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530 Health Assessment > Week 13: Nervous System and Mental Health > Flashcards

Week 13: Nervous System and Mental Health Flashcards

1
Q

What are the five categories of the neurological exam?

A
  1. Mental status
  2. cranial nerve testing
  3. motor system
  4. sensory system
  5. reflexes
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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
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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
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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
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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

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6
Q

What does the acronymn FAST stand for?

A

Stroke symptoms

  • Face drooping
  • arm weakness
  • speech difficulty
  • time to call
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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
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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

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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

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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
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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
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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

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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
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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
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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
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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
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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
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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
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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
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20
Q

How would the FNP assess for diabetic neuropathy?

A
  • Pin-prick sensation
  • Ankle reflexes
  • Vibration perception
  • Plantar light touch sensation
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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
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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
Q

What findings are consistent with Parkinson’s disease?

A

Patients are slow getting started

Short, shuffling steps

Decreased arm swings

Turns around stiffly “all in one piece”

Stooped posture

Pill-rolling tremor

26
Q

How would the FNP assess sensory function in the infant? What would abnormal findings indicate?

A

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
Q

Primitive reflexes: Palmar grasp

Test, infant response, normal resolution, what does persistence indicate?

A

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
Q

Primitive reflexes: Plantar grasp

Test, infant response, normal resolution, what does persistence indicate?

A

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
Q

Primitive reflexes: Rooting reflex

Test, infant response, normal resolution, what does persistence indicate?

A

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
Q

Primitive reflexes: Moro reflex

Test, infant response, normal resolution, what does persistence indicate?

A

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
Q

Primitive reflexes: Asymmetric tonic neck

Test, infant response, normal resolution, what does persistence indicate?

A

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
Q

Primitive reflexes: Spinal galant/trunk incurvation

Test, infant response, normal resolution, what does absence & persistence indicate?

A

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
Q

Primitive reflexes: Landau reflex

Test, infant response, normal resolution, what does persistence indicate?

A

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
Q

Primitive reflexes: Parachute reflex

Test, infant response, when does it appea, what does delay in appearance indicate?

A

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
Q

Primitive reflexes: Positive support reflex

Test, infant response, normal resolution, what does lack of reflex and spasticity indicate?

A

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
Q

Primitive reflexes: Placing and stepping reflex

Test, infant response, normal resolution, what does absence indicate?

A

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
Q

What exam findings would be present in the newborn that has been exposed to maternal substance abuse or the infant experiencing neonatal abstinence syndrome?

A

Neonatal abstinence syndrome: irritable, jittery, tremors, hypertonicity, hyperactive reflexes

38
Q

What are the six components of the mental health examination?

A

Appearance and behavior

Speech and language

Mood

Thoughts and perceptions

Insight & Judgement

Cognition

39
Q

What terminology do we use to refer to level of consciousness and how are these defined? (5)

A
  • 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
Q

What are the classifications of personality disorders? What are their characteristic behavior patterns? - Odd & Eccentric (3)

A

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
Q

What are the classifications of personality disorders? What are their characteristic behavior patterns? - Dramatic, emotional or erratic (4)

A

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
Q

What are the classifications of personality disorders? What are their characteristic behavior patterns? - Anxious or fearful (3)

A

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
Q

Define blocking. Which disorder(s) does this occur in?

A
  • definition: sudden interruption of speech midsentence or before the idea is completed
  • disorders: normal patients, may be striking in schizophrenia
44
Q

Define the following: dysarthria, dysphonia, receptive & expressive aphasia

A
  • 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
Q

What is the difference between anxiety disorder, panic disorder, obsessive-compulsive disorder, PTSD, and social anxiety disorder?

A
  • 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
Q

Define circumstantiality. Which disorder(s) does this occur in?

A
  • definition: speech with unnecessary detail, indirection and delay in reaching the point
  • disorders: many mental disorders, obsessions
47
Q

Define clanging. With which disorders does this occur?

A
  • define: choice of words based on sound rather than meaning
  • disorders: schizophrenia and manic episodes
48
Q

Define confabulation. With which disorders does this occur?

A
  • definition: fabrication of facts or events to fill in gaps from impaired memory
  • disorders: Korsakoff syndrome from alcoholism
49
Q

Define derailment. With which disorders does it occur?

A
  • 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
Q

Define echolalia. With which disorders does it occur?

A
  • definition:repetition of words and phrases from others
  • disorders: manic episodes and schizophrenia
51
Q

Define flight of ideas

A
  • 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
Q

Define incoherence. With which disorders does it occur?

A
  • 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
Q

Define neologisms. With which disorders does it occur?

A
  • definition: invented or distorted words, or words with new and highly idiosyncratic meanings
  • disorders: schizophrenia, psychotic disorders and aphasia
54
Q

Define perseveration. With which disorders does it occur?

A
  • definition: persistent repetition of words or ideas
  • disorders: schizophrenia and other psychotic disorders

530 Health Assessment (15 decks)

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