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PHC2 Practice > Neuro Exam Info > Flashcards

Neuro Exam Info Flashcards

1
Q

Cranial nerves

A

I- olfactory
II- optic
III- oculomotor
IV- trochlear
V- trigeminal
VI- abducens
VII- facial motor
VIII- vestibulocochlear
IX- glossopharyngeal
X- vagus
XI- accessory
XII- hypoglossal

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2
Q

I olfactory nerve assessment

A

History questioning: any changes in sense of smell?
Think taste Vs smell
If testing req: use coffee, vanilla or peppermint on each nostril
If anosmia: inspect nose

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3
Q

General facial inspection prior to cranial Ass: x 4 items

A

Wasting of facial muscles
Facial asymmetry ptosis
Inability to close an eye
Endocrine facies: acromegaly, Paget’s, scars, vesicles, haemangiomas

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4
Q

II Optic nerve assessment: x 5 items

A

Snellen’s chart @ 6m - use glasses if normally worn (3m if difficult, closer 1m, no. of fingers, moving hand, light detection. AND 6/9 or pinhole needed)

Visual fields - confrontation or hands moving in (cover own eye, mirror image, to help detect peripheral margins)

Pupils - direct light each eye & swinging light test.

Fund us exam - fundoscopy

Colour vision test - coloured tests

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5
Q

III Oculomotor/IV Trochlear/VI Abducens

A

Pupils - size, shape, equality, regularity
Presence of any ptosis - dropping upper eyelid
Testing the light reflex - ? Already
Accommodation - look at wall, then adjust to pen closer to face… move pen even closer to face too.
Eye movements - following finger patterns to test full fields
Nystagmus - follow pen/finger from midline to sides & paper to each side & ask Pt to focus on wall behind it

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6
Q

Nystagmus terminology

A

Jerk (described by the direction of the quick phase, more common) or Pendular (slow pendulum like movement)

Horizontal/Vertical/Rotational

Frequency (how often they move back & forward - high/low) & Amplitude (distance eyes move - high/low)

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7
Q

Central Vs Peripheral Nystagmus

A

Central:
- low frequency, high amplitude
- vertical nystagmus
- gaze fixation does NOT affect nystagmus
- pendular & rotatory nystagmus
- does NOT get exhausted

Peripheral:
- high frequency, low amplitude
- horizontal nystagmus
- gaze fixation can suppress nystagmus
- quick phase & slow phase (unidirectional)
- can get exhausted

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8
Q

V Trigeminal (motor): x 4 points

A

Motor division:
- inspect for wasting of temporalis muscle
- clench teeth & palpate masseter muscle
- open mouth & hold open while examiner tries to close
- jaw jerk/masseter (exaggerated in UMN lesions: pseudobulbar palsy)

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9
Q

V Trigeminal (sensory)

A

Test divisions:
V1 - ophthalmic; forehead
V2 - maxillary; cheek
V3 - mandibular; chin
(Sharp before soft!!)

Test corneal reflex:
- lightly touch w cotton tip to edge of eye [afferent: sensory div of Trigem & efferent: facial for corneal reflex]

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10
Q

VII Facial nerve

A

Motor div:
- Facial asymmetry
- look up check: loss of wrinkling
- fell check: pushing down on each side
- ask Pt to frown
- shut eyes tightly: & try to open (look for Bell’s phenomenon: upward movement of eyeball)
- smile: ?loss of nasolabial folds
- puff out cheeks: test power by pushing against

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11
Q

VIII Vestibulocochlear nerve

A

Test for hearing: Rinne’s & Weber’s tests

? Dix-Hallpike manoeuvre if req

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12
Q

IX Glossopharangeal & X Vagas nerves

A

Ask Pt to open mouth & say ‘Ah’: inspect palate & uvula for any displacement (uvula displaced away from side of lesion)

Assess for:
- hoarseness of voice
- bovine cough
- any Hx of dysphagia
NOT gag reflex!!

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13
Q

XI Accessory nerve

A

Ask Pt to:
- shrug shoulders: feel bulk of traps & try to push shoulders down
- turn head to left against assessors resisting hand (checking R sternocleidomastoid) & vice versa

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14
Q

XII Hypoglossal nerve

A

Inspect tongue at rest: ? Wasting/fasciculations
[LMN lesions; weakness, wasting & fasciculations, UMN lesions; small immobile tongue]

Ask Pt to:
- stick out their tongue: look for deviations (towards side of lesion)
- check for any problems with speech articulation

Fasciculations: visible, spontaneous & intermittent contractions of muscle fibres.

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15
Q

Neuro Exam of limbs (gen insp & motor)

A

General inspection:
- asymmetry
- abnormal posture
- involuntary movements
- muscle wasting
- scars
- skin lesions

Motor System:
- R or L handed
- hands by sides: look for fasciculations (w wasting & weakness = LMN lesion)

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16
Q

Pronator drift

A

Ask Pt to:
Hold both arms out straight, palms up & eyes closed

Drifts:
- downward: pyramidal lesion
- upward: cerebellar lesion
- any direction: loss of proprioception (searching movements affecting fingers)

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17
Q

General Muscle assessment

A

Bulk:
- atrophy (distal/proximal, unilateral/bilateral, symmetrical/asymmetrical): best seen in hands & shoulders
- feel for muscle bulk

[atrophy & fasciculations present = LMN disease]

Tone:
- normal residual tension in relaxed muscle
- test by noting resistance to passive movement (support Pt’s limb w one hand & move passively w other)

Check flexion & extension: of all joints & passive range of motion of appropriate joints

Descriptions:
- flaccid/hypotonic: acute phases spinal cord injury, stroke & cerebellar lesions
- hypertonic: UMN or extrapyramidal lesions
- rigid (cogwheel/lead pipe rigidity): Parkinson’s Dx or clasp like in lesions of pyramidal tract.

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18
Q

Muscle strength: grading

A

Test joint by joint, one side at a time.

Grading:
0- no contraction/complete paralysis
1- flicker or trace contracted
2- active movement possible with gravity eliminated
3- active movement possible against gravity, but no further resistance added
4- slight/mod/submaximal movement against gravity & some resistance
5- active movement against full resistance without evident fatigue (normal power)

Remember:
- compare from side to side
- muscle strength is tested by gauging the examiner’s ability to overcome the Pt’s full voluntary muscle resistance
- all movement is released by the examiner unless the Pt is unable

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19
Q

Upper Limbs muscle testing: direction & nerve tracts involved

A

Shoulder:
- abduction C5, C6: abduct w elbows flexed against Ex
- adduction C6, C7, C8: adduct w elbows flexed against Ex

Elbows:
- flexion C5, C6: bend against Ex
- extension C7, C8: extend against Ex

Wrist:
- flexion C6, C7: make fist & flex, then resist Ex trying to extend
- extension C7, C8: (radial nerve) make fist & extend, then resist Ex trying to flex

Fingers:
- flexion C7, C8: grip strength
- extension C7, C8: straighten against Ex
- abduction C8, T1: spread against Ex
- adduction C8, T1: hold fingers together & prevent Ex abducting

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20
Q

Gait assessment

A

Ask Pt to:
-walk normally a few metres, turn around quickly & walk back
- walk heel to toe (exclude midline cerebellar lesion)
- walk on toes (ex. S1 lesion)
- walk in heels (ex. L4, L5 lesions or foot drop)
- perform Romberg test

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21
Q

Romberg test

A

Procedure:
- Pt standing feet together, warms crossed across chest
- 20-30secs eyes open
- repeat with eyes closed

Romberg Pos if: irregular sway or falling when eyes closed (Defective proprioception)

22
Q

Lower Limb muscle testing: directions & nerves

A

Hip:
- flexion L2, L3: raise straight leg against Ex
- extension L5, S1, S2: Pt to keep leg down & prevent Ex pulling it up
- adduction L2, L3, L4: prevent abduct of knees
- abduction L4, L5, S1: prevent adduct of knees

Knee:
- extension L3, L4: knee slightly bent, ask Pt to extend against Ex
- flexion L5, S1: bend knee against Ex

Foot:
- dorsiflexion L4, L5: flex foot against Ex
- plantar flexion S1, S2: extend foot against Ex
(Also tested w Romberg test)

Ankle:
- extension/hallucis longus: (big toe L5 resistance) bring big toe towards Pt against Ex
- inversion L4: push foot In against Ex (w lower leg immobile)
- eversion L5, S1: push foot Out against Ex (w lower leg immobile)

23
Q

Reflexes grading

A

Grading:
0 = absent
+ = present but reduced
++ = Normal
+++ = increased/brisk, poss normal
++++ = very brisk, hyperactive, poss w clonus

Remember:
- 0 or + is Normal in some people
- compare from side to side & comment on symmetry/asymmetry
- if reflex appears absent, always test again following reinforcement (distraction = get Pt to clench teeth for test)
- increased jerk = UMN lesion
- decreased/absent jerk = any part of reflex arc breached [muscle itself (myopathy), motor nerve (neuropathy), anterior spinal cord root (spondylosis), anterior horn cell (poliomyelitis), or sensory arc (sensory root or sensory nerve)

24
Q

Upper limb Reflexes

A

Biceps (C5, C6):
- w Pt’s arm flexed, hand pronated, not overlapping: place finger on biceps tendon & strike finger w hammer
[watch for contraction of biceps tendon & flexion of forearm]

Triceps (C7, C8):
- w Pt’s arm supported & flexed @ elbow: strike triceps tendon directly w hammer [watch for triceps contraction & forearm extension]

Supinator/Brachioradialis (C5, C6):
- w Pt’s arm resting on thigh & partly pronates: strike yr finger over the radius 1-2 inches above the wrist [watch for flexion of elbow & supination of forearm]

25
Q

Lower limb Reflexes: x 3 items

A

Knee jerk (L3, L4):
- w Pt seated legs dependant: strike patellar tendon [watch for contraction of quadriceps]
(Can be done supine w Ex supporting flexed knee)

Ankle jerk (S1, S2):
- w foot in mid- position, knee bent & thigh externally rotated (easier on bed) while maintaining dorsiflexion at ankle: strike Achilles tendon [watch for plantar flexion]
(Can be done sitting w foot held in dorsiflexion)

Plantar reflex (L5, S1, S2):
- w Pt supine or seated: stroke lateral surface of foot from heel to ball of foot w blunt object [watch for flexion of big toe]

Babibski’s response: extension of big toe & fanning of other toes. Normal in infants BUT = UMN lesion in adults.

26
Q

Important Dermatomes for Sensory tests

A

C3- front of neck
T4- nipples
T7- xiphisternum
T10- umbilicus
L1- inguinal
L2- upper anterior thigh
L3- area around front of knee
L4- medial aspect of leg
L5- lateral aspect of leg
S1- heel & sole of foot
S2- posterior aspect of thigh

27
Q

Testing Sensory function

A

Less is more

Start distally & work proximally

Sensory modalities:
- pain/temp (spinothalamic tract)
- position/vibration (posterior column)
- light tough (posterior column & spinothalamic tract)

28
Q

Upper limb sensory testing

A

Pain:
- demonstrate first (sternum)
- arms In anatomical position
- compare L & R in same dermatomes
- ask if sharp or dull
- can be done eyes open or closed

Proprioception:
- demonstrate w little finger
- demo w eyes open
- test w eyes closed & get Pt to identify the random Up & Downs
- any abnormality distally, work more proximal to wrists or even elbow. [loss of position sense: posterior column Dx or lesion in peripheral nerve or root]

Vibration:
- 128Hz tuning fork
- demonstrate vibrating fork on sternum
- perform test w eyes closed
- place on DIP joint of thumb while vibrating & ask Pt to indicate when stopped
- abnormality distally, work proximally on bot prominences: head of ulna at wrist or olecranon process at elbow.
[first sensation lost in peripheral neuropathy, eg; diabetes]

Light touch:
- cotton wool
- demonstrate first
- test w eyes closed
- compare L & R & each dermatome
- do not Stroke

Temperature:
- not normally tested regularly
- can use metal object
- start distally & move proximally rapidly asking if temp changes
- better tolerated then Pain!!

29
Q

Lower limb Sensory testing

A

Pain:
- demo on sternum
- legs in anatomical position
- compare L & R dermatomes
- ask if it feels sharp or dull
- eyes open or closed
- if sensation decreased peripherally: assess for ‘stocking’ sensory loss (rapid pricks from toes up tibia)

Proprioception:
- passively move Pt’s DIP of big toe
- demo eyes open
- test eyes closed & get Pt to identify random Up & Downs
- if abnormal distally, work proximally: ankle or even knee

Vibration:
- 128 Hz fork
- demo vibrating on sternum
- eyes closed, test on DIP of big toe: vibrating & when it stops
- compare L & R
- abnormality distally, work proximally: malleoli to patella.

Light touch:
- cotton wool
- tested last
- eyes closed & say Yes when touch felt
- compare L & R dermatomes
- do not Stroke

Temperature:
- not tested regularly
- distal to proximal rapidly & ask if temp changes
- better tolerated than Pain!!

30
Q

Upper limbs Coordination (3)

A

Rapid alternating movements:
- ask Pt to supinate & pronate one hand on other palm as rapidly as possible
- Dysdiadochokinesis: slow, clumsy or irregular = cerebellar dysfunction, pyramidal or extrapyramidal tract abnormalities.
- DDK performance by Non-dominant hand can also be slow & inaccurate

Finger Nose Test:
- eyes open, ask Pt to touch finger to nose then Ex’s finger at nearly full extension range
- Ex moves finger to 2-3 diff locations
- eyes closed: look for past pointing & intention tremor [cerebellar dysfunction]

Rebound:
- ask Pt to lift arms rapidly from the sides & then stop
- hyptonia due to Cerebellar Dx can cause delay in stopping arms

31
Q

Lower limb Coordination

A

Heel to Shin test:
- w Pt supine, heel of one foot on opposite knee & slide down shin to big toe, at moderate pace & as accurately as poss
- clumsy movements, or heel moving from side to side, over shoots position = cerebellar dysfunction

Toe-Finger test:
- ask Pt to lift foot & touch Ex’s finger

Foot-tapping test:
- ask Pt to tap foot on Ex’s hand as fast & as accurately as poss.

32
Q

Rinne’s test

A

Bone Vs air conduction

  • 512 Hz tuning fork
  • vibration on mastoid process 2-3 secs Vs vibration of forks parallel & 1 cm from ear, 2-3 secs

Normal:
- air louder then bone: Rinne’s Positive

Conductive hearing loss:
- bone louder than air: Rinne’s Negative

Sensorineural hearing loss:
- air louder than bone (Rinne’s false pos)

33
Q

Weber’s test

A

Comparison of L & R hearing

  • 512 Hz fork
  • place vibrating fork on cranial midline
  • ask Pt if sound is louder in one ear than the other?

Normal:
- sound heard in midline/balanced

Conductive hearing loss:
- sound heard in Bad ear

Sensorineural hearing loss:
- sound heard in Good ear

34
Q

SWIFT

A

Scars
Wasting of muscles
Involuntary movements
Fasciculations
Tremor

35
Q

Vertigo causes: central/peripheral/systemic

A

Central- brainstem or cerebellum

Peripheral- vestibular apparatus or 8th cranial nerve

Systemic- psychogenic, cardiovascular, metabolic, trauma or toxicity aetiologies

36
Q

Vertigo physical assessment: x 9 items

A

Check:
- general appearance
- vital signs
- ECG to rule out arrhythmias
- BGL to rule out hypo/hyper
- assess for gross neurological signs: facial palsy, hemiparesis, limb ataxia or gait issues
- cranial nerve assessment: esp. 2, 3, 4, 5, 6 & 7… w particular focus on 8th! (Rinne’s & Weber’s tests)
- assess Cerebellum & it’s connections: gait, coordination, reflexes, Romberg test, finger to nose test
- perform Ear exam
- perform positional nystagmus testing (Dix-Hallpike)

37
Q

Vertigo investigations

A

May include:
- BGL
- Hb
- renal & liver function tests
- ECG +/- Halter monitoring
- audiometry
- rotational tests
- radiology eg; MRI

38
Q

Vertigo intervention x 5 points

A

Explain & encourage: self-limiting in a few weeks

Rest from normal activities or triggers

For BPPV - Epley manoeuvre May assist

Labyrinthine sedatives: prochlorperazine in acute stage, for a few days Max. (Prolonged use can prevent compensation)

Consider: antihistamines or antiemetics to ameliorate vertigo

39
Q

Vertigo red flags

A
  • accompanying neurological signs
  • ataxia out of proportion to vertigo
  • nystagmus out of proportion to vertigo
  • central nystagmus
  • central eye movement abnormalities
40
Q

Dix-Hallpike manoeuvre

A
  • sit Pt on exam table & turn head to one side 45 degrees
  • place Pt supine rapidly so head hangs over edge of bed (ask Pt to keep eyes open)
  • keep Pt in this position for 30 secs or no nystagmus occurs
  • return Pt to upright sitting position & observe of another 30 secs to see if nystagmus occurs
  • Repeat with head turned to opposite side

Notes:
- will tend to aggravate paroxysmal vertigo & nystagmus if posterior canal dysfunction is present in inner ear
- nystagmus will appear after a latency of a few secs & generally last less than 30secs
- generally, eyes will beat toward the ground & then when repositioned they will beat towards the opposite direction
- this test may induce nausea & vomiting

41
Q

Meniere’s Dx

A

Classic triad: vertigo, hearing loss & tinnitus

Dx: increased endolymph in cochlea & labyrinth, unknown pathogenesis
- usually 30-50yo w equal prevalence across genders
- usually unilateral, but may become bilateral across time

Symptoms:
- vertigo
- tinnitus
- nausea & vomiting
- sweating & pallor
- progressive hearing loss
- nystagmus observed only during an attack

Hx:
- abrupt onset
- variable ear pressure/fullness/decreased hearing & tinnitus
- episodes 30mins to hrs
- variable time interval between attacks
- may be prev Hx of same

42
Q

Dix-Hallpike Contradictions

A

Any neck pathology:
- cervical instability
- # ondontoid peg
- recent cervical spine #
- Atlantic-axial subluxation
- cervical disc prolapse
- vertebra-basilar insufficiency
- recent neck trauma that restricts torsional movement
- cervical myelopathy
- recent neck surgery
- rheumatoid arthritis affecting neck

Carotid bruits!

Prior cerebrovascular Dx
- carotid sinus syncope
- cardiac bypass

43
Q

Dix-Hallpike precautions: x 3 items

A
  • severe neck pain
  • severe back pain
  • severe orthopnoea may restrict duration of test
44
Q

Meniere’s Dx complications

A

May include:
- injury due to associated falls
- anxiety symptoms
- disability due to unpredictable vertigo
- progressive imbalance or deafness
- intractable tinnitus

45
Q

Meniere’s Dx advice/Ed

A
  • notify Pt about disease to reduce anxiety (often fear malignancy)
  • avoid excessive intake: salt, caffeine, tobacco
  • low salt diet <3gm per day
  • stress management techniques
  • ensure Pt has regular check ups w PC Phys
  • advise Pt around further sources of info/Ed
46
Q

Epley manoeuvre (posterior canal BPPV)

A

Ind: rotatory nystagmus

Prep: pillow under shoulders to give room for head support

Start:
- sitting & like Dix-Hallpike: 45 degree turn
- go supine, holding 45 d turn for 30-60secs
- turn head to other side (45 d angle opposite side) & Hold 30-60secs
- turn head a further 90 d (req Pt to roll onto side & keep head at same position) ?Hold
- assist to sitting

47
Q

Lempert manoeuvre (lateral canal BPPV)

A

Ind: lateral nystagmus

Prep: lie so head supported by bed

Start:
- supine: turn head 90 d to one side, Hold 30-60secs
- turn a further 90 d, onto side, head facing down, Hold 30-60secs
- turn a further 90 d, onto front, head facing over shoulder, Hold 30-60secs
- turn final 90 d to original position & Hold 30-60secs
- assist to sitting

48
Q

Deep head hanging manoeuvre (superior canal BPPV)

A

Ind: vertical nystagmus

Prep: edge of bed so head hangs down when supine

Start:
- supine on bed, shoulders on edge, head hanging as low as poss, Hold 30-60 secs
- lift chin to chest (probable support req!), Hold 30-60secs
- assist Pt to sitting

49
Q

Migraine triggers & clinical focus points

A

Triggers:
- sound, odour, oestrogen fluctuations
- Foods: red wine, chocolate, ripe cheese, foods containing tyramine or tryptophan
- stress

Clin focus:
- no one Rx superior in all respects
- pharmacologic app: directed by severity, associated N&V, Rx setting & Pt specific factors (ie; vascular risk factors/drug preference)
- non-pharmacologic: Pt preference
- symptomatic Rx: more effective when given earlier & one dose, not repeat small doses
- oral agents: many are ineffective because of poor absorption 2nd to migraine-induced gastric stasis

50
Q

Migraine pharmacological Rx (symptom focus; doses; stepwise; combo; alternates)

A
  • simple analgesics: some Pt’s respond well to aspirin, NSAIDs, paracetamol
  • anti-emetics: IV metoclopramide, chlorpromazine, & prochlorperazine - dopamine receptor antagonists & found to be effective in reducing pain
  • opioids & barbiturates: Last resort Only!! (High risk & assoc w chronic migraine development)
  • Triptans: selective 5-HT agonists that cause cranial vasoconstriction, peripheral inhibition & inhibition of transmission thru 2nd-order neurons of trigeminocervical complex: first line abortive therapy though effective w pain in migraines 15-80% of Pts. Onset: 10-120mins, some side effects tho: heat, tingling, chest discomfort & injection site reactions. (Check contraindications!)
  • Crystalloid IV solution: rehydrate vomiting Pts.

Standard doses:
Aspirin - 300-900mg
Ibuprofen - 200-400mg
Naproxen - 750mg initial; 250-500mg after 1 hr if needed
Diclofenac - 75-150mg
Ketorolac - 10mg IM initial; then 10-30mg every 4-6hrs
Paracetamol - 1000mg

Antiemetics:
Metoclopramide - 10mg IV/IM
Prochlorperazine - 12.5mg IM
Ondansetron - 4-8mg IV/IM/wafer

Triptans:
Sumatriptan (most commonly used) 6mg SC.
Alternate: eletriptan, naratriptan, rizatriptan.

Mild-Mod:
- no N&V - simple analgesics
- w N&V - add antiemetic & consider parenteral/rectal routes

Mod-Severe:
- no N&V - oral options firstline, inc Triptans
- w N&V - parental routes for Triptans & antiemetics

Combo Rx:
- synergistic effect of Sumatriptan & Naproxen; significant improvement by 2hrs

Non-pharmacological:
- rest in quiet, darkened cool room
- cool packs to forehead/neck
- avoid: tea, coffee, orange juice
- avoid: moving around too much
- don’t read/watch TV

PHC2 Practice (13 decks)

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