Quiz #4 Neurological Flashcards
Central Nervous System
brain and spinal cord
Peripheral nervous system
Cranial and Spinal nerves.
Afferent fibers to CNS and efferent fibers from CNS.
Autonomic messages to internal organs and blood vessels.
Cerebral cortex
Gray matter
Highest functions: thought, memory, reasoning, sensation, voluntary movement
What brain functions should be assessed?
- Sensation
- Vision/Hearing
- Language comprehension/Aphasia
What can damage to the cerebral cortex produce? (5)
- Loss of function in affected area
- Motor weakness
- Paralysis
- Loss of sensation
- Impaired ability to understand and process language
Cerebellum function
- motor coordination of voluntary movements
- equilibrium
- muscle tone
What cranial nerves originate from the brainstem?
CN III through XII
Where are samples of CSF taken from?
The lumbar cistern
Crossed representation of nerve tracts
The left cerebral cortex receives sensory information from and controls motor function on the right side of the body.
The right cerebral cortex receives sensory information from and controls motor function on the left side of the body.
Sensory pathways
Sensory fibers transmit and conduct sensations of:
- Pain
- Temperature
- Crude or Light touch
- Position
- Finely localized touch
Motor pathways
Pyramidal and extrapyramidal tracts
Pyramidal (corticospinal) tract
Motor pathway
Skilled and purposeful ovement
Extrapyramidal tracts
More primitive motor pathway
Controls muscle tone and gross movements like walking
Upper motor neurons
Located completely within the CNS
Disease of UMN includes stroke, CP, and MS
Lower motor neurons
Located in peripheral nervous system
Final direct contact with the muscles
Cranial nerves and spinal nerves are LMNs
Diseases of LMN include spinal cord lesions, poliomyelitis, ALS
Reflexes mediated by
spinal nerve fibers
Reflex mechanism
Tapping a tendon stimulates sensory nerve at a synapse in the spinal cord with the motor neuron, and efferent fibers travel to the muscle snd stimulate a contraction.
5 components of a deep tendon reflex
- Intact sensory nerve (afferent)
- Functional synapse at the spinal cord
- Intact motor nerve (efferent)
- Neuromuscular junction
- Competent muscle
Where do CN I and II begin?
The cerebrum
Spinal nerves- 31 pairs arise from:
Spinal cord. Breakdown: 8 cervical 12 thoracic 5 lumbar 5 sacral 1 coccygeal
Sensory nerves exit through
posterior (dorsal) roots
Motor nerves exit through
anterior (ventral) roots
What controls movements in infants
primarily primitive reflexes from the spinal cord and the medulla. Reflexes disappear as the cerebral cortex develops.
What determines infant’s sensory and motor development?
Gradual acquistion of myelin
Changes in neurological system in the aging adult
Steady loss of neuron structure in the brain and spinal cord
Decrease in weight and volume, thinning of the cerebral cortex
What does neuron loss cause in the aging adult?
General loss of muscle bulk
Loss of muscle tone in the face, neck, and spinal area
Impaired fine coordination and agility
Loss of vibratory sense at the ankle
Decreased/absent achilles reflex
Loss of position sense at the big toe
Pupillary miosis
Irregular pupil shape, decrease pupillary reflexes
touch, pain, taste, and smell may diminish
Reaction time slows
Velocity of nerve conduction decreases by what % in aging adult?
5-10%
Reaction time is slower
Where is decrease in muscle bulk most apparent in the aging adult?
Dorsal hand muscles
What causes dizziness and loss of balance with position change in the aging adult?
Decrease in cerebral blood flow and oxygen consumption
When in good health, older adults walk
about as well as they did when younger, but more slowly and deliebrately
Where is the stroke belt in the US? Where is the buckle?
Southeast US
Buckle is the coastal plain of NC, SC, and Georgia- stroke mortality 20% higher than the rest of the stroke belt and 40% higher than the rest of the US
Subjective Data for neurological assessment (12)
- Headache
- Head injury
- Dizziness/vertigo
- Seizures
- Tremors
- Weakness
- Incoordination
- Numbness or tingling
- Difficulty swallowing
- Difficulty speaking
- Patient centered care/ personal hx
- Environmental/occupational hazards
Additional subjective hx for the aging adult
- Dizziness— When? Rx? Falls?
- Decrease in memory or mental function/Confusion
- Tremor
- Sudden vision change
“Worst headache of my life”
Needs emergency referral- possible stroke
Vertigo indicates
neurological disease
What to ask about seizures
- aura
- motor activity
- associated signs that others notice
- post-ictal period: sleepy, confused, weakness, headache
- precipitating factors
- medications
- effect on daily life/quality of life/coping strategies
- course of duration of seizure
What to ask about tremors
precipitating and palliative factors
paresis
partial or incomplete paralysis, diminished strength
paralysis
loss of motor function caused by a lesion in the neurologic or muscular system or loss of sensory innervation. absence of strength
paresthesia
abnormal sensation- burning, tingling
What to ask about dysphagia
Solids or liquids? Excessive saliva or drooling?
dysarthria
difficulty forming words
dysphasia
difficulty with language expression or comprehension
What to ask about past neuro hx
- stroke
- meningitis
- encephalitis
- spinal cord injury
- congenital defect
- alcohol use
Environmental hazards (4)
- insecticides
- organic solvents
- lead
- mercury
What medications are important for neuro subjective hx (4)
- anticonvulsants
- antitremor
- antivertigo
- pain meds
Causes of increased fall risk in aging adult (5)
- dx of stroke
- dx of dementia
- gait & balance disorders
- use of assistive devices
- hx of recent falls
micturition syncope
Getting up at night and feeling faint while standing to urinate
Change and memory and decrease in cognitive function in the aging adult may indicate
Alzheimer’s— often mistaken for normal cognitive decline of aging
Senile tremor may be relieved by
alcohol—assess for whether alcohol is being used to relieve tremor symptoms
Objective data for neuro
- Test cranial nerves
- Inspect and palpate the motor system
- Test movements
- Test sensation
Atrophy
abnormally small muscle with a wasted appearance. occurs with disuse, injury, LMN disease, diabetic neuropathy
hypertrophy
increased size and strength of muscle with isometric exercise
testing muscle strength
test power of homologous muscles simultaneously. test muscle groups of extremities, neck, and trunk
muscle tone
the normal degree of tension in voluntarily relaxed muscles
testing muscle tone
move extremities through passive range of motion
flaccidity
decreased resistance, hypotonia with peripheral weakness. Associated with LMN injurym polio, periperal neuritis, guillain-barre, early stroke and spinal cord injury at first
spasticity and rigidity
increased resistance that occurs with central weakness- associated with UMN injury to corticospinal motor tract- paralysis with stroke after a few days or weeks
dysdiadochokinesia
slow, clumsy, sloppy response with cerebellar disease
test of coordination and skilled movements
Rapid Alternating Movements (RAM) test
Finger-to-nose test (eyes closed)
Heel-to-Shin test
dysmetria
clumsy movement, overshooting the mark. Occurs with cerebellar disorders and alcohol intoxication
past-pointing
constant deviation to one side
intention tremor
occurs when reaching to a visually directed object
ataxia
uncoordinated or unsteady gait
testing gait
have pt walk 10-20 feet, turn, and return to starting point
Tandem walking
have pt walk a straight line in heel-to-toe (tandem) fashion.
More sensitive test for ataxia.
Inability to tandem walk may indicate upper motor neuron lesions—MS, acute cerebellar dysfunction/alcohol intoxication
Romberg test
Stand up with feet together and arms to the side. Close eyes and hold position. Positive sign (loss of balance) occurs with cerebellar ataxia (MS, ETOH), loss of proprioception, loss of vestibular function
Sensations to test for (8)
Pain Light touch Vibration Position Tactile discrimination Graphesthesia Two-point discrimination Extinction
hypoalgesia
decreased pain sensation
analgesia
absent pain sensation
hyperalgesia
increased pain sensation
hypoesthesia
decreased touch sensation
anesthesia
absent touch tensation
hyperesthesia
increased touch sensation
Loss of ability to perceive vibration with
peripheral neuroapthy (DM and alcoholism)
Kinesthesia
position sense
test of kinesthesia
have person close eyes. Move a finger up or down and ask pt which way finger was moved.
Tactile discrimination tests
Stereognosis Graphesthesia Two-point discrimination Extinction Point location
Stereognosis
ability to recognize objects by feeling them
astereognosis- occurs in sensory cortex legions (stroke)
Graphesthesia
ability to read a number traced on the skin.
Inability comes with sensory cortex lesion (stroke)
Two-point discrimination test
test ability to distinguish separation of two points of a paper clip on the skin. Varies according to location. Increase in distance associated with sensory cortex lesions
Extinction test
Ability to recognize only one of two applied stimuli. Stimulus extinguished on side OPPOSITE the cortex lesion.
Point location
Touch the skin, withdraw stimulus.
“Put your finger where I touched you”
Abnormality indicates sensory cortex lesion
Reflex response scale
4+ very brisk, hyperactive with clonus, indicative of disease
3+ brisker than average, may indicate disease but probably normal
2+ average, normal
1+ diminished, low normal, or only with reinforcement
0 no response
Clonus
rapid, rhythmic contractions of the same muscle
hyperreflexia
exaggerated reflex seen when the monosynaptic reflex arc is released from the usually inhibiting influence of high cortical levels. occurs with UMN lesions, eg stroke
hyporeflexia
absense of a reflex. LMN issue. Occurs with interruption of sensory afferents of destruction of motor efferents and anterior horn c`ells (spinal cord injury)
Biceps reflex
c5-c6
triceps reflex
c7-c8
brachioradialis reflex
c5-c6
Quadriceps reflex (knee jerk)
L2-L4
achilles reflex (ankle jerk)
(L5-S2)
clonus test
Support lower leg and move foot up and down a few times, then stretch the muscle by briskly dorsiflexing the foot. Hold the stretch.
Clonus- rapid, rhythmic contractions of the calf muscle and foot. Occurs with UMN disease.
Superficial reflexes
abdominal reflexes- T8-T10, T10-T12 cremaster reflex (L1-L2) plantar reflex (L4-S2)
superficial reflex absent with
diseases of the pyramidal tract- absent on contralateral side with stroke
Babinski reflex
Check plantar reflex (L4-S2). Stroke sole of foot.
If dorsiflexion of big toe and fanning of other toes, positive Babinski sign- indicates UMN disease of corticospinal or pyramidal tract
Glasgow coma scale
Eye opening response: spontaneous, speech, pain, none
Motor response: to verbal commands, localized pain, flexion/withdrawal, abnormal flexion, extension, none
Verbal response: A&O x3, conversation confused, speech inappropriate, speech incomprehensible, none.
Normal total=15
Neurological recheck
- Level of consciousness
- Motor function
- Pupillary response
- Vital signs
Increasing stimuli to use for level of consciousness recheck
- Name called
- Light touch on arm
- Vigorous shake of shoulder
- Pain applied (pinch, rub knuckles on sternum)
Motor function
check for weak grip, pronator drift, abnormal posturing of feet, decerebrate rigidity
localizing
pushing hand away after a painful stimuli- characterized as purposeful movement
abnormal posturing, decorticate rigidity, decerebrate rigidity on motor function recheck indicates
diffuse brain injury
Pupillary abnormalities indicate
increasing ICP pushing the brainstaim down (uncal herniation), puts pressure on CN III and causes pupil dilation
Cushing reflex vital signs
signs of increasing ICP:
Sudden elevation of BP and widening pulse pressure
Decreased and bounding pulse
FAST signs of stroke
Face drooping
Arm weakness
Speech difficulty
Time to call 911
10 Warning signs of Alzheimer’s diease
- Memory Loss
- Losing track of steps in a task
- Forgetting words
- Getting lost
- Poor judgment
- Abstract thinking failure
- Losing things
- Mood swings- changes in mood or behavior
- Personality change (dramatic)
- Growing passive- loss of initiative
Rigidity
constant state of resistance- lead pipe rigidity- resists passive movement in any direction, dystonia. Occurs with injury to extrapyramidal motor tracts- eg parkinsonism
cogwheel rigisity
Rigidity in which increased tone is released by degrees during passive range of motion- feels like small, regular jerks
Associated with parkinsonism
Fasciculation
Rapid, continuous twitching of resting muscle or part of muscle without limb movement
Fine- occurs with LMN disease, associated with atrophy and weakness
Coarse- occurs with cold exposure or fatigue, not signficant
Myoclonus
rapid, sudden jerk or series of jerks at regular intervals. Single extremity jerk normal when falling asleep. Severe with grand mal seizures.
Tic
involuntary, compulsive twiching of a muscle due to neurologic or psychogenic cause. Tardive dyskineasia, tourette’s.
Chorea
sudden, rapid, jerky movement involving limbs, trunk, or face. More convulsive than a tic. Accentuated with voluntary movement. Occurs in Sydenham chorea and Huntington disease.
Athetosis
Slow, twisting, writhing, continuous movement. Snakelike. Distal more than proximal. Cerebral palsy- disappears with sleep. Athetoid hand- some fingers flexed, some extended.
tremor
involuntary contraction of opposing muscle groups, results in rhythmic back and forth movement of one or more joints. May occur at rest or with voluntary movement. Disappears while sleeping. May be slow or rapid.
Rest tremor
Occurs when muscles are quiet and supported against gravity. Coarse and slow. Disappears with voluntary movement- parkinsonism
Intention tremor
Worse with voluntary movement, reaching towards an object. Occurs with cerebellar disease and MS
Essential tremor (familial)
intention tremor, most common tremor in older adults. Benign but may cause emotional stress. Improves with sedatives, propranolol, or alcohol.
Parkinsonism vs senile tremors
Parkinsonism includes rigidity and slowness, weakness of voluntary movement.
Vibration sensation in older adult
Loss of sensation of vibration in the ankle malleolus is common along with loss of ankle jerk.
Position sense in the big toe in the aging adult
may be lost
Sensation in the aging adult
tactile may be impaired
stronger stimuli for light touch needed
pain sensation dulled
DTRs in aging adult
less brisk usually present in upper extremities ankle jerk commonly lost knee jerk may be lost, but less common Always use reinforcement in aging adult- may be harder to relax limbs
Plantar (Babinski) reflex in aging adult
May be absent or difficult to interpret
Flexor plantar response in aging adult
often no normal definite response
Extensor plantor response in aging adult
Definite response is still abnormal!
