

Lateral eye movement

145
Q

CN VII motor or sensory

A

Motor and sensory, parasympathetic

146
Q

CN VII motor

A

Movement of facial expression muscles except jaw
Close eyes
Labial speech sounds (b, m, w, p)

147
Q

CN VII sensory

A

Taste on anterior 2/3 of tongue (salty/sweet)
Taste on posterior 1/3 tongue (bitter)
Sensation to pharynx, auricle, and small area skin posterior

148
Q

Anterior tongue

A

Anterior 2/3 salty/sweet

149
Q

Posterior tongue

A

Posterior 1/3 bitter

150
Q

Parasympathetic CN VII

A

Secretion of saliva and tears

151
Q

CN VII testing facial function

A 
Motor function assessed by facial functions:
Raise eyebrows
Squeeze eyes shut as tightly as possible and against resistance
Wrinkle forehead
Smile
Show teeth
Frown
Purse lips
Puff cheeks
Listen to speech
152
Q

CN VII taste testing

A

Not routinely done unless abnormality suspected
Four solutions - salty, sweet, sour, bitter
Apply one at a time to area of tongue

153
Q

What other CN are we testing when testing taste with CN VII

A

CN IX - taste to posterior 1/3 of tongue

154
Q

Reflexes involving CN VII

A

Corneal V –> VII
Bright light II –> VII
Loud noise VIII –> VII
Suck reflex in infant V –> VII

155
Q

CN VII Bell’s palsy

A 
Inability to wrinkle brow
Drooping eyelid
Inability to close eye
Inability to puff cheeks - no muscle tone
Drooping mouth
Inability to pucker or smile
156
Q

CN VIII

A

Special sense
Auditory info from cochlea
Balance info from semicircular canal

157
Q

Testing auditory CN VIII

A

Whisper test
Weber
Rinne
Audiometric evaluation

158
Q

Testing vestibular CN VIII

A

Romberg test

159
Q

Romberg test

A

Patient stands with feet tightly together, eyes closed, arms out in front
Observe for drifting, loss of balance

160
Q

Positive Romberg test indicates…

A

Vestibular dysfunction
Cerebellar ataxia
Sensory loss

161
Q

What do you need to make sure to do when doing the Romberg test?

A

Protect your patient!

162
Q

CN IX motor or sensory

A

Motor, sensory, parasympathetic

163
Q

CN IX motor

A

VOluntary muscles for swallowing and phonation

164
Q

CN IX sensory

A

Sensation of nasopharynx
Gag reflex
Taste - posterior 1/3 of tongue

165
Q

CN IX parasympathetic

A

Secretion of salivary glands

Carotid body/sinus reflex

166
Q

What nerve is simultaneously tested during examination, and for what sensations?

A

IX is simultaneously tested during exam of CN X for nasopharyngeal sensation (gag reflex) and motor function of swallowing

167
Q

CN X motor or sensory

A

Motor and sensory, parasympathetic

168
Q

CN X motor

A

Voluntary muscles of phonation and swallowing

169
Q

Voluntary muscles of phonation

A

Guttural speech sounds - harsh sounds produced in throat/back of mouth

170
Q

CN X sensory

A

Sensation behind ear and part of external auditory canal

171
Q

CN X parasympathetic

A

Secretion of digestive enzymes
Peristalsis
Carotid reflex
Involuntary action of heart, lungs, and GI tract

172
Q

Gag reflex CN

A

CN IX and X

173
Q

Gag reflex

A

Evaluating nasopharyngeal sensation
Tell patient
Touch posterior wall of pharynx with tongue blade
Observe upward mvmt of palate and contraction of the pharyngeal muscles
Uvula should remain midline
No drooping or absence of arch on either side of soft palate should be noted

174
Q

CN IX and X

A

Motor function is evaluated by again inspecting soft palate for symmetry
Have pt say aahh and observe for mvmt and asymmetry
Easily swallows water
Listen to speech

175
Q

Damage of IX and X

A

Palate will fail to rise and uvula will deviate from midline
Retrograde passage of water through the nose
Hoarseness, nasal quality, difficulty with guttural sounds

176
Q

CN XI motor or sensory

A

Motor

177
Q

CN XI

A

SCM and trapezius innervation

178
Q

Testing CN XI

A

Have pt shrug shoulders against resistance

179
Q

CN XII motor or sensory

A

Motor

180
Q

CN XII motor

A

Tongue movement for lingual speech articulation (l, t, n) and swallowing
Inspect tongue while at rest on floor of mouth and while protruding
Assess strength of tongue by having pt press tongue against inside of each cheek against resistance

181
Q

Tongue deviation with CN XII lesion

A

Deviates towards lesion

182
Q

Evaluation of proprioception and cerebellar function

A

Rapid rhythmic alternating movements
Accuracy of movements
Balance (equilibrium, gait)

183
Q

Rapid rhythmic alternating movements

A

Ask seated patent to pat his hands on his knees with both hands, alternately turning palm up and down
Gradually increase rate

Pt touches thumb to each finger on same hand and increase speed

Movements should be smooth, maintaining rhythm
Looking for stiff, slowed, nonrhythmic, or jerky clonic movements

184
Q

Accuracy of movement tests

A

Finger to finger test
Finger to nose test
Heel to shin test

185
Q

Finger to finger test

A

Pt uses index finger to alternately touch his nose and your index finger
About 18 inches away
Moving around

186
Q

Finger to nose test

A

With eyes closed have pt touch their own nose with their index finger, alternating hands
Increase speed

187
Q

Heel to shin test

A

Sitting, standing, or supine
Pt runs the heel of one foot down the shin of the other leg
Heel should move straight up and down shin in straight line

188
Q

Equilibrium test

A

Romberg test

189
Q

If patient staggers or loses balance during Romberg test…

A

Defer further tests of cerebellar function requiring balance

190
Q

Further test of balance

A

Push pts shoulder with enough force to throw him off balance
Should recover balance quickly

Pt closes eyes, arms straight at sides, have pt stand on one foot, then the other
Should balance in about 5 seconds

Have pt hop on one foot, then the other
Should maintain balance for 5 seconds or more

191
Q

Gait test

A

Observe pt walk without shoes
First with eyes open
Then eyes closed

Heel to toe walk
Walk on heels
Walk on tip toes

192
Q

What to note during gait examination

A 
Simultaneous arm movement and posture
Shuffling
Widely placed feet
Toe walking
Foot flop
Leg lag
Scissoring
Staggering
Loss of arm swing
193
Q

Pronator drift

A 
Standing or sitting
Pt puts arms straight out in front, palms up and eyes closed
20-30 seconds
Tap arms briskly downward
Arms should return smoothly
194
Q

What are we testing during pronator drift?

A

Muscle strength
coordination
Sense of position

195
Q

Positive pronator drift

A

Pt with upper motor neuron disease
Will not maintain position
Arm will drift down and start to pronate

196
Q

Patients with asterixis

A

Metabolic encephalopathy

Uremia
Severe pulmonary insufficiency
Cerebrovascular disease

197
Q

Asterixis test

A

Pt extends both arms in front with hands cocked up and fingers spread (stop traffic)
Sudden, brief, nonrhythmic “flapping” of hands

198
Q

Meningeal signs

A

Nuchal rigidity
Brudzinski sign
Kernig sign

199
Q

Nuchal rigidity

A

Patient is supine
Try and flex neck
Should be done with ease and pain free
Pain or resistance to neck motion is positive nuchal rigidity

200
Q

Brudzinski sign

A

Involuntary flexion of hips and knees when flexing the neck

201
Q

Kernig sign

A

Flexing the leg at the knee and hip with patient supine
Attempt to straighten the leg
Pain in the lower back and resistance to straightening the leg

202
Q

Abnormal posture in comatose patients

A

Decorticate rigidity

Decerebrate rigidity

203
Q

Decorticate rigidity

A

Abnormal flexor response
Upper arms are held tight to sides with elbows, wrists, and fingers flexed
Legs are extended and internally rotated
Feet plantar flexed

204
Q

Cause of decorticate rigidity

A 
Indicates damage to corticospinal tract above brainstem
Ex. IC hemorrhage
Head injury
Increase IC pressure
Stroke
205
Q

Which is more favorable, decorticate or decerebrate?

A

Decorticate

206
Q

Decerebrate rigidity

A

Abnormal extensor response
Jaws clenched, neck extended
Arms fully extended, forearm pronated, wrist/fingers flexed
Back may be arched
Feet plantar flexed
May occur spontaneously or only response to stimuli (nose, light, pain)

207
Q

Causes of decerebrate rigidity

A

Indicates lesion in diencephalon, midbrain, or pons, although severe metabolic DOs (hypoxia, hypoglycemia) may also be the cause

208
Q

Oculocephatlic reflex

If brainstem is intact…

A

Doll’s eyes
Make sure there is no neck injury
Hold open eyelids, then turn head quickly to one side, then to other side
If intact, as head turns to one side, the eyes move towards the opposite side

209
Q

What does oculocephalic reflex assess?

A

Assesses brainstem function in stuporous or comatose patients

210
Q

Does an alert patient have a oculocephalic reflex?

A

No, because the reflex is suppressed

211
Q

Cause of lack of Doll’s eyes

A

If reflex is absent, suggests lesion or disorder of midbrain or pons

212
Q

Oculovestibular reflex

A

Make sure TM intact and external canal is clear
Pts head at 30 degrees
With large syringe, inject cold water into ear canal
Watch for deviation of eyes in horizontal plane

If brainstem is intact, eyes drift toward irrigated ear

213
Q

Do we test the oculovestibular reflex on alert patients?

A

No

214
Q

What does the oculovestibular reflex assess?

A

Further assesses brainstem function when oculocephalic reflex is absent

215
Q

Cause of absent oculovestibular reflex

A

If absent, suggests lesion of pons, medulla, or less commonly CN III, IV, VI, or VIII

216
Q

Determining death for most patients

A

Cardiac activity
Respiratory activity
Neurologic activity

217
Q

Cardiac activity to determine death

A

Palpate for pulsations in carotids
Auscultate precordium for heart sounds
If in doubt, get EKG

218
Q

Respiratory activity to determine death

A

Listen for breath sounds over lungs and mouth

Can hold cold mirror over mouth to look for water vapor

219
Q

Neurologic activity to determine death

A

Call to patient to test mentation
Retract eyelids - pupils fixed and dilated in death
Rote head from side to side for Doll’s eyes
If absent, perform oculovestibular reflex
Sternal run or squeeze Achilles to test for deep pain perception
Lift and let limbs fall to test for muscle tone
Gag reflex

220
Q

Apnea test

A 
Pre-oxygenate
Baseline ABG for CO2 level
Disconnect ventilator (but do not take O2 away)
Administer oxygen
Observe respirations
Draw ABG in 8-10 minutes
221
Q

Brain death criteria of apnea test

A

pCO2 of greater than 60, or increase of greater than 20 over normal baseline, with no respiratory effort supports a positive apnea test consistent with brain death

222
Q

Brain death

A

Irreversible cessation of all brain activity

Brain is not capable of maintaining life without advance life support

223
Q

What structure death is equivalent to brain death?

A

Brainstem death is equivalent to brain death because brainstem is essential to maintain life

224
Q

Does a patient have a heartbeat with brain death?

A

Yes, they could

225
Q

What happens to patients in a coma?

A

Some recover
Some enter persistent vegetative state
Some become brain dead

Physical Diagnosis (10 decks)

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