Week 13: Nervous System and Mental Health Flashcards
1
Q
What are the five categories of the neurological exam?
A
- Mental status
- cranial nerve testing
- motor system
- sensory system
- reflexes
2
Q
What are some common or concerning symptoms that the FNP should assess for as part of the neurological history?
A
- Headache
- Dizziness or lightheadedness
- Weakness
- Numbness or abnormal or absent sensation
- Fainting and blacking out
- Seizures
- Tremors or involuntary movements
- Confusion
- Memory loss
- Trouble speaking
- Vision loss or double vision
- Difficulty walking
3
Q
What are some red flags associated with headaches?
A
- Sudden onset thunderclap headache
- Worst headache of my life
- Headaches after 50
- Headaches that increase by coughing or reoccur in the same position
- Fever/stiff neck
- Migraine
4
Q
What are the modifiable risks for TIA/stroke?
A
- HTN
- diabetes
- a.fib
- dyslipidemia
- smoking
- physical inactivity
- CKD
- overweight
- nutrition
- alcohol use
- carotid artery disease
- sickle cell disease
- sleep apnea
5
Q
What does ABCD2 stand for and what does it indicate?
A
- Age greater/equal to 60 years
- blood pressure greater/equal to 140/90
- clinical features of focal weakness or impaired speech without focal weakness
- duration 10-59 minutes or greater/equal to 60 minutes and diabetes
Tool to predict stroke likelihood after TIA
6
Q
What does the acronymn FAST stand for?
A
Stroke symptoms
- Face drooping
- arm weakness
- speech difficulty
- time to call
7
Q
What history and exam findings are consistent with TIAs/strokes? (5)
A
- Sudden numbness or weakness of the face, arm or leg
- Sudden confusion, trouble speaking or understanding
- Sudden trouble seeing in one or both eyes
- Sudden trouble walking, dizziness or loss of balance or coordination
- Sudden severe headache
8
Q
What are the vascular territories for strokes and the corresponding clinical findings?
A
Occlusion of the middle cerebral artery: visual field cuts and contralateral hemiparesis and sensory deficits
Occlusion of the left middle cerebral artery: aphasia
Occlusion of the right middle cerebral artery: neglect or inattention to the opposite side of the body
9
Q
What are dizziness, vertigo, presyncope and syncope?
A
Dizziness: nonspecific term
Vertigo: spinning sensation within the patient or of the surroundings accompanied by nystagmus and ataxia
Presyncope: lightheaded or weak but fail to lose consciousness
Syncope: sudden but temporary loss of consciousness and postural tone from transient global hypoperfusion
10
Q
What is weakness? What are some etiologies? What patterns should you identify about weakness?
A
- May mean fatigue, apathy, drowsiness or actual loss of strength
- Etiologies: TIA, stroke, Guillain-Barre, ALS, injury of the NMJ, myopathies
- Assessment: Time course and location, what parts of the body are involved
- Proximal: parts of the body that are closer to the thorax
- Distal: hands/feet
- Symmetric: same areas on both sides of the body
- Asymmetric: one sided
11
Q
How do you test for discriminative sensations? What could abnormal findings indicate?
A
- Stereognosis: ability to identify an object by feeling it
- Abnormal = astereognosis
- Impaired: posterior column disease
- Number identification: draw a number on the hand and ask them to identify it
- Abnormal = graphesthesia
- Impaired: lesion in the sensory cortex, posterior column disease
- Point localization: touch a point on the skin, open eyes and point to the location touched
- Impaired: sensory cortex impairment
- Extinction: touch each arm individually, then simultaneously touch corresponding areas on both arms, ask where the patients feels your touch with each stimulus
- Impaired: lesions in the cerebral hemisphere cause extinction of the contralateral side
12
Q
What tests can be used to assess gait?
A
Observe: casual walk, walk on toes and on heels, walk heel to toe in a straight line
13
Q
What does spastic hemiparesis look like on exam? What impairment is present?
A
- Spastic hemiparesis - corticospinal tract lesions
- affected arm is flexed, immobile, held close to the side with elbow, wrists and interphalangeal joints flexed
- Affected leg extensors are spastic; ankles are plantar-flexed and inverted
- Patients may drag toe, circle leg stiffly outward and forward or lean trunk to contralateral side to clear affected leg while walking
14
Q
What does steppage gait look like on exam? What impairment is present?
A
- Steppage gait - foot drop, secondary to peripheral nervous system disease
- Drag the feet or lift them high
- Cannot walk on heels
- May involve one or both legs
- Tibialis anterior and toe extensors are weak
15
Q
What does cerebellar ataxia look like on exam? What impairment is present?
A
- Cerebellar ataxia- disease of the cerebellum or associated tracts
- Staggering and unsteady gait with feet wide apart and exaggerated difficulty on turns
- Cannot stand steadily with feet together with eyes open or closed
- Dysmetria, nystagmus and intention tremor may be present
16
Q
What does scissors gait look like on exam? What impairment is present?
A
- Scissors gait - spinal cord disease that causes spasticity
- Stiff gait, advance each leg slowly and thighs cross forward on each other with each step
- Short steps
- Patients appear to be walking through water, may be compensating sway of the trunk
17
Q
What does the Parkinsonian gait look like on exam? What impairment is present?
A
- Parkinsonian gait - basal ganglia defects of Parkinson disease
- Posture stooped with flexion of the head, arms, hips and knees
- Slow to get started
- Short and shuffling steps with involuntary hesitation (festination)
- Arm swings decreased and patients turn around stiffly
- Postural control is poor
18
Q
What does sensory ataxia look like on exam? What impairment is present?
A
- Sensory ataxia - polyneuropathy or posterior column damage
- Unsteady gait, wide based
- Throw their feet forward and outward and bring them down, first on the heels then on the toes
- Watch the ground for guidance when walking
- With eyes closed, patients cannot stand steadily with feet together (positive Romberg sign), staggering gait worsens
19
Q
What are tests of coordination? What do abnormal findings indicate?
A
- Rapid alternating movements: rapid alternating arm movements, rapid finger tapping
- Point to point movements: finger to nose test, heel to shin test
- Abnormal findings
- Ataxia = loss of control of voluntary movements
- Cerebellar disease = nystagmus, dysarthria, hypotonia, ataxia
- Rapid alternating movements will be slow, irregular and clumsy (dysdiadochokinesis)
- Finger tapping is imprecise with irregular rhythm
- Finger to point movements will be clumsy, unsteady and inappropriately variable in speed, force and direction
- Slow and low amplitude in finger tapping test may indicate upper motor neuron weakness and basal ganglia diseas
20
Q
How would the FNP assess for diabetic neuropathy?
A
- Pin-prick sensation
- Ankle reflexes
- Vibration perception
- Plantar light touch sensation
21
Q
What is the Romberg test? What does an abnormal finding indicate?
A
- Position sense: stand with feet together and eyes open, then close both eyes for 30 seconds without support
- Abnormal = inability to maintain upright posture, some minimal swaying is normal
- May indicate sensory or cerebellar ataxia
22
Q
What is reinforcement and how can it be used to assess reflexes?
A
Reinforcement = used when reflexes seem diminished or absent - isometric contraction of other muscles for 10 seconds that may increase reflex activity
Eg. Have patient lock fingers and pull hands against each other when testing the patellar reflex
23
Q
What are meningeal signs?
A
- Nuchal rigidity = neck stiffness with resistance to flexion; found in patients with acute bacterial meningitis and subarachnoid hemorrhage
- Brudzinski = flexion of the hips and knees in reaction to neck flexion
- Kernig = pain and increased resistance to knee extension
- joint accentuation of headache
24
Q
What are causes of neurologic headaches and how would they present? (3)
A
- Subarachnoid hemorrhage: very severe thunderclap headache; associated with N/V, LOC, neck pain
- Meningitis: steady, throbbing, severe; fever, stiff neck, photophobia, change in mental status
- Mass lesions: aching, steady dull pain worse on awakening and better after several hours; associated with seizures, hemiparesis, field cuts, personality changes, N/V, vision change, gait change
25
What findings are consistent with Parkinson’s disease?
Patients are slow getting started
Short, shuffling steps
Decreased arm swings
Turns around stiffly “all in one piece”
Stooped posture
Pill-rolling tremor
26
How would the FNP assess sensory function in the infant? What would abnormal findings indicate?
Test for pain sensation by flicking palm or sole with your finger - observe for withdrawal, arousal and change in facial expression
Change in facial expression + cry but no withdrawal can indicate weakness or paralysis
27
Primitive reflexes: Palmar grasp
Test, infant response, normal resolution, what does persistence indicate?
Test: place fingers into infants hand's and press against palmar surfaces
Infant response: infant should flex all fingers to grasp your fingers
Normal resolution: present until 3-4 months
Persistence beyond 4-6 months suggests pyramidal tract dysfunction
Persistence of clenched hand past 2 months suggests CNS damage
28
Primitive reflexes: Plantar grasp
Test, infant response, normal resolution, what does persistence indicate?
Test: touch sole at the base of the toes
Infant response: toes will curl
Normal resolution: present until 6-8 months
Presence past 8 months suggests pyramidal tract dysfunction
29
Primitive reflexes: Rooting reflex
Test, infant response, normal resolution, what does persistence indicate?
Test: stroke the perioral skin at the corners of the mouth
Infant response: mouth will open and infant will turn head toward the stimulated side and suck
Normal resolution: present until 3-4 months
Absence indicates severe generalized or CNS disease
Persistence beyond 4 months = neuro disease
30
Primitive reflexes: Moro reflex
Test, infant response, normal resolution, what does persistence indicate?
Test: hold supine and lower body abruptly 1 foot
Infant response: arms will abduct and extend, hands will open, legs will flex, may cry;
Normal resolution: present until 4 months
Persistence beyond 4 months suggests neuro disease, persistence beyond 6 months strongly indicates neuro disease
31
Primitive reflexes: Asymmetric tonic neck
Test, infant response, normal resolution, what does persistence indicate?
Test: supine, turn head to one side holding the jaw over the shoulder
Infant response: arms/legs on side to which head is turned will extend and opposite arm/leg will flex
Normal resolution: present until 2-3 months
Persistence past 3 months indicates asymmetric CNS development
32
Primitive reflexes: Spinal galant/trunk incurvation
Test, infant response, normal resolution, what does absence & persistence indicate?
Test: support infant prone and stroke one side of the back 1 cm from the midline, from shoulder to buttocks
Infant response: spine will curve toward stimulated side
Normal resolution: present until 3-4 months
Absence suggests transverse spinal cord lesion or injury
Persistence suggests delayed development
33
Primitive reflexes: Landau reflex
Test, infant response, normal resolution, what does persistence indicate?
Test: suspend prone with one hand
Infant response: head will lift up and spine will straighten
Normal resolution: present until 6 months
Persistence suggests delayed development
34
Primitive reflexes: Parachute reflex
Test, infant response, when does it appea, what does delay in appearance indicate?
Test: suspend infant prone and slowly lower the head toward a surface
Infant response: arms and legs will extend in a protective fashion
Normal resolution: present at 8 months and beyond
Delay in appearance may predict future delays in voluntary motor development
35
Primitive reflexes: Positive support reflex
Test, infant response, normal resolution, what does lack of reflex and spasticity indicate?
Test: hold infant around trunk and lower until feet touch a flat surface
Infant response: hips knees and ankles will extend, the infant will stand up, partially bearing weight and sag after 20-30 seconds
Normal resolution: present at birth or 2 months until 6 months
Lack of reflex suggests hypotonia or flaccidity
Fixed extension and adduction of legs suggests spasticity from neuro dx
36
Primitive reflexes: Placing and stepping reflex
Test, infant response, normal resolution, what does absence indicate?
Test: hold infant upright as in positive support reflex, have one sole touch the surface
Infant response: hip and knee of that foot will flex and the other foot will step forward;
Normal resolution: present at birth, best after 4 days, and variable age to disappear
Absence of placing may indicate paralysis, newborns born breech may not have placing reflex
37
What exam findings would be present in the newborn that has been exposed to maternal substance abuse or the infant experiencing neonatal abstinence syndrome?
Neonatal abstinence syndrome: irritable, jittery, tremors, hypertonicity, hyperactive reflexes
38
What are the six components of the mental health examination?
Appearance and behavior
Speech and language
Mood
Thoughts and perceptions
Insight & Judgement
Cognition
39
What terminology do we use to refer to level of consciousness and how are these defined? (5)
* Alert: eyes open, looks at you when spoken to in a normal tone of voice, responds fully and appropriately to stimuli
* Lethargy: lethargic patient appears drowsy but opens eyes when spoke o in a loud voice and responds to questions then falls asleep
* Obtundation: opens eyes to tactile stimulus, responds slowly and is somewhat confused
* Stupor: arouses to painful stimuli, verbal responses slow or absent, lapses into unresponsive state when stimulus ceases
* Coma: unarousable with eyes closed; no evident response to inner need or external stimuli
40
What are the classifications of personality disorders? What are their characteristic behavior patterns? - Odd & Eccentric (3)
Odd & Eccentric
* Paranoid: Distrust and suspiciousness
* Schizoid: Detachment from social relations with a restricted emotional range
* Schizotypal Characteristic Behavior Patterns: Eccentricities in behavior and cognitive distortions; acute discomfort in close relationships
41
What are the classifications of personality disorders? What are their characteristic behavior patterns? - Dramatic, emotional or erratic (4)
Dramatic, emotional or erratic
* Antisocial: Disregard for, and violation of, the rights of other
* Borderline: Instability in interpersonal relationships, self-image and affective regulation; impulsivity
* Histrionic: Excessive emotionality and attention seeking
* Narcissistic: Persisting grandiosity, need for admiration and lack of empathy
42
What are the classifications of personality disorders? What are their characteristic behavior patterns? - Anxious or fearful (3)
Anxious or fearful
* Avoidant: Social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation
* Dependent: Submissive and clinging behavior related to an excessive need to be taken care of
* Obsessive-compulsive: Preoccupation with orderliness, perfectionism, and control
43
Define **blocking.** Which disorder(s) does this occur in?
* definition: sudden interruption of speech midsentence or before the idea is completed
* disorders: normal patients, may be striking in schizophrenia
44
Define the following: dysarthria, dysphonia, receptive & expressive aphasia
* Dysarthria: defective articulation
* Dysphonia: impaired volume, quality or pitch
* Aphasia
* Wernicke (receptive aphasia): impaired comprehension and fluent speech
* Broca (expressive aphasia): preserved comprehension with slow, nonfluent speech
45
What is the difference between anxiety disorder, panic disorder, obsessive-compulsive disorder, PTSD, and social anxiety disorder?
* Anxiety Disorder: excessive worry persisting over a 6-month period
* Panic disorder: recurrent panic attacks followed by a period of anxiety about further attacks
* Obsessive-compulsive disorder: intrusive thoughts and ritualistic behaviors
* Posttraumatic stress disorder: characterized by re-experiencing, avoidance, persistent negative alterations in cognition and mood, and alterations in arousal and reactivity
* Social anxiety disorder: marked anticipatory anxiety in social situations
46
Define **circumstantiality.** Which disorder(s) does this occur in?
* definition: speech with unnecessary detail, indirection and delay in reaching the point
* disorders: many mental disorders, obsessions
47
Define **clanging.** With which disorders does this occur?
* define: choice of words based on sound rather than meaning
* disorders: schizophrenia and manic episodes
48
Define confabulation. With which disorders does this occur?
* definition: fabrication of facts or events to fill in gaps from impaired memory
* disorders: Korsakoff syndrome from alcoholism
49
Define **derailment.** With which disorders does it occur?
* definition: tangential speech with shifting topics that are loosely connected or unrelated, unaware of lack of association
* disorders: schizophrenia, manic episodes and other psychotic disorders
50
Define **echolalia.** With which disorders does it occur?
* definition:repetition of words and phrases from others
* disorders: manic episodes and schizophrenia
51
Define **flight of ideas**
* definition: continuous flow of accelerated speech with abrupt changes from one topic to the next, based on understandable associations, play on words or distracting stimuli but ideas not well connected
52
Define **incoherence**. With which disorders does it occur?
* definition: speech incomprehensible and illogical with lack of meaningful connections, abrupt changes in topic or disordered grammar or word use
* disorders: severe psychotic disturbances
53
Define **neologisms.** With which disorders does it occur?
* definition: invented or distorted words, or words with new and highly idiosyncratic meanings
* disorders: schizophrenia, psychotic disorders and aphasia
54
Define **perseveration.** With which disorders does it occur?
* definition: persistent repetition of words or ideas
* disorders: schizophrenia and other psychotic disorders
