Physical Examination Flashcards
RAPD
(Marcus-Gunn pupil)
Normal: light shone into either eye constricts both pupils equally
Afferent limb of optic nerve damaged: light shone into affected eye causes less constriction of that eye. Therefore pupil appears to relatively dilate when light swung from good eye to affected eye. (Relevant afferent pupillary defect).
Potential causes: retinal damage of affected eye e.g. CRAO, CRVO, large retinal detachment or due to significant optic neuropathy e.g. optic neuritis, unilateral advanced glaucoma, compression secondary to tumour or abscess
Visual fields
Bitemporal hemianopia: loss of temporal visual field in both eyes (central tunnel vision). Causes: optic chasm compression by tumour e.g. pituitary adenoma
Homonymous field defect: affect same side of the visual field in both eyes. Causes: stroke, tumour, abscess (pathology affecting visual pathways posterior to optic chiasm). Hemianopia for half of the fields or quadrantanopia for quarter
Scotoma: area of absent/reduced vision surrounded by area of normal vision. Causes: demyelinating disease e.g. MS, diabetic maculopathy
Monocular vision loss: total loss of vision in one eye secondary to optic nerve pathology (e.g. anterior ischaemic optic neuropathy) or ocular disease (e.g. CRAO, total retinal detachment)
Oculomotor nerve palsy (CNIII)
“down and out” appearance of eye
+ ptosis
+ mydriasis
Trochlear nerve palsy (CN IV)
Vertical diplopia when looking inferiorly. Patients often tilt head forward and tuck chin in to compensate.
Abducens nerve (CN VI)
convergent squint due to unopposed action of medial rectus muscle
horizontal diplopia worse when trying to look to affected side
HINTS exam
Head Impulse
Nystagmus
Test of Skew
Head impulse:
Positive = consistent with peripheral vertigo
Positive when there is a significant lag with corrective saccades (in ONE direction, horizontally - BOTH or VERTICAL concerning for central)
Nystagmus:
Unidirectional horizontal nystagmus consistent with peripheral vertigo. Multidirectional/torsional/vertical concerning for central.
Skew:
deviation of eye once uncovered concerning for central vertigo
Stroke mimics
migraine aura hemiplegic migraine Todd's paralysis CNS tumour or abscess functional/conversion reaction hypertensive encephalopathy head trauma MS PRES MELAS syncope subdural systemic infection toxic metabolic disturbance transient global amnesia carotid artery dissection extending aortic dissection bell's palsy vestibular neuronitis cerebral venous sinus thrombosis
Medial medullary syndrome
–> anterior spinal artery or vertebral artery
contralateral weakness
contralateral vibration and proprioception loss
ipsilateral tongue weakness
Lateral medullary syndrome
–> vertebral, basilar, anterior spinal artery, or PICA
Ipsilateral
- facial sensory loss
- nystagmus
- horner’s syndrome
- loss of gag reflex
- ataxia, with tendency to fall to ipsilateral side
Contralateral
- pain and temperature sensory loss in the extremeties
Generally
- vertigo
- nausea
- dysphagia
Locked-in syndrome
–> basilar artery
bilateral whole body weakness
bilateral facial weakness
lateral gaze weakness
dysarthria
able to move eyelids and have vertical gaze
ACA syndrome
contralateral hemiparesis of LL
contralateral sensory loss of UL
anosmia
frontal lobe dysfunction - altered judgement, insight, mentation
PCA syndrome
PROXIMAL
- contralateral homonymous hemianopia (cortical blindness)
- contralateral hemiplegia
- chorea and hemibalismus
- oculomotor nerve palsy, loss of voluntary eye movements
- thalamic pain/hyperalgesia syndrome
- emesis centres
- crossed deficits - motor on one side, sensory on the other
DISTAL
- contralateral homonymous hemianopia
- visual agnosia
Dominant MCA (Gerstmann syndrome)
agraphia
acalculia
finger agnosia
R-L disorientation
–> contralateral weakness, sensory loss, hemineglect (weakness usually worse in arm and face than in leg)
contralateral homonymous hemianopia global aphasia (receptive and expressive)
Expressive aphasia
Broca’s aphasia
can’t communicate verbally but understanding may be intact
Receptive aphasia
Wernicke’s
unable to understand speech
Non dominant MCA syndrome
contralateral weakness, sensory loss, hemineglect (as for dominant)
contralateral homonymous hemianopia (as for dominant)
apraxia and spacial disorientation
FAST-ED stroke score
(F)acial palsy
(A)rm weakness (drift, effort against gravity)
(S)peech changes
(T) - no score for T
(E)ye deviation
(D)enial/neglect
ROSIER
Recognition of Stroke in the Emergency Room (ROSIER)
(-1) loss of consciousness or syncope
(-1) seizure activity
rest = +1 each new, acute onset (or on awakening from sleep) finding of - asymmetric facial weakness - asymmetric arm weakness - asymmetric leg weakness - speech disturbance - visual field defect
score of 1 or more = stroke possible
Reflexes in acute stroke
may be decreased initially
progress to be increased
Reflexes in spinal cord injury
may be decreased initially
progress to increased
Reflexes in peripheral nerve injury
decreased
Neurogenic shock
hypotension and relative bradycardia due to circulatory collapse from loss of sympathetic tone
spinal shock
temporary loss of spinal cord function and reflex activity below the level of a spinal cord injury characterised by - flaccid areflexic paralysis - bradycardia and hypotension - absent bulbocavernosus reflex
usually resolves after 48 hours
