Week 13 NEURO Flashcards
Infant CN 1
Olfactory
Difficult to test
how to test for visual acuity in infants? CN?
CN II
Optic
look for facial response & tracking
How to test for response to light in infants? CN?
CN II & III
Optic & Oculomotor
darken room
Optic blink reflex
pupillary response
How to test for EOM in infants? CN?
CN 3, 4, 6
Oculomotor, Trochlear, Abducens
how well infant tracks smiling face & if eyes move together
How to test for the motor system in infants? CN?
CN 5 Trigeminal
rooting reflex
suckling reflex & strength of suck
How to test the infant’s face? CN?
what does an abnormal response mean?
CN 7 Facial
Observe infant crying; symmetrical?
Asymmetry = congenital facial nerve palsy from birth trauma or developmental defects
How to test acoustics with infant? which CN?
CN 8 Vestibulocochlear
Blinking of both eyes in response to loud noise
Observe tracking in response to sound
How to test swallowing with infant? CN?
CN 9 & 10
Glossopharyngeal & Vagus
observe coordination with swallowing
Gag reflex
Dysphagia in an infant indicates injury to what cranial nerves?
Injury to CN 9, 10, 12
Glossopharyngeal, Vagus, Hypoglossal
How to test spinal accessory in infant? CN?
CN 11 Spinal Accessory
symmetry of shoulders
how to test hypoglossal in infant? CN?
CN 12 Hypoglossal
coordination of sucking, swallowing and tongue thrusting
Pinch nostrils; tongue midline?
Palmar Grasp reflex
Maneuver
Age
Meaning if it goes beyond? #2
fingers in infants hand
AGE:
Birth - 4 months
PERSISTENCE:
-beyond 6 months suggests pyramidal tract dysfx
-Persistance beyond 2 months= CNS damage, especially
if fingers over lap thumb
Plantar Grasp Reflex
Maneuver
AGE
persistence meaning?
Touch base of toes; toes should curl
AGE:
Birth - 8 months
PERSISTENCE:
-Pyramidal tract dysfx (corticospinal tract)
Rooting Reflex
Maneuver
AGE
absence?
Stroke perioral corners; mouth should open and infant turn head to suck
AGE
Birth - 4 months
ABSENCE:
generalized or CNS disease
Moro reflex
Maneuver
age
persistence
assymmetry
“startle reflex”
Abruptly lower supine infant 1 foot; arms abduct, hands open, legs flex
AGE
birth - 4 months
PERSISTENCE: Neurologic disease (CP) esp if beyond 6 months
ASYMMETRY:
clavicle/humerus fracture
brachial plexus injury
Asymmetric tonic neck reflex
maneuver
age
persistence
turn head to one side, holding jaw over shoulder; opposite arm/leg will flex
AGE
Birth - 3 months
PERSISTENCE:
asymmetric CNS development
CP development
Galant Reflex
maneuver
age
absence
persistence
“Trunk Incurvation”
Prone infant & stroke 1 side of back 1cm from midline; spine should curve toward the stimulated side
AGE
Birth - 4 months
ABSENCE:
transverse SCI
PERSISTENCE:
delayed development
Landau reflex
maneuver
age
persistence
suspend infant prone; the head should lift & spine straighten
AGE
Birth - 6 months
PERSISTENCE:
delayed development
Parachute reflex
maneuver
age
DELAY
prone infant & lower head to surface; arms and legs extend
AGE:
8 months - lifetime
DELAY:
predict future delays in voluntary motor development
Positive support reflex
maneuver & what’s normal?
age
meaning if there’s no reflex?
Meaning if there is only fixed extension & adduction?
hold infant around trunk until both feet touch surface; partial weight-bearing
AGE:
birth/2mos. - 6 months
:
NO REFLEX = flaccidity or hypotonia
-Fixed extension & Adduction (SCISSORING) = spasticity/neuro disease (CP)
Placing and Stepping reflex
maneuver
age
absence
hold upright w/ one foot touch surface; alternate stepping
AGE:
Birth - varies
ABSENCE = paralysis
*breech delivery may not have this
Define lethargy
drowsy, opens eyes when spoken to in LOUD VOICE
response to questions then falls asleep
Define Obtundation
opens uses with TACTILE STIMULUS
looks at you, responds slowly & CONFUSED
define stupor
arouses with PAINFUL stimuli
unresponsive when stimulus stops
Define & disease thought blocking
interruption in speech midsentence “lost the thought”
Schizophrenia
define & disease circumstantiality
speech with unnecessary detail, delay reaching the point
OCD
define & disease clanging
words based on sounds “wise eyes; rosey nosey”
Schizophrenia
Manic
define & disease confabulation
fabrication of facts; fill in teh gaps
Korsakoff syndrome from alcoholism
define & disease derailment
shifting topics that are loosely connected. Pt unaware there is no connection
schizophrenia
mania
echolalia
involuntary repetition of words
manic
schizophrenia
flight of ideas
the continuous flow of accelerated speech abrupt changes of topic
ideas not well connected
manic
incoherence
incomprehensible speech
schizophrenia
neologisms
invented words
schizophrenia
aphasia
perseveration in speech
persistent repetition of words or ideas
“unsolicited reiterations”
schizophrenia
What is dysarthria? indicate?
defective muscular control of speech
words are slurred or indistinct
CNS, PNS lesions
Parkinson
Cerebellar disease
Aphasia indicates?
disorder producing or understanding language
Lesions in dominant cerebral hemisphere, usually left
Dysphonia indicates?
which cranial nerve may be effected?
impaired volume, quality or pitch of voice
hoarse or only can whisper
laryngitis, tumors
unilateral vocal cord paralysis (CN 10 Vagus)
Aphonia indicates?
loss of voice
Larynx disease or nerve
Broca aphasia
Expressive aphasia
Comprehends language but nonfluent speech
Lesion of posterior inferior frontal lobe
Wernicke aphasia
Receptive aphasia
impaired comprehension; speech fluent but lacks meaning
- What are some of the most important questions to ask of the depressed patient?
Over the past 2 weeks, have you felt down, depressed, or hopeless?
Over the past 2 weeks, have you felt little interest or pleasure in doing things (anhedonia)?
- What are the five categories of the neurological exam?
**Mental status/speech/language
(alertness, appropriate speech, orientation)
- *Cranial nerves
- Visual acuity
- pupillary light reflex
- Eye Movements
- Hearing
- Facial Strength (smile, eye closure)
- *Motor system
- Assess strength
- coordination (Rapid alternating movements)
- Position sense (Romberg)
- Gait
- *Sensory system
- light touch/pain/temperature/vibration/proprioception
- *Reflexes
- muscle stretch reflex
- superficial stimulation reflex (anal, plantar, abdominal)
What could a headache indicate?
What are the red flags? #5
warrants careful evaluation for life-threatening causes EX meningitis, subarachnoid hemorrhage, or mass lesion
Red flags “ sudden onset,” onset after 50 years. Associated symptoms like fever & stiff neck. Papilledema & focal neurologic signs
What could dizziness indicate?
Dizziness: Positional Vertigo, or Meniere disease. Diplopia? (stroke) Related to medications?
7
What are some common or concerning symptoms that the FNP should assess for as part of the neurological history?
Headache Dizziness Weakness Numbness/Abnormal sensation Syncope Seizure Tremors/involuntary movement
What could numbness/abnormal sensation indicate?
paresthesias or dysthesia (distorted sensation EX light touch causes burning sensation)
What could syncope indicate?
Syncope: Actually lose consciousness? (Vasovagal, hypotension, arrythmia) Or Seizure?
What information do you know about morbidity and mortality in relation to strokes?
Ischemia stroke is more common
More women die
More AA effected
What history and exam findings are consistent with TIAs/strokes?
TIA – resolves in 24 hours
Stroke risk – highest if you had TIA, >60 years, diabetes, focal symptoms, symptoms lasting more than 10 mins.
Findings for ACA stroke?
contralateral leg weakness
Findings for left MCA stroke?
aphasia
findings for Right MCA stroke?
neglect of opposite side of body
findings for middle MCA stroke?
contralateral hemiparesis & sensory deficits (no aphasia or neglect)
findings for PCA stroke?
contralateral visual field loss
findings for brainstem stroke?
dysphagia, dysarthria, tongue palate deviation, ataxia w/contralateral body
findings for basilar artery stroke?
“locked in” syndrome = intact consciousness but quadriplegic/can’t speak
Resting (static) Tremor
Prominent at rest; disappear with movement; Parkinson pill-rolling
Postural Tremor
Appears when actively maintain posture. EX: rapid fine tremor of hyperthyroidism. OR essential tremor
Intention Tremor:
what diseases do you find this with?
Absent at rest; appear w/movement and get worse when limb approaches target. EX cerebellum stroke or MS
What are dizziness, vertigo, presyncope and syncope?
Presyncope: about to pass out or fall; Cause: orthostatic hypotension
Vertigo: spinning sensation w/ nystagmus & ataxia; Cause: peripheral vestibular dysfunction or brainstem lesion
Dizzy: includes presyncope, disequilibrium or vertigo
What disease has….progressive & rapid development of lower weakness followed by upper
Guillain-Barre
What disease has…chronic, gradual, progressive weakness
ALS or expanding tumors
What disease has…Proximal limb weakness
Alcohol myopathy, glucocorticoids & inflammatory muscle
What disease has..proximal weakness gets worse with effort (fatiguability)
Myasthenia Gravis:
What disease has..Bilateral, distal weakness w/sensory loss
Diabetes
How do you test for discriminative sensations
Absent stereognosis, graphesthesia & 2 point discrimination = posterior (dorsal) column disease
Point Localization
Briefly touch point on patient’s skin and then ask to point to place touched
somatosensory test
Graphesthesia
Identify numbers in patient’s palm
Stereognosis
Identify an object by feeling it within 5 seconds
Extinction:
How to test?
What does an abnormal result mean?
double simultaneous stimulation
sensory neglect = if only one side recognized (R parietal lobe or R basal ganglia lesions)
What tests can be used to assess gait?
Walk across the room
Walk heel-to-toe/Tandem walking
Walk on toes, then on heels
What does the inability to walk on heels mean?
corticospinal damage
What do you see with spastic hemiparesis? what does it mean?
Unilateral weakness w/ spasticity of affected muscles & increased tendon reflexes
-Affected arm flexed & immobile; Drag toe/circle leg while walking
Corticospinal tract lesions: Cerebral Palsy/Stroke
What do you see with steppage gait? what does it mean?
drag feet or lift them high with a SLAP onto floor; can’t walk on heels
-Foot drop; 2nd peripheral nervous system disease
What do you see with scissors gait? What does it mean?
Stiff, slow, thighs cross forward on each other
Spinal cord disease w/ spasticity
What are tests of coordination?
rapid alternating movements
Point-to-Point movements
Gait & stance
What do the point-to-point movements test?
What are the Point to Point tests?
What is abnormal and its meaning?
COORDINATION TEST
Finger To Nose
Abnormal: clumsy, unsteady, inappropriate speed/force = cerebellar disease
Abnormal: unable to touch providers finger with eyes closed means a loss of position sense = sensory ataxia
Heel-to-Shin
Abnormal: overshoots knee (dysmetria) & oscillates side to side (intention tremor) = cerebellar disease
What do the rapid alternating movements test for? what does abnormal look like?
Strike hand on thigh
In cerebellar disease instead of alternating quickly, these movements are slow, irregular, and clumsy = dysdiadochokinesis
Alternating fingers
- imprecise, irregular rhythm = cerebellar disease
- slow, low amplitude = UMN & basal ganglia
What does imprecise, irregular rhythm with rapid alternating fingers mean?
cerebellar disease
While rapidly alternating fingers…the pt is slow and has low amplitude…what does this mean?
UMN weakness
Basal ganglia disease
What is the Biceps Reflex reponse?
Where on spine?
Biceps (C5,C6) [Flexion elbow & muscle contract]
What is the brachioradialis reflex???
Where?
Brachioradialis reflex (C5, C6) [hand on rest on lap, flexion at elbow & supination of forearm]
What do you see with the Triceps Reflex?
Where in spinal cord?
Triceps (C6, C7) [extension elbow]
What do you see with the Patellar reflex?
Where?
Patellar reflex (L2-4) flex knee…tap below knee…quadriceps contract & knee extends
What is the Achilles Reflex?
Where?
Achilles Reflex (S1) dorsiflex foot…plantar flexion at ankle
What is the plantar response in adults?
What is normal?
What is abnormal?
Plantar Response…normal = plantar flexion; abnormal = dorsiflexion big toe; Babinski
What is the anocutaneous reflex?
Where on spine?
What is abnormal and what does it mean?
Anocutaneous Reflex (S3-4)…normal = external anal sphincter contraction; abnormal = cauda equina lesion
What could cause a slowed relaxation phase of reflex?
Hypothyroidism
What do hyperreactive reflexes mean?
CNS lesions involving corticospinal tract usually with weakness, spasticity or Babinski
What do hyporeactive reflexes mean?
PNS lesions associated with weakness, atrophy & fasciculations
How does the FNP assess for clonus? What does clonus indicate?
Knee in flexed position…sharply dorsiflex foot & maintain in dorsiflexion…rhythmic oscillations = clonus
What does a sustained clonus mean?
CNS disease of corticospinal tract
5
How would the FNP assess for diabetic neuropathy?
Vibration sense if first sensation lost in peripheral neuropathy.
Loss of position sense (can’t sense big toe proprioception)
Pin-prick sensation
Ankle reflex (diminished)
Plantar light touch
What is reinforcement and how can it be used to assess reflexes?
Used if a reflex seems diminished or absent
Involves isometric contraction of other muscles for 10 seconds that increases reflex activity.
If reinforcement is used, grade reflex response to 1
What is the Romberg test? What does an abnormal finding indicate?
Tests POSITION SENSE
Stand w/ feet together & eyes open then with eyes closed
- Loss of balance with eyes closed = + positive Romberg = Sensory Ataxia
- Loss of balance with eyes closed & open = Cerebellar Ataxia
How is muscle strength graded?
• Muscle strength graded on a 0 to 5 scale:
o 5 – Active movement against full resistance without evident fatigue
Normal muscle strength
o 4 – Active movement against gravity and some resistance
o 3 – Active movement against gravity
o 2 – Active movement of the body part with gravity eliminated (planar motion)
o 1 – A barely detectable flicker or trace of contraction
o 0 – No muscular contraction detected
What are meningeal signs?
Nuchal rigidity
Brudzinski sign
Kernig Sign
Jolt accentuation of the Headache
Nuchal rigidity
neck stiffness w/ resistance to flexion
Brudzinski Sign
+meningitis
flex neck & watch hips and knees in reaction…
+sign = flexion of hips & knees
Kernig Sign –
Meningitis
Flex patient’s leg at hip & knee then slowly extend the leg and straighten knee…
+ sign= pain & increased resistance to knee extension
Jolt accentuation of the Heachache (JAH) –
patient nods “no”…
+sign = headache worsened
Analgesic rebound
PROCESS LOCATION QUALITY/SEVERITY ONSET DURATION COURSE ASSOCIATED S/S AGGRAVATORS
PROCESS: withdrawal medication
LOCATION: previous headache pattern
QUALITY/SEVERITY: Varies
ONSET/DURATION/COURSE/ASSOCIATED S/S : Varies
AGGRAVATE: Fever, carbon monoxide, caffeine withdrawal,
Errors of Refraction (farsightedness & astigmatism NOT nearsight)
PROCESS LOCATION QUALITY/SEVERITY ONSET DURATION COURSE ASSOCIATED S/S #3 AGGRAVATORS RELIEF
PROCESS: sustained contraction EOM
LOCATION: around & over eyes, radiates to occipital
QUALITY: steady, ache,dull
ONSET: gradual
DURATION/COURSE: varies
ASSOCIATED SYMPTOMS: eye fatigue, “sandy,” red conjunctiva
AGGRAVATORS: prolonged eye use, close work
RELIEF: rest
Acute Glaucoma
PROCESS LOCATION QUALITY/SEVERITY ONSET DURATION COURSE ASSOCIATED S/S AGGRAVATORS
PROCESS: sudden increase intraocular pressure
LOCATION: pain in/around one eye
QUALITY/SEVERITY: steady & severe, ache
ONSET: Rapid DURATION/COURSE: Varies
ASSOCIATED S/S: blurry vision, N/V, halos around lights, red eye
AGGRAVATE: mydriatic drops RELIEF: none
Sinusitis Headache
PROCESS LOCATION QUALITY/SEVERITY ONSET DURATION COURSE ASSOCIATED S/S #4 AGGRAVATORS #3 RELIEF
PROCESS: inflammation paranasal sinuses
LOCATION: frontal sinuses above eyes or over maxillary sinus
QUALITY/SEVERITY: ache/throb, possibly migraine
ONSET: varies
DURATION: daily several hours, persists until tx
COURSE: daily repetitive pattern
ASSOCIATED S/S: local tender, congestion, discharge, fever
AGGRAVATOR: cough, sneeze, jarring head
RELIEF: Nasal decongestants, antibiotics
Meningitis
PROCESS LOCATION QUALITY/SEVERITY ONSET DURATION COURSE ASSOCIATED S/S
PROCESS: viral/bacterial infection
LOCATION: generalized QUALITY/SEVERITY: severe steady throbbing ONSET: rapid, sudden DURATION: varies COURSE: viral <1wk; bacterial persistent until tx
ASSOCIATED S/S: fever, stiff neck, photophobia, mental status change
Subarachnoid Hemorrhage
PROCESS LOCATION QUALITY/SEVERITY ONSET DURATION/COURSE ASSOCIATED S/S AGGRAVATORS
PROCESS: bleeding ruptured aneurysm
LOCATION: generalized
QUALITY/SEVERITY: very severe “worst of my life” thunder clap
ONSET: Sudden
DURATION/COURSE: varies
ASSOCIATED S/S: N/V, unconscious, neck pain,
AGGRAVATORS: Increased ICP, cerebral edema, rebleeding
Brain Tumor
QUALITY/SEVERITY DURATION COURSE ASSOCIATED S/S #6 AGGRAVATORS #3
QUALITY/SEVERITY: ache, steady, dull, worse on awakening and better after several hours
DURATION: brief, depends on location and rate of growth
COURSE: intermittent but progresses intensity over days
ASSOCIATED S/S: seizures, hemiparesis, field cuts, personality change, N/V, vision & gait change
AGGRAVATORS: cough, sneeze, sudden movements
Giant Cell (temporal) Arteritis
PROCESS LOCATION QUALITY/SEVERITY ONSET DURATION COURSE ASSOCIATED S/S AGGRAVATORS RELIEF
PROCESS: transmural lymphocytic vasculitis involving multinucleated giant cells that disrupt internal elastic lamina of large caliber arteries
LOCATION: near involved artery, usually temporal
QUALITY/SEVERITY: Severe throb, generalized, persistent,
ONSET: gradual or rapid
DURATION: varies
COURSE: recurrent/persistent over weeks- months
ASSOCIATED S/S: tender, fever, weight loss, new headache, jaw, visual loss, rheumatica
AGGRAVATE: movement neck or shoulders
RELIEF: steroids
How would the FNP assess sensory function in the infant? What would abnormal findings indicate?
Can only test for pain by flicking infant’s palm or sole.
Observe for withdrawal, or change in facial expression.
Paralysis = If infant cries but there is no withdrawal
What exam findings would be present in the newborn that has been exposed to maternal substance abuse or the infant experiencing neonatal abstinence syndrome?
Irritable, jittery, tremors, hypertonicity & HYPERreflexes.
Poor feeding, seizures, autonomic signs
What are the 6 components of the mental health examination?
Appearance & Behavior – LOC, Dress, Mannerisms
Speech & language – fluency, articulation, rate/volume
Mood – describe level & fluctuations r/t life events
Thoughts & Perceptions – Thought process (how they think/ logic, coherence, relevance, organization) Thought content (what they think about/ insight, judgment,
hallucinations)
Cognitive function – orientation, attention, memory, new learning ability
Insight & Judgement
What are the classifications of personality disorders? What are their characteristic behavior patterns?
Odd or Eccentric Disorders
(Paranoid/schizoid/schizotypal)
Dramatic, Emotional or Erratic
(Antisocial, borderline, histrionic, narcissistic)
Anxious or Fearful
(Avoidant, dependent, OCD)
What is dysdiadochokinesis? What disease is it found in?
In cerebellar disease instead of alternating quickly, these movements are
slow, irregular, and clumsy
While rapid alternating fingers you find the movements irregular and imprecise…What does this mean?
cerebellar disease
What are the characteristics of an ectopic pregnancy?
abdominal pain
adnexal mass/tenderness
uterine bleeding
What is paget’s disease of the nipple?
- scaly, eczema lesion on nipple that weeps/crusts/erodes.
- Suspect Pagets for persistent dermatitis of nipple.
sign of breast cancer
What is cranial nerve II? How do you test for it? infant?
Optic
Tests for visual acuity & optic fields
“tell me when you see the finger”
INFANT:
look for facial response and tracking
What is CN III? How do you test for it? infant?
Oculomotor
pupillary constriction, eyelid opening, EOM
TESTS: Ptosis Convergence test (follow finger to bridge of nose) Nystagmus (focus on distant object) 6 Cardinal fields
INFANT:
“blink reflex”
pupillary response w/ light
Tracks smiling face & if eyes move together
What is CN IV? How do you test for it?
Trochlear
Downward inward rotation of the eye
Cardinal fields
What is CN V? How do you test for it? Infant?
Trigeminal
Motor (jaw clenching & lateral jaw movement)
Sensory (Facial) *pain sensation?
INFANT:
Rooting reflex
sucking reflex
What is CN VI? How do you test for it?
Abducens
Lateral deviation of eye
Cardinal fields
What is CN VII? How do you test for it? Infant?
Facial
Motor (facial expressions) *puff cheeks, forehead, neck muscles
Sensory (taste ant tongue)
INFANT
symmetry of crying
What is CN VIII? how do you test for it? Infant?
Vestibulocochlear
Hearing & balance
whisper test
INFANT:
Blinking in response to loud sound
What is CN IX? how do you test for it? Infant?
Glossopharyngeal
- “aah”
- Gag reflex
INFANT:
coordination swallowing
What is CN X? how do you test for it? Infant?
Vagus
Motor (palate)
Sensory (pharynx & larynx)
INFANT:
coordination swallowing
What is CN XI? how do you test for it?
What abnormalities are you looking for?
Infant?
Spinal accessory nerve
Sternocleidomastoid and trapezius
- *Shrug shoulders against hands
- Turn head against chin
- tun chin into hand
LOOKING FOR:
fasciculations = small irregular twitching or atrophy
INFANT:
symmetry of shoulders
What is CN XII? how do you test for it? Infant?
Hypoglossal nerve
*Stick out tongue and move side to side
INFANT:
Pinch. nostrils to open mouth and observe tongue midline
If the palate fails to rise…what CN lesion is this?
CN X Vagus
If you see a patient’s should droop and the scapula is displaced downward and laterally…what does this mean? Which CN might be effected?
CN XI Spinal Accessory
Trapezius muscle paralysis
The patient’s tongue is protruding and toward the side of the CN ____ lesion
CN XII Hypoglossal
The whispered voice tests CN ___
CN VIII Vestibulocochlear
A peripheral injury to CN ___ , as seen in Bell’s Palsy, affects both the upper and lower face
CN VII Facial
You notice flattening of the nasiolabial fold and drooping of the lower eyelid that suggests facial weakness. There is a problem with CN ___
CN VII Facial
What 3 senses do you test for CN V (trigeminal)
light touch, pain, temperature
Your patient is having difficulty clenching their jaw, what CN dysfunction is this?
CN V trigeminal
Which cranial nerve palsy would you see ptosis?
CN III Oculomotor
