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CFB > WCS04 Central Nervous System > Flashcards

WCS04 Central Nervous System Flashcards

1
Q

3 key questions in approach

A
  1. Where is lesion —> Anatomical diagnosis
    - brain (hemisphere, brainstem, cerebellum)
    - spinal cord, root, plexus
    - peripheral nerve
    - NMJ (only motor symptom with fasciculation, no sensory deficit)
    - muscle (only motor symptom, proximal muscle affected but not distal muscle ∵ proximal much larger bulk)
  2. What is underlying pathology? —> Pathological diagnosis
  3. Neurological / Functional?
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2
Q

History taking

A
  1. Chief complaint
  2. Mode of onset
  3. Duration
  4. Course
  5. Associated symptoms
  6. Risk factors
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3
Q

Physical examination

A
  1. Elicit signs according to history
  2. General examination (focused)
    - conscious state
    - body habitus
    - dysmorphic features / cutaneous lesions e.g. neurofibromatosis
    - posture e.g. hemiplegic posture in stroke
    - movement e.g. resting tremor in Parkinsonism
    - facial features e.g. ptosis, facial asymmetry, mask facies
    - bulbar dysfunction e.g. tube feeding
    - respiratory weakness e.g. ventilators
    - micturition dysfunction e.g. Foley catheter
  3. Neurological examination (screening vs focused)
  4. Other systems examinations
  5. Interpret findings
    - normal vs abnormal
    - anatomical diagnosis
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4
Q

Neurological examination

A
  1. Higher mental functions
    - patient’s ability to provide coherent history
    - GCS scale: Eye 4, Verbal 5, Motor 6
    - MMSE (30 full mark, ***18/21: Low)
    - MoCA (Montreal cognitive assessment)
  2. Speech + Language
    - understand?
    - able to speak?
    - comprehension?
    - articulation?
  3. Cranial nerves
    - 1, 2: Cerebrum
    - 3, 4: Midbrain
    - 5, 6, 7, 8: Pons
    - 9, 10, 11, 12: Medulla
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5
Q

CN1 Olfactory nerve

A

Change in smell

- test with aromatic + non-irritant materials

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6
Q

CN2 Optic nerve

A
  1. Visual acuity
    - Snellen’s chart
  2. Pupil
    - size, shape, symmetry
  3. Direct + Consensual light reflex
  4. Accommodation reflex
  5. Visual field
  6. Fundus with Ophthalmoscope
    - optic disc atrophy
    - papilloedema
    - macular edema
    - retinopathy
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7
Q

Ocular movement

A 
EOM:
SO: Abduct + Depress
IO: Abduct + Elevate
SR: Adduct + Elevate
IR: Adduct + Depress
Test:
SO望左*下
IO望左*上
SR望右上
IR望右下
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8
Q

Diplopia

A
  1. Confirm with covering one eye —> see if still diplopia
  2. Image may be affected: False image
    - not lie in centre
    - side by side with normal image
    - at angle with each other
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9
Q

CN5 Trigeminal nerve

A
  1. Muscles of mastication
  2. Sensory
    - ophthalmic CNV1
    - maxillary CNV2
    - submandibular CNV3
  3. Jaw jerk reflex
    - brisk: UMN lesion i.e. above pons
  4. Corneal reflex
    - afferent: **CNV1
    - efferent: **    CN7
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10
Q

CN7 Facial nerve

A
  1. Muscles of facial expression
    - Frowning (upper face: Frontalis)
    - Blow cheek (lower face: Buccinator)
  2. Taste of anterior 2/3 tongue
  3. Saliva (Submandibular + Sublingual) + Lacrimal secretion
  4. UMN vs LMN weakness
    - upper face **bilateral innervation
    - lower face **    contralateral Innervation
    —> UMN lesion: Upper face not affected, Lower face contralateral paresis
    —> LMN lesion: Upper + Lower face ipsilateral paresis
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11
Q

CN8 Vestibulocochlear nerve

A
  1. Rinne’s test —> Conductive deafness
    - ear wax
    - middle ear damage
  2. Weber’s test —> Sensorineural deafness
    - CN8 injury
    - tumour
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12
Q

CN9 Glossopharyngeal nerve

A
  1. Soft palate
  2. Pharynx
  3. Ear canal
  4. Sensory
  5. ***Parotid salivation
  6. Taste and sensation ***posterior 1/3 tongue
  7. Position + Movements of soft palate and uvula
  8. ***Gag reflex (afferent CN9, efferent CN10)
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13
Q

CN10 Vagus nerve

A
  1. Pharynx
  2. Larynx
  3. Viscera
  4. Somatic
  5. Autonomic function
    - GI tract
  6. Motor function
    - pharynx + larynx
    - vocal cord
  7. Sensory
  8. Gag reflex (afferent **CN9, efferent **CN10)
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14
Q

CN11 Accessory nerve

A
  1. SCM
    - rotate head to opposite side
  2. Trapezius
    - shrug shoulders against resistance
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15
Q

CN12 Hypoglossal nerve

A

Intrinsic + Extrinsic tongue muscle (except Palatoglossus: CN10)

  1. Atrophy
  2. Fibrillation
  3. Deviate on protrusion
  4. Tongue movement
  5. Power
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16
Q

Arms and Legs

A

Motor system

  • Inspection
  • Tone
  • Power (MRC scale: 3: against gravity but not resistance, 2: not against gravity)
  • Reflexes
  • Sensation
  • Coordination

Sensory system

  • Spinothalamic system: Pinprick, Warmth, Fine touch
  • Dorsal column: Proprioception, Vibration, Sensation
17
Q

Motor examination of arms

A
  1. Wasting / Muscle bulk
    - distribution
  2. Fasciculation (LMN sign) / Scars / Tremor
  3. Posture / Movement
  4. Muscle tone
    - elbow
    - wrist
    - normal / hypotonia / hypertonia (rigidity / spasticity)

Rigidity: increased resistance throughout movement —> **Extrapyramidal
—> Lead-pipe
—> Cogwheel (in Parkinsonism)
Spasticity: 彈弓 resistance greater with speed of movement —> **Pyramidal (e.g. Clasp-knife spasticity)

  1. Pronator drift
    - UMN (Pyramidal) weakness —> downward pronator drift
    - ***Ataxia (loss of cerebellar coordination) —> upward pronator drift
    - Loss of proprioception —> a searching movement that usually affects only the fingers (can be in any direction)
  2. Muscle power (MRC scale: 0-5)
  • Shoulder abduction (**C5-6)
    —> Deltoid
    —> **    Axillary nerve
  • Elbow flexion (**C5-6)
    —> Biceps
    —> **    Musculocutaneous nerve
  • Elbow extension (C7-8)
    —> Triceps
    —> ***Radial nerve
  • Wrist + Finger extension (**C6-8)
    —> Extensor carpi radialis longus, Extensor carpi ulnaris, Long finger extensors
    —> **    Radial nerve
  • Hand grip (**C8-T1)
    —> Long finger flexors, Small hand muscles
    —> **    Median + ***Ulnar nerve

Ulnar nerve:

  • Dorsal interossei: finger ABduction
  • Palmar interossei: finger ADduction

Median nerve (Thumb):

  • Abductor pollicis brevis: thumb ABduction
  • Opponens pollicis: thumb OPposition
  1. Reflex
    - Biceps, Supinator jerk: **C5-6
    - Triceps jerk: **    C7-8
    - Finger jerk: **C8-T1
    - Hoffmann sign for **    C8-T1 hyperreflexia
  2. Coordination
    - Finger-nose test
    - Rapid alternating movements
18
Q

Motor examination of legs

A
  1. Wasting / Muscle bulk / Leg length discrepancy / Pes cavus
    - distribution
  2. Fasciculation / Tremor
  3. Posture / Movement
  4. Muscle tone
    - hip, knee, ankle
    - normal / hypotonia / hypertonia (rigidity / spasticity)
    —> knee clonus
    —> ankle clonus

Rigidity: increased resistance throughout movement —> **Extrapyramidal
Spasticity: 彈弓 resistance greater with speed of movement —> **Pyramidal

  1. Power
    - Hip flexion (**L2-3)
    —> Iliopsoas
    —> **    Nerve to Iliopsoas
  • Hip extension (**L4-5, S1)
    —> Gluteus
    —> **    Gluteal nerve
  • Hip adduction (**L3-4)
    —> Hip adductors
    —> **    Obturator nerve
  • Hip abduction (**L5-S1)
    —> Gluteal medius, Tensor fascia lata
    —> **    Superior Gluteal nerve
  • Knee extension (**L3-4)
    —> Quadriceps femoris
    —> **    Femoral nerve
  • Knee flexion (**L5-S1)
    —> Hamstrings
    —> **    Sciatic nerve
  • Ankle dorsiflexion (**L4-5)
    —> Toe extensors
    —> **    Peroneal nerve
  • Ankle plantar flexion (**S1-2)
    —> Toe flexors
    —> **    Popliteal nerve
  1. Reflexes
    - Knee jerk: L3-4
    - Ankle jerk: S1-2
    - Plantar response down-going
    - Upgoing plantar response = Babinski sign for UMN lesion
  2. Coordination
    - Heel-shin
    - Heel-toe gait
  3. Gait
    - Antalgic
    - Hemiplegic
    - ***Wide based ataxic: Cerebellar disorder
    - Shuffling, lack of arm swing: Parkinsonism
    - Turn around: Bradykinesia, Postural instability, Freezing in Parkinsonism
19
Q

***UMN signs

A
  1. Spastic paralysis
  2. Little atrophy
  3. Hyperactive reflexes
  4. Clonus
  5. Babinski’s sign (lower limb) / Hoffman’s sign (upper limb)
20
Q

***LMN signs

A
  1. Flaccid paralysis
  2. Early-onset atrophy
  3. Reduced reflexes
  4. Fasciculations + Fibrillation
21
Q

Sensory examination of arms / legs

A

Spinothalamic

  1. Pinprick / Pain
  2. Light touch
  3. Temperature

Dorsal column

  1. Joint position: thumb / big toe movement
  2. Vibration: tuning fork 128Hz
22
Q

Bedside case

A
  • Reduced pinprick sensation on left side whole body
  • Past pointing + Heel shin intentional tremor on both sides —> Bilateral cerebellar signs
  • Left facial weakness

Multiple sclerosis —> Repeated attacks

CFB (43 decks)

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